10/25/2018. Facilitators. Emergency Preparedness &Life Safety Code for Administrators. Participant Guide

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1 Emergency Preparedness &Life Safety Code for Administrators 1 Participant Guide Emergency PreparednessHandouts Graphic Organizer Sample Checklist for Emergency Preparedness Regulation Compliance Crosswalk and References Regulation Numbers by Provider Type Life Safety Handouts NFPA Handbook Page Sample CMS Form 2786R page sample and form 2 Facilitators Duane Van Beek Deborah Ward 3 1

2 1. Describe the 4 required basic elements of the Emergency Preparedness regulation and the 2 additional requirements for Long Term Care facilities 2. Describe fundamental requirements of the Life Safety Code (LSC) and the chapters that reference new and existing facilities 3. Evaluate compliance and survey readiness for both Life Safety and Emergency Preparedness Session Objectives 4 Activity Graphic Organizer 5 Helpful Considerations Handout 6 2

3 Landmark Events the Precipitated theemergency Preparedness Rule September 11, 2001, Terrorist Attack Hurricane Katrina Superstorm Sandy Infectious Disease Outbreaks (e.g., Ebola, Zika) 7 Emergency Preparedness: Rationale and Regulation Establish national emergency requirements Plan for natural and manmade disasters Coordination with emergency preparedness systems Meet the needs of all patients, residents, clients, and participants 8 Maintaining Access to Health Care inemergencies Safeguarding human resources Maintaining business continuity Protecting physical resources 9 3

4 Final Rule Requirements Effective date of regulation was November 15, 2016 Required implementation date was November 15, 2017 All provider types must have an Emergency Preparedness Program consisting of 4 elements: 1. Risk Assessment and Emergency Planning 2. Policies and Procedures 3. Communication Plan 4. Training and Testing 10 LTC have 2 additional requirements Risk Assessment and Emergency Planning Policies and Procedures Communications Plan Training and Testing Emergency and Standby Power Integrated Health Care Systems 42 CFR Long Term Care Reg Reference 11 Required compliance for the followingproviders: 1. Religious Nonmedical Care Institutions 2. Ambulatory Surgical Centers 3. Hospices 4. Psychiatric Residential Treatment facilities 5. Programs of All Inclusive Care for the Elderly 6. Hospitals 7. Transplant Centers 8. Intermediate Care Facilities for individuals with Intellectual Disabilities 9. Long Term Care Facilities 10. Home Health Agencies 11. Critical Access Hospitals 12.Comprehensive Outpatient Rehabilitation Facilities 13.Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech Language Pathology Services 14.Community Health Centers 15.Organ Procurement Organizations 16.Rural Health Clinics & Federally Qualified HealthCenters 17.End Stage Renal Disease Facilities 12 4

5 Regulatory Purpose Anticipate and plan for needs Rapidly respond as a facility Integrate with other entities Rapidly recover after disaster 13 Six Elements of an Emergency PreparednessProgram for Long Term Care Facilities 1 EmergencyPlan 2 Policies and Procedures 3 Communication Plan 4 Training and Testing T 5 Emergency and Standby Power 6 Integrated Health Care Systems 14 Emergency Preparedness Program Element 1: Emergency Plan An emergency plan reviewed and updated at least annually to meet the following requirements Based on a documented risk assessment of Facility Community Includes strategies to address identified emergency events Addresses resident population Includes process for cooperation and collaboration with other entities 15 5

6 Facility based Risk Assessment... Beyond your 4 walls Care related emergencies Equipment/utility failures Communication interruptions, including cyberattacks Loss of all or a portion of a facility Interruptions to normal supply of essential resources 16 Community based Risk Assessment Community in context Not the same as typically thought of a community Not defined in regulation Determined by facility Health care community State or multistate regional area May use assessment developed by others 17 Mitigation Strategies Required Identify potential events Base on risk assessments Locale Community 18 6

7 Emergency Preparedness Program Element 2: Policies and Procedures Based on Emergency Plan and Communication Plan Reviewed and updated at least annually Aligns with identified hazards Maintain emergency preparedness documents in central location 19 8 Required Components 1. Subsistence Needs 2. Staff and Resident Tracking System 3. Facility Evacuation 4. Shelter in Place 5. Medical Documentation 6. Use of Volunteers and Others 7. Arrangement with LTC s and Others 8. Waivers 20 Emergency Preparedness Program Element 3: Communications Plan Written communication plan required Reviewed and updated at least annually 8 components and Contact Information Primary and Alternate Communication Information Sharing Method for Releasing Resident Information Method for Providing Condition and Location of Residents Communication with Incident Command Center Sharing Emergency Plan with Residents and Families 21 7

8 Emergency Preparedness Program Element 4: Testing & Training Develop and maintain EP training and testing program based on: The emergency plan Policy and procedures Communication plan Annual review and update T 22 Training Program Components A training program must include: 1. Initial training 2. Annual training (at least) 3. Documentation of training 4. Demonstration of staff knowledge T 23 Testing Part 1: Full Scale Community Exercise Contact local and state agencies, healthcare coalitions: Determine availability to participate in full scale community exercise If unable must document Date, personnel and agency/healthcare contacted T If unavailable, must conduct facility wide exercise 24 8

9 Testing Part 2: Additional Exercise Options Second full scale community exercise or facility exercise Facilitator led table top exercise T 25 Emergency & StandbyPower Life Safety Code compliance is a minimum Emergency plan regulation requires emergency and standby power based on: The emergency plan Risk assessment Policies and procedures 26 Required Components if Generator Required Location Inspection and testing Fuel 27 9

10 Integrated Health Care Systems (IHCS) Integrated Health Care Systems (IHCS) consists of multiple separately certified healthcare facilities Using a unified and integrated emergency preparedness program 28 IHCS Requirements IF facility part of an IHCS, each facility must: Actively participate in development of plan Account for unique circumstances, patient population and services offered Demonstrate compliance and capability of using the Emergency Preparedness Program 29 Sample Emergency Preparedness Checklist 30 10

11 Checklist Categories 1. Required documentation 2. Interview questions Facility leadership Staff Resident and family representative 3. Six elements of emergency preparedness for LTC 31 Life Safety Code 32 LSC History Timeline Tragic Fires LSC Action 33 11

12 Fatal Healthcare Fire Greenwood Health Care Center, Hartford, CT February 26, deaths 34 Greenwood Health Care Center The building is a 1 story, Type II (111), protected noncombustible structure with a partial basement built in A 30 bed addition of similar construction type was constructed in The building has a wood frame ornamental mansard roof. A new Acute Care Unit with 21 beds was added in July 1994 by renovating the existing 800 Wing. The 800 Wing has a piped in medical gas and vacuum system. 35 EXIT EXIT EXIT SMOKE BARRIERDOOR SMOKE BARRIERDOOR 36 12

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26 76 State of Connecticut Department of Public Health Division of Health Systems Regulation Building & Fire Safety Unit 410 Capitol Ave Hartford, CT f Steven J. Longo Health Services Fire Safety & Construction Unit Supervisor steven.longo@po.state.ct.us 77 NFPA 101 LIFE SAFETYCODE 2012 EDITION National Fire Protection Association (NFPA) Formal Code Title NFPA 101 LIFE SAFETY CODE (2012 edition) Written by NFPA Issued August 11, 2011 Adopted by CMS May 4, 2016 Effective Date July 5, 2016 Surveying for Compliance November 1,

27 NFPA 99 HEALTH CARE FACILITIES CODE 2012 EDITION NFPA 99 Health Care Facilities Code (2012 edition) Written by NFPA Issued August 11, 2011 Adopted by CMS May 4, 2016 Effective Date July 5, 2016 Surveying for Compliance November 1, NFPA Handbook New and Existing healthcare occupancy requirements are side by side Green shading includesengineers notes Diagramsprovide clarifying information Annex information shown directly below requirement 80 What the LSC isnot 1. Fire prevention code 2. Building code 81 27

28 Purpose of the LSC To provide minimum requirements To avoid precluding new developments if they offer equal protection To leave Authorities Having Jurisdiction (AHJ) with flexibility 82 LSC Organization & Structure Table of Contents Overview of topics Code Requirements Annexes Annex A Annex B Supplemental Information Index Identify section by specific topic 83 LSC Numbering 84 28

29 General Chapters How to provide fire protection measures Chapters 1 4 and 6 11 apply to all occupancies Chapter 5 Performance Based Option 85 Specific Chapters Occupancy Chapters occupancy requirements per classification Chapter 18 applies to New HealthCare Occupancies Chapter 19 applies to Existing Health Care Occupancies 86 New vs Existing HealthcareOccupancies New Healthcare Occupancy Defined Pre construction permits issued after November 1, 2016 Existing healthcare occupancies Plans approved or built before November 1,

30 Existing Facility Restriction Buildings constructed with features that exceed the requirements for an existing occupancy but do not exceed the requirements for a new occupancy shall not be further reduced. Section * 88 Fundamental Requirements Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Multiple Safeguards Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance More than 1 approach Alarm systems, exits, etc

31 2. Appropriateness of Safeguards Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Based on the following considerations: Size, shape, and nature of the occupancy Capabilities of occupants Number of occupants Fire protection available Abilities of response people Building height and construction type Means of Egress Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Number of means of egress Unobstructed egress Awareness of egresssystem Lighting of means of egress Occupant Notification Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Fire alarm system Smoke detection Heat detection Manual pull stations Horn/strobe 93 31

32 5. Situation Awareness Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Staff knowledge of fire protection systems in building State of critical building systems Trained staff Vertical Openings Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Openings between floors Stairs, pipe chase, and elevators Suitably enclosed or protected System Design/Installation Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Requires the following installed and approved according to applicable NFPA standards: fire protection systems, building service equipment, and features of protection 96 32

33 8. Maintenance Eight Fundamental LSC Requirements 1 Multiple Safeguards 2 Appropriateness of Safeguards 3 Means of Egress 4 Occupant Notification 5 Situation Awareness 6 Vertical Openings 7 System Design/Installation 8 Maintenance Requires that system and equipment be maintained unless the code exempts such maintenance Not maintained is considered to not be there 97 Life Safety Survey State differences in organizational oversight Various expertise ofsurveyors Backgrounds Protocols Tools 98 CMS Form 2786 R 99 33

34 How to use the2786 R Recognize that surveyors use the 2786 R to conduct surveys. 100% of requirements in synopsis form (this is NOT the code itself). References to the CFR are embedded, but not always fully described in the synopsis. Highlights new and existing requirements WARNING: Not a substitute for understanding the code! The 2786 R is NOT a substitute for complete and accurate knowledge of the LSC. 100 Summary These Life Safety and Emergency Preparedness requirements are currently being surveyed. Checklists and the 2786 R are helpful tools that can be used to prepare for LS and EP surveys, but they do not replace expertise in your facility. 101 Stump the Chump