TOPICS IN CODE ENFORCEMENT

Transcription

1 TOPICS IN CODE ENFORCEMENT CAHED SE DISTRICT MEETING FEBRUARY 17, 2017 Mark Jelinske Cator, Ruma, and Associates

2 TALKING POINTS Conducting Surveys on NFPA 2012 as of Nov CMS Surveyor Guidelines being developed New CMS rules on Emergency Management Enforcement of ASHRAE 170 addenda Fire Watch Stand Alone ED vs Urgent Care 2012 NFPA 99 requirements for Med Gas systems specifically related to existing systems 2012 NFPA 99 Risk Categories

3 TALKING POINTS Zoning of Fire Alarm and Sprinkler with Smoke Compartments and Facility Fire Plan Silencing of Fire Alarm Visible AND Audible CMS K-Tags 2012 NFPA 101 CH 43 requirements for repairs, renovations, modifications, and reconstruction Decommissioning of Anesthetizing Location Smoke Evac N2O in patient rooms (LDR in particular) Door Locking Schemes

4 TALKING POINTS Sterile Core as Storage and Sterile Supply Fire Door Inspections and Labels Power Strips CDPS Permitting Process Resources available through CDPS and ASHE websites

5 CMS Emergency Preparedness Requirements Effective date is November 15, 2016 Implementation date is November 15, 2017

6 CMS Emergency Preparedness Rule Applies to 17 provider types Covers 5 key elements 1. Emergency planning and risk assessment 2. Policies and procedures 3. Communication plan 4. Training and testing 5. Emergency standby power system

7

8

9

10 Major implications If you are Joint Commission accredited or comply with NFPA 99 EM requirements: 28% of CMS requirements are met 35% of CMS requirements evaluate your policies and plans to be sure of compliance 37% of CMS requirements could require relocating existing information or adding new

11 NFPA 99 RISK CATEGORIES 4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers 4.1.2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort Category 4. Facility systems in which failure of such equipment would have no impact on patient care

12 NFPA 99 RISK CATEGORIES

13 NFPA 99 RISK CATEGORIES EFFECT ON EMERGENCY POWER Essential Electrical Systems (EES) Critical care rooms (Category 1 Room) shall be served only by a Type I EES General care rooms (Category 2 Room) shall be served by a Type I or Type II EES Basic care rooms shall not be required to be served by an EES Rooms other than patient care rooms shall not be required to be served by an EES.

14 NFPA 99 RISK CATEGORIES * Patient Care Room. Any room of a health care facility wherein patients are intended to be examined or treated * Basic Care Room. Room in which the failure of equipment or a system is not likely to cause injury to the patients or caregivers but can cause patient discomfort (Category 3) * Critical Care Room. Room in which failure of equipment or a system is likely to cause major injury or death of patients or caregivers (Category 1) * General Care Room. Room in which failure of equipment or a system is likely to cause minor injury to patients or caregivers (Category 2) * Support Room. Room in which failure of equipment or a system is not likely to have a physical impact on patients or caregivers (Category 4).

15 NFPA 99 RISK CATEGORIES Governing Body of the Healthcare Organization Responsible For: Risk Analysis Room Type Classification, Designating Wet Procedure Locations Designating Anesthetizing Locations

16 NFPA 99 EXISTING MEDICAL GAS

17 NFPA 99 EXISTING MEDICAL GAS 2012 NFPA 99, TIA 12.4 Labeling, Room Signage, Gas cylinder handling, Cylinder Temperature, Relief Valves vented to outside Dedicated Locked, Rated, Indirect Heated, Cylinder storage No motor driven machinery in Cylinder Room Can t have reserve Medical Air Cylinders in same room as Medical Air compressor Instrument air cylinders/compressor OK Permitted uses for medical air Automatic or manual alternation for equal runtime

18 NFPA 99 EXISTING MEDICAL GAS 2012 NFPA 99, TIA & Operations & Management, Maintenance Maintenance Programs Inspection and Testing Staff Qualifications Record Keeping Breaches

19 NFPA 99 EXISTING MEDICAL GAS Can always be cited for not meeting code at time of construction 1999 version or earlier. Can t (Shouldn t) be cited for new requirements. Additions/Revisions only affected portions Valve Locations? Gauges? Ventilation? Vac Pump Oxygen compatibility?

20 CMS K-TAGS

21 FIRE WATCH FIRE ALARM -out of service for more than 4 hours in a 24-hour period FIRE SPRINKLER - out of service for more than 10 hours in a 24-hour period DFPC acknowledges website needs updating 15 Min interval most Hospitals, LTC No other duties Facility Administrator s or Owner s Responsibility CDPS Fire Watch Requirements

22 Stand Alone ED vs Urgent Care Occupancy? NFPA 101 CH 18 Healthcare on an inpatient basis NFPA 101 CH 20 Ambulatory Healthcare on an outpatient basis CMS trigger is one, not four incapable of self preservation IBC B with Section 422 Ambulatory Healthcare Less than 24 hour basis IBC I2 More than 5 Persons on a 24 hour basis Licensing and Reimbursement may override Fire Resistive Construction FGI and ASHRAE 170 NFPA 99 Risk Categories

23 FIRE ALARM/SPRINKLER 2012 NFPA , Defend-in-place Fire Alarm notification zone coincide with smoke compartments Sprinkler zones coincide with smoke compartments Or in compliance with the Facility Fire Plan 2010 NFPA Both audible and visual must silence This bothers some FDs for Defend In Place Hardware and software issues Old vs New systems CDPS tries to work this out with FDs

24 Fire Door Inspections and Labels Annual Fire Door Inspection in accordance with NFPA 80. Reference: Inspecting-Swinging-Fire-Doors--P15879.aspx?icid=D538 De-rated Fire Doors Facilities are constantly updated, and Life Safety Plans/Statement of Conditions need to keep up with changes You do this, right? NFPA Life Safety features obvious to the public, but no longer required shall be maintained or removed Healthcare Interpretation Task Force (HITF) addressed this Doors no longer required to be rated can have the label removed NOTJUST COVERED

25 Power Strips CMS K Tag K920 Electrical Equipment Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of Power strips in the patient care vicinity may not be used for non PCREE(e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL Power strips for non-pcree in the patient care rooms (outside of vicinity) meet UL In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of (NFPA 99), (NFPA 99), (NFPA 70), 590.3(D) (NFPA70), TIA 12-5

26 CDPS RESOURCES Division of Fire Prevention and Control Website DFPC Health Facility Rules LSC Fire Watch Policy Permit Plan Review Application Guide Plan Review Instruction Sheet Pre-Construction Meeting Request Permit Plan Review Application

27 CDPS RESOURCES Health Facility Information Sheet Limited Scope Project List Fee Calculator Plan Review Local Fire & Building Signoff Form Health Facility Inspection Request Permit Shipping Request Memorandum: Life Safety Code Time Limited Waiver Guidance for Submission Emergency Preparedness (CDPHE)

28 ASHE RESOURCES Focus on Compliance CMS Emergency Preparedness Rule Webinar /cms-emergency-preparedness-rule.shtml CHC Community Hazard Vulnerability Analysis Tool Management Tools

29 Utility systems (EC ) (posted on focus site) Means of egress (LS ) (posted on focus site) Built environment (EC ) (posted on focus site) Fire protection (EC ) (posted on focus site) Building and Fire Protection Features (LS ) Life safety protection (LS ) Automated suppression systems (LS ) (Aug./Sept.) Hazardous materials and waste management (EC ) (Oct./Nov. 2016)

30 CMS Adoption of the 2012 Life Safety Code and Health Facilities Code, Video produced by ASHE