EXPLORING LIFE SAFETY COMPLIANCE FOR HEALTH CARE

Transcription

1 2016 EXPLORING LIFE SAFETY COMPLIANCE FOR HEALTH CARE James Woodson, Engineer Engineering Department The Joint Commission HOSPITAL BREAKFAST BRIEFINGS PART 6 Disclosure Statement The following staff and speakers have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: James Woodson Leslie LaBelle George Riccio Steve Chinn 2 The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products. Department of Engineering PUBLICATIONS AND RECORD RESTRICTIONS The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited. Department of Engineering

2 PUBLICATIONS AND RECORD RESTRICTIONS 4 Copyright 2016 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 W. 22 nd Street, Suite 1300W, Oak Brook, Illinois, Department of Engineering Expectations Unannounced Survey Life Safety Code Surveyor Life Safety Building Tour Review any approved equivalencies or waivers Current Documentation EC Management Plans EC/Safety Committee Minutes Annual Evaluations of EC Plans Department of Engineering Tracer Methodology Unannounced Survey Clinical Surveyor Start Tracer and Follow Patient Process Sample Patient Waiting Room Security Environment Medical Equipment Ventilation Procedure Room Exam Room Infection Control Life Safety Department of Engineering

3 IMMEDIATE THREAT TO LIFE ITL Triggers in the Physical Environment Significantly compromised fire alarm system Significantly compromised sprinkler system Significantly compromised emergency power supply system Significantly compromised medical gas master panel Significantly compromised exits Other situations that place patients, staff or visitors at extreme danger Department of Engineering STANDARDS NFPA EFFECTIVE JULY 5, 2016 The NFPA created a series of codes to provide guidance in building and maintaining buildings CMS adopted this body of codes, incorporating them into their COP as K-Tags The Joint Commission has also recognized the NFPA body of codes The Life Safety Chapter is based on NFPA In the Environment of Care several other NFPA codes are referenced, including: NFPA , Standard for Portable Fire Extinguishers NFPA , Standard for Water-based Systems ITM Activity NFPA , Fire Alarm Code NFPA , Health Care Facilities Code Department of Engineering IMPACT OF CMS ADOPTION CMS S&C Life Safety Code (NFPA ) Chapter 2 Mandatory References Chapter 18 (new) Chapter 19 (existing) Tentative Interim Amendments (TIA) NFPA 101: 12 1 (Ch 8), 12 2 (Ch 18/19), 12 3 (Ch 17), and 12 4 (Ch 19) NFPA 99: 12 2 (Ch 9), 12 3 (Ch 6), 12 4 (Ch 5), 12 5 (Ch 10) and 12 6 (Ch 11)

4 IMPACT OF CMS ADOPTION From July 5 to November 1, 2016 IN INSTANCES WHERE THE SURVEY PROCESS IDENTIFIED DEFICIENCIES THAT WOULD BE COMPLIANT UNDER THE 2012 LSC, A FACILITY MAY VERIFY COMPLIANCE WITH THE 2012 LSC AS AN ACCEPTABLE PLAN OF CORRECTION AND THE DEFICIENCY WOULD NOT BE CITED. After November 1, 2016 Compliance with 2012 LSC LS Assigns an individual to assess compliance with the Life Safety Code, and manage the Statement of Conditions (SOC) when addressing survey-related deficiencies. Current and accurate life safety drawings. In timeframes defined by the hospital, the hospital performs a building assessment to determine compliance with the Life Safety Chapter. Department of Engineering LS Existing life safety features obvious to the public must be either maintained or removed ( ). When the hospital plans to resolve a deficiency through a Survey-Related Plan for Improvement (SPFI) the hospital meets the 60-day time frames. NOTE: If the corrective action will exceed the 60-day time frame the organization must request a Time Limited Waiver Department of Engineering

5 STATEMENT OF CONDITIONS CHANGES AS OF AUGUST 1, 2016 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. RETIREMENT OF PLANS FOR IMPROVEMENT CMS requires 60-day or less corrective action plan for deficiencies found during survey CMS, as the Governing Body, requires control of corrective plan timelines that exceed 60-days CMS will only respond to deficiencies discovered during survey not a proactive process Therefore The PFI process is no longer a viable tool Department of Engineering PFI: A PROACTIVE PROCESS When a Life Safety Code deficiency is found during survey it results in a survey action: If the organization has a PFI already identifying the deficiency, the finding (RFI) is not written All open PFIs will be imported into the final survey report No ESC required as the PFI has the Projected Completion Date already identified If the organization does not have a PFI identifying the deficiency, then a finding is written as a RFI Department of Engineering

6 IMPACT OF (D) ON PFI The PFI Process is now an optional management program made available to the accredited organizations PFIs are no longer reviewed as part of survey Do not show PFI s to the Surveyors All open PFIs are no longer considered when a Life Safety Chapter deficiency is identified See it, Cite it The Open PFIs will no longer be imported into the Final Report Department of Engineering SURVEY-RELATED DEFICIENCIES All survey-related deficiencies are to be cited as RFIs All survey-related deficiencies are to be corrected within 60-days from the end of survey If additional time is required the organization must submit a Time Limited Waiver This is managed in Salesforce, and a notification is sent to the organization affirming the TLW request submittal This notification will be used if a MEDDEF or ESC review occurs as Evidence of Compliance (ESC) Department of Engineering SURVEY-RELATED PLAN FOR IMPROVEMENT For those survey related deficiencies that may take greater than 60 days the organization will need to create a SPFI within 45 days This initiates the Time Limited Waiver request process The Survey-related Plan For Improvement will change colors as they mature Blue at 30 days before the Scheduled Completion Date (SCD) Yellow at 15 days before the SCD Failure to complete the SPFI on time will result in an AFS action Department of Engineering

7 SUMMARY IMPACT OF (D) The SPFI/TLW requested Scheduled Completion Date is a not to exceed date The Open PFI section of the Final Report will be removed The surveyor will no longer review and accept open PFIs The PFI component becomes a management program for the organization to use without survey involvement Department of Engineering STATEMENT OF CONDITIONS Not Surveyed Basic Building Information (BBI) Plan for Improvement (PFI) Surveyed Survey Plan for Improvement (SPFI) Time Limited Waiver (TLW) Department of Engineering EXTENSIONS ARE NO LONGER GRANTED GRACE-PERIODS ARE NO LONGER ALLOWED EXTENSIONS OR GRACE-PERIODS Department of Engineering

8 TO MANAGE DEFICIENCY CORRECTIONS All survey-related deficiencies are to be corrected within 60-days from the end of survey.or TIME LIMITED WAIVER The SPFI tool will guide the organization through the TLW process. SIG-Engineering submits TLW to CMS Regional Office for approval. Department of Engineering NON-DEEMED STATUS ORGANIZATIONS Same SPFI / TLW / Equivalency process. SIG-Engineering replaces CMS Regional Office as the approver. Department of Engineering EQUIVALENCIES / WAIVERS ONLY SURVEY-RELATED EQUIVALENCIES / WAIVERS WILL BE PROCESSED Department of Engineering

9 LS INTERIM LIFE SAFETY MEASURES CHANGES July 1, 2016 EP Re-order August 1, 2016 Inclusion into SPFI Process CHANGES Add ILSM Wildcard LS When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital either evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. (For full text, refer to , and NFPA : ) Department of Engineering CREATING A NEW SPFI WITH ILSM ASSESSMENT Department of Engineering

10 CATEGORICAL WAIVERS Previous 2000 LSC Categorical Waivers are now part of the adopted 2012 LSC CMS S&C Openings in Exit Enclosures Doors locking arrangements Suites Clean Waste & Patient Record Recycling Containers CMS S&C Wheeled Equipment and Fixed Furniture Alternative Type Cooking Arrangements Fireplace allowances Combustible Decoration Density Allowances Department of Engineering LS BUILDING AND FIRE PROTECTION FEATURES Minor design detail changes Cannot reduce features below New Occupancy requirements (Ch 18) Chapter 43 Building Rehabilitation Repair Renovation Modification Reconstruction Change of use Addition Department of Engineering LS MEANS OF EGRESS Mechanical Room open to an Exit Stair (CW 13-58) Use NFPA (9)(c) Appropriate entry door fire rating Sprinklered room Non-fuel-fired mechanical equipment No combustible storage Department of Engineering

11 LS MEANS OF EGRESS Delayed-Egress Door Locks NFPA Access-Controlled Egress Door Locks NFPA Elevator Lobby Door Locks (new provision) NFPA Department of Engineering LS MEANS OF EGRESS Special Locking Arrangements (CW 13-58) Expands Clinical Needs Applications Patient pose a security risk (Emergency Dept) Patient requires specialized protective measures (pediatric units) Total (complete) smoke detection all rooms Sprinkler protected 18/ (TIA 12-4) If electronic keys are used by staff as other reliable means, the system must be connected to emergency power with no interruption (UPS) Department of Engineering LS MEANS OF EGRESS Horizontal sliding doors serving an occupant load of fewer than 10 Non-suite ICU s or Emergency Department Swinging breakout feature not required Latch that prevents rebounding At least 2 Exits from any smoke compartment Access to exits can be through adjacent smoke compartments, but not the same smoke compartment Dead-End corridors not exceeding 30-ft Existing ok if a hardship to alter Department of Engineering

12 LS MEANS OF EGRESS (CW 12-21) Corridor allowances for Wheeled Equipment Unobstructed corridor at least 5-ft Emergency actions described in fire response plan In-use wheeled equipment < 30-min, medical emergency, lift/transport Corridor allowances for Fixed Furniture Constructed width at least 8-ft With furniture, unobstructed at least 6-ft on just one side of the corridor Sprinklered smoke compartment Secured to wall/floor; check 18/ for spacing Department of Engineering LS MEANS OF EGRESS Suites (18/ ) (CW 13-58) Distinguishes Patient sleeping, Patient non-sleeping, Non-patient care Patient sleeping suites when constructed and operated appropriately, in increments up to 5,000 SF, 7,500 SF and 10,000 SF Non-patient egress provisions in accordance with its use Exit access allowances when more than one suite exit 1 must be Exit access corridor or Horizontal exit Other can be Exit stair, Outside, Suite-to-suite allowances Total (complete) smoke detection all rooms Department of Engineering LS PROTECTIVE FEATURES Cooking allowances with detail provided Commercial NFPA 96 Residential-type for 30 or fewer persons (CW 12-21) Fire detection/suppression/extinguishment requirements, ventilation, no deep-fat frying, no solid fuel ABHR deployment requirements No change, but detail provided Guidance: Life Safety Code Information & Resources information_resources/ Department of Engineering

13 LS PROTECTIVE FEATURES Hazardous rooms Collected trash and soiled linen with content exceeding 64-gallons (minimum added) Gift shops removed from hazardous room requirements < 500 SF open to corridor allowance remains Corridor doors Protective plate restrictions removed Powered door allowances 5 ft-lb closure force and remains closed Department of Engineering LS PROTECTIVE FEATURES Spaces open to Corridor (18/ ) Review type, size, feature and operational restrictions Every Patient Sleeping Room must have an outside window or outside door Requirement removed in 2012 LSC, but Requirement restored by CMS Department of Engineering LS FIRE ALARM Provisions for Positive Alarm Sequencing Up to 3-minute fire alarm investigation Still attend to Fire alarm panel circuit breaker is red Circuit identification at the fire alarm panel Unobstructed FA pull stations Department of Engineering

14 LS FIRE EXTINGUISHING Exceptions for fully sprinklered buildings and smoke compartments ( ; not Ch 18) Sleeping suite, Special door locking Supervised sprinkler system connected to fire alarm Exceptions for fully sprinklered buildings and smoke compartments ( ; not Ch 18) Fixed furniture, Sleeping suite, Spaces open to corridor Supervised sprinkler system connected to fire alarm Quick-response or listed residential sprinklers throughout Department of Engineering LS FIRE EXTINGUISHING Sprinkler requirements based upon construction type Patient sleeping room Closet sprinklers Required if exceeds 6 SF Still attend to 18-inch storage rule Escutcheon plates Accessible fire extinguishers Spare sprinkler heads Department of Engineering LS SPECIAL FEATURES High-rise building requirements Sprinkler installation deferred until 12-years after code adoption (2028) or per Ch 43 during building rehabilitation Department of Engineering

15 LS BUILDING SERVICES Fire safety for Electrical, HVAC, Elevators, Chutes Existing systems can continue in service unless they present a serious hazard to life Fireplace allowances (CW 12-21) Existing laundry chutes permitted to discharge into the same room as rubbish discharge chutes if sprinklered Department of Engineering LS OPERATING FEATURES Flame propagation requirements not applicable to patient sleeping room window drapes in sprinklered smoke compartment Clear drapery, furniture and mattress provisions Decorations / Postings / Artwork based upon Flame retardant NFPA 701 or NFPA 289 Wall/ceiling coverage allowance versus sprinklered 96-gallon recycling clean waste allowance FM 6921 constructed or equivalent Department of Engineering KEY POINTS Most changes are allowances not prohibitions Pay attention to Locking arrangements Clutter and storage Door maintenance Attend to fire-rated and smoke barrier walls Sprinkler system condition Deployment trash containers Train in-house staff and select competent, reliable contractors Department of Engineering

16 BUILDING MAINTENANCE PROGRAM Not required, but an effective compliance tool Inspect Life Safety Code building features Fire-rated barriers Fire-rated doors Means of Egress integrity / illumination Smoke barriers Smoke barrier doors BUILDING MAINTENANCE PROGRAM Performance Requirements: a. FRRA & Corridor Doors: properly functioning positive latching devices. b. FRRA & Smoke Barrier Doors: properly functioning self-closing or automatic closing devices. c. FRRA Doors: </= 1/8" gaps between meeting edges of door parts. d. FRRA doors: </= 3/4" undercuts. e. Smoke Barrier & Corridor doors: maintained to prevent the spread of smoke. f. FRRA & Smoke Barrier Doors: appropriate labeling on doors and frames (as applicable); readable labels; structural integrity. g. Exit Door: Insure proper operation and unhampered egress. Automatic sliding doors: verify proper operation of break-out feature. Inspect Initials Floor Asset No. Performance Check FRRA Smoke Architect No. Corridor a b c d e f g (Fire) Barrier Description Leafs FRRA Rating Notes 1 G DOOR- A0051 -F1 Storeroom (Education Ctr) Single 1 hr FRRA within smokecompartment GA 2 G DOOR- A0042 -F1 Storeroom (Education Ctr) Single 1 hr FRRA within smokecompartment GA 3 G DOOR- A0039 -F1 Storeroom (Bed 1) Double 1 hr FRRA within smokecompartment GB; auto Performance Requirements: ops. 4 G DOOR- FRRA A0040& Corridor -F1 Doors: -C properly functioning positive Storeroom (Bed 2) Single 1 hr FRRA within smokecompartment GB a. latching devices. 5 G DOOR- A0005 -F2 Mechanical Room; Elevator #7 Single 1-1/2 hr FRRA within smokecompartment GB FRRA & Smoke Barrier Doors: properly functioning self-closing or automatic 6 G DOOR- A0006 -F1 TV Closet Single 1 hr FRRA within smokecompartment GB b. closing devices. 7 G DOOR- FRRA A0010Doors: -F1</= 1/8" gaps between meeting edges of door Electrical Room (northwest) Single 1 hr FRRA within smokecompartment GB c. parts. 8 G DOOR- A0013 -F1 -S -C IT Room (northwest) Single 1 hr FRRA smoke compartment separation FRRA doors: </= 3/4" GB/GC 9 G DOOR- d. undercuts. A0016 -F1 -C Conference Room; Plano A Single 1 hr FRRA within smokecompartment GB; mag hold open. 10 G DOOR- Smoke A0017 Barrier -F1 & Corridor -C doors: maintained to prevent the spread Conference Room; Plano B Single 1 hr FRRA within smokecompartment GB; mag e. of smoke. hold open. 11 G DOOR- A0018 -F1 -C Conference Room; Physician's Single 1 hr FRRA within smokecompartment GB 12 G DOOR- f. FRRA A0019& Smoke -F1 Barrier Doors: -C appropriate labeling on doors and Lounge; frames Physician's(as applicable); Singlereadable 1 hr FRRA labels; within smokecompartment structural integrity. GB 13 Exit Door: Insure proper operation and unhampered egress. Automatic sliding doors: verify proper operation of break-out G DOOR- A0020 -C Restroom; Staff Single na g. feature. 14 G DOOR- A0021 -C Restroom; Staff Single na 15 G DOOR- A0022 -C Lounge; Staff Single na 16 G DOOR- A0023 -S -C Electrical Room (Kitchen) Single na within smokecompartment GB SURVEY RESOURCE To prepare for Building Tour This resource is located on The Joint Commission website at jointcommission.org/life_safety_code_ information_resources/ Department of Engineering

17 RESOURCES Joint Commission Physical Environment Portal (JCPEP) Most-scored standards Links to ASHE compliance tools jointcommission.org/topics/the_physical_ environment.aspx Page 1 of 2 Department of Engineering THE JOINT COMMISSION DISCLAIMER These slides are current as of 9/26/2016. 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. Department of Engineering

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