Michigan Society for Healthcare Engineering Environment of Care, Life Safety, and Emergency Management Update

Transcription

1 Michigan Society for Healthcare Engineering Environment of Care, Life Safety, and Emergency Management Update Kathy Tolomeo, CHEM, CHSP, Certified Yellow Belt Engineering Department The Joint Commission September 29, 2017

2 Statement of Conditions Effective August 1, 2016

3 Statement of Conditions - Terms BBI: Basic Building Information Sites are populated by eapp (electronic application) Buildings are created, modified, and deleted by the HCO PFI: Plan For Improvement No longer recognized in the survey process effective August 1, 2016 Organization may continue to utilize as a resource Benefits with new SAFER Matrix Extensions No longer utilized effective August 1, 2016 SPFI: Survey-Related Plan For Improvement TLW: Time Limited Waiver Equivalency: Traditional or FSES (Fire Safety Evaluation System) Engineering Department Organizations may now modify all PFIs in their SOC

4 Statement of Conditions - Background Organizations conduct routine building inspections During inspections deficiencies are discovered Resolution of deficiencies occurs either NEW FAQ: Immediately Corrected is defined by the Joint Commission as the shift in which the deficiency was identified, plus one additional shift. Scheduled activity (i.e. corrective maintenance) Scheduled activity (i.e. Plan For Improvement ) Engineering Department Immediately

5 Statement of Conditions longer recognize the PFI process. Surveyors no longer have access to the SOC. CFR Title 42: Public Health (d) Ordinarily a provider or supplier is expected to take the steps needed to achieve compliance within 60-days of being notified of the deficiencies, but the State survey agency may recommend that additional time be granted by the Secretary in individual situations, if in its judgment, it is not reasonable to expect compliance within 60-days, for example, a facility must obtain the approval of its governing body, or engage in competitive bidding. Engineering Department Effective August 1, 2016 the survey process will no

6 Statement of Conditions All RFIs effective January 1, 2017 will have a 60 day ESC If the organization is planning on submitting an Equivalency, the SPFI and TLW may be submitted prior to the submission of the Equivalency. The organization s SPFI and TLW request should consider the time to develop and approve an equivalency. Once the Joint Commission approves an equivalency it will be documented in the organization s History/Audit Trail and then sent to CMS for approval (if applicable). Engineering Department from the last day of survey. If a physical environment deficiency that is scored under EC or LS cannot be resolved within the 60 day ESC, no later than 30 days from the last day of survey the organization must submit for a SPFI and a TLW.

7 Statement of Conditions or TLW for the ESC submission. They just need to be submitted. Follow-up surveys need to either show: 1. The RFI has been corrected 2. Evidence that the RFI will be completed within the 60 day ESC (work order, invoice, etc.) 3. A submitted SPFI and a Joint Commission approved TLW TLWs and Equivalencies are only sent to CMS for deemed status HCOs Engineering Department The organization does not need to have an approved SPFI

8 Statement of Conditions (SOC) Engineering Department Documenting your mitigation actions

9 Time Limited Waiver (TLW) complete Life Safety Chapter corrective actions Organizations that use Joint Commission accreditation for deemed status purposes are to follow this process: Create a Survey-related Plan For Improvement (SPFI) Enter the requested date in the Scheduled Completion Date field When prompted, complete the Time Limited Waiver form Submit to the Joint Commission The Joint Commission will review and forward the request to the Regional Office for final decision Once the final RO decision has been made the Department of Engineering enters the organization SPFI and accepts the new date After the Department of Engineering modifies the SPFI they will annotate the History Audit Trail Engineering Department A Time Limited Waiver is a process to provide additional time to

10 Time Limited Waiver (TLW) complete Life Safety Chapter corrective actions Organizations that DO NOT use Joint Commission accreditation for deemed status purposes : Create a Survey-related Plan For Improvement (SPFI) Enter the requested date in the Scheduled Completion Date field When prompted, complete the Time Limited Waiver form Submit to the Joint Commission The Joint Commission will review the request Once the decision has been made the Department of Engineering enters the organization SPFI and accepts the new date After the Department of Engineering modifies the SPFI they will annotate the History Audit Trail Engineering Department A Time Limited Waiver is a process to provide additional time to

11 Statement of Conditions Equivalencies

12 CMS & Equivalencies deemed status purposes: Survey-related equivalencies will continue to be submitted to our offices The Engineering staff will work with the organizations until the request is acceptable Once the equivalency is considered acceptable the Joint Commission will forward the entire request to the CMS Regional Office (RO) for final decision The CMS RO will send a response to both the organization and Joint Commission If approved the History Audit Trail will be updated If denied, the organization will need to either correct the deficiency or re-submit a corrected equivalency Engineering Department Organizations that use Joint Commission accreditation for

13 CMS & Equivalencies Organizations that DO NOT use Joint Commission August 2016 Perspectives Engineering Department accreditation for deemed status purposes: Survey-related equivalencies will continue to be submitted to our offices The Engineering staff will work with the organizations until the request is acceptable Once the equivalency is considered acceptable the Joint Commission will respond to the organization in the History Audit Trail

14 Challenging Standards Top 10 Findings

15 Top 10 Findings Comparison Summary LS % 5 Manage systems for extinguishing fires LS % 6 Building and fire protection features EC % 3 Manage risk associated with Utility Systems IC % 2 Reduces risk of infections associated with equipment, devices and supplies EC % 1 Maintain a safe, functional environment LS % 6 Building and fire protection general requirements EC % 7 Manage risk associated with hazardous materials LS % 4 Manage the Means of Egress EC % - Inspects, tests, and maintains utility systems RC % 7 Maintain complete and accurate medical records Engineering Department Standard 2017 % 2016 Non-compl Rank iant

16 #1 LS % EP 4 Piping for the AASS is not used to support any other Engineering Department item.

17 #1 LS % EP 5 Sprinkler heads are not damaged. They are also free from corrosion, foreign materials, and paint and have necessary escutcheon plates installed. Dirty or corroded sprinkler heads Missing escutcheons EP 6 18 inches or more of open space maintained Engineering Department Gap greater than 1/8 scored

18 Perimeter Shelving 18 Inch Rule Perimeter Shelving Ceiling Wall OK Wrong OK OK Wall

19 #1 LS % EP 7 At least six spare sprinkler heads for each type of system, with associated wrenches, are kept in a cabinet that will not exceed 100 F. NFPA , The stock of spare sprinklers shall include all types and ratings installed and shall be as follows: One wrench as specified by the sprinkler manufacturer must be in the cabinet for each type of sprinkler installed for removal and installation list of the sprinklers installed needs to be posted in the sprinkler cabinet. Sprinkler Identification Number (SIN) General description Quantity of each type in the cabinet Issue or revision date of the list Engineering Department Under 300 = no fewer than to 1000 = no fewer than 12 Over 1000 = no fewer than 24

20 #1 LS % EP 7 At least six spare sprinkler heads for each type of system, with associated wrenches, are kept in a cabinet that will not exceed 100 F. NFPA , The stock of spare sprinklers shall include all types and ratings installed and shall be as follows: One wrench as specified by the sprinkler manufacturer must be in the cabinet for each type of sprinkler installed for removal and installation list of the sprinklers installed needs to be posted in the sprinkler cabinet. Sprinkler Identification Number (SIN) General description Quantity of each type in the cabinet Issue or revision date of the list Engineering Department Under 300 = no fewer than to 1000 = no fewer than 12 Over 1000 = no fewer than 24

21 #1 LS % EP 10 The travel distance from any point to the nearest Engineering Department portable fire extinguisher is 75 feet or less. Portable fire extinguishers have appropriate signage, are installed either in a cabinet or secured on a hanger made for the extinguisher, and are at least four inches off the floor. Those fire extinguishers that are 40 pounds or less are installed so the top is not more than 5 feet above the floor. Installation

22 #1 LS % EP 14 Meets all other Life Safety Code automatic extinguishing requirements related to NFPA Ceiling tiles misplaced in rooms Blocked access to fire extinguishers Blocked sprinkler spray pattern NFPA , Quick response sprinklers mixed with other types in patient sleeping smoke compartments Engineering Department Compartments defined differently in NFPA 13 and 101

23 #2 LS % to protect individuals from the hazards of fire and smoke. EP 2 and EP 3 Hazardous Areas Primarily door issues Latching Self-closing Penetrations Lack of identification on life safety drawings is at LS EP 3. Engineering Department The hospital provides and maintains building features

24 #2 LS % to protect individuals from the hazards of fire and smoke. EP 10 Penetrations in corridor smoke partitions EP 11 Corridor Doors Includes latching requirement of suite doors since they are considered corridor doors Roller latches not permitted CMS no longer permitting 5lbf. Suite door gaps at LS EP 23 EP 18 and 19 Smoke Barrier Management Engineering Department The hospital provides and maintains building features

25 #2 LS % to protect individuals from the hazards of fire and smoke. EP 18 and 19 Smoke Barrier Management Penetrations Door issues Gaps and undercuts If equipped with latching hardware scored at LS EP requires that existing life safety features obvious to the public but not required must be removed or maintained. Includes all latches and rods Engineering Department The hospital provides and maintains building features

26 #3 EC % EP 2 Maintaining a written inventory EP 3 Identifying high-risk equipment Primarily scored for temperature and humidity monitoring Critical spaces at EC EP 15 Organization s to define frequencies Ongoing does NOT mean constant Will survey to policy/procedure Engineering Department EP 4 Defining activities and frequencies

27 #3 EC % partial or complete emergency shutdowns. Note 1: Examples of utility system controls that should be labeled are utility source valves, utility system main switches and valves, and individual circuits in an electrical distribution panel. Note 2: For example, the fire alarm system s circuit is clearly labeled as Fire Alarm Circuit; the disconnect method (that is, the circuit breaker) is marked in red; and access is restricted to authorized personnel. Information regarding the dedicated branch circuit for the fire alarm panel is located in the control unit. For additional guidance, see NFPA : 18/ ; ; NFPA : Engineering Department EP 8 The hospital labels utility system controls to facilitate

28 #3 EC % EP 14 The hospital minimizes pathogenic biological agents Engineering Department in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems. Cooling towers Air handling units Potable hot/cold water systems Other aerosolizing water systems The typical method is treating the water in the cooling towers or open source locations.

29 #3 EC % EP 14 The hospital minimizes pathogenic biological agents Site survey to identify risk points o i.e. water towers Mitigation strategies o Water treatments o What to do if contamination occurs, such as secondary treatment Engineering Department in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems. ASHRAE Prevention of Legionellosis Associated with Building Water Systems Considered a best practice Provides guidance related to Legionella mitigation

30 #3 EC Bacteria, 90% of all Healthcare-Associated Infections (HAI) Legionella Over 30 different species; legionella pneumophila most common Transmission via aerosolization Tolerates temperatures up to 140o F; growth up to to 10 days to show symptoms Mycobacterium Non-tuberculous mycobacteria (NTM) Highly resistant to chemical disinfectants Engineering Department %

31 #3 EC % Causes Legionnaire s Disease Lengthy pipe runs Dead legs Cooling towers Fountains Showers Faucets Ice machines Water-based humidifiers Engineering Department Legionella

32 #3 EC % Be aware of Legionella treatment techniques Copper/Silver Not as effective in hard water applications Limited effectiveness for biofilm Chlorine Good for Legionella; fair to poor for biofilm control Corrosive and hazardous vapors High temperature (> 140⁰ F) Scalding Not effective for cold water systems Impact to corrosion, seals, and gaskets Engineering Department Excessive use corrosive to some piping

33 #3 EC % pressure relationships, air-exchange rates, filtration efficiencies, relative humidity, and temperature. What is the difference between EC EP 15 and EC EP 16? Criticality EC EP 15 is specific to areas designed to control airborne contaminants. Operating rooms, sterile storage, laboratory, etc. Adjacent area that can impact these areas (i.e. clean and soiled utility, environmental service closets, adjacent non-sterile corridors) Engineering Department Ventilation system is unable to provide appropriate

34 #3 EC % EP 15: Appropriate ventilation in critical care areas: Negative or positive pressures in relationship to Electronic Monitoring VaneOmeter Flutter Strip Testing Engineering Department adjacent areas Correct number of air changes per hour Filtration Temperature and Humidity Ongoing process for monitoring

35 #3 EC % EP 16 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided. i.e. doors held open by air pressure; odors Propping doors or lack of self-closing devices can impact air pressure relationship Temperature and Humidity o Can be managed through staff surveillance during the regular course of performing their duties. o Includes decentralized locations that include sterile supplies. o Knowledgeable staff should examine sterile supplies before use and contact facilities management personnel if space temperature and RH levels are determined to be inadequate. Engineering Department Ventilation:

36 Relative Humidity (RH) FGI Guidelines (2014) allows expanding the RH range Engineering Department from 35 60% to 20 60% RH > 35 % RH is based on NFPA , Section % RH is based on ASHRAE See EC EP 1 CMS S&C Hospital, CAH & ASC letter dated 2/20/2015 S&C LSC & ASC permits hospitals and CAH to use a LSC categorical waiver to establish

37 Relative Humidity (RH) 2/20/2015 stated S&C LSC & ASC permits hospitals and CAH to use a LSC categorical waiver to establish an RH level <35% in anesthetizing (i.e. OR) locations Before electing to use the categorical waiver hospitals and CAHs are expected to ensure the humidity levels in their ORs are compatible with manufactures instructions for use (IFUs) for supplies and equipment used in that setting Engineering Department CMS S&C Hospital, CAH & ASC letter dated

38 Survey Process EC CoP (c) referring specifically to NFPA for ventilation NFPA 99 refers to ASHRAE 170, Ventilation of Health Care Facilities, 2008 Endoscopy is required to be positive pressure Deemed vs. Non-deemed Engineering Department

39 Survey Process If the organization can repair the process that led to non-compliance the LSCS may review Following LSCS review, the LSCS may contact the Central Office to discuss the possibility of reducing the CLD to SLD, with no change to the finding Resolution should include the area affected by the equipment identified as non-compliant, not just the identified room/area i.e. ensure zone is balanced Is there an ongoing process to assess Engineering Department EC EP 15 will generate a CLD

40 #5 EC EP 1 68% EP 1 Interior spaces meet the needs of the patient Ligature/self harm risks (i.e. BHC) Current Risk Assessment and appropriate clinical mitigation State Rules and Regulations or Guidelines Evidence-Based Guidelines Design Guide for the Built Environment of Behavioral Health Facilities Veterans Association NY Office of Mental Health Designated vs. Non-designated Engineering Department population and are safe and suitable to the care, treatment and services provided.

41 #5 EC EP 1 68% EP 1 Interior spaces meet the needs of the patient Patient bathroom doors (full door, handles, hinges, latch) Patient bedroom doors (full door, handles, hinges, latch) Patient beds Is there a medical need? Same concept for medical equipment Exposed plumbing Sink and shower faucets Handrails Other mounted items in corridor (signs, lights, suggestion boxes, etc.) Engineering Department population and are safe and suitable to the care, treatment and services provided.

42 #5 EC EP 1 68% EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided. Dropped Ceilings Other doors and hardware (closets, corridor doors, fire/smoke doors) Common areas Self-closing and self-locking door Toilet seats Work with your clinical team on MITIGATION! Will still result in a finding, but will reduce the potential of an Immediate Threat to Life (ITL). Engineering Department

43 #5 EC EP 1 66% Nurse Call Requirements Wrapped, Length, or Missing Missing Location and Length EC EP 1 State rules and regulations 2014 FGI Guidelines or other reputable standards or guidelines. Where optional, TJC requires a risk assessment Length best practice is 4 to 6 inches Stained ceiling tiles Wall surfaces Flooring Engineering Department Inaccessible emergency pull cords

44 #6 LS % maintained to minimize the effects of fire, smoke, and heat. EP 1 Buildings meet requirements for construction type in accordance with NFPA , 18/ Missing fireproofing Fully sprinklered Elevator mechanical space Kitchen freezers AHJ Waiver must submit for an equivalency Engineering Department Building and fire protection features are designed and

45 #6 LS % Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. EP 5 Appropriate fire-rating for openings EP 7 Functioning hardware for fire-rated doors Latching Self-closing or automatic closing Gaps no more than 1/8 between pairs Undercuts no more than ¾ from the bottom NO blocking or wedging EP 10 Penetrations in fire walls Engineering Department Unapproved protective plates not greater than 16 inches

46 #7 EC % handling, storing, transporting, using, and disposing of hazardous chemicals. Personal protective equipment Emergency Showers and Eyewash Stations OSHA Reduce the risk of injury from contact with caustic and corrosive materials Risk Assessment OSHA recommends American National Standards Institute (ANSI) standard Z for installation and maintenance Engineering Department EP 5 The hospital minimizes risk associated with selecting,

47 #7 EC % Installation: Placed so that the eyewash is within 10 seconds or 55 feet from where the corrosive chemicals is used Tepid water Mixing valve or documentation to validate tepid water Risk assess potential exposure to determine if cold water only would be acceptable Maintenance: Weekly flush until clear is required Annual inspection to ensure the system is fully functional Engineering Department ANSI Z for installation and maintenance:

48 #7 EC % EP 8 Manage hazardous medication disposal risks Inventory EPA RCRA Segregated into toxic or ignitable P: includes epinephrine, nicotine, and warfarin U: includes cyclophosphamide, lindane, melphalan, and mitomycin C Heavy metals and mercury (i.e. vaccines, eye/ear drops, barium) Ignitable - > 24% alcohol Engineering Department

49 #7 EC % EP 11 Has permits, licenses, manifests, and safety data Cradle to Grave Responsibility Engineering Department sheets required by law and regulation. OSHA Hazard Communication Standard 29 CFR Department of Transportation (DOT) Title 49 for the Code of Federal Regulation, subchapter C Part 171 Training requirements for staff signing manifests Environmental Protection Agency (EPA), typically state level

50 #7 EC % EP 12: The hospital labels hazardous materials and waste. Pathological Transfer Containers Tissue Secondary Containers Chemotherapy Clear & Legible Material with trace Written in English chemo (<3%) No P and U-listed waste Engineering Department Labels identify the contents and hazard warnings* OSHA Bloodborne Pathogen Standards OSHA Hazard Communications Standards National Fire Protection Association (NFPA) See also IC , EP 6; IC , EP 3

51 #8 LS % EP 1 Doors in a means of egress are not equipped with at Engineering Department latch or lock that requires the use of a tool or key from the egress side. Unless permitted by one of the following: (1) Locking arrangements complying with (2) Delayed Egress (3) Access Controlled (4) Elevator lobby exit access door (5) Approved existing door-locking installations

52 #8 LS % : Where the clinical needs of patients require specialized security measures or where patients pose a security threat. Must meet : 1. Provisions for rapid removal of occupants by one of the following: a) Remote control of locks b) Keying of all locks to keys carried by staff at all times c) Other such reliable means available to the staff at all times 2. Only one locking device on each door 3. More than one lock, must be approved by AHJ Engineering Department Locking arrangements complying with :

53 60% Locking arrangements complying with : Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met: 1) Staff can readily unlock doors at all times in accordance with ) Smoke detection system throughout the locked space or locked doors can be remotely unlocked at a constantly attended location within the locked space. 3) Building is protected throughout by an supervised automatic sprinkler system. 4) Release upon loss of power 5) Release by activation of smoke detection and/or waterflow Engineering Department #8 LS EP 1

54 #8 LS EP 1 60% Special Locking Arrangements ensure they meet all of Delayed-Egress Locking Systems Allowed on door assemblies serving low and ordinary hazards in buildings protected by an approved automatic fire detection system OR and approved automatic sprinkler system. Door leaves shall unlock upon actuation of one of the following: Sprinkler system Not more than one heat detector Not more than two smoke detectors Loss of power controlling the lock or locking mechanism Engineering Department the requirements:

55 #8 LS EP 1 60% Special Locking Arrangements ensure they meet all of Delayed-Egress Locking Systems Irreversible process shall release the lock with 15 seconds (30 seconds where approved by AHJ) Force shall not exceed 15 lbf. Force shall not be required to be continuously applied for 3 seconds Audible alarm Relocking shall be my manual means only Sign Push Until Alarm Sounds Door Can Be Opened in 15 Seconds Egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting. Engineering Department the requirements:

56 #8 LS EP 1 60% Special Locking Arrangements ensure they meet all of Access-Controlled Egress Door Assemblies Electrical lock hardware that prevents egress, provided that ALL the following criteria are met: Sensor on egress side, arranged to unlock upon detection of approaching occupant. Loss of power to the sensor OR to part of the access control system that locks the door leaves Manual releasing device complying with ALL of the following: o Located on egress side 40 in. to 48 in. vertically above the floor, and within 60 in. of the secured door opening. Engineering Department the requirements:

57 #8 LS EP 1 60% Special Locking Arrangements ensure they meet all of Access-Controlled Egress Door Assemblies o Located on egress side 40 in. to 48 in. vertically above the floor, and within 60 in. of the secured door opening. o Sign Push To Exit o When operated it shall result in direct interruption of power to the lock and shall remain unlocked for not less than 30 seconds. Activation of the building fire-protective signaling system and/or automatic sprinkler system and remain unlocked until the system has been manually reset. Engineering Department the requirements:

58 #8 LS EP 1 60% Special Locking Arrangements ensure they meet all of Access-Controlled Egress Door Assemblies Activation of manual fire alarm boxes shall not be required to unlock. The egress side of access-controlled egress doors, OTHER than existing access-controlled egress doors, shall be provided with emergency lighting. (Different than delayed-egress!) Elevator Lobby Exit Access Door Assemblies Locking Engineering Department the requirements:

59 #8 LS % egress Anything in the egress corridor more than 30 minutes is storage Dead end corridors may be used for storage Less than or equal to 50 sq.ft. space Wheeled equipment allowed as long as all of the following is met: a) The unobstructed corridor width shall not be less than 60 inches in width b) Fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency. Engineering Department EP 13 The hospital maintains the integrity of the means of

60 #8 LS % Wheeled equipment allowed as long as all of the Engineering Department following is met: c) Wheeled equipment is limited to: i. In-use Equipment (i.e. isolation carts, etc.) ii. Medical emergency equipment not in use (i.e. crash carts, etc.) iii. Patient lift and transport equipment Fixed furniture allowances 8 foot corridor

61 #10 EC % EP 2 Testing of utility system components before initial use. components. High-risk Infection Control Non-high-risk Maintenance Lack of timely corrective action EC Generators Ventilation Blocked electrical panels Open junction boxes Engineering Department EPs 4 6 Inspects, tests, and maintain utility system

62 #10 EC % EP 7 The hospital meets all other HealthCare Facilities Code requirements for electrical distribution, HVAC, as related to NFPA : Chapters 6 and 9. General anesthesia EES critical branch Heating and cooling ASHRAE and Manufacturer s Instructions for medical supply and equipment Smoke control systems in supply and exhaust systems Prevents recirculation Operating rooms are considered wet locations unless risk assessment determines otherwise Wet Location = protected by isolated power or ground-fault circuit interrupters. Engineering Department for windowless locations

63 #10 EC % EP 7 The hospital meets all other HealthCare Facilities Code requirements for electrical distribution, HVAC, as related to NFPA : Chapters 6 and 9. Testing of hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered. Initial after installation Replacement Servicing Tamper-resistant Pediatric locations = patient rooms, bathrooms, play rooms, and activity rooms (does not include nurseries). Life safety and critical branch electrical receptacles are a distinctive color or marking. Engineering Department

64 EC Fire Drills quarter in each building defined as a health care occupancy by the Life Safety Code. The hospital conducts quarterly fire drills in each building defined as an ambulatory health care occupancy by the Life Safety Code. Note 1: Evacuation of patients during drills is not required. Note 2: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms. Note 3: In leased or rented facilities, drills need be conducted only in areas of the building that the hospital occupies. Engineering Department EP 1: The hospital conducts fire drills once per shift per

65 EC Fire Drills EP 3: When quarterly fire drills are required, at least 50% Engineering Department are unannounced. Fire drills are held at unexpected times and under varying conditions. Fire drills include transmission of fire alarm signal and simulation of emergency fire conditions. Note 1: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms. Note 2: For additional guidance, see NFPA : 18/19: 7.1.7; 7.1; 7.2; 7.3.

66 EC Sterilizers EP 4: The hospital conducts performance testing of and Engineering Department maintains all sterilizers. These activities are documented. (See also IC , EP 2). Manufacturer s Recommendations Cleaning Procedures End User managing Daily, weekly, monthly, quarterly, etc.

67 LS Monthly Fire Fighter Recall Testing EP 2: NFPA , All elevators equipped with Engineering Department fire fighters recall shall be subject to monthly operation with a written record.

68 EC Annual Inspection and Testing of Fire/Smoke Barrier Doors EP 25: Written documentation of annual inspection and Start surveying January 1, 2018, CMS S&C Fire and Smoke Door Assemblies Corridor doors that are not required to be fire doors or smoke door assemblies (for example, patient room doors) are not subject to the NFPA annual inspection and testing but should be routinely inspected as part of the organization s facilities maintenance program. Engineering Department testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested.

69 Doors to be included in the annual door inspection (based on ) include the following: Doors equipped with panic hardware or fire exit hardware in accordance with Door assemblies in exit enclosures Electrically controlled egress doors Door assemblies with special locking arrangements subject to The Joint Commission does not require the following doors to be included in the annual door inspection: Corridor doors (for example, patient room doors) Office doors (provided that the room does not contain flammable or combustible materials) Engineering Department EC Annual Inspection and Testing of Fire/Smoke Barrier Doors

70 EC Annual Inspection and Testing of Fire/Smoke Barrier Doors Per NFPA , Section , existing fire protection features obvious to the public, if not required by the code, shall be either maintained or removed. Therefore, doors shall be maintained as per the barrier assembly requirements, but in cases where a fire-rated door is used in a nonrated barrier assembly, the fire door must be maintained as a fire door unless the features that identify it as a fire door have been removed in a manner that maintains the opening protective requirements applicable to the barrier into which it is installed. If a 90-minute fire-rated door were installed in an existing smoke barrier, the door would need to be annually inspected and tested as a fire door and the smoke barrier maintained as a smoke barrier. If the 90-minute door were modified to remove all fire door hardware (such as the bottom rod and floor receiver) and labeling and repaired as a smoke barrier door (see NFPA , 5.1.4), the door could be annually inspected and tested as a smoke door. Engineering Department

71 Engineering Department the_physical_environment.aspx

72 Engineering Department Questions

73 Department of Engineering George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt Director Andrea Browne, PhD., DABR John Maurer, CHFM, CHSP, SASHE Medical Physicist Interim Director, Engineer Herman McKenzie, MBA, CHSP Kathy Tolomeo, CHEM, CHSP Engineer James Woodson, P.E., CHFM Kate Dolezal Engineer Technical Coordinator Engineering Department Engineer

74 The Joint Commission Disclaimer 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 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 These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission Engineering Department These slides are current as of 9/11/2017.