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It’s not the heat, it’s the humidity (no, really…)

Good news for those of you who might be struggling a bit with low humidity levels (below 35%) in your surgical procedure areas. CMS issued a categorical waiver based on the recent changes to the FGI Guidelines for the Design and Construction of Health Care Facilities (including the recently updated ASHRAE 170 standard) that allows for relative humidity (RH) values in surgical procedure areas down to a 20% level. Could this be an example of science triumphing over bureaucracy? Only time will tell.

As always, there are some caveats involved: the waiver does not apply if more stringent humidity levels are required under state or local law or regulation or if the reduction of the RH would negatively affect ventilation system performance (which means you need to “know” where you stand relative to state/local requirements as well as the design specifications for your HVAC equipment—and if that sounds like a risk assessment, quack quack!).

Also, the waiver does not specifically establish an upper limit for RH in these areas; it does, however, strongly recommend that an upper level of 60% be maintained based on ASHRAE keeping that upper limit. So I guess those of you in more swampy areas of the world are going to have to keep on keeping on with that. Make sure you’ve got your response to out-of-range values process in good working order.

Administratively, while you will not have to apply in advance for the waiver or wait until you’ve been cited (which is always a fun thing), you must document that you’ve decided to use the waiver. Also, be prepared to notify the survey team assessing Life Safety Code® compliance at the opening conference of the survey that you have decided to use the waiver. Failure to provide documentation of your prior decision to use the waiver could result in a citation.

I guess this is just one more step on the road to the adoption of the most contemporary of codes and regulations. Can you say 2012 edition of NFPA 101? Sure you can! And hopefully, we’ll all be able to say that before too very long…

And where it’s going, no one knows

Continuing on our recap of survey adventures, we finish out the Top 10:
EC.02.06.01 – Establishment and maintenance of a safe, functional environment (#9, with 32% of hospitals having been cited)
A couple of somewhat disparate conditions are coalescing under this particular standard:

  • Safety and suitability of interior spaces – this apparently is where the unsecured compressed gas cylinders are ending up when they are found during survey. Not necessarily the place I would have picked (I’d run with EC.02.01.01 EP #3 – minimization of safety risk in the environment), but I can see where it would fit;
  • Management of ventilation, temperature and humidity in the care environment – this is one that will cause you so much heartache, it’s not funny. Temperature and humidity logs? You better have ‘em (and yes, I know that they are not specifically required in the regulatory verbiage, but that doesn’t mean a (insert descriptor of your choice) thing. Trust me on this, if on nothing else, ever!) Make sure that you have extremely reliable pressure relationships in every spot where you’ve got clean/soiled environments cheek-to-jowl; clean/sterile; sterile/soiled, etc. The air has got to flow from the good to the bad (euphemistically speaking), if it flows from the bad to the good, you are going to get lit up like a Roman candle during survey, likely resulting in a CMS visit to boot – none of us want that, none of us at all.
  • Finally, and I don’t know that this got a whole lot of play in the official version, but there is a universal opportunity relative to cleanliness in the patient environment. There are some that I’ve seen who do a pretty good job, but I also know that I’ve not encountered anything close to perfect. If you have a surveyor with a mind to find dust, etc. somewhere in the patient environment, it will be found and it will be cited. Tell me the EVS folks aren’t shoveling against the tide sometimes…

EC.02.02.01 – Management of Hazardous Materials Risks (#10, with 29% of hospitals having been cited)
Lots of funky conditions can reside here, to name just a couple:

  • Management of eyewash stations – weekly checks, temperature, obstructions, where they are installed, etc.
  • Labeling secondary containers – if the chemical leaves its home vessel and is placed in another vessel, the second vessel (spray bottle, basin, sink) needs to have the hazard identified, unless the second vessel is absolutely attended until it is used/properly disposed – and even then, I’d do the label;
  • Access to the Hot Lab in Nuclear Medicine – you’ve got to have a policy that makes sense about access, particularly for couriers delivering the materials – and remember, they’re already driving around with the stuff – if they want to swipe the stuff, they’ll just keep driving – so keep an eye on your stuff (George Carlin would want you to). That said, you should track down the July 2012 edition of Perspectives – there’s a lovely article on just this subject – can you say risk assessment? Thought so.

OK, we’ll do one more for this week, breaking into the next 10
EC.02.05.01 – Managing risks associated with Utility Systems (#11, with 28% of hospitals having been cited)

For those of you with older buildings and/or older utility system components, this one may keep you up at night. The sort of overarching way this is popping up during surveys (other than temperature, humidity, and ventilation, about which we’ve already spoken and will, no doubt, speak of again) is the inability of the system (whichever system it might happen to be) to achieve required results. Now, the sticking point here relates very much to what constitutes a “required result”. In case you hadn’t noticed, CMS is pretty much calling the shots when it comes to enforcement and, with increasing frequency, the practice of grandfathering older, lesser-performing systems is going by the wayside. If you (or someone you love) has a utility system that is not performing up to modern standards, then you had best get going on a risk assessment and identify mitigation strategies for appropriately managing the risks associated with the current performance level of the systems (and, perhaps, a plan for how you’re going to get to where you need to be).

The other condition that has been popping up is the identification, in writing, of inspection and maintenance activities (and the appropriate intervals) for all operating components of utility systems on the utility management inventory (which is, of course, populated through an arduous risk assessment process). It’s my understanding that continuous monitoring through the good graces of a building automation system is an acceptable means of compliance with this requirement, but if you don’t have a building automation system, you’d best be prepared to produce, in writing, the activities and intervals as noted above (a computerized work order system might work – but it has to be a pretty robust platform).

And so we’ve reached the end of yet another batch of fun facts and figures – next week, we’ll wrap it all up – until next year!

You’ve got a new favorite…

Generally speaking, we in Safety Land don’t get too involved with Centers for Medicare & Medicaid Services (CMS) doings until they show up on our doorstep. But sometimes, the Feds weigh in on matters that can have far-ranging implications for safety operations. I think we need go back no further than the turn of 2010 to 2011, when it looked as if CMS was going to turn the whole world into a healthcare occupancy. Fortunately, through the good graces and advocacy of ASHE, that’s a bullet dodged. Bravo.

At any rate, there is a means of tracking interpretations, utterances, and the like—and it’s web-based (your tax dollars actually at work):

https://www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp

Basically, this site is a repository of all sort of what we might euphemistically characterize as “CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.” (Okay, not my characterization; it’s what CMS calls this stuff.) Certainly not everything found here is germane to safety and the environment, but it is searchable. (I couldn’t offer an opinion yet on how efficient the search capacity might be; to be determined.) The information could be considered a—if not the—final word on what’s happening at the ol’ Centers for Medicare & Medicaid Services. I don’t know that you would need to check it every day (and I can’t quite find a means of signing up for e-mail notifications of new postings), but probably worthy of a drop in from time to time.

NFPA approves new versions of Life Safety Code®, NFPA 99

Boston’s buzzing today as hockey fans celebrate the Bruins winning their first Stanley Cup in 39 years, but that’s not the only action that took place here this week. Earlier in the week, the National Fire Protection Association (NFPA) held its 2011 Conference and Expo in Boston, which was followed by the NFPA Technical Meeting on Tuesday and Wednesday.

Of particular interest to healthcare facilities folks, at the Technical Meeting the association approved new versions of NFPA 101, Life Safety Code® (LSC), and NFPA 99, Standard for Health Care Facilities. The 2012 editions of each standard are expected to be published officially in the next few months.

Once the 2012 editions are published, CMS and The Joint Commission are expected to follow suit and adopt the 2012 editions. Currently, both require hospitals to comply with the 2000 edition of the LSC. The most recent edition of the LSC was published in 2009.

It could take up to 18 months before CMS adopts a newer edition of the LSC. Once that happens, The Joint Commission, Det Norske Veritas, and the Healthcare Facilities Accreditation Program will also adopt it, and then accredited hospitals must comply with the new requirements.

Visit the NFPA’s Conference blog for more information on the votes and see the upcoming issue of Healthcare Life Safety Compliance for details and analysis of these actions and what they’ll mean for your facility.

Dust bunnies find their way into Missouri hospital

Calling all dust busters, feather dusters, and brooms: The University of Missouri Health Care needs you.

After a Centers for Medicare & Medicaid Services (CMS) five-day survey at the Columbia, MO, facility in November, 66 findings of dust were recorded in the 47-page survey report, according to Fierce Healthcare.

The report found dust collecting in a same-day surgery suite, a pre-op room, and on a portable ultrasound machine. In the same-day surgery suite, surveyors found 100 sticky spots on the floor and a dust layer on top of an anesthesia cart and a fluoroscopic camera located above the surgical table. In the pre-op room, sterile gloves and other supplies pulled from a storage bin had pieces of dust sticking to the packaging, reported Fierce Healthcare.

The hospital was visited by eight CMS surveyors after a past employee filed a complaint.

Take a look at the report given by the CMS surveyors.

How does your facility manage dust? Let us know in our comment section.

Alleged fire safety worries, other lapses spell big trouble for a hospital

There was an attention-getting article in this week’s issue of our Hospital Safety Connection e-newsletter about a California hospital that got fined 100 grand by the state for low humidity levels in an OR, which raised concerns that electrosurgical instruments could spark and ignite a fire in the dry air.

I have to admit that in my years of covering life safety, I never [more]

Is there any leeway to not test automatic transfer switches monthly?

I was asked whether there was any flexibility to test transfer switches at intervals less than normally prescribed. For example, might you be able to test low-risk transfer switches, such as those serving the kitchen, less frequently?

Let’s start with Joint Commission environment of care standard EC.02.05.07. EP 6 requires that, “Twelve times a year at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches. The completion date of the test is documented.”

The key word here is “all,” and the key pain in the posterior is that [more]

Look beyond The Joint Commission for rules on who inspects imaging items

The Joint Commission does not specify in the environment of care standards who inspects imaging equipment, but where this all kind of spins out from is in the CMS Conditions of Participation (COPs).

The Joint Commission has been working very diligently– though often, seemingly, at the business end of a sharp stick — to come into closer compliance with the COPs.

The COPs section on nuclear medicine (and yes I recognize that imaging and nuclear medicine are not necessarily synonymous, but sometimes compliance becomes a function of how far you can stretch a concept) requires the following [more]