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Compliance in Operation

Compliance in Operation. Charles Workman, CHFM, CHSP, CHEP Director, Regulatory Programs Hospital Corporation of America. Introduction. Expected Outcomes from this presentation: The attendees should be able to understand these processes at the conclusion of the presentation.

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Compliance in Operation

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  1. Compliance in Operation Charles Workman, CHFM, CHSP, CHEP Director, Regulatory Programs Hospital Corporation of America

  2. Introduction • Expected Outcomes from this presentation: • The attendees should be able to understand these processes at the conclusion of the presentation. • Activities that have combined maintenance requirements and compliance activities. • Techniques and resources to align vendors with compliance activities. • Methods to validate compliance on a continual basis. • Please ask questions at any time during the presentation, or • Save them for the end of the session.

  3. CMS Memo 12-21: Intent and Content Content: Intent: to allow the 2012 NFPA 101, 18/19.2.3.4 to be adopted as long as the criteria is met. • Smoke compartments are required to be fully sprinkled and automatic fire alarm system installed. • Projections into the corridor shall be permitted for wheeled equipment: • 6 feet corridors must maintain 60 inches clearance • 8 feet corridors must maintain 6 feet clearance • Fire plan addresses the relocation of the wheeled equipment • Limitations of the equipment: In use, Emergency equipment, Lift and Transport • Fixed equipment is allowed in the 8 foot corridors

  4. To Implement or Not? The decision must be made with the clinical staff and engineering so everyone understands the implications. • Advantages • Disadvantages • Items will collect in the corridors! • Obstructions to Fire Protection features and medical gas shut off valves must be prevented. • Free parking for wheeled equipment. • When implemented, NFPA 101, 7.1.10.1 will not apply, even though it is still in the 2012 edition of the code.

  5. CMS Memo 13-58 Implementation • Medical Gas Master Alarms – Allows a Computer System to substitute for one of the Category 1 alarm panels. • Openings in Exit Enclosures – Mechanical room doors into stairwells. • EPSS Testing – Reduces the 2-hour to 1.5 hours. • Existing = 25% (30 Mins), 50% (30 Mins), 75% (1 hour). New = 50% (30 Mins), 75% (1 hour). • Doors – From single delayed door in an egress to multiple • Suites – Sleeping to 10,000 square feet • Extinguishing Systems • Electric Fire Pump to Monthly (Churn Test) • Waterflows to Semi-Annually • Clean Waste and Patient Record Containers – Capacity to 96 gallons from 32 gallons • Adoption of CMS Memo 12-21

  6. Suite Adoption Issues – Dead End Corridors Existing Building – no limitations on distance Suite “A” Dead End Corridor Suite “B” Utilizing 2000 LSC for 5000 SF suites If Utilizing CMS Memo 13-58, distance must meet new occupancy requirements

  7. Specifics of the Corridor • Fixed furniture: • Must be secured to the floor. • Must be located on one side of the corridor. • Space must be located to allow direct supervision from the nurse station. • Area cannot exceed 50 square feet. • This places the area under criteria for a Hazardous Area. (18/19.3.2.1) • CMS Memo

  8. Process for Implementation • Key Actions If adopted, the language must be included under the “Additional Comments” section of the Basic Building Information (BBI) in the electronic Statement of Conditions (e-SOC). • Mark the clearance in the corridor. • Place colored tape on the ceiling tile framing to mark the threshold. • Develop fire plans for the individual clinical areas. • Assignment of person/s to remove equipment in the event of an emergency should be general and not specific. For example: • CNA’s on 3 South will move wheeled items to Nurse station. • Charge nurse will assign staff to remove equipment and place in vacant patient room. • Submit in the minutes of the EOC/Safety Committee the adoption of the Memo.

  9. Fire Plan Example • Fire Plan must include: • Exit access, • Area to move wheeled equipment, • Areas of refuge (if meets the criteria of 7.2.12), • Access to a public way, • Elevator with firefighter service, • Two-way communication system, and • Must be protected by a 1-hour separation

  10. Fire Alarm Devices and Components • EC.02.03.05 • Includes EPs: • 1: Supervisory signals • 3: Duct detectors • 4: Audio/visual devices • 5: Off-site notification • 13: Kitchen systems • 14: CO2 systems • Testing and inspection requirements are detailed in NFPA 72, Chapter 7. (These include inspection and testing frequencies and procedures.) • EP 25 was directly translated from NFPA 72, specifically: • An inventory must be complete and accurate for all devices. (NFPA 72: permanent records, 7-5.2.2 (7) – “Designation of the detector(s) tested, for example, Tests performed in accordance with Section_____________.”) • The example provided in NFPA 72, Figure 7-5.2.2 will not be sufficient to satisfy an inventory. Other components are covered in Fire Suppression Systems

  11. Fire Alarm and Devices • Functionality The testing of the devices must correspond to the output of the fire alarm system. • It must be recorded that activation devices set off a sequence in the fire alarm system. • Supervisory signals must be tested to show a “global” activation of the system. (Requires action by occupants.) • The following table from NFPA 72 shows how initiating devices correspond to the fire alarm system and activate the notification devices.

  12. Fire Suppression Inspections • Inspection of Devices The components of the fire suppression system are required to be inspected as to their condition. • Sprinklers are required to be inspected from floor level annually. (2-2.1.1*) • Sprinklers with corrosion, foreign materials, paint, physical damage, or having the incorrect orientation must be replaced. • Gauges in wet pipe systems are required to be inspected monthly. (2-2.4.1*) • Gauges must be in good condition. • Normal water supply pressure must be maintained. • Gauges must be inspected Monthly and replaced or tested every 5 years. (2-2.4 and 2-3.2*) • Gauges testing outside 3 percent of the full scale must be recalibrated or replaced.

  13. Fire Suppression Inspections (continued) • Inspection of Devices • Hydraulic nameplate must be inspected quarterly. (2-2.7*) • Must be legible and securely attached to the sprinkler riser. • Sprinkler spares shall be inspected for quantity. (2-4.1.5) For protected facilities, required quantities are: • (a) With less than 300 sprinklers — no fewer than 6 sprinklers • (b) With 300 to 1000 sprinklers — no fewer than 12 sprinklers • (c) With more than 1000 sprinklers — no fewer than 24 sprinklers • A special sprinkler wrench for installing and removing sprinklers is required. (2-4.1.6*) • One sprinkler wrench for each type of sprinkler installed.

  14. General Recommendations for Improvement • EC.02.03.05 The vendor must follow EP25 and the language from NFPA 72 (1999 edition): • Test methods must be identified (Table 7-2.2) • Visible frequencies must be identified (Table 7-3.1) • Testing Frequencies must be identified (Table 7-3.2 and CMS memo 13-58) • EP25 is TJC trying to convey the language from NFPA 72, 7-5.2 • 15 items must be reviewed and documented (see NFPA 72 which states “designation of detector(s)”) • Example inspection and testing form (Figure 7-5.2.2) If the vendor is not providing the information as per these references, they are in breach of the contract.

  15. Utility Failure Policy and Matrix • Policy reads “Follow the Utility Failure Matrix.” • Matrix is located with the Administrator on Call, PBX Operator, and Engineering

  16. General Recommendations for Compliance • Interim Life Safety Measures (ILSM) ILSM must be evaluated and documented. • The ILSM evaluated box must be entered on the electronic Statement of Conditions (eSOC) • Not all 11 elements in LS.01.02.01 are applicable to all ILSM conditions Example If penetrations are present in a fire or smoke assembly, the integrity has been compromised. The Life Safety Code was designed to provide a sequence of measures. Measure: maintain the next lower protective level until the penetrations are corrected (e.g., next smoke barrier or smoke partition). We need to develop more realistic measures!

  17. Evaluation of ILSM Made Simple

  18. Building Maintenance Program? • Do we need one and how do we implement one that is effective? • Doors are verified during fire drills: • Corridor doors positively latch • Some barrier doors close upon activation of fire alarm • Exits and hazardous areas self close and latch • The inventory is assigned to each floor • Smoke Barriers – Survey once a year • Fire Barriers surveyed once a year • The main focus is being Proactive – Above the ceiling access control

  19. Above the Ceiling - Permit or Tagging • Pro-Active • Purpose: Control activities that penetrate smoke and fire barriers. • Being proactive is the only solution. • Inspections are to measure the expectations of the barrier integrity. • Process must be discussed with Infection Prevention Professionals to determine level of control to access the ceiling spaces. • Permit Process: Detailed description of activities and location of work • Tagging Process: Identify the area on drawings, number tags, evaluate with ICRA

  20. Permit Process • Detailed description of area. • Work being completed • All areas requiring inspection • Signature of Engineering representative • Retain the Permit? • Once work is completed, there are No requirements for record retention. Permit

  21. Tagging Process • Tags are two-sided • Tag number is identified on a set of drawings • Tag is effective for 24 hours only • At the end of each day, tags are returned • If area involved Smoke/Firerated walls or partitions - Inspect • If area did not involve Smoke/Firerated walls or partitions • Discard the tag

  22. ICRA and Tag Process

  23. Drawings for Tagging Process • Have a set of life safety drawings laminated • Identify the area being accessed with erasable ink • End of day once inspected/not inspected • Erase the drawings at the end of the day • Recommend a reward program for all staff for access to the ceiling • Meal tickets • Something from gift shop

  24. After Work is Complete No Inspection 3945 Inspection 3945

  25. General Recommendations for Improvement • Medical Gas Systems Per NFPA 99 (1999 edition): • 4-3.1.2.14 Identification • “Piping shall be identified by stenciling or adhesive markers” • All locations where the piping is to be marked are listed • If the medical gas testing company writes on their report that the systems were inspected and tested in accordance with NFPA 99, they should identify missing labels If the testing company does not list missing labels, they are in breach of the contract.

  26. General Recommendations for Improvement (cont’d.) • – • LS.02.01.30 Per NFPA 101, (2000 edition) 18/193.6.2: • The smoke compartment must be identified as being sprinkled or non sprinkled • The ceiling is allowed to terminate above the ceiling, in an existing building, the smoke compartment must be sprinkled • In new buildings, sprinklers are not optional; the building must be fully sprinkled Identifying sprinkled area on drawings will alleviate the finding for corridor walls that Do Not go from deck to deck.

  27. General Recommendations for Improvement (cont’d.) • EC.02.03.05 • Per NFPA 25 (1998 edition) 2-2.1.1, “Sprinklers shall be inspected from the floor level annually.” • If the fire suppression vendor presents you with a document that they have performed sprinkler testing and inspection or water-based fire protection system testing and inspection in accordance with NFPA 25, they are in breach of their contract! We must hold contractors accountable for the service they are to provide!

  28. Physical Environment and Utility Systems

  29. Conditions of Participation (COP) • CMS • Language from the CMS COP: • CMS COP 482.41 (Physical Environment) allows the hospital to decide on which Guideline they choose. • Each operating room should have separate temperature control. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the Facilities Guidelines Institute (FGI) should be incorporated into hospital policy. • Designation of the Guideline being utilized. • A policy must be implemented reflecting the specific guideline • Other Acceptable standards: • Association for the Advancement of Medical Instrumentation (AAMI) • American Institute of Architects (AIA)

  30. Joint Commission Standards • Specific Standards • EC.02.05.01 EP 6: • In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies. • The EP has this designation, indicating it is a Direct Impact for scoring • EC.02.06.01 EP 13: • The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided. • Not a Direct impact! • EC.02.06.05 EP 1: • Planning for New, altered or renovated spaces use: State rules and regulations, Facility Guidelines Institute (FGI) or a reputable standard or guideline. 3

  31. State Regulations • Variance from State to State: • Florida utilize a State Operations Manual developed and enforced by Agency for Health Care Administration (AHCA) • Texas utilizes a State Operations Manual developed and enforced by the Department of State Health Services (DSHS). Texas Administrative Code (TAC) • Kentucky utilizes a State Operations Manual developed and enforced by the Office of the Inspector General (OIG). • The Kentucky State design laws state the use of the AIA 2006 edition

  32. Utility Systems - Design • Design: The parameters in which the HVAC systems were designed is dependent on the State. • Example standard from ASHRAE 170, Attachment D to 2010 FGI:

  33. Utility System - Operation • Define the Needs • The needs of the patient are a consideration: • The primary reason for the lower temperatures are for the surgeons! • During Cardiac cases, the physicians like to lower the temperature to stop the heart and reduce the organs need for oxygen. • Before closing, the physician wants the temperature raised to increase blood flow and reduce the possibility of hypothermia. • The colder temperature will keep the bacteria count down. • Some consideration must be given to cardiac catheterization cases where all of the clinical staff are wearing lead shielding to prevent excessive dosing from the “C” arm.

  34. Variables in Operations Next Steps: Variables: The system was designed for one range and the demand is much lower or higher from the clinical staff! • If the temperatures and relative humidity fall out of range once the physicians request a lower temperature, the HVAC system is not operating within the design parameters. • Present to the clinical staff the following: • Once a parameter is requested outside of the design range, it is no longer an engineering issue! • The clinical staff must meet and decide if they are comfortable with the operating room being out of parameters. • The decision to continue the case must be with the clinicians.

  35. Where are Eye Wash Stations Required?

  36. Purpose • EC.02.02.01 • Emergency first aid as required by OSHA. • The Material Safety Data Sheets (MSDS) describes the first aid actions. • Evaluate the MSDS and determine if flushing is required for a certain period of time. • If no time period is identified in the MSDS. • Flushing station is adequate until the person is taken tothe emergency room.

  37. Questions? • I can be reached at: • Charles.workman@hcahealthcare.com • 615.344.1187Thank You

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