Transcript Categorical CMS Waivers”

“Categorical CMS Waivers”
• Who is in charge?
“Centers for Medicare & Medicaid Services” - AKA: CMS
• Who is the babysitter?
“The Joint Commission” - AKA: TJC (formerly JCAHO)
Use their own standards based on CMS regulations
“Det Norske Veritas” - AKA: DNV
Use the ISO:9001 quality principles
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Is anyone else in charge, or just CMS?
At Kaweah Delta, we must meet the regulations of: CMS, TJC,
CDPH, State of CA Fire Marshal (via OSHPD), local authority
having jurisdiction (in Visalia, this is the Fire Marshal), OSHA, etc.
• Whose rules do we have to follow?
Whoever is most strict
Health Care Hierarchy
Health Care “Bibles”
BUREAUCRACY
It’s never okay to break the rules,
except sometimes.
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Relative humidity in anesthetizing locations
Medical gas master alarms
Openings in exit enclosures
Emergency generators and standby power systems
Door locking arrangements
Multiple delayed egress locks
Suites
Extinguishing requirements
Clean waste and patient record recycling containers
Items in the corridor
Kitchens open to the corridor
Gas fireplaces in common areas
Installation of combustible decorations
Bending the Rules –
Categorical Waivers
NFPA 99, 1999 edition: § 5-4.1.1
• Why is it important?
• Current requirement is ≥ 35% relative humidity
• Waiver decreases to ≥ 20% relative humidity
• What do we do?
• Monitor relative humidity levels in anesthetizing locations, take
action when needed to ensure that levels remain at or above 20%.
• Document, Document, Document.
• UPDATE: S&C: 15-27-Hospital, CAH & ASC
• Issued by CMS February 20, 2015
Relative Humidity in
Anesthetizing Locations
NFPA 110, 1999 edition: § 6-4.2.2
• Why is it important?
• Shorter run times on the annual generator load bank tests equate
a lower cost for testing, reduction in the use of diesel and reduced
negative environmental impacts.
• What do we do?
• Ensure that you are in compliance with ALL other applicable NFPA
110, 1999, operational inspection and testing provisions and
§8.4.2.3 of NFPA 110, 2010.
• Document, Document, Document
Emergency Generators and
Standby Power Systems
NFPA 101, 2000 edition: § 18/19.2.2.2.2 – 18/19.2.2.2.6
• Why is it important?
• Previously, we were not allowed to have doors that remained
locked in the event of a fire alarm or power outage (if on magnet
locks).
• In units where the clinical needs of the patient (i.e. psychiatric,
Alzheimer, dementia, neonatal, pediatric) require specialized
security measures for their safety, door locking arrangements are
permitted.
• What do we do?
• Ensure that you are in compliance with ALL other applicable NFPA
101, 2000 door provisions, as well as §18/19.2.2.2.2 –
18/19.2.2.2.6 of NFPA 101, 2012.
• Document, Document, Document
Door Locking Arrangements
NFPA 101, 2000 edition: § 18/19.2.5
• Why is it important?
• Prior to the waiver, every habitable room was required to have an
exit access door leading directly to an exit access corridor.
• Only allowed exit through another suite under certain
circumstances.
• Limits the size of sleeping room suites to 5,000 sq. ft.
• One of the two required exits can be: exit stair, exit passageway, or
exit door to the exterior.
• Can now exit through another suite.
• Allows suite size up to 10,000 sq. ft.
• What do we do?
• Meet with your local AHJ to ensure that they approve of the
changes.
• Document, Document, Document
Suites
NFPA 101, 2000 edition: § 18/19.7.5.5
• Why is it important?
• Increases the can size of clean waste (bottles, cans, paper) from
32 gallons to 96 gallons.
• Reduce the number of receptacles, which creates more room in
the corridor.
• What do we do?
• Must be compliant with NFPA 101, 2012 §18/19.7.5.7.2
• e.g. 96 gallon containers shall be labeled and listed as meeting
the requirements of FM approval standard 6921, Containers for
Combustible Waste.
• Document, Document, Document
Clean Waste and Patient
Record Recycling Containers
NFPA 101, 2000 (Several Sections)
• Why is it important?
• 2000 edition of the Life Safety Code mandates 8 feet of unobstructed
with in Hospital corridors.
• With today’s technological advancements and the inception of
Electronic Medical Records, we have more equipment that is used in
the course of patient care.
• The 2012 code will allow previously restricted items to be in the
corridor.
• CANNOT USE CORRIDOR FOR STORAGE
• What do we do?
• Ensure that you are in compliance with ALL other applicable NFPA
101, 2012 §18/19.2.3 standards are met. This includes compliance
with §7.3.
• Meet with your local AHJ to ensure that they approve of the changes.
• Document, Document, Document
Items in the Corridor
NFPA 101, 2000 edition: § 18/19.7.5.4
• Why is it important?
• Previous code had severe restrictions on furnishings, mattresses
and decorations.
• “Combustible decorations shall be prohibited in any health care
occupancy unless they are flame-retardant.”
• Waiver permits following NFPA 101, 2012.
• What do we do?
• Meet with your local AHJ to ensure that they approve of the
changes.
• Document, Document, Document
• http://osfm.fire.ca.gov/licensinglistings/pdf/flameretardant/chemical/Ch
emicalList.pdf
Installation of
Combustible Decorations
1. Gather and prepare documentation along with a
Categorical Waiver Declaration.
2. Document your decision to use a categorical
waiver(s). Most commonly done during an
Environment of Care meeting.
3. Prepare a binder or file of Categorical Waivers with
back up documentation and a summary to have at
the ready.
4. Notify surveyors (CMS, TJC, DNV, CDPH) at the
beginning of the survey that they have chosen to
declare a categorical waiver. THIS IS CRITICAL.
How to bend the rules
“An administrative assistant called in a work request
stating that her desk lamp did not work. When the
technician responded to the request he discovered
that:
A.
B.
C.
the desk lamp was not plugged in.
there was no bulb in the lamp.
the admin had brought the lamp from
her home.”
“Tenant: When the fire alarm goes off, please send a
quick email to let everyone know if it is a false alarm
or if they should actually start evacuating.”
“Tenant Request: “Can the speed bumps be shaved
down? They are too high. I have to go too slow to go
over them.””
“This occurred last week on the first day of the year to
exceed 80 degrees. The occupants of one office
complained they were too hot. I addressed it myself due
to the political expediency of the issue. Upon arriving,
the occupants expressed their dissatisfaction of our
department and how we can’t get anything right.
The space has two windows. In one of them is mounted
a window A/C. It was set for 60 degrees, and was
working beautifully. The other window was wide open. I
informed them that the unit can’t cool the entire
outdoors. I then noticed that one of the occupants had a
small portable heater on under the desk. I asked why it
was running, and she complained that her feet were
cold.”
“I was on call one night when at 3 a.m. my pager goes off.
I call in to the hospital and was connected with a nurse who
had worked (there) for 30 years.
She says, “I have a patient in room 21 and the
lights don’t work.” I crawl out of bed, get dressed, and
drive the eight miles. I go to the room and turn on the light
switch, and all the lights go on.
Puzzled, I step in the hallway and asked her what
was I missing. She said, “I didn’t try the switch. I just
thought that as it was dark in there that the lights must be
burnt out.”
I didn’t say any bad words until I was in my car on
the way back home.”
“We once received an emergency work order (highest
priority) to turn around the toilet paper roll because it
was installed backwards. Our response was, “Toilet
paper roll direction is a matter of personal preference
and may depend on multiple critical life safety issues
such as whether or not you have a kitten on the
loose.””
Thank you