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Permission comes in all shapes and sizes

Quick question—do you folks have conditions or practices in your facilities that might be a little squishy relative to a strict interpretation of regulatory codes, but your local AHJ has seen fit to grant you permission to engage in that pursuit? And, if so, have you also used that permission to request a traditional equivalency from TJC?

You haven’t?!? Well, my advice would be to do so with all due haste (you can request an equivalency either using snail mail or as an online submittal through the electronic Statement of Conditions on the Joint Commission Connect site). [more]

Don’t pass/fail me by – what does it all mean…

I was recently reviewing some fire alarm testing documentation and I encountered an interesting dichotomy in which a number of smoke detectors were identified as having passed the inspection/testing process, but were also identified as having been installed within 3 feet of air supply vents. [more]

Watching the detectors

This week’s topic of conversation is the fascinating story of having smoke detectors in staff sleep rooms, and how TJC is surveying things at the moment.

So, a bit of background. Generally speaking, chapter 19, the existing healthcare occupancy chapter of the Life Safety Code (NFPA 101 – 2000) does not specifically require the installation of smoke detectors in physician sleeping rooms that are within the healthcare occupancy. It is also the case that physician sleeping rooms in other occupancies, particularly Hotels and Dormitories, would certainly indicate the need for smoke detection. [more]

Gaining some Perspectives on The Doors of Perception

I’m going to guess that you all out in the audience do not necessarily place The Joint Commission’s Perspectives periodical on your list of must-reads, but for the May and June 2012 issues (and who knows beyond that), you really owe it to yourself to grab a copy and prepare for some hard-hitting door and barrier conversation with our esteemed colleague, one Mr. George Mills, Director of the Engineering Department at The Joint Commission.

At any rate, I think we can point to an increasing level of frustration on the part of the various and sundry regulatory agencies (and us, don’t forget us) relative to the number of findings in the life safety (LS) chapter and the omnipresence of these issues in the most frequently cited standards during surveys. How do we make this go away? The answer to that question, interestingly enough, is adopting a risk-based strategy for the ongoing inspection and maintenance of whatever building component is in play – this month its doors. [more]

Update: Link correction for CMS memorandum on LSC

I have been alerted that the link below did not work. I have corrected that link, but I’ll provide it here too:

Click here to directly access the CMS memorandum the changes regarding the Life Safety Code®.

(Ref: S&C-12-21-LSC)

There’s a light, a certain kind of light – and it’s not an oncoming train!

This one has the potential to be the game-changer we’ve been hoping (waiting) for – the emergence of the 2012 edition of the Life Safety Code® as a CMS-sanctioned regulatory standard.

Once you lay your hands on this plucky little document –  the official CMS memorandum – you will see that it appears) to represent a fair degree of flexibility when it comes to, among other things, corridor storage, and the amount of combustible decorations that are allowed. One thing this likely means is that everyone’s going to be inundating NFPA for their own personal copy of the 2012 Life Safety Code® – this is going to become a go-to resource from here on out.

Now, the first thing you will notice is that there’s a lot of mention of nursing homes, and not so much of hospitals, particularly on Page 1. To that end, let me direct you toward the bottom of page 2 of the document (under the section titled “Effective Date”), which specifically indicates that the memorandum and all its components are “in effect for all applicable healthcare facilities such as Hospitals and Nursing Homes.”

The other caveat, at least for the moment, is that it appears that the changes are only “accessible” through the CMS waiver request process, which will, in turn, result in a process in which “each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.” I’m not entirely certain whether this would drive anything more than a review of the waiver request, but I’m not entirely certain how they’d be able to ensure compliance with LSC requirements, etc., without eyeballing a facility. That said, there’s a whole heck of a lot of hospitals that would be pursuing this, so maybe there’s a process in place, maybe based on past TJC/DNV/HFAP and/or CMS survey results.

So, what it looks like we have here is some room for stuff in the corridors, including fixed furniture; and the presence of combustible decorations on “walls, doors and ceilings.”

That’s enough yapping from me for the moment; I encourage you to check out the document and let us know what you think. I think it’s very interesting.

And your bird can sing…

One of the topics that resurfaces every once in a little while concerns those most critical documents– your life safety drawings – and what should be contained therein. If you are still uncertain about what those suckers oughta look like, I would direct your attentions to the February 2012 edition of The Joint Commission’s EC News in the “Asked and Answered” section. The laundry list of items to be included on your life safety drawings is not particularly surprising by those among us who have been advocating for a certain contingent of information. So, if you were going to air out your “dirty” life safety drawings, some items for consideration might include:

  • a legend that clearly identifies fire safety features of your building
  • identification of those areas of the building that are fully sprinkled (if your building it partially sprinkled – no need for such detail if you’re fully sprinkled)
  • the location of all of your hazardous storage areas (if you’re not sure what that entails, check out EP #2 under LS.02.01.30 and/or NFPA 101-2000: 18/;
  • the locations of all your rated barriers (yes, all of them – don’t leave any out)
  • locations of all your smoke barriers
  • the boundaries of any areas that have been designated as suites – and don’t forget to include the square footage of the suites – both sleeping (maximum 5,000 square feet) and non-sleeping (maximum 10,000 square feet)
  • locations of your smoke compartments
  • the locations of any chutes and/or shafts (as opposed to chutes and ladders – that’s kids’ stuff)
  • any approved waivers or equivalencies.

A quick word about waivers and equivalencies: It’s always nice to share those ahead of time with your various “Authorities Having Jurisdiction.” A proactive approach to communications, as with most proactive approaches, will yield much goodwill. This whole thing works best as a collaborative process. No surprise on either side and you’ve got yourself a pretty good survey experience.

Breaker, breaker…

Recently I received a question from a colleague regarding a survey finding an RFI under EC.02.05.01, performance element numero 7, which requires hospitals to map the distribution of its utility systems. The nature of the finding was that there was an electrical panel in which the panel schedule did not accurately reflect the status of the breakers contained therein.

My guess is that there was a breaker labeled as a “spare” that was in the “on” position, which is a pretty common finding if one should choose to look for such a condition. At any rate, the finding went on to outline that staff were unaware of the last time the mapping of the electrical distribution was verified. The question thus became: How often do we need to be verifying panel schedules, since the standard doesn’t specify and there is no supporting FAQ, etc., to provide guidance.

Now, first, I don’t know that this would be the most appropriate place to cite this condition; my preference would be for EP #8, which requires the labeling of utility systems controls to facilitate partial or complete emergency shutdowns, but I digress. Strictly speaking, any time any work is done in an electrical panel, the panel schedule should be verified for accuracy, which means that any breaker that is in the “on” position should be identified as such on the panel schedule. This is not specifically a Joint Commission requirement, but I think that we can agree that the concept, once one settles the matter as a function of logic and appropriate risk management behavior, “lives” in NFPA 70 the National Electrical Code®.

As I noted above, unfortunately, this is a very easy survey finding if the surveyor looks at enough panels; it is virtually impossible to not have at least one breaker in the “on” position that is identified on the panel schedule as a spare or not identified at all. That said, if you get cited for this, you are probably going to have to wrestle with this at some point and your facilities folks are going to have to come up with a process for managing this risk, as it’s really not safe to have inaccurately labeled electrical panels.

As to a desired frequency, without having any sense of how many panels are involved, which would be a key indicator for how often the folks would be able to reasonably assure compliance (a concept not very far away from the building maintenance program [BMP] concept), it’s tough to predict what would be sufficient. That said, the key compliance element remains who has access to the electrical panels. From my experience, the problem with the labeling of the breakers comes about when someone pops a breaker and tries to reset it without reaching out to the facilities folks. Someone just goes flipping things back and forth until the outlet is working again (floor buffing machine operators are frequent offenders in this regard).

From a practical standpoint, I think the thing to do in the immediate (if it’s not already occurred) is to condcut a survey of all the panels to establish a baseline and go from there, paying particular attention to the breakers that are not properly labeled in the initial survey. Those are the breakers I’d try to secure a little better, just to make sure that they are not accessible by folks who shouldn’t be monkeying around with them. Another unfortunate aspect of this problem is that both EP 7 and EP 8 are “A” performance elements, so it’s a one-strike-and-you’re-out scenario. Certainly worth a look-see, perhaps during hazard surveillance rounds.

So many panels, so little time…

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Follow the leader

Another survey condition that has been surfacing of late—which you could say makes it a “sighted citation—” is the bundling of EC-LS-EM findings and generating a further finding under Leadership for not ensuring that the care environment was appropriately managed. Generally, this seems to occur when there are “enough” EC-LS-EM findings to drive a condition-level status as a function of the CMS Conditions of Participation. Unfortunately, at least at the moment, it is not clear how much “enough” is required to drive the finding to this precarious level.

Not having personally participated in the applicable surveys, I can’t tell whether or not there may have been mitigating circumstances that resulted in the survey team feeling that the organization was not appropriately mustering resources to manage risk in the physical environment. That said, I can certainly tell you that one of the things that seems to thread its way through these findings is a gap in correcting deficiencies identified during maintenance and testing, including timely follow-up testing for failed systems, and timely follow-up in general. It is absolutely imperative that we have a process for managing identified deficiencies, including the identification of any interim measures (these ain’t just for life safety folks any longer, boys and girls) that would be implemented to compensate for the deficiencies. It is clear to me that there has been a shift toward the ongoing management of deficiencies through a formal process, at least in terms of survey expectations.

Although it is well understood that healthcare is not swimming in money, our overall charge is to ensure that the care environment is appropriately managed at every moment of every day; people’s lives are potentially at risk here, and we have got to be absolutely certain that we are doing everything in our power to protect them.