MARCH 2014 Volume 16 Issue No.3 Healthcare Life Safety Compliance In a long-anticipated move, CMS announced on De- cember 20, 2013, in its Survey & Certification (S&C) memo 14-07 that it will allow hospitals to adjust their maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, centered on a risk-based assessment by qualified personnel. In this memo, CMS says hospitals may find that the man- ufacturer’s recommendations for some equipment are not available to them or their contractors, or they may through experience have identified a more efficient or effective maintenance strategy that does not reduce the safety of the equipment. This announcement is a culmination of extended efforts by the American Society for Healthcare Engineering (ASHE) and The Joint Commission. For decades, The Joint Commission has allowed its CMS approves new risk-based preventive maintenance strategy on hospital equipment Emergency preparedness The industry is looking at upcoming changes to emergency preparedness requirements—is your organization ready? Fire drill safety Guest columnist Robert Hunn, CHFM, CHSP, discusses tips to meet fire drill life safety requirements. Fire pump fires p. 8 A recent event turns attention to fire pump fires and what the industry can do to avoid them. Editorially speaking This month’s editorial turns to springtime and what we can do this time of year to improve life safety preparedness. Q&A This month’s Q&A looks at card read- ers on locked doors, fire damper test- ing frequencies, and more. Inspection and testing form Check out this month’s sample tool: a weekly inspection and testing form for diesel-driven fire pumps. P5 The newsletter to assist healthcare facility managers with fire protection and life safety accredited hospitals the option of using a risk-based strategy when it came to preventive maintenance (PM) activities on medical and plant equipment. In recent years, hospitals that underwent a CMS valida- tion survey by state agencies discovered that CMS’ Conditions of Participation and standards did not allow for this contemporary approach to mainte- nance, inspections, and testing, but instead required the organization to follow the manufacturer’s recom- mendations on the frequency of the PM as well as the procedure for the PM. While the risk-based approach for equipment PM utilized by The Joint Commission made sense and was actually proven to be more effective than following the manufacturer’s recommendations, CMS refused to recognize anything other than what the manufacturer recommended. P6 P8 P9 P10 P12
Transcript
MARCH 2014Volume 16Issue No.3
Healthcare Life Safety Compliance
In a long-anticipated move, CMS announced on De-cember 20, 2013, in its Survey & Certification (S&C) memo 14-07 that it will allow hospitals to adjust their maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, centered on a risk-based assessment by qualified personnel. In this memo, CMS says hospitals may find that the man-ufacturer’s recommendations for some equipment are not available to them or their contractors, or they may through experience have identified a more efficient or effective maintenance strategy that does not reduce the safety of the equipment.
This announcement is a culmination of extended efforts by the American Society for Healthcare Engineering (ASHE) and The Joint Commission. For decades, The Joint Commission has allowed its
CMS approves new risk-based preventive maintenance strategy on hospital equipment
Emergency preparednessThe industry is looking at upcoming changes to emergency preparedness requirements—is your organization ready?
Fire drill safetyGuest columnist Robert Hunn, CHFM, CHSP, discusses tips to meet fire drill life safety requirements.
Fire pump firesp. 8 A recent event turns attention tofire pump fires and what the industry can do to avoid them.
Editorially speakingThis month’s editorial turns to springtime and what we can do this time of year to improve life safety preparedness.
Q&AThis month’s Q&A looks at card read-ers on locked doors, fire damper test-ing frequencies, and more.
Inspection and testing formCheck out this month’s sample tool: a weekly inspection and testing form for diesel-driven fire pumps.
P5
The newsletter to assist healthcare facility managers with fire protection and life safety
accredited hospitals the option of using a risk-based strategy when it came to preventive maintenance (PM) activities on medical and plant equipment. In recent years, hospitals that underwent a CMS valida-tion survey by state agencies discovered that CMS’ Conditions of Participation and standards did not allow for this contemporary approach to mainte-nance, inspections, and testing, but instead required the organization to follow the manufacturer’s recom-mendations on the frequency of the PM as well as the procedure for the PM.
While the risk-based approach for equipment PM utilized by The Joint Commission made sense and was actually proven to be more effective than following the manufacturer’s recommendations, CMS refused to recognize anything other than what the manufacturer recommended.
This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.
Nearly four years ago, George Mills, MBA, FASHE, CEM, CHFM, director of the Department of Engineering at The Joint Commission, pursued negotiations with CMS to change its Conditions of Participations to allow the use of a risk-based or history-based strategy on hospital equipment main-tenance, inspection, and testing frequencies and procedures. An example that Mills used at the time to demonstrate the need for a risk-based strategy is the PM frequency of an automated external defibrillator (AED). An AED that is placed on the wall in a hospital lobby does not require the same PM frequency as an AED that rides in the backseat of a hospital security vehicle. The AED in the security vehicle is at a higher risk due to the potential rough environment inside the vehicle than the AED mounted on the lobby wall.
Mills did not initially achieve success in convincing the relevant decision-makers at CMS, so he turned to ASHE for assistance. ASHE then focused its attention on the issue and CMS verbally acknowledged that the risk-based option made sense and promised to endorse that approach.
S&C memo 12-07This led to CMS issuing its S&C memo 12-07 on De-
cember 2, 2011, that clarified its position on hospital equipment maintenance requirements.
In this memo, CMS said hospitals may adjust main-tenance, inspection, and testing frequencies only, for limited facility and medical equipment, below those recommended by the manufacturer’s recommenda-tions. The memo specifically excluded all equipment considered critical to patient health and safety and any new equipment that does not have an established history with the organization. S&C 12-07 continued to limit the methods and techniques that the hospital used in maintenance, testing, and inspection of equip-ment to that which the manufacturer recommended.
S&C 12-07 was a direct blow to the efforts by ASHE and The Joint Commission, and was contrary to the verbal agreement those organizations believed they had achieved with CMS. S&C 12-07 did not explain which equipment was considered “critical to patient health and safety” and was believed to be too ambigu-ous for effective and uniform enforcement. ASHE
contended that any equipment considered critical to patient health and safety should also qualify for test-ing and inspection frequencies that are less than the manufacturer’s recommendations when the risk of the equipment to patient safety is minimal or nonexistent. Historical evidence of the equipment’s performance and reliability was totally ignored by the CMS memo.
CMS overlooked the severe restrictions that S&C 12-07 placed on equipment technicians with regard to the methods and techniques used. The memo specifi-cally prohibited alternative equipment maintenance methods and required hospitals to follow the manu-facturer’s recommended techniques and methods for all maintenance activities. This restriction alone would have cost millions of dollars for hospitals to purchase unnecessary special tools and manuals recommended by manufacturers in the PM of their equipment. That does not take into account those manufacturers who have discontinued operations and maintenance tools, in which case manuals would not be available.
ASHE and The Joint Commission continued to negotiate with CMS on the issue, which resulted in CMS issuing a communication that it never intended for hospitals to have to purchase additional tools or manuals if they already had effective methods and techniques in equipment maintenance. CMS again agreed to review the evidence that ASHE presented on risk- and history-based strategies for equipment PM, and promised it would issue a new communication on the subject.
Draft memoDuring the summer of 2013, CMS issued a draft
of a revised S&C memo on the subject of equipment maintenance requirements to its state agencies and the accreditation organizations seeking guidance and comments. This led to the eventual S&C 14-07 issued December 20, 2013, which nearly endorses everything ASHE and The Joint Commission had requested. In that memo, CMS states that S&C 14-07 supersedes S&C 12-07 previously issued, and says a hospital may adjust its maintenance, testing, and inspection frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel. This memo clearly does not limit the provisions for testing
and inspecting equipment to frequencies less than the manufacturer’s recommendation to noncritical equip-ment only. The memo does not even raise the issue of equipment that does not qualify for this new risk-based strategy, other than the following:• Equipment required to comply with other federal
or state law that mandates adherence to the manu-facturer’s recommendations
• Equipment required by hospital Conditions of Participation mandating adherence to the manu-facturer’s recommendations (CMS provides the example of all imaging and radiologic equipment)
• All medical laser devices• New equipment without sufficient maintenance
history
The December 2013 memo specifically allows not only frequencies other than what the manufacturer recommends, but also alternative methods and tech-niques in maintaining the equipment, which is a huge accomplishment by ASHE and The Joint Commission in convincing CMS to adopt this strategy.
However, there are many conditions to qualify for the use of alternate frequencies and methods in the maintenance, testing, and inspection of hospital equipment. S&C 14-07 clearly identifies each condi-tion, before these alternate activities may begin. CMS refers to the alternative strategies for equipment maintenance as the Alternate Equipment Manage-ment (AEM) program.
Hospitals electing to adjust facility or medical equipment maintenance must develop policies and procedures and maintain documentation supporting their AEM program, and must adhere strictly to their established AEM program activities and frequen-cies. The term “facility equipment” refers to devices intended to support the physical environment of the hospital, and the term “medical equipment” refers to devices intended to be used for diagnostic, therapeu-tic, or monitoring care provided to a patient.
The AEM program must be based on generally accepted standards of practice for facility or medical equipment maintenance. Examples of standards for a medical equipment program can be found in the American National Standards Institute/Association for the Advancement of Medical Instrumentation
document: ANSI/AAMI EQ 56:1999/(R) 2008 Recommended Practice for a Medical Equipment Management Program. Likewise, an example of written guidelines for physical plant equipment may be found in the ASHE 2009 document Maintenance Management for Health Care Facilities. To its credit, CMS states in the December 2013 memo that it welcomes identification of other recognized sources of recommendations for facility and medical equipment maintenance.
The determination of whether it is safe to perform facility or medical equipment maintenance in an alter-nate manner must be made by qualified individuals, regardless of whether the individuals are hospital em-ployees or contractors. In the case of medical equip-ment, a clinical or biomedical technician or engineer would be considered to be qualified. In the case of facility equipment, a healthcare facility management professional (e.g., facility manager, director of facili-ties, or VP of facilities) would be considered qualified.
Hospitals must maintain records of the qualifica-tions of hospital personnel who make decisions on placing equipment in an AEM program, and must be able to demonstrate how they ensure contracted per-sonnel making such decisions are qualified.
The hospital must take into account the typical health and safety risks associated with the equip-ment’s use when determining whether it is safe to include that equipment in the AEM program. The hospital is expected to identify any “critical equip-ment” in its AEM program, which is defined as facility or medical equipment for which there is a risk of seri-ous injury or death to a patient or staff person should the equipment fail.
Multiple factors must be considered since different types of equipment present different combinations of severity of potential harm and likelihood of failure. The risk may vary for the same type of equipment depending on the patient care setting in which it is used. For example, a slightly miscalibrated scale for an adult in an internal medicine outpatient clinic might not present a significant risk; however, a mis-calibrated scale in a neonatal ICU could have serious consequences for patient care.
How widespread is the harm likely to be if the equipment failed or malfunctioned? Equipment
failure and malfunction would be a cause for concern even if the harm from the failure or malfunction is not widespread.
Other factors hospitals must consider when evaluat-ing risks associated with equipment are:• Information on the manufacturer’s equipment
maintenance recommendations (if available), including the rationale for those recommendations
• The timely availability of alternate devices or back-up systems in the event of equipment failure or malfunction
• Incident history of identical or very similar equipment
Additionally, maintenance requirement factors must also be considered:• Are the maintenance procedures simple or
complex?• Are the manufacturer’s instructions and proce-
dures available in the hospital, and if so, can the hospital explain how and why it is modifying the manufacturer’s instructions?
• If the manufacturer’s instructions are not avail-able in the hospital, how does the hospital assess whether the AEM uses the appropriate mainte-nance strategies?
• How readily can the hospital validate the effective-ness of AEM methods for particular equipment? For example, can the hospital explain how it en-sures there is no reduction in the performance of biomedical equipment subjected to alternate main-tenance methods?
Hospitals must be able to demonstrate to a surveyor the factors they considered in their risk assessment for equipment placed in their AEM program. They must have policies and procedures that address the ef-fectiveness of the AEM program. Although CMS does not specify how often the effectiveness of the AEM program is required to be evaluated, it is generally thought to be at least once per year.
In evaluating the effectiveness of the AEM program, hospitals are expected to address multiple factors, including but not limited to:• How incidents of equipment malfunction are
• How incidents of equipment malfunction are in-vestigated, whether the malfunction could have been prevented, and what steps will be taken to prevent future malfunctions
• How a determination is made as to whether the mal-function resulted from the use of an AEM strategy
• The process for removal from service of equipment determined to be unsafe or no longer suitable for its intended application
• The use of performance data to determine whether modifications to the AEM procedures are required
CMS is also instructing its surveyors who review the AEM program for compliance to focus their review on the critical equipment and the hospital’s docu-mentation of the factors and evidence it considered in developing an AEM strategy for that equipment.
If the hospital chooses to use an AEM program, the equipment managed through that program must be readily separately identifiable as subject to AEM. Critical equipment, regardless of whether in an AEM program, must also be readily identified as such.
This new AEM program is not the same as what The Joint Commission has allowed for years. It is much more extensive and requires additional de-tailed information. A note in standard EC.02.05.01, EP 3 allows hospitals to use a different approach to maintenance. Examples provided include predictive maintenance, reliability-centered maintenance, or metered maintenance. This is far from what CMS’ new AEM program requires. If you want to use the new AEM program, be prepared for additional documentation and evaluation from what you are used to. H
Upcoming changes proposed for emergency preparedness program
On December 27, 2013, CMS issued a new proposed rule that would affect all healthcare providers who receive Medicare and Medicaid reimbursement funds should it become final. The comment period for the pro-posed rule has expired, and the federal agency will begin the task of reviewing comments and suggestions made by the public. CMS is expected to publish a final rule on this subject, along with its replies to public comments and suggestions, in the Federal Register in approximate-ly six to 12 months. According to the federal agency, the purpose of the proposed rule on emergency prepared-ness is to establish national emergency requirements for all Medicare and Medicaid participating providers and suppliers, and to ensure that they adequately plan for both natural and man-made disasters.
CMS believes the current system for emergency plan-ning and response is not effective when considering all the agencies affected by their programs. It believes it is essential to have a national set of standards that apply across the healthcare continuum.
Joint Commission–accredited hospitals are very much aware of effective on Emergency Management (EM) preparedness standards, as many individuals
Who is impacted?
CMS has identified 17 providers and suppliers that
would be affected by this proposed rule:
1. Religious nonmedical healthcare institutions
2. Ambulatory surgical centers3. Hospices4. Psychiatric residential treatment facilities5. Programs for the all-inclusive care of the elderly6. Hospitals7. Transplant centers8. Long-term care facilities9. Intermediate care facilities for individuals with intellec-
tual disabilities10. Home health agencies11. Comprehensive outpatient rehabilitation facilities12. Critical access hospitals13. Clinics, rehabilitation agencies, and public health
must be conducted to determine the organiza-tion’s capacities and capabilities that are critical in preparing for a full spectrum of emergencies or disasters. Other names for this process are Hazard Vulnerability Analysis and Emergency Operations Plan.
• Policies and procedures. Facilities are required to develop and implement policies and procedures based on the emergency plan and risk assessment.
• Communication plan. Facilities are required to develop and maintain an emergency preparedness communication plan that complies with both fed-eral and state law.
• Training and testing. Facilities must develop and maintain an emergency preparedness training and testing program.
While it makes sense to have a national set of rules on emergency preparedness, it appears CMS “borrowed” heavily from The Joint Commission in developing its own set of standards. H H
believe that they have written the best set of standards on emergency preparedness for healthcare institu-tions. But not all healthcare providers and suppliers are Joint Commission accredited, and other accrediting organizations and government agencies do not have standards that are as comprehensive. Because of this, CMS believes that healthcare providers would not have the necessary planning and response preparations in place in the event of a disaster. CMS further states in its proposed rule that the current regulatory patchwork of federal, state, and local law and guidelines, combined with various accrediting organizations’ emergency preparedness standards, fall far short of what is needed by hospitals, nursing homes, and ambulatory surgical enters to be adequately prepared for a disaster.
The existing Joint Commission EM standards appear to have influenced CMS when it developed its new pro-posed standards, as the agency requires the same items that the accreditor does: • Risk assessment and planning. Prior to es-
tablishing an emergency plan, a risk assessment
You must first start with a written fire response plan that works well in your facility and also meets the re-quirements of compliance. The most important aspect of designing fire drills is to remember the intent of having a comprehensive fire response plan—that is, to ensure all hospital employees are trained to respond safely and appropriately in the event of a significant fire and/or smoke incident. Training hospital employ-ees to fully understand the proper response steps to a fire incident is simple in concept but not always easily achieved given the many other demands put on clini-cal staff as well as administrative and support staff.
Stay with the basics. Each employee should know the steps of the acronym RACE:
R—Rescue patients or staff from the fire area A— Alert staff in the area and activate the fire alarm
pull station or call the emergency numberC—Contain the fire by closing doors and windowsE— Extinguish the fire if it is safe to do so and
evacuate to another compartment
Editor’s note: The following article was written by Robert Hunn, CHFM, CHSP, owner of Hospital Safe-ty by Design, a consulting firm located in San Francisco.
Conducting fire drills in hospitals and meeting the requirements of the Life Safety Code® (LSC) can be more an art than a science. Each hospital seems to ap-proach completion of its required fire drills differently. Some overdo the frequency of the drills, resulting in staff burnout, while others complete the minimum, some-times resulting in a noncompliant fire response plan.
The 2000 LSC sections 18/19.7.1.2 only require fire drills to be conducted quarterly on each shift in healthcare occupancies. Joint Commission standard EC.02.03.03, EP 1 also says fire drills are conducted once per shift per quarter in each building defined as a healthcare occupancy. EP 4 requires staff to participate in the drills according to the hospital’s fire response plan. Neither requirement prescribes exactly how to de-sign and conduct your drills to meet these requirements.
Meeting the fire drill requirements of the Life Safety Code
Another acronym to know and follow is PASS:P—Pull the pin from the fire extinguisher leverA—Aim the nozzle at the base of the fireS—Squeeze the lever to spray the fireS—Sweep the nozzle along the base of the fire
Employees should also know the location of fire extinguishers and fire alarm pull stations in their area as well as the best evacuation routes for patients and staff.
Participation in a fire drill can be achieved by active participation or by observing and responding to fire alarm activation. Active participation is achieved at the fire drill initiation location when the safety officer (or designee) initiates a drill by asking an employee to respond to a fire or smoke scenario. The employee must follow these steps:• Follow the steps in the RACE acronym, with assis-
tance from other staff.• Demonstrate the PASS procedure.• Ensure that patient room doors, other room doors,
and the cross corridor doors are closed upon alarm activation. It is best when many staff participate in this exercise. If there is confusion or the drill does not go well, there must be documented follow-up training and a repeated documented fire drill.
It’s a good idea to have staff sign a form confirming their participation in the drill.
Observation participation can be achieved during the drill on the floor above and below the drill activa-tion location and other adjacent departments. Staff in these areas participate by:• Observing the strobe activation • Acknowledging the overhead announcement• Ensuring all doors close or are closed• Clearing the egress corridors of any obstructions
Staff in these areas should sign the Fire Drill Observ-ers Report confirming these actions.
An additional quality knowledge assessment of the fire response plan can be included during your routine safety rounds. Ask one or two employees during these rounds about how they would respond to a fire in their area. Employees should demonstrate their knowledge of RACE and PASS. This additional step does not
replace the requirements for completing fire drills, but rather enhances employees’ understanding of the fire response plan.
Documenting participation in fire drills throughout the hospital demonstrates compliance with the re-quired standard of conducting a fire drill once per shift per quarter in a hospital building. A comprehensive fire response plan not only meets the intent of the stan-dard, but also reinforces each employee’s knowledge of what to do when a fire occurs in his or her area. H
Life Safety news in Brief
CMS issues new proposed ruleThe Centers for Medicare & Medicaid Services (CMS
has issued a new proposed rule in the Federal Register. This is a Notice of Proposed Rulemaking and is not a Final Rule. CMS is soliciting comments on this proposed rule concerning healthcare facility disaster preparedness, and the general public has 60 days to respond.
Being a Federal Agency, CMS must follow the Administra-tive Procedure Act of 1946 whenever they want to add, re-move or change a rule or regulation, and they must issue a public notice in the Federal Register that they are proposing a new rule. Then there is a 60-day window for the public to re-spond with comments to the proposed rule. After the 60-day window is over, CMS will take the time to review the com-ments made and will respond to them when they issue a final rule. The changes that CMS is proposing are to the respective Conditions of Participation or Conditions for Coverage to 17 different sets of rules (or laws) for healthcare organizations.
CMS identified four core elements that they believe are central to an effective emergency preparedness system and must be addressed by healthcare organizations to offer a more comprehensive framework of emergency pre-paredness requirements for the various Medicare- and Medicaid-participating providers and suppliers. The four elements are—(1) risk assessment and planning; (2) poli-cies and procedures; (3) communication; and (4) training and testing.
CMS admits that they took into consideration the exist-ing standards and regulation of national agencies, such as The Joint Commission and AOA/HFAP. The current CMS Conditions of Participation (CoP) for acute care hospitals are light on specific requirements for emergency manage-ment, and most experts agree that The Joint Commission Emergency Management chapter provided better guidance for healthcare facilities than any other standard.
When a fire pump catches fireIn January, an engine-driven fire pump at
FirstHealth Moore Regional Hospital in Pinehurst, N.C., caught fire while operating due to activation of the sprinkler system. According to published reports, firefighters found heavy smoke coming from the fire pump room with the fire pump in flames when they arrived on the scene. They were able to extinguish the fire quickly, limiting the fire damage to the pump and the room itself.
According to John Ganley, CHFM, CHSP, safety officer for FirstHealth, the fire was likely caused by a battery cable shorting out a fuel line on the diesel engine.
“It appears that one of the battery cables shorted out causing a fire on the top end of the diesel-driven pump,” says Ganley. “When there was enough heat, the fuel line ruptured, igniting a larger fire on the pump.”
The health system safety officer explained that hospital staff responded in accordance with their fire safety plan.
“Our security department arrived on the scene first and used four portable ABC-type extinguishers on the fire but were unable to extinguish it,” says Ganley. “Then the fire department arrived and they finished extinguishing the fire.”
The reason the fire pump was operating in the first place was due to a cold weather snap in the region.
“We had a dry pipe system fail in a detached build-ing, due to possible water trapped in a low point, freezing and breaking a tee fitting,” says Ganley. “The dry system lost its holding air pressure, and the del-uge valve activated, releasing water into the pipe. This caused the fire pump to operate as designed.”
The fire pump is located on the ground level of the hospital’s parking deck, and no patients were in any danger. After the fire was extinguished, a fire watch was instituted throughout the facility and arrange-ments were made with the fire department to connect a pumper truck to the sprinkler system until a replace-ment fire pump could be installed. Within 24 hours, the hospital had a replacement fire pump assembly in place and operating, allowing the fire department to remove its pumper truck.
While it is uncertain whether the fire was a result of improper testing and inspection operations, this event offers an opportunity to review the special activities re-quired for an engine-driven fire pump. NFPA 25 (1998 edition), Chapter 5, has much to say about fire pump inspection, testing, and maintenance.
The purpose of a fire pump inspection is to verify that the pump assembly, including the power unit to drive the pump, is in operating condition and free from physical damage.
Once a week, the following visual observations must be performed for diesel-driven fire pumps:• Minimum temperature of 70ºF in a fire pump room
with diesel-driven pumps without engine heaters • Ventilating louvers in the pump house are free to
operate• Fuel tank is at least two-thirds full• Controller selector switch is in the AUTO position• Battery voltage readings are normal• Battery charging current readings are normal• Battery pilot lights are on, or the battery failure
pilot lights are off• All alarm pilot lights are off• Engine running time meter is reading• Oil level in the right angle gear drive is normal• Crankcase oil level is normal• Cooling water level is normal• Electrolyte level in batteries is normal• Battery terminals are free from corrosion• Water-jacket heater is operating
A weekly test of diesel-driven fire pumps without flowing water must be conducted for a minimum of 30 minutes. The method of starting this weekly test is to release water pressure at the start switch.
The main purpose of testing the pump assembly on a weekly basis is to ensure the pump will operate auto-matically. A secondary reason is to detect deficiencies of the pump assembly that are not evident during the visual inspection.
While the recent CMS categorical waivers allow for monthly no-flow tests on electric-driven fire pumps, that option is not available for engine-driven pumps, which must continue to be tested weekly. H
Editor’s note: This month, Senior Editor Brad Keyes, CHSP, offers his thoughts, concerns, and comments on issues pertaining to healthcare life safety.
This issue of HLSC arrives when spring is start-ing to make her warm appearance after a long cold winter. The signs are all around us—the crocuses are emerging, the trees are starting to bud, the sleepy animals surface from their dens, the robins return from their warm winter grounds, and the most obvi-ous sign of spring is the phrase every baseball fan wants to hear: “Pitchers and catchers report!”
The start of a new baseball season is synonymous with the start of a new healthcare regulation compli-ance season—sort of. Spring is the time to do your cleaning, to throw out the old and bring in the new; it’s a time for new beginnings, and taking the time to learn about regulations and interpretations that the authorities will be using; and it is the time to stop and reflect on how things went last year and find ways to improve.
Most of the national accreditation organizations will have new requirements or interpretations that will likely affect you. Take the time to review the official communications from these accreditors to healthcare organizations. Unfortunately, most of the communications are sent to the CEO and/or the individual in charge of accreditation management at healthcare organizations and often are not passed along to the facility manager or safety officer who needs to know about the content. It is important to always assume some changes have been made over the winter; find out what those changes are and how they will affect you and the performance of your job.
The Joint Commission will be focusing more atten-tion on the physical environment this year. Reports have shown that the accreditor continues to spend its assessment efforts on proper ventilation and air exchange rates in clean areas. The one area that is catching many hospitals by surprise is the typical soiled utility room located on the nursing care unit. By definition, a soiled utility room is a dirty area, and according to EC.02.06.01, EP 13, the hospital
Editorially Speaking …must maintain ventilation levels suitable for the care, treatment, and services provided. For a soiled util-ity room, this means the airflow needs to go into the room but not flow out of the room. This standard is based on recommended guidelines on the design and construction of hospitals that are decades old. This is not a new requirement, and it applies to all healthcare organizations, regardless when the facil-ity was constructed. What is new is the fact that The Joint Commission is now enforcing this requirement, and it is catching many hospitals by surprise as they have not checked the airflow in the soiled utility room since the area was constructed. All it takes is a simple “tissue test,” whereby you take a tissue and place it at the bottom of the door. If the tissue moves in, you have negative airflow, which is the proper ventila-tion; but if the tissue moves out, then you have a positive airflow, pressurized from the soiled utility room, which is unsafe for your immune compromised patients who may be wheeled past this room in the corridor.
Other issues the accreditor is looking for that many healthcare organizations are not aware of include:• Door gaps exceeding 1/8 inch• Penetrations in fire-rated barriers• Missed opportunities for testing and inspection of
fire safety features• Staff response on what to do in case of a fire• Monthly exit sign inspections
When I consult in hospitals, it always amazes me when I ask to review certain fire safety inspection or testing documents, and the facility manager has no clue that he was supposed to perform that activity. Ig-norance is not bliss! You must read the standards and understand what the accreditor expects you to do.
To start off a new season, I recommend that you become a member of the American Society for Healthcare Engineering and join your local chapter. Become involved; network with your fellow facility managers. It is an education that is very affordable and you will make a lifetime of friends in the health-care industry. H
Editor’s note: Each month, Senior Editor Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, answers your questions about life safety compliance. Our editorial ad-visory board also reviews the Q&A
column. Follow Keyes’ blog on life safety at www.keyeslifesafety.com for up-to-date information.
Card readers on door locks
QDuring a recent survey, the surveyor said a card reader on the stairwell door cannot be located on an
adjacent wall or door frame, but it must be an integral part of the lockset itself. Is this true? They were talking about card readers on the stairwell side for reentry to a floor.
ADid the surveyor cite you for noncompliance? Surveyors sometimes say things that are misun-
derstood, especially if there is no citation. Doors not in the path of egress are permitted to be locked, and a reentry door from a stairwell usually is not in the path of egress. As long as the reentry door in the stairwell is not in the path of egress, I do not see any reason that what you describe would be a problem. The Life Safety Code® (LSC) would allow for a card reader de-vice to unlock a stairwell reentry door as long as the door is not in the path of egress. If the card reader is mounted in the stairwell on the door leading to a floor of the building (not a discharge door), then the card reader is not on the egress side of the door. There is nothing in the LSC or in NFPA 80, Standard for Fire Doors and Fire Windows (1999 edition), that would require the card reader to be mounted on the door leaf, rather than on the wall near the door.
Therefore, it is clear that the LSC permits card access readers to be mounted on the wall near the door, since it is not a device or motion to operate the door. I cannot think of any situation that would require the card access reader to be mounted on the door leaf itself.
Fire damper testing frequencies
Q Our facility is a freestanding ambulatory surgi-cal center and we only perform gastrointesti-
nal procedures, not surgery. We lease a suite on the ground level in a three-story building with multiple tenants. We had a state inspection recently and they asked us for documentation that we tested our fire and smoke dampers every four years. What are they looking for? We’ve been in the building for 13 years and no one has ever asked us about fire and smoke damper testing before.
A Since it appears that the inspector is holding you accountable for compliance with the 2000 LSC, I
will assume you need to comply with Chapter 21, for ex-isting ambulatory healthcare occupancies.
Section 21.5.2.1 requires compliance with section 9.2, which in turns requires compliance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 edition). Section 3-4.7 of NFPA 90A requires the fire and smoke dampers to be tested once every four years.
For clarification, CMS did issue a Survey & Certifi-cation memo on October 30, 2009, which permitted hospitals to change the frequency of fire and smoke damper testing to once every six years, but this memo applies only to hospitals, not ambulatory healthcare occupancies.
It is not unusual for authorities who inspect your building to fail to ask for certain documentation (such as test results of fire/smoke dampers), and then at a later date another authority will request that information.
Just because the previous surveyors/inspectors did not ask to see this information does not mean it was not required. This inspector is now holding your organization accountable to what has always been an LSC requirement.
Q If renovation requires replacement of fire doors in multiple areas of the hospital and
must be completed in a short period of time, what would be appropriate interim life safety measures (ILSM)? This would cover multiple areas of the hospital.
A Appropriate ILSMs for replacing multiple fire doors in a hospital all at once would be deter-
mined by the hospital’s ILSM policy. According to Joint Commission standard LS.02.01.01, EP 3, the IL-SM policy must include criteria for evaluating when and to what extent the hospital follows special mea-sures to compensate for life safety risks. What this means is the hospital gets to decide what ILSMs to implement for which life safety impairments, within reason. But, to directly answer your question, I would think the following measures should be considered for implementation: • Staff education. Issue a memo to all depart-
ments affected by the fire door replacement noti-fying them of alternative routes for exiting.
• Temporary construction partitions. Fire re-tardant plastic sheeting needs to be installed to contain dust and dirt during the demolition and construction phase of the fire door replacement project.
• Additional fire extinguishers. Place extra fire extinguishers in the project area and provide instructions to the construction workers on how to operate them.
• Daily surveillance. Perform daily surveillance to ensure the fire door project area is clean and free from debris as long as the project is active.
• Signage. If the project to replace the fire doors blocks access through the egress corridor in that area, signage should be posted indicating the nearest alternative exit.
• Fire watch. If any portion of the fire alarm sys-tem or sprinkler system is impaired for four or more hours in a 24-hour period due to the fire door replacement project, notification of the local fire department is required and a fire watch must be performed.
Fire protection of equipment rooms
Q What must the fire rating be in the walls of hos-pital equipment rooms, such as the generator
room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required.
A According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have two-hour
fire-rated barriers that protect the room from fire out-side the room. Any two-hour fire-rated barrier is re-quired to have 90-minute fire-rated doors and frame, and if there are any HVAC duct penetrations through the two-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-min-ute fire damper. A boiler room is considered a hazard-ous area, and according to the 2000 edition of the LSC, sections 18/19.3.2.1, the hazardous area is required to be protected with one-hour fire-rated barriers if it is considered new construction, or one-hour barri-ers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke-resistant walls. All door openings in a one-hour barrier are required to be ¾-hour fire rated, with fire-rated frames.
However, unlike the two-hour barrier, a one-hour fire-rated barrier for a hazardous area is not required to have any fire dampers in an HVAC duct penetra-tion, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire-rated barriers (walls); however, NFPA 13 (1999 edition), Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with two-hour fire-rat-ed barriers in lieu of being protected with sprinklers.
Therefore, if the room has fire-rated barriers for any reason (including local or state building codes), it would need fire dampers in the HVAC duct penetration if it is two-hour fire rated or greater. Chiller rooms typically do not require fire-rated barriers, unless the chillers are fuel-fired, in which case they would require the same protection as the boilers. As always, please check with your local and state authorities to determine whether there are other regulations that may affect this situation. H
Check packing glands for slight discharge; adjust if necessary
Record engine oil pressure
Record engine speed indicator
Record engine water temperature
Record engine oil temperature
Confirm engine cooling system is flowing water
At conclusion of test, record engine timer reading
* All “Fail” answers must be documented, investigated, and resolved with work orders. Source: NFPA 25, 1998 edition
Sample tool
Weekly inspection and testing form for diesel-driven fire pumps
Date ___________ Work order # ______________________ Name off property_________________________________________
Inspection/test performed by: ________________________ Fire pump assembly and location: ___________________________
Inspection activities
Procedure Pass/Fail* (N/A) Comments
Pump house heat is not less than 70°F for diesel pumps with-out engine heaters
Ventilating louvers are free to operate
Fuel tank is at least two-thirds full
Controller selector switch is in AUTO position
Battery voltage readings are normal
Battery charging current readings are normal
Battery pilot lights are on, or battery failure pilot light is off
All alarm pilot lights are off
Engine running time meter is reading
Oil level in right angle gear drive is normal
Crankcase oil level is normal
Cooling water level is normal
Electrolyte level in batteries is normal
Battery terminals are free from corrosion
Water-jacket heater is operating
Record engine timer reading
Start engine by releasing water pressure at start switch control
Testing activities (30 minute churn test)
Procedure Pass/Fail* (N/A) Comments
1. (T) (F) CMS issued a new Survey & Certification memo in December 2013 that approves a new risk-based Alternate Equipment Management (AEM) program for preventive maintenance strategies and activities.
2. (T) (F) Together the American Society for Healthcare Engineering and The Joint Commission were effective in convincing CMS to allow a risk-based AEM program.
3. (T) (F) CMS’ new AEM program is not exactly the same as The Joint Commission’s standard that allows for a risk-based strategy for equipment maintenance, and will require more docu-mentation.
4. (T) (F) The determination of whether it is safe to perform facility or medical equipment mainte-nance in an alternate manner must be made by qualified individuals.
5. (T) (F) Hospitals are only one of the 17 different healthcare providers and suppliers that are affect-ed by the new CMS proposed rule on emergency preparedness.
6. (T) (F) The CMS proposed new rule on emergency preparedness is very similar to the standards from the Healthcare Facilities Accreditation Program.
7. (T) (F) The 2000 edition of the Life Safety Code® (LSC) requires fire drills to be conducted quar-terly in all healthcare occupancies.
8. (T) (F) The January fire at FirstHealth Moore Regional Hospital in Pinehurst, N.C., was caused by hot exhaust igniting stored combustibles in the fire pump room.
9. (T) (F) The minimum temperature in a fire pump room with diesel-driven pumps without engine heaters is 45°F.
10. (T) (F) Soiled utility rooms must have a positive airflow in relation to the surrounding area.
QuizQuizHealtHcare life Safety complianceThe newsletter to assist healthcare facility managers with fire protection and life safety
Vol. 16 No. 3March 2014
Quiz questions March 2014 (Vol. 16, No. 3)
A supplement to Healthcare Life Safety Compliance
Quiz answers March 2014 (Vol. 16, No. 3
Copyright 2014 HCPro, a division of BLR. Current subscribers to Healthcare Life Safety Compliance may copy this quiz for use at their facilities. Use by others, including those who are no longer subscribers, is a violation of applicable copyright laws. ® Registered trademark, the National Fire Protection Association, Inc.
1. True
2. True
3. True
4. True
5. True
6. False They are very similar to The Joint Commission’s Emergency Management standards.
7. False The LSC requires fire drills to be conducted quarterly on all shifts in healthcare occupancies.
8. False According to John Ganley, safety officer for FirstHealth, the fire appeared to start due to a battery cable short on a fuel line.
9. False The minimum temperature in a fire pump room without engine heaters is 70°F.
10. False Soiled utility rooms must have a negative airflow in relation to the surrounding area.
