ASHE 7 07 Emerg Mgmt - the Healthcare Facilities
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Transcript ASHE 7 07 Emerg Mgmt - the Healthcare Facilities
2012
THE HEALTHCARE ENVIRONMENT
George Mills, Director
Engineering Department
The Joint Commission
© Copyright, The Joint Commission
UPDATE
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
LS.02.01.20 (56%)
of the means of egress.
EP 13 Corridor Clutter
Also scored
EPs 16 – 22 Suites issues
Equivalize > 5000 sq ft
EP 1 Doors locked in means of
egress
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The hospital maintains the integrity
CORRIDOR STORAGE
“If the corridor looks cluttered…it probably is”
Corridor clutter is not a PFI issue
Carts Allowed:
Carts
Isolation Carts
Chemo Carts
Based on a HITF the following carts are not
allowed:
Linen Hampers
Latex Carts
Anything in the egress corridor more than 30
minutes is storage
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Crash
CORRIDOR STORAGE
storage
Less than or equal to 50sqft space
Surge issue: based on policy patients
may be treated in the egress corridor
during surge conditions
Goal is continuous compliance for
patient safety
NOT
oscillating compliance
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Dead end corridors may be used for
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
LS.02.01.10 (52%)
Building and fire protection features
are designed and maintained to
minimize the effects of fire, smoke,
and heat.
9 Penetrations
EPs 5 – 7 Door issues
EPs 1 & 2 Building Type issues
EP 8 Duct issues
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EP
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
LS.02.01.30 (45%)
The hospital provides and maintains
building features to protect
individuals from the hazards of fire
and smoke.
16 – 23 Smoke Barriers & Doors
EP 2 Hazardous Areas
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EPs
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
EC.02.03.05 (40%)
The hospital maintains fire safety
equipment and fire safety building
features.
of fire protection
NOTE: #1 for Critical Access Hospitals
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Features
LD.04.01.05 EP 4: WHAT TO DO WHEN THE
DOCUMENTATION ISN’T THERE…
as non-compliant
Also score LD.04.01.05 EP 4
If the documentation becomes available later in the survey
to the survey team, the team can:
Consider removing the previous finding if documentation
confirms the activity was completed as per the EP
LD.04.01.05 EP 4 may also be removed during survey
If the survey team would prefer not to evaluate the
documentation the organization can submit clarification
If the organization clarifies after survey:
SIG Engineers will review and evaluate compliance
LD.04.01.05 EP 4 remains
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During survey specific documentation is reviewed
If the documentation is not available write the observation
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 42% EC.02.03.05
LS.02.01.35 EP 6
There are 18” or more of open
NOTE: Perimeter wall and stack
shelving may NFPA 25-1998, 2-2.1.1
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space maintained below the
sprinkler deflector to the top of
storage.
Perimeter
Shelving
18” RULE
Perimeter
Shelving
Ceiling
18”
18”
Wall
OK
Wrong
OK
OK
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Wall
LIFE SAFETY CODE SURVEYOR
LSCS Background
or Environment of Care based
Prefer CHFM certification
All HAP and CAH will be surveyed for a minimum of
2 days by a LSCS
Greater than 1.5 million sq ft will be surveyed
for a third day by the LSCS
An additional day is added for every three
buildings that are classified as healthcare
Example: for a HAP organization with 2 million
square feet of healthcare occupancy and 5
buildings classified as healthcare occupancy:
the number of LSCS days would be 4
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Facilities
LIFE SAFETY CODE SURVEYOR
Interfaces with survey team member(s)
LSCS Survey Focus
Safety Chapter
EC.02.05.03
EC.02.05.07
EC.02.05.09
May conduct the EC Session
May conduct the EM Session
Other “Observations”
May also survey
LD.04.01.05 EP 4 Accountability
LD.04.04.01 EP 2 Hi-Priority
LD.01.03.01 EP 5 Resources
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Life
WHAT TRIGGERS ITL
(IMMEDIATE THREAT TO LIFE)
system
Significantly compromised sprinkler system
Significantly compromised emergency
power supply system
Significantly compromised medical gas
master panel
Significantly compromised exits
Other situations that place patients, staff
or visitors at extreme danger
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Significantly compromised fire alarm
WHAT TRIGGERS ITL
(IMMEDIATE THREAT TO LIFE)
CONT01
The Immediate Treat to Health or
Safety has been successfully abated
and verified through the direct
observation or other determining
method.
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PDA01
An Immediate Threat to Health or
Safety exists for patients or the public
within the hospital.
AFS 10 IS RELATED TO THE
SOC AND PFIS
previously accepted PFIs (LS.01.01.01 EP 2)
Failure to develop ILSM policy and
implement appropriate ILSMs (LS.01.02.01
EP 3)
Failure to manage previously accepted PFIs
affects the Joint Commission
Both organizations are aware of
deficiencies that have been managed
using the PFI process
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Failure to make sufficient progress on
Resolution to a deficiency:
Resolve it immediately
Correct it within 45 days:
Management process that
documents the deficiency and
actions to resolve
ILSM must be considered
Plan For Improvement located in the
Statement of Conditions™
Corrected within 6 months of the
Projected Completion Date
ILSM must be considered
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DEFICIENCY RESOLUTION
45 DAY CORRECTIVE ACTION
Documented
Origination date
Completion date
Kept available for rolling 3 years
Life Safety deficiencies
Must not exceed 45 days
Improvement (PFI)
If originally a work order, close out as complete
and generate the PFI
Must be made available to the Joint Commission
During survey to confirm management of the
deficiency
During CMS/Joint Commission validation process
upon request
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If greater than 45 days create a Plan For
HOW MANY OPEN PFIS
ARE TOO MANY?
organizations to self assess and create a
Plan for Improvement
The self disclosure has never defined how
many is too many
The ILSM process was created to allow both
the organization and The Joint Commission
to be aware of Life Safety Code deficiencies
Failure to make progress on previously
accepted PFIs, including failure to
implement ILSMs results in Conditional
Accreditation
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The PFI process was created to allow
HOW MANY OPEN PFIS
ARE TOO MANY?
Survey Process:
is no limit to the number of PFIs
Evaluate both closed and currently open PFIs
in the View All screen
Spot check during building tour both some
closed and open PFIs to evaluate how well the
organization is managing the PFI process
Evaluate the scope of PFI entries
Are there life safety deficiencies
Are they greater than maintenance items
(i.e. screws missing from a door hinge)
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There
STATEMENT OF CONDITIONS: PFI
PFIs should be related to the LS Chapter
clutter is not a legitimate PFI
PFIs should provide specific information
No blanket statements
“…penetrations on 3rd floor”
Specific references to Life Safety Drawings is
acceptable
32 penetrations as identified on LS
Drawing 3rd Floor, Center Tower dated
3/3/2010
Projected Completion Date is for all listed
items (i.e. “32 penetrations”)
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Corridor
TWO FORMS OF EQUIVALENCIES
Fire Safety Evaluation System (FSES)
process of calculating the features of life
safety and deducting any deficiencies, with the
outcome determining if the building is
equivalized based on the FSES
Traditional Equivalency
A process of field verification identifying
alternative methods of fire safety that off-set
the identified deficiency
Field verification from one of the following:
Registered architect
Fire Protection Engineer
Local AHJ responsible for fire safety
Department of Engineering 2012 - 26
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A
HISTORY AUDIT TRAIL
Engineers when considering extensions or
other activities related to an organization
Prior to surveying, the surveyor must
preview the History Audit Trail to discover
if equivalencies or other actions have
occurred by SIG Engineers
When surveying, brief but accurate
information entered in the File Room is
important
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The History Audit Trail is used by SIG
George Mills, Director
Department of Engineering
The Joint Commission
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2012 LIFE SAFETY CODE
NFPA 101-2012
1. Means of Egress Enhanced
Patient lift & transport equipment may be
stored in the Means of Egress, provided
5ft clear corridor width is maintained
Fire plan addresses management of
storage
Accommodates current “equipment in use”
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NFPA 101-2012
Fixed seating permitted
provided 6ft clear width
< 50sqft with 10’ between
groupings
Groupings must be on same
side of the egress corridor
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2.
4. Cooking Facilities
One cooking area may be open to the egress
corridor per smoke compartment
Any additional cooking areas must be in
protected room similar to hazardous areas
Provisions:
No deep fat fryers
Safety equipment to de-activate fuel supply
Grease baffles installed
No solid fuel (i.e. charcoal)
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NFPA 101-2012 CORRIDOR COOKING
NFPA 101-2012 FIREPLACES
patient sleeping rooms
Section 18/19.5.2(2), (3) and (4)
Allow the installation of direct vent
gas fireplaces
In smoke compartments containing
patient sleeping rooms
Installation of solid fuel burning
fireplaces in areas other than patient
sleeping areas
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5. Fireplaces in smoke compartments with
NFPA 101-2012 DECORATIONS
Allow the use of Furnishings, Mattresses,
and Decorations including Section 18/19.7.5
Allows the installation of combustible
decorations on
Walls
Doors
Ceilings
LSC Section 18/19.7.5.6
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6.
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GENERAL
INTERPRETATIONS
BUILDING MAINTENANCE PROGRAM
(BMP)
All EPs related to the original
ten BMP items are ‘C’ categories
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The BMP is no longer available to offset
findings during survey, but is
considered “best practice”
GENERAL LIFE SAFETY INTERPRETATIONS
placement:
LS.02.01.29 EP 12 and NFPA 101
19.3.2.6 (6) states, The dispensers
shall not be installed over or directly
adjacent to an ignition source.
The Joint Commission published
information in 2006 defining
“adjacent to” as no closer than
6inches, center of the dispenser to
center of the ignition source
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Alcohol Based Hand Rub (ABHR)
NFPA 101, 2012: 18/19.3.2.6. (8) Dispensers
shall not be installed in the following
locations:
Above an ignition source for a horizontal
distance of 1 in (25 mm) to each side of
the ignition source.
To the side of an ignition source within a
1 in. (25 mm) horizontal distance from
the ignition source.
Beneath an ignition source within a 1 in.
(25 mm) vertical distance from the
ignition source.
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GENERAL LIFE SAFETY INTERPRETATIONS
FIRE & SMOKE DAMPER INSPECTIONS
are by random sampling
Confirm ILSM policy is implemented
for any horizontal exits or egress
enclosures that are compromised
by inaccessible dampers
Evaluate adequacy of damper
accessibility plan
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Ensure inaccessible dampers truly
EC.02.06.05 EP 1
recognize the Facilities Guidelines Institute (FGI)
Guidelines for Design & Construction of Health Care
Facilities
ASHRAE 170 has been attached to the Guidelines
Ventilation Table
20 – 60 % RH requirement of relative humidity in
seven affected areas of the Surgical
Environment, and one in Diagnostic & Treatment.
NOTE CMS has not adopted this, but remains
at 35 – 60%RH
The established 60% upper range however
should be maintained for issues such as mold
growth.
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Effective 1/1/2011 the Joint Commission will
RH% TREATMENT AREAS
Class A Operating/Procedure room
Class B and C operating rooms
Operating/surgical cystoscopic rooms
Delivery room (Caesarean)
Treatment rooms
Laser eye room
Diagnostic & Treatment: Gastrointestinal
Endoscopy Procedure Room
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Trauma room (crisis or shock)
CENTRAL STERILE LAYOUT
Physically separated soiled and clean work rooms
Soiled Work Room:
Work surface, sink, washer/sterilizer decontaminators
Soiled room is not to have direct contact with the OR
Clean assembly /work room
Hand washing station
Sufficient workspace and equipment
Self-closing door or pass through is acceptable between
soiled and clean work rooms
Storage
provisions for humidity, temperature, and ventilation
Location of storage may be within the clean assembly/
workroom in a permanently designated space
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.7-5.1.2 - 3.7-5.1.2.3
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ENDOSCOPY PROCESSING ROOM
May be one room, dedicated to endoscopy equipment processing
Sized as per amount of equipment processed
Work flow from soiled to clean
Clean should not be exposed to soiled
• 3ft min clearance clean from soiled at all times
• Droplet contamination is concern
Work surface and sink
Hand washing station
Sufficient workspace, utilities and equipment
Ventilation
Negative air pressure to surrounding areas
Minimum 10 ach (2 fresh, outside); direct exhaust
NO requirements for temperature or humidity
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.9-5.1.1 - 3.9-5.1.1.2
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ENDOSCOPY PROCESSING ROOM
Storage
May be a cabinet in the endoscopy processing room
Cabinet must have doors
Cabinet must be at least 3ft from potential
droplet contamination
• Consider route from processor to the cabinet
• Route should not cross through soiled
processing area
Storage may be in a separate room
Inventory of Scopes
Recommended practice is to include scopes in the
Medical Equipment Inventory
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.9-5.1.1 - 3.9-5.1.1.2
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SCORING
design
Inability of the mechanical system to
achieve required results
EC.02.05.01 EP 4: Lack of written
inspection, testing & maintaining
frequencies
Continuous monitoring by a building
automation system (BAS) is
acceptable
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EC.02.05.01 EP 1: Improper system
SCORING
to provide appropriate pressure relationships,
air-exchange rates and filtration efficiencies
Specific areas lack
negative or positive pressures in
relationship to adjacent areas
• i.e. Endoscopy Processing Room should
be negative to the egress corridor
the correct number of air changes per hour
Improper filtration
• MERV = minimum efficiency reporting
value
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EC.02.05.01 EP 6: Ventilation system is unable
SCORING
evaluate if further investigation needs to occur
To perform the flutter test take a tissue and let it hang
just off the floor near the bottom edge of a door
If the tissue indicates incorrect air flow, stabilize the
area by closing doors and windows, wait a few minutes
and re-screen
If the organization presents a Testing & Balancing
report the following questions should be asked
• when was the balancing done (seasonal issues)
• are any specific requirements (such as keeping a
door closed) needed to achieve satisfactory
results
If non-compliance is determined write a clear and
specific finding
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Tissue test: only to be used as a pre-screening tool to
SCORING
Maintains ventilation, temperature and humidity
levels suitable for care, treatment and services
provided
Ventilation:
• i.e. doors held open by air pressure; odors
Temperature:
• Hot / Cold calls
Humidity
• Primary concern is for areas >60%RH
− Mold growth is possible
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EC.02.06.01 EP 13
SCORING
EC.02.05.05 EP’s 4 & 5
4: Infection Control systems are not
maintained
i.e. an isolation room that should be
negative is positive
EP 5: non-life support utility system
components are not inspected, tested or
maintained
Improper number of air changes results in
offensive odors in geriatric unit
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EP
GENERAL LIFE SAFETY INTERPRETATIONS
labels on the door and jambs
Jambs prior to 1966 may not
have a rating label
Are ILSM in place where noncompliant door assemblies
are found?
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Rated doors must have legible
NON FLAMMABLE MEDICAL GAS
VOLUME & STORAGE: SCORING
Score EC.02.03.01 EP 1 …fire risk
‘E’ cylinders (<300ft³) per smoke compartment
(22,500ft²) may be open to the egress corridor in a rack
or appropriate holders
Between 300 and 3000ft³ must be stored in a room that
is limited construction with doors that can be locked
“In use” verses “in storage”
Properly secured to a gurney is considered “in use”
Properly racked is “in storage”
Empty are NOT considered part of the 12 in storage
Empty and full must be stored (racked) separately
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12
NFPA 99-2005 edition has additional language
regarding O2 storage requirements, specifically:
Storage of nonflammable gases:
9.4.1
> 3000 cubic feet
9.4.2
300 – 3000 cubic feet
9.4.3
0 - 300 cubic feet
Other:
5.1.3.3.2
design and construction
5.1.3.3.3
ventilation of locations for manifolds
5.1.3.3.3.2 ventilation for motor driven equipment
5.1.3.3.3.3 ventilation for outdoors
NOTE: CMS also recognizes 9.4.3 reference
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NON-FLAMMABLE GAS STORAGE:
NFPA 99-2005
NON-FLAMMABLE MEDICAL GAS
UNSAFE CONDITIONS: SCORING
Score EC.02.06.01 …unsafe condition
cylinders
Laying on top a gurney mattress; leaning against the wall
Free standing
Comingling of full and empty cylinders
Transfilling liquid oxygen
Transfer of any gases from one cylinder to another in
patient care areas of health care facilities is prohibited.
Transfilling of liquid oxygen only in an area that is:
• mechanically ventilated
• sprinklered
• ceramic or concrete flooring
• separated with at least 1 hour construction from any
patient care areas
Department of Engineering 2012 - 52
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Unsecured
TANK FARM
maintains critical components of the piped medical gas
systems.
Tank Farm is included in this EP
The bulk storage tank(s) and associated systems are
critical components of the piped medical gas system
Tanks above ground, not on roofs
No electrical service above tanks
10’ Clear from vehicles & sidewalks
50’ from wood frame buildings
• At least 1’-0” from other buildings
• At least 10’ form any opening in wall of adjacent
structures
• Concrete pads at all spill points (3’ min)
Permanent signage:
OXYGEN – NO SMOKING – NO OPEN FLAMES
Access controlled (i.e. locked)
Department of Engineering 2012 - 53
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EC.02.05.09 EP 1 states the hospital tests, inspects and
NFPA 110: EMERGENCY &
STANDBY POWER SYSTEMS
devices that have normal electrical power entering
and leaving the ATS
The power continues on to distribution panels
When a ATS senses a disruption in power it sends a
signal to the alternative power source seeking power
This start circuit initiates the emergency generator
starter
The ATS is also equipped with a test switch to
simulate the power disruption
Recommended practice is to rotate which ATS
initiates the start circuit to the emergency
generator
Department of Engineering 2012 - 54
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Automatic Transfer Switches (ATS) are self-acting
Month, day year and initials of inspector as per NFPA 10-1998
EC.02.03.05 EP 15
4-3.4 Inspection Recordkeeping.
4-3.4.1 Personnel making inspections shall keep records of all
fire extinguishers inspected, including those found to
require corrective action.
4-3.4.2 At least monthly, the date the inspection was
performed and the initials of the person performing the
inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the
fire extinguisher, on an inspection checklist maintained on
file, or in an electronic system (e.g., bar coding) that
provides a permanent record.
DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION
Department of Engineering 2012 - 55
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FIRE EXTINGUISHER: DATING
GENERAL LIFE SAFETY INTERPRETATIONS
Perimeter shelving and sprinkler provision:
Are
perimeter wall shelving that
extends to the ceiling required to be
fastened to the wall?
NO
Shelving is not required for storage
There is no correlation between
• Shelving
• Clearance
• The need to secure any shelving
Department of Engineering 2012 - 56
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Firestop:
Existing application is acceptable when
It was installed in a manner
consistent with original design
specifications
It is in acceptable condition
currently
If the firestop is cracking, etc,
then it is to be removed and
repaired using current
technologies
Department of Engineering 2012 - 57
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GENERAL LIFE SAFETY INTERPRETATIONS
GENERAL LIFE SAFETY INTERPRETATIONS
purposes is NOT an acceptable
firestop in any fire or smoke barrier
This product does have a UL label:
for insulation properties
Easily ignited
Toxic gases may occur when
burned
NOTE: There are several acceptable
fire stop products that expand when
installed
Department of Engineering 2012 - 58
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Expanding foam used for insulation
Electrical
Unlocked distribution panels in patient
care areas
Based on policy
Consider risk assessment
Score EC.02.01.06 EP 1
Open junction boxes
Score at EC.02.03.01 EP 1
• Risk: arcing resulting in fire or loss
of service
Department of Engineering 2012 - 59
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GENERAL LIFE SAFETY INTERPRETATIONS
Staff Safety
EC.02.02.01
EP 3: Precautions & PPE
EP 4: Spill procedures
EPs 5 – 10: minimizes risk
EC.04.01.01
EP 1: Monitoring & Reporting
EPs 2 – 11: Specifics
Manifests: EP 11
DOT training for those signing
Department of Engineering 2012 - 60
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GENERAL LIFE SAFETY INTERPRETATIONS
OUTDOOR SAFETY
EC.02.01.01 EP 5
hospital maintains all grounds and
equipment
Grounds includes
Sidewalks
Parking lots
Park ways
Picnic and patio areas
Play structures
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The
OUTDOOR SAFETY
EC.02.01.01 EP 5
hospital maintains all grounds and
equipment
Equipment includes
Lawn maintenance equipment
Snow removal equipment
Maintenance equipment
Paving
Road repair
Lighting
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The
GENERAL LIFE SAFETY INTERPRETATIONS
A stairwell may be allowed to be
substituted as an “exit access
corridor”
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Suite Exiting
LS.02.01.20 EP 21 (18/19.2.5.1)
Suites have access to an “exit
access corridor”
LS.02.01.20 EP 17(18/19.2.5.3)
Suites must have at least two exits
remote from one another
SURGICAL SITE FIRES
>50 million hospital & ASC surgeries
100 surgery fires per year
20 Serious
1 – 2 deaths
Fire sites:
34% airway
28% head/face
38% other
74% occurred in oxygen enriched
environment
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Estimated
SURGICAL SITE FIRES
Source:
electrosurgical equipment
13% lasers
Recommendations:
Fire drills & Staff Education
Review alarm procedures
Review rescue techniques
Review shut off locations
Joint Commission response:
Life Safety Code Surveyors gown and survey
Department of Engineering 2012 - 65
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68%
CMS CONDITIONS OF PARTICIPATION
42 CFR 482.41
must maintain adequate facilities for its
services
42 CFR 482.41(c)(2)
Facilities, supplies and equipment must be
maintained to ensure an acceptable level of
safety and quality.
The CMS Interpretive Guideline states “the
hospital must monitor, test, calibrate and maintain
equipment periodically in accordance with the
manufacturer’s recommendation and Fed and
State law.”
Department of Engineering 2012 - 66
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Hospital
BACKGROUND
on 42 CFR 482.41(c)(2)
2009 hospital system implemented EQ56
CMS Regional Office stated that any risk or
evidence based program conflicted with 42
CFR 482.41(c)(2)
Other CMS Regional Offices accepted the
Joint Commission processes
The hospital system asked CMS why they
were inconsistent with 42 CFR 482.41(c)(2)
1/2010 CMS instructed Joint Commission to
comply with 42 CFR 482.41(c)(2)
Department of Engineering 2012 - 67
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2007 two hospitals cited by state agents based
CMS RESPONSE
CMS Deputy Director
July 26, 2010
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I am happy to inform you that the
Joint Commission’s approach of
utilizing a preventive maintenance
schedule has been approved.
Thank you for your cooperation
and collaboration.
S&C: 12-07-HOSPITAL PUBLISHED 12/11
Allows non-life support to adjust frequencies
Restricts non-life support from adjusting
FTE & other re-occurring costs ($4 – 10 Billion):
Clinical Equipment: $2 – 5 Billion
Facilities Equipment: $2 – 5 Billion
New capital investment ($2 – 6 Billion):
Clinical Equipment: $1 – 3 Billion
Facilities Equipment: $1 – 3 Billion
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maintenance activities
Restricts life support from frequencies and
maintenance activity adjustments
Restricts equipment maintenance methods
Estimated financial impact to comply:
4/9/2012 DISCUSSION WITH CMS
Ad Hoc team began to meet every Monday to
create united response to CMS
Provided council and resources
Joint Commission leadership is supportive of
discussing the issues with CMS
Joint Commission met with CMS to discuss the
S&C: 12-07 April 9, 2012
Restriction related to test equipment lifted
Saving estimated as $2 – 6 Billion to healthcare
Collaborative discussion with the conclusion
research would be of benefit
Research should be specific to reliability of
the Joint Commission process in EC.02.04.01
Department of Engineering 2012 - 70
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Research Issues:
How many organizations use the Joint
Commission process?
What guidance is used to modify
frequency and maintenance activities?
Have there been any adverse outcomes
based on solely on this process
If so, what?
Self diagnostic equipment:
How many devices with this feature?
Department of Engineering 2012 - 71
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DISCUSSION, CONTINUED
ACTION ITEMS
AAMI & ASHE hosted Survey Monkeys
webinars to review Joint Commission
standards and make the field aware of the
importance of the survey
AAMI had 526 sites
ASHE had 216 sites
JCR had 794 sites
Survey responses:
AAMI had 1526
ASHE had 790
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5/18 AAMI, ASHE & JCR hosted free
QUESTION 1
Range
Percentages
Responses
<100
27.1
221
100 – 200
15.7
123
201 – 350
23.5
183
351 – 500
12.8
100
>500
20.9
162
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How many acute care beds is your
organization licensed or authorized for?
QUESTION 2
Range
Percentages
Responses
<500
20.1
158
500 – 1,000
19.1
150
1,000 – 2,500
22.8
180
2,500 – 5,000
17.4
135
>5,000
20.6
162
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How many pieces of equipment are in
your inventory?
QUESTION 3
Percentages
Responses
Yes
90.9
714
No
9.1
70
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Do you use the Joint Commission
process identified in EC.02.05.01
EPs 2 – 4 (i.e. have an inventory
based on risk and other criteria)?
QUESTION 4
Percentage
Responses
Yes
92.7
728
No
7.3
57
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Do you use the Joint Commission
process identified in EC.02.05.01 EP 3
to establish maintenance activities (i.e.
preventive maintenance procedure)?
QUESTION 5
Percentage
Responses
Yes
90.9
711
No
9.1
71
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Do you use the Joint Commission
process identified in EC.02.05.01 EP 4
to establish maintenance frequencies?
QUESTION 6
Percentage
Responses
Yes
1.0
8
No
99.0
782
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Have you had any adverse outcomes
(i.e. patient injuries or deaths)
because you have modified the PM
procedures or frequencies from the
manufacturer’s recommendations,
using the Joint Commission process
identified in EC.02.05.01 EPs 2 – 4?
None of the 12 that answered YES to
question 6 had an adverse event
4 are not accredited by the Joint
Commission
3 had comments that did not pertain to
the topic
4 were pro-Joint Commission process
comments
1 reported a bed brake failed to engage
and a patient fell when leaning on the
bed
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COMMENTS TO QUESTION 6
NEXT STEPS
continued to actively help navigate
this process
AAMI, ASHE and Joint Commission
will be meeting with CMS to review
the research results
Goal is to resolve the conflict with
sound evidence provided by the
research
Department of Engineering 2012 - 80
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The Ad Hoc committee has
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QUESTIONS?
DEPARTMENT OF ENGINEERING
630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Director
Michael Chisholm, CPE, CHFM
Engineer
John Maurer, CHFM, CHSP
Engineer
Bruce Boggan, MBA, CHFM
Engineer
Department of Engineering 2012 - 82
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Anne Guglielmo, CFPS, LEED, A.P., CHSP
Engineer
THE JOINT COMMISSION DISCLAIMER
These slides are current as of 6/21/2012. The Joint
Commission reserves the right to change the content of
the information, as appropriate.
These slides are only meant to be cue points, which
These slides are copyrighted and may not be further
used, shared or distributed without permission of the
original presenter or The Joint Commission.
Department of Engineering 2012 - 83
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were expounded upon verbally by the original presenter
and are not meant to be comprehensive statements of
standards interpretation or represent all the content of
the presentation. Thus, care should be exercised in
interpreting Joint Commission requirements based
solely on the content of these slides.
EYE WASH STATION
FEDERAL REQUIREMENTS: OSHA
recommendation to
reduce the risk of injury from contact with caustic and
corrosive materials in areas such as
Power Plant
Lab
Placed so that the eyewash is within 10 seconds or 55
feet from where the corrosive chemicals is used
Weekly flush until clear is required
Annual inspection to ensure the system is fully functional
Mixing valve recommended to achieve tepid
Risk assess potential exposure to determine if cold
water only would be acceptable
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Score Eye Wash issues at EC.02.02.01 EP 5
Risk assess location / application based on OSHA
Medical services and first aid 1910.151(c)
The eyes or body of any person may be exposed to injurious
corrosive materials, suitable facilities for quick drenching
or flushing of the eyes and body shall be provided within
the work area for immediate emergency use.
Formaldehyde 1910.1048(i)(3)
If there is any possibility that an employee's eyes may be
splashed with solutions containing 0.1 percent or greater
formaldehyde, the employer shall provide acceptable
eyewash facilities within the immediate work area for
emergency use.
Battery charging and changing 1917.157(i)
Facilities for flushing the eyes, body and work area with
water shall be provided wherever electrolyte is handled,
except that this requirement does not apply when
employees are only checking battery electrolyte levels or
adding water.
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EYE WASH STATION:
RECOMMENDED LOCATIONS (I.E. OSHA)
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