Transcript TJC Survey Prep Guide

Prepared for HFMADV
By Dennis Rudloff and Dan Campbell
TJC Prep Guide
Preparation Outline
 Current SOC and status of Previously Accepted RFI’s,
any equivalencies or extensions granted.
 Survey team arrives after 7:30AM biographies are on
internet; this starts your facilities team into action by
calling a code “J” to scour the building within one and
a half to two hours.
 The surveyor can opt to do the building tour or the
document review first. Doing the document review
has its advantages.
LSCS surveyor will focus on:
 EC.02.03.03
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Fire Drills
EC.02.03.05
Features of Fire Protection
EC.02.05.07
Emergency Power Systems
EC.02.05.09
Medical gas Systems
Hazard Vulnerability Analysis (HVA)
Emergency Operations Plan
LSCS surveyor will focus on:
 And may also survey
 LD.04.01.05
EP-4 Accountability (Leaders at the
program, service, site, or department level create a culture
that enables the hospital to fulfill its mission and meet its
goals. They support staff and instill in them a sense of
ownership of their work processes. Leaders may delegate
work to qualified staff, but the leaders are responsible for the
care, treatment, and services provided in their areas.)
 LD.04.04.01
EP-2 Hi-Priority (Leaders give priority to
high-volume, high-risk, or problem-prone processes for
performance improvement activities.)
 LD.01.03.01
EP-5 Resources (The governing body
provides for the resources needed to maintain safe, quality
care, treatment, and services)
Scoring
 All findings of less than full compliance are cited as
RFI, RFI resolution is through Evidence of Standards
Compliance (ESC).
 Score based on the number of times an EP is not met,
i.e.: sample size is at least 10 items surveyed.
Score of 2 is for 0-1 instance of non-compliance
 Score of 1 is for 2 instances of non-compliance
 Score of 0 is for 3 or more instances of noncompliance
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Criticality
 Immediate threat to life (samples on next slide): Preliminary
Denial of Accreditation (PDA) until resolved. PDA can
only be issued by TJC President. Follow-up survey
required.
 Situational Decision Rules: Contingent Accreditation
and PDA
 Direct Impact Requirements must be resolved within a
short time (45Days)
 Indirect Impact Requirements must be resolved within
60 days, these generally do not impact the
accreditation decision.
Immediate threat to life Triggers (ITL)
 When these items are significantly compromised:
 Fire Alarm
 Sprinkler Alarm
 Emergency Power Supply System
 Medical Gas Master Panel
 Compromised Exits
 Other situations that place patients, staff, or visitors at
extreme danger.
 Note:
 Any ITL will automatically trigger an RFI at LD.01.03.01 EP-2.
(The governing body’s ultimate responsibility for safety and
quality derives from its legal responsibility and operational
authority for hospital performance. In this context, the
governing body provides for internal structures and
resources, including staff, that support safety and quality.)
NEW – Time Frequencies Defined:
 Daily, weekly, monthly are considered calendar references.
 Quarterly, is once every three months ± 10 days.
 Semi-Annual, is 6months from the last scheduled event month ±
20 days.
 Annual, is 12months from the last scheduled event month ± 30
days
 3 Years, is 36 months from the last scheduled event month ± 45
days.
 Note: Time frames do not apply to required frequencies such as
emergency generator testing (see EC.02.05.07 EP-4 and EP-8).
 Frequencies required by code may not be modified.
Issues with EC.02.03.05
 Each device tested is required to be in an inventory.
 Lack of an inventory results in a finding at that EP
 Documentation for a specific EP is not available at
time of the survey will result in a finding for that EP.
 If a finding is clarified after the survey TJC will
review and evaluate for compliance.
 But the finding for LD.04.01.05 EP-4 (Staff is held
Accountable) will remain
EP.02.03.05 EP-25 Requires the
following summary information
 Name of the Activity
 Date of the Activity
 Required Frequency of the Activity
 Name, contact information, including affiliation, of
person who performed the activity
 NFPA standard(s) referenced for the activity
 Results of the activity
Interim Life Safety Measures (ILSM)
 Standard LS.01.02.01
 ILSM’s are required for EP-1 (notify local fir dept., fire watch and document it)
and EP-2 (post signage to ID exits) regardless of the ILSM policy.
 EP-3 must clearly define in writing the ILSM policy
including; (No policy Conditional RFI)
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When to implement
What to do to protect patients and other occupants
Both construction related and non-compliance with the
LSC
 EP-4 to 14 aligns with the policy and implementation
strategies.
Life Safety Assessment - SOC
 Current Statement of Conditions
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Basic Building Information
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Plan for improvement
 Ladder and flashlights
 Accurate Life safety Drawings with information that
shall include. Life Safety Legend that clearly identifies
features of LS. (next slide)
Life Safety Assessment – SOC
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page 2
Identify:
Areas that are sprinklered
Hazardous storage areas
All Rated barriers
All Smoke barriers
Suite boundaries include size, if sleeping (5,000 sq.ft.)
or non-sleeping (max 10,000 sq.ft.)
 Locations of smoke compartments
 Locations of chutes and shafts
 Any approved equivalencies or waivers
Management Plans
 Facilities managers are usually responsible for at least three
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possibly more management plans.
All plans should be consistent with the organizations
Mission, Values, and Philosophy statements. One way to
do this is have them approved annually by the Safety
Committee.
Your plan will be assessed base3d on its written program if
it exceeds the minimum interpretation of the Elements of
Performance.
Your Policies and Procedures are the guidance that defines
the programs responses.
Your documentation will ensure the activities being carried
out have been pre-planned.
Equipment Survey Process
( 1 of 2 )
 Documentation is completed for both Life Support
and Non-Life Support devices on the inventory. You
must have an inventory with time frames of PM work.
 Inventory must be accurate:
 All Life Support equipment must be on the inventory
 PM frequencies must be clearly defined in writing.
Equipment Survey Process
(cont’d)
 Surveyor will confirm the work is done as per schedule
activities
 Ensure appropriate work is scheduled based on
maintenance strategies.
 Evaluate equipment failure and scheduled action. Do
not forget to include ILSM consideration for
equipment failures.
 Report equipment failures and all follow-up actions to
the EOC committee.
CMS LSC Waiver Summaries
CMS LSC Waiver Conditions
 CMS is granting LSC waivers due to unusual
hardships and no alternatives that provide an equal
level of protection.
 Applications for the waiver is not required.
 Waivers elected for use must be documented and
meet all conditions of the waiver.
 Notify the any LSC survey team and present the
information at the entrance conference of waivers
elected. Otherwise your waivers will be accepted.
 LSC survey team will review information and confirm
you are meeting the circumstances of the waiver.
CMS LSC Waiver Summary ( 1 of 7 )
 Medical gas master alarms:
 Allows substitution of a centralized computer system
for one Category 1 medical gas master alarm.
 Code Requirement
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NFPA 99-2012, 5.1.9.4 and compliance with all other
applicable NFPA 99-1999 medical gas master alarm provisions
 Facilities Must
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Demonstrate that it complies with all other applicable NFPA
99-1999 medical gas master alarm provisions, as well as with
section 5.1.9.4 of NFPA 99-2012
CMS LSC Waiver Summary ( 2 of 7 )
 Openings in Exit Enclosures
 Permits existing openings in exit enclosures to
mechanical equipment spaces if they are protected by firerated door assemblies.
 Code Reference
 NFPA 101-2012, 7.1.3.2.1(9)(c) and all other applicable NFPA
101-2000 exit provisions
 Mechanical Equipment Space Must
 Be in a building protected with an approved supervised
automatic sprinkler systems.
 Be used only for non-fuel-fired mechanical equipment.
 Contain NO storage of combustible materials and,
 Be protected by a fire rated door
CMS LSC Waiver Summary ( 3 of 7 )
 Emergency generators and standby power systems
 Reduces the annual diesel-powered generator
exercising requirement from two (2) continuous hours
to one and a half hours.
 Code Reference
 NFPA 110-2010, 8.4.2.3 and all other applicable NFPA
110-1999 operational inspection and testing provisions.
 The annual load test is only required when the
monthly diesel generator test does not comply with
minimum loading requirements to avoid wet stacking.
CMS LSC Waiver Summary ( 4 of 7 )
 Door locking arrangements
 Allows door locking arrangements in areas where
there are clinical needs, security risks or specialized
protective measures required for safety.
 Code Reference
 NFPA 101-2012, 18/19.2.2.2.2 through 18/19.2.2.2.6 as well
as all other applicable NFPA 101-2000 door provisions.
 Facilities staff must make adequate provisions in the
rapid removal of occupants by means such as remote
control locks or keys carried by the staff at all times.
CMS LSC Waiver Summary ( 4 of 7 part two )
 Multiple delayed egress locks
 Allows more than one delayed-egress lock in the
egress path where the clinical needs require
specialized security measures or when a patient
requires specialized protective measures for safety.
 Code Reference
 NFPA 101-2012, 18/19.2.2.2.4 and compliance with all
other applicable NFPA 101-2000 door provisions.
 Facilities Must also use compensating safety measures
specified in those sections that facilitate rapid removal
of occupants.
CMS LSC Waiver Summary ( 5 of 7 )
 Suites
 Accommodates the use of suites by allowing: (1) one of the required
means of egress from sleeping and non-sleeping suites to be through
another suite, provided adequate separation exists between suites; (2)
one of the two required exit access doors from sleeping and nonsleeping suites to be into an exit stair, exit passageway, or exit door to
the exterior; and (3) an increase in sleeping room suite size up to 10,000
sq. ft.
 Code Reference
 NFPA 101-2012, 18/19.2.5.7 and compliance with all other applicable
NFPA 101-2000 suite provisions
 Facility must meet the corridor wall and door requirements for the
outer boundary (perimeter) of the suite and meet the requirements for
the smoke zone.
 One or more egress routes may be required, depending on the size of
the suite. *
CMS LSC Waiver Summary ( 6 of 7 )
 Extinguishing requirements
 Allows for the reduction in the testing frequencies for
sprinkler system vane-type and pressure switch type
water-flow alarm devices to semiannual, and electric
motor-driven pump assemblies to monthly.
 Code Reference
 NFPA 25-2011, 5.3 and 8.3 and all other applicable NFPA
25-1998 (as referenced in section 9.7.5 of the NFPA 1012000)
 Facility must meet the code references stated.
CMS LSC Waiver Summary ( 7of 7 )
 Clean waste and patient record recycling containers.
 Allows the increase in size of containers used solely
for recycling clean waste or for patient records
awaiting destruction outside of a hazardous storage
area to be a maximum of 96 gallons.
 Code Reference
 NFPA 101-2012, 18/19.7.5.7.2
 Facility must document that the container has passed
an FM fire test.
Miscellaneous
 Facilities that do not meet all the requirements of the
waiver will be cited.
 Where do these waivers leave the 2012 LSC?
 ASHE believes the agency still wants to adopt the 2012
edition, but because the lengthy adoption process is
contingent on other priorities, CMS wanted to give
hospitals some relief from burdensome requirements in
the meantime.
 I personally am skeptical!
Questions ?????