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Catch a waiver and you’re sitting on top of the world

Lots going on in the regulatory landscape lately—much of it potentially very beneficial to you folks out there in radioland.

On August 30, the folks at CMS issued a whole new set of waivers for consideration including such party-ready favorites as:

  • Medical gas master alarms
  • Openings in exit enclosures
  • Emergency generators and standby power systems
  • Doors (just doors, not The Doors)
  • Suites
  • Extinguishing requirements
  • Clean waste and patient record recycling containers
  • Clarification of the process for adopting the March 9, 2012 waivers

We’ll be discussing some of the ins and outs of the whole waiver scene in coming weeks, but I didn’t want to let too much time go by without letting you folks kick this around. Which reminds me: If anyone has any particular questions on any of the above-noted topics, please feel free to weigh in as we go through them. Not sure that we’ll be doing one per week (maybe two per week—depends on how long-winded I get), but I’d love to include any thoughts or concerns you folks might have.

Finally, if you want to start the required reading in this regard, an excellent starting point would be with the ASHE folks (if you’ve not already tapped into that resource).

Suites for the sweet

Continuing our coverage of George Mills’ address to the ASHE folks last fall, we turn to what was described as an area with a “lot of problems”:  The management of suites.

So, before we get started on this one, I’d like you to make a mental list of all the areas in your organization that have been designated as suites (if you’re not sure what a “suite” is, please e-mail me on the side at the address listed below and I will try to help you to get acquainted with this most useful of life safety concepts). Now that you have that mental list appropriately populated, take out your life safety drawings and check to see how many of those suites are specifically identified (this means the perimeter boundaries of the suite, as well as the square footage of the suite). If you have suites that you have mentally designated, but haven’t gone through the process of having them identified on your life safety drawings, in all likelihood you are looking at RFIs for anything from corridor storage to non-latching corridor doors (suites can have stuff and patient rooms doors that don’t latch – benefit!).

In some ways, this very much comes under the category of things that you have to “know”; it is not nearly enough to “think” that something is compliant. If you expect to successfully navigate the survey process, you have to translate the “think” to the “know.” As a facilities management professional, it is incumbent upon you to have absolute knowledge of where your facility “lies” on the compliance chart. By all means, use your vendors and service folks to gain that knowledge, but be assured of one thing: They won’t be the ones in the “hot seat” come survey time—and you’d better know how to cool off that seat.

It’s up to you to heed the call out

If you’re reading this, then in all likelihood you’re a regular subscriber to this august publication (august in February—what kind of crazy talk is that, but I digress). In which case, I’m sure you read with some interest the article a couple of weeks ago in which one Mr. George Mills (of the Joint Commission Mills) called out facilities professionals for something akin to dereliction of duty (okay, that might be a wee bit hyperbolic, but this topic, and Mr. Mills stance on said topic, are as serious as all get out), based on the continued frequency of findings in the EC/LS part of the survey process.

At any rate, back in October 2012, Mr. Mills addressed a group of facility managers during a webinar sponsored by ASHE. During the webinar, there was much discussion of the persistence of  EC/LS findings during surveys, including attribution of many of those findings to what was characterized as a “lack of management.”  I think we can agree that, as characterizations go, that is a very strongly worded characterization indeed.  So what types of things are resulting in this level of unhappiness in Chicago? Stay tuned and we’ll find out (by the way, be prepared not to be surprised about much, or even any, of the sticking points during surveys. If you’ve been following this space for any period of time, you are already intimately familiar with the foibles and follies of the modern-day survey process.

PFI – Pretty Freaking Important – you’d better believe it!

I’m reasonably certain that we’ve dealt with this before, but there’s been a wee bit of a bump in survey findings relative to the practical assessment of PFI’s as a function of Interim Life Safety Measures.

It’s really quite simple, when you come right down to it. The Joint Commission standards require us to assess for Interim Life Safety Measures, based on the criteria in our policy, any Life Safety Code® (LSC) deficiencies that cannot be immediately corrected (BTW – it’s a good idea to define immediately in your policy – the standard holds no specific definition, so it’s a bit of self-determination – but don’t go crazy trying to define immediately as something much more than the end of the shift/end of the day). Okay, that’s a pretty solid LSC deficiency that we can’t fix right away.

So, the next question in this little chain is this – what is the defining characteristic of a PFI? Why, it’s a Life Safety Code deficiency that is going to take some time to resolve (something very much less than immediately)! So, as a simple quid pro quo arrangement (or equation, if you like), we have:

PFI = ILSM Assessment

Where you have the first, you must also have the second, otherwise you could find yourself staring down the barrel of a Situational Decision and potential Joint Commission re-survey. Is there anyone in the studio and broadcast audience that has any desire to endure that fate?

I didn’t think so – so, make sure you have ILSM assessments for each of your PFI’s and you will avoid this particular world of hurt. You should go check right now…

Ride the lightning…tales from the survey wars!

Just a quick little list of recent survey findings – not necessarily having anything to do with the Top 20 most frequently cited standards. That said, I do think that this provides ample indication that the survey process is intent on identifying any EC/LS/EM deficiency that could be lurking in the furthest (farthest?) regions of your facility. So, how about:

Have you included (those of you who have them) lightning protection systems in your Utility Management inventory – or completed a risk assessment that indicates inclusion in the inventory is not appropriate?

Do you still maintain (at least) one hard copy of your organization’s Material Safety Data Sheets? If not, what’s your backup and how do you know it’s effective?

What about those rooftop exhausts for isolation rooms—have they been labeled? The biohazard symbol on your rooftop exhausts (or any isolation exhausts) makes quite a statement – and never goes out of style.

What about those flexible and rigid endoscopes? Have you included them in your medical equipment inventory or completed a risk assessment that indicates inclusion in the inventory is not appropriate?

How about those electrical receptacles in locations within 6 feet of sinks and other water sources—are they on GFCI protection? Could be the outlet, could be at the panel, but you need to know, ‘cause if you don’t…

Those of you who are performing manual disinfection of patient care devices / instruments, most frequently using an OPA product: Have you evaluated the process as a function of what is actually required by the manufacturer? This is a very complicated process (with lots of steps to go awry) and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…

What about those open floor plan areas (frequently ED’s, ICU’s, PACU’s, OR’s) where staff have all manner of equipment and stuff parked outside the rooms (hopefully not obstructing access to the zone shutoff valves) – have you officially designated those areas as suites, and updated the life safety drawings to reflect that designation? If you haven’t, that’s a survey slam dunk for an RFI – better get on it!

I know we’ve spoken of this in the past (or at least I think we have), you have to pay very close attention to the ins and outs of LS.02.01.30 EP #2, which has to deal with combustible storage areas greater than 50 square feet in area. (Storage room = door that self or auto-closes and latches.) And if there’s a “former” patient room (including procedure rooms in the OR, etc.) that’s been converted to storage (particularly if the conversion occurred after March, 2003), then you are looking at the requirements for “new” healthcare, which means sprinklers, one-hour walls, with a 45 minute fire-rated door. I know folks are trying to minimize corridor clutter, but you get right into a whole ‘nother pickle if you don’t watch for these kinds of transformations.

Anything ring any bells for anyone? Might be worth a little mental checklist to make sure you’ve got these areas covered.

Things that go bump (or don’t) in your egress stairwells

There has been a little increase in findings relative to various items (utility system components, security cameras, evacuation devices) being located in egress stairwells. NFPA 101-2000 Life Safety Code 7.1.3.2.1 (e) gets pretty specific about what you can have in terms of penetrations into and openings through an exit enclosure assembly:

(1) Electrical conduit serving the stairway

(2) Required exit doors

(3) Ductwork and equipment necessary for independent stair pressurization

(4) Water or steam piping necessary for the heating or cooling of the exit enclosure

(5) Sprinkler piping

(6) Standpipes

This means, strictly speaking, that things like security cameras, water lines, phone/radio system repeaters, electrical conduit that does not serve the stairwell, etc. are pretty much off the table, particularly if they have been installed after March, 2003 (the official dividing line between new and existing construction).

There is an exception for existing penetrations as long as they are appropriately protected (firestopping, etc.), but if you’ve got newer than ’03 stuff in your egress stairwells, you may have some work ahead to square things away (I’d start with a conversation with either your state AHJ or maybe the engineers at TJC).

And who do you think gave you permission to do that, mister man?

One of the interesting dynamics that can come into play relative to code compliance is the concept of getting permission for this, that, or the other thing, from our old friend the Authority Having Jurisdiction (AHJ).

For instance, there are probably a number of you who work in facilities of a certain vintage that indicated the installation of “occupant hoses”—you know, those canvas-y things that used to be coiled up in lovely cabinets. And many, if not most, of you who had such hoses were able to get the permission of the local fire folks to remove them. I mean, really—you’re not going to use them, your staff is not going to use them, and the fire department sure isn’t going to use them, so it’s not a difficult thing to imagine. In some instances, you may have to wait until your facility is fully sprinkled, but generally you can get the locals to sign off on it.

Likewise, you may have a fire pump that, for whatever reason, can’t undergo the annual test at a flow of 150% of the rating for the fire pump. Or you may have a medical gas system component that is not quite up to code, but is allowed by the AHJ as long as you agree to correct the condition when you renovate the applicable space. A common condition is the placement of medical gas zone shutoff valves in the same space as the outlets being controlled—no intervening wall to separate the valve from the outlet (I see this a lot in PACU’s of a certain vintage) and the condition poses no significant risk to occupants, etc. These are both examples of conditions that you wouldn’t have to fix as long as you had the permission of the AHJ.

So, you might ask, what’s the point of this? Well, an interesting phenomenon has been popping up periodically this survey year and it revolves around reliance on the permission of the local AHJ to defer correction of certain items like those noted above. And the sticking point is this – if you have not, upon receipt of this “permission” from the AHJ, then submitted that permission to TJC as a request for a traditional equivalency (you can submit the request on-line through the e-SOC portal – I think you’re going to find you’re using this portal more and more frequently in the future).

To be honest, the process of submitting equivalency requests with TJC has long been in the mix, but it appears that it is becoming a focus in survey year 2012. So, if you’ve been given permission from your AHJ for whatever little condition it might be, you better make sure you’ve submitted the equivalency request to TJC. I have no reason to think that these requests wouldn’t be approved, so long as they are reasonable (i.e.,not indicative of a significant risk). After all, I think one of the key elements in the relationships we have with the folks in Chicago is to let them know what’s going on in an open and forthright manner. I suspect it’s what we would all want if the roles were reversed.

And the beat goes on – La de da de de, la de da de da…

Alright – so anybody come up with any bright ideas about the looming presence of the EC/LS standard in the list of most frequently cited standards during Joint Commission surveys? Keep those cards and letters coming and maybe we’ll make some sense of this whole thing.

One good thing I can report (and we’ll cover the numbers more thoroughly when we discuss the individual standards and potential vulnerabilities) is that there was some improvement in the standards cited towards the top of the charts, but there were definitely some rising tides as well. Continuing through the rest of the 20, we have:

–          At #11, with 28% of hospitals having been cited – EC.02.05.01 – Managing risks associated with Utility Systems

–          At #16, with 24% of hospitals having been cited – EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems

–          At #17, with 23% of hospitals having been cited – EC.02.05.07 – Inspection, testing and maintenance of emergency power systems

–          And, at #20, with 19% of hospitals having been cited – EC.02.03.01 – Management of fire risks

So, only 40% representation in the 11-20 group, but for my money, this is getting kind of ridiculous when you think about it.

All in all, I think we (in the aggregate) do a pretty decent job of protecting folks in our organizations from the various and sundry risks that we might encounter.  (I believe to my heart that we haven’t quite hit our stride relative to the management of risks associated with workplace violence, but we’re getting there, but that’s the only area in which I generally see significant improvement opportunities.) We do not generally have people perishing from fires in hospitals, and while we may not get everything right every single time (we demand perfection, but the human element frequently intrudes on that demand), I believe that hospital safety/life safety/facilities professionals perform at a very high rate (keep that thought about rates in your mind’s eye – we’ll come back to rate-based management of survey vulnerabilities as we move through the details of the Top 20).

I guess we avoided having to take it on the chin for a whole bunch of years, and now it’s our turn in the barrel. That said, I’m looking for lots of improvement in the next survey year – and I hope I can help you get there.  So, next week, we’ll cover each in greater detail, maybe talk a little strategy – it’s all good. Until then…

Smoke ‘em if you got ‘em, but be careful where you install them…

Every once in a while, someone will “challenge” me relative to something I “know” is the real deal. Now, just so we’re clear on this, I absolutely encourage the respectful pursuit of knowledge, and it helps keep me on my toes, metaphorically speaking.

The issue in question during this recent survey was regarding the requirements for the placement of smoke detectors vis-à-vis the location. Or, in the vernacular, “Where does it say that it the code?” At this particular facility (as will happen from time to time), I noted that there were several smoke detectors that were located within three feet of air supply/return vents. I fully recognize that moving such devices around can represent a not-insignificant expense, so I was happy to respond to the “nobody’s ever said anything about that before” conversation, but had to admit that I was not certain as to the chapter and verse that governed this particular metric.

So, for the purposes of furthering the knowledge base, I give you NFPA 99 – 1999 edition, which is the edition of record referenced in the 2000 Life Safety Code®:

2-3.5.1*: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

Now you may have noticed that there is no specific distance indicated, just a (not particularly useful) thou shalt not. So, how do we figure out where to go with this? Luckily, the little asterisk, points in a very useful direction. And so, to the Appendix!

A-2-3.5.1: Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Which provides us with a minimum distance of 3 feet (or 36 inches, for those of you inclined to such measures). While there is still a little wiggle room (not necessarily related to the little asterisk) relative to distance from larger and/or high velocity sources (in fact, you could make the interpretive case that supply and/or return sources in hospitals might indeed be larger than those commonly found in residential and small commercial establishments), this gives us the means of drawing a line in the sand beyond which we shouldn’t traverse. As a final thought, for those of you eagerly awaiting the opportunity to embrace the 2012 edition of The Life Safety Code®, the 2010 edition of NFPA 99 provides this little piece of the regulatory pie under 17.7.4.1.

Keep the home (and OR) fires not burning

I was not able to attend the recent NFPA conference in Las Vegas, but I have heard tell that there was some indication that beginning this year (2012) organizations can anticipate some closer attention being paid to all things in the surgical fire realm. I don’t know that this is one that has ever really gone away (fairly surveyor-dependent from my experience), but it appears that this will increase as a topic of survey conversation. (I suspect that the EC-LS survey process is going to continue to focus on the surgical environment-lots and lots of risks to be managed and not necessarily the easiest audience to capture when it comes to safety and related education).

Among the items that will likely surface in conversation:

  • Fire drills and education for surgical staff
  • Fire response procedures
  • Risk assessments to minimize the risks of surgical fires and/or injuries
  • The roles and responsibilities of physicians in the management of the above-noted considerations

As a final thought in this regard, don’t forget that the grand ol’ folks at CMS take this pretty seriously and there have been instances in which an inadequate response from frontline surgical staff (the metaphorical equivalent of the “shrug,” maybe even metaphysical as well, but we’ll leave that for another time) drove an Immediate Jeopardy finding. When it comes to areas of greatest risks for conflagration, the surgical environment is right there at the top of the pyramid. So, we need to make sure that everyone in that environment understands the whole picture: preparedness, mitigation, response. This is way too important to leave to chance, so let’s get to it!