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Understanding the Life Safety Code Scoring Impact & Interim Life Safety Measures 1

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Presentation on theme: "Understanding the Life Safety Code Scoring Impact & Interim Life Safety Measures 1"— Presentation transcript:

1 Understanding the Life Safety Code Scoring Impact & Interim Life Safety Measures 1

2 Disclosures  “Courtemanche & Associates Healthcare Synergists is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.”  Continuing Education Contact Hours will be awarded upon full attendance of the program and receipt of the participant course evaluations.  There are no influencing financial relationships or commercial support relating to this activity.  Participation in an accredited activity does not imply endorsement by the provider or NCNA of any commercial products displayed in conjunction with this activity.  Courtemanche & Associates does not discuss any products for use for a purpose other than that for which they were approved by the Food and Drug Association. 2

3 Session Objectives  At the conclusion of the session, participants will be able to:  Identify 2009 TJC expectations for LS Document Review  Obtain an overview in Interim Life Safety Measures (ILSM)  Learn why and when ILSM and ICRA are used  Discuss the impact on the increase in standards and elements of performance  Speak to the challenge of the LSS tour 3

4 Glossary  EC/EOC – Environment of Care  EM – Emergency Management  LS – Life Safety  LSC – Life Safety Code  LSS – Life Safety Specialist  e-SOC – Electronic Statement of Conditions  e-PFI – Electronic Plans for Improvement 4

5 The 2009 Standards  Let’s review the 2009 standards.  There was a total revision and increase in standards in this area.  There has been increased scoring since

6 The Evolution of EC  Since the inception of the Life Safety Specialist in 2004/2005, the focus on the Environment of Care has shifted to Life Safety  As of 1/1/2008, all Hospitals, regardless of size, were scheduled for a LSS focused visit  This was in answer to continued disparities in CMS look back surveys 6

7 The Evolution of EC  The Environment of Care chapter and scoring process changed for 2009  EC evolved to three separate chapters  Environment of Care (EC)  Emergency Management (EM)  Life Safety (LS) 7

8 The Evolution of EC 8 EC Environment of Care Emergency Management Life Safety

9 The Evolution of EC  Where are we now - it’s 2009?  EOC issues are scoring more in recent surveys  There has been an increase in scoring for Immediate Threat to Life and Conditional Accreditation rules 9

10 Thresholds – January – Serve as “Screens”  Thresholds:  The number of RFIs will not automatically trigger a decision  Decision for review is based on number of non-compliant direct impact standards and surveyor days  Will serve as a “screen” for more intensive review by TJC central office – Standards Interpretation Group & Division of Accreditation & Certification Operations Management 10

11 Screens = Surveyor Days & Direct Impact RFIs (for Hospital) 11 Band CategorySurveyor Days RFIs (Non- Compliant Direct Impact Standards) Band Band Band Band Band 5≥1413

12 Central Office Review  Were “situational” rules actually triggered but not identified during survey?  Do “systemic” problems exist in the organization – based on magnitude & nature of findings?  Would findings result in CMS “Condition” level deficiency for those programs having deemed status? 12

13 What is Condition-Level Deficiency? CMS Finding:  Standard Level or Condition Level Based on nature (how severe, dangerous, critical) and extent (how prevalent, often, pervasive, how many)  Condition Level:  Non-compliance with single standard or several within a CoP representing severe or critical safety or health breach  Standard Level:  Does not substantially limit ability to give good care nor jeopardizes patient health or safety 13

14 2009 Chapters & Standards  EC chapter now has  20 standards  143 elements of performance  EM chapter now has  12 standards  111 elements of performance  LS chapter now has  17 standards  194 elements of performance 14

15  1 Chapter  33 Standards  234 Elements of Performance  3 Chapters  49 Standards  448 Elements of Performance 2008 Manual 2009 Manual 15 Let’s Compare

16 More Impact for 2009  There are four tiers in the scoring model  Immediate Threat  Situational Decision Rules  Direct Impact Standards  Indirect Impact Standards  The new chapters reflect this scoring  There are automatic rules in some areas, such as LS  BEWARE: Failure to implement ILSMs! 16

17 Direct Impact Standards  In the three new chapters, there are several direct impact standards.  LS has 20 direct impact standards  EC has 43 direct impact standards  EM has 3 direct impact standards 17

18 Get Ready for 2009  There is an increase in the number of chapters  There is an increase in the number of standards  There is an increase in the elements of performance  The LSS surveys all hospitals  The CMS disparity rate for physical environment has increased to 29 %! 18

19 Top Scoring Issues 19 TJC 2007 (final #s) TJC – 1 st Quarter 2008 IssueComments MM.2.20 (43%)  (31%) Storage of medications NPSG 2C (36%) No DataCritical test/results data requirements  from prior year EC.5.20 (29%)  (45%) Life Safety Code (now LS ) IM.6.10 (26%)= (24%)Completeness of medical record IM.6.50 (25%)  (35%) Telephone & verbal orders NPSG 2B (25%) No DataUnapproved abbreviations  from prior year UP 1C (21%)No DataTime out

20 Top Scoring Issues 20 TJC 2007 (final #s) TJC – 1 st Quarter 2008 IssueComments NPSG 8A (19%)No DataMedication reconciliation on admission  from prior year NPSG 3D (18%)No DataMedication labeling on & off sterile field  from prior year EC.5.40 (18%)  (30%) Maintenance of fire equipment & building features (now EC ) PC (18%)=Pre-anesthesia assessment EC.7.40 (16%)* Testing emergency power systems (now EC )  Early ‘08 numbers show 50% increase EC.7.50 (14%)*Testing medical gas & vacuum systems (now EC )  Early ‘08 numbers show over 50% increase * While not ranking in TJC’s final Top 14 Compliance Issues, preliminary TJC data had indicated that EC.7.40 had been scored in 8% of organizations surveyed and EC.7.50% had been scored in 6% of organizations

21 Interim Life Safety Measures

22 What are Interim Life Safety Measures?  Additional measures for fire prevention  Required when: 1. There are Life Safety Code deficiencies 2. There is construction that may interrupt normal exit pathways, fire prevention systems or create potential for explosion.  Based on proactive risk assessment (PRA)  Consider PRA for any project, renovation or life safety deficiency that could impact life or fire safety in the organization. 22

23 What are the Additional Measures?  Providing free and unobstructed access to emergency services and for fire, police, and other emergency forces  Providing fire alarm, detection, and suppression systems are in good working order.  When system impaired, must use a temporary but equivalent system  Must inspect and test temporary systems monthly  Use temporary construction partitions that are smoke-tight and built of noncombustible or limited combustible materials that will not contribute to the development or spread of fire 23

24 What are the Additional Measures?  Institute additional fire-fighting equipment and staff training staff in its use  NO SMOKING ! throughout the hospital’s buildings and in and near construction areas (INCLUDES CONSTRUCTION WORKERS)  Keep the building’s flammable and combustible fire load to the lowest feasible level  Create and enforce storage, house keeping, and debris-removal practices  Perform a minimum of two fire drills per shift per quarter 24

25 What are the Additional Measures?  Heighten surveillance of buildings, grounds, and equipment, with special attention to excavations, construction areas, construction storage, and field offices  Provide staff training to compensate for impaired structural or compartmentalization features of fire safety  Provide organization wide safety education programs to promote awareness of fire safety building deficiencies, construction hazards, and ILSMs 25

26 The Process Consider ILSM’s when:  Out of compliance with LSC  For any renovation or construction project  For above ceiling work – i.e., removing more than 4 -5 ceiling tiles may constitute the need for an assessment to be done  Loss of certain utilities  Any interruption in the fire alarm/sprinkler system for 4 or more hours  Any change in exit/egress pathways  Medical gas system compromised 26

27 What is the ILSM Process?  This process is activated to reduce potential risk by setting procedures in place to enhance awareness of threats and to protect patients, staff, visitors and everyone during construction or times when not in compliance with the Life Safety Code. 27

28 What is the ILSM Process?  The assessment process for ILSM’s  Analyzes the project  Identifies the risks  Implements strategies and safeguards  Protects against those risks

29 Now Let’s Examine ICRA  ICRA is Infection Control Risk Assessment  When is it needed?  Whenever the environment may be compromised with unintended infectious risk due to demolition, renovation, construction, or other reason i.e., ventilation system failure  Must always be considered when you undergo construction, demolition or renovation 29

30 Why is ICRA Important? During Demolition, Construction, and Renovation, infection risks may present.  Release of mold, spores, dormant infectious agents  Release of contaminated air, water, materials  Introduction of bacteria, viruses, molds and fungi  Creation of reservoirs to enhance growth of infectious organisms  Release of dust, debris, airborne hazards 30

31 Where do ICRAs and ILSMs Meet?  As discussed earlier, whenever your organization is considering or involved in demolition, renovation or construction, you should proactively assess for the potential for compromise related to life safety (fire safety) and infection  Using a combined approach to assess for both creates an ongoing approach to consider multiple hazards in one process 31

32 ILSMs and ICRA – A Renewed Focus  Interim Life Safety Measures have been around for years  Infection Control Risk Assessment (ICRA) is always required when you consider construction, demolition or renovation.  Both are used to assess risk to ensure the safety and well being of everyone in the facility, patients, staff, visitors, etc.  Everyone needs to know roles and responsibilities, not only the staff in the area of the project - includes staff, volunteers, students, LIP’s, contractors, construction workers, and each of you.  YOU are the first line to ensuring the safety here! 32

33 ILSM and ICRA Process  While most of the responsibility falls to Facilities/ Engineering and Infection Control, everyone needs to be involved  Policies and procedures for ILSM and ICRA should be available for ready review  Develop a comprehensive risk assessment policy, ICRA, Hot Works Policy, and other related policies for routine review when you consider facilities projects 33

34 Once Activated, What is Required?  Ongoing assessment and monitoring to assure safe conditions 1. Conduct pre-assessment 2. Assure activation of appropriate measures 3. Provide ongoing assessment 4. Do daily or more often checks as needed 5. Document on checklist 34

35 What Does Checking Entail?  For ILSM’s checking includes:  Checking for exit egress  Clear evacuation paths  Marked routes  Is fire alarm and suppression system functioning and operable in the area?  Clear Emergency Access for Police/Fire  Management of combustible load  New risks emerging during project 35

36 What Does Checking Entail? For ILSMs checking includes: Is there adequate fire fighting equipment, working fire extinguishers? When fire suppression or alarm system out of service for 4 or more hours, are fire authorities notified? Is fire watch implemented? And documented? Watch out for other issues, such as hot work issues, welding, etc. Assuring use and availability of PPEs 36

37 What Does Checking Entail? For ILSMs checking includes:  Limit debris and clutter  Test staff education for roles and responsibilities  Can everyone get out safely? Do they know the routes?  If an exit is blocked or out of service, show them the way, map alternate route  Make sure construction barriers are sealed based on needs in area. Remember “No Smoking” in any area under this rule. 37

38 What Does Checking Entail? For ICRA checking includes:  Preventing unintended spread of dust, debris, and other potential sources of infection  Assuring containment of area under work  Lock down ventilation systems connected to work  Awareness of potential for release of airborne pathogens  Awareness of patients with special needs or who are immunocompromised 38

39 What Does Checking Entail? For ICRA checking includes:  Daily or more frequent checking to assure safety of area and containment of potentially pathogenic organisms  Ventilation systems and protection of patients in other parts of organization  Are construction barriers intact?  Use of appropriate PPE, such as respirators during demolition  Dust, debris and particulate matter compromising adjacent patient care areas 39

40 What Does Checking Entail? When you implement ILSM’s and the ICRA process, you need to document your efforts.  Daily ( 7 days a week) rounds to ensure these details.  Additional fire drills are also needed.  When in ILSM’s you need to increase awareness and drills (two per shift, per quarter).  Staff and all involved (that means you!) need training. 40

41 How Does the Process Happen?  Training needs to address fire fighting and infection prevention roles  Can you use a fire extinguisher?  Remember P-A-S-S, pull the pin, aim low, squeeze the handle, spray or sweep side-to-side (pass)  If you see dust from the construction site in your area – do something about it!  You are all that stands between the project and the patient  Step up, listen and take action to provide a safe environment 41

42 Safety is Everyone’s Job!  Take your safety role seriously  YOU can prevent unintended fires and infections with vigilance and activation of appropriate measures  Failure to respond and implement ILSM’s not only can harm those in your facility  Failure can impact your accreditation (TJC and CMS)  Safety matters! YOU can make a difference! 42

43 Your Role in Fire Safety and Infection Prevention  Not only do you need to understand the why’s and when’s, you need to know you can report concerns.  If you think any renovation project or construction issue, or any loss of utility, or service might impact the safety of the population service in this healthcare facility, SPEAK UP!  Talk to your supervisor or contact Facilities/Engineering and/or Infection Control  Even the little jobs can cause big issues – report a safety concern 43

44 Life Safety Code Issues and Responses

45 Stay Alert – Challenges in 2009  e-SOC  ILSMs  Life Safety Specialist  Situational Decision Rules Insufficient progress on e-SOC Failure to implement ILSMs  More Standards;  More Potential for Scoring  More Pressure from CMS

46 Things to Watch for in 2009  Control and use your eSOC  It is color coded  Heed the orange – you’re past expected date of completion  Heed the red color – you’re past the 6 month window  Expect TJC to come knocking! 46

47 Things to Watch for in 2009  Beware of situational decision rules  CON04 The organization has failed to implement or make sufficient progress toward the corrective actions described in a Statement of Conditions™, Part 4, Plan for Improvement, which was previously accepted by The Joint Commission, or has failed to implement or enforce applicable interim life safety measures. (LS , EP 3; LS , EP 3) 47

48 Things to Watch for in 2009 What is an accepted ePFI ?  These are PFI’s that are “signed off” by TJC during a survey  These are the ones you need to track progress on, watch the colors 48

49 Things to Watch for in 2009 If its out of compliance you have 4 choices: 1. Fix it right away 2. Put on a work order system 3. Repair within 45 days 4. Enter on ePFI, or ask for an equivalency and document with TJC 49

50 Things to Watch for in 2009  All other ePFI’s are under your control, you can change the expected completion dates and manage internally until “signed off and accepted.”  Once accepted you can automatically get one six month extension 50

51 Things to Watch for in 2009 The Building maintenance Program  The BMP scoring advantage is gone  The BMP is still a “good PM” program  You need to manage your compliance with the LS Code and your SOC 51

52 Things to Watch for in 2009  Increased focus on ILSM’s this year  HCO’s should consider ILSM’s with multiple PFI’s  Also look at any areas you are not in compliance with LSC and EC, not just for construction 52

53 Things to Watch for in 2009  If your organization has findings on a CMS validation survey, you should consider entering in ePFI’s or manage within the timeframes (> 45 days and work order system)  TJC wants to know about your process here in dealing with CMS 53

54 Things to Watch for in 2009  Acceptable projected completion dates are within the 3 year survey time frame or less  Only exception is inaccessible dampers. SIG now granting “six year” projected completion date, with possible six year extension  Dates should be reasonable for deficiency 54

55 Things to Watch for in 2009  TJC is still using the 2000 edition of the Life Safety Code  If you want to use a more current code, you need to get an equivalency from TJC  Only exception is 2005 NFPA 99 code (# 9.4.3) for medical gas storage issues 55

56 2005 NFPA 99 (#9.4.3) for Medical Gas Three Levels  cu.ft. limit in smoke zone with no protection  cu.ft. if 1 hour wall & 45 min door for the storeroom, no ventilation required, but combustible storage next to O2 tanks limited to 5 feet if sprinklered or 20 feet if no sprinklers.  Over 3,000 cu.ft. has lots of requirements including ventilation 56

57 More on Medical Gases  An individual container of medical gas placed in a patient room for “as needed” (but regular) individual use is not required to be stored in an enclosure, when properly secured.  Oxidizing gases such as oxygen and nitrous oxide should not be stored with any flammable gas, liquid or vapor.  All storage areas should be secured to limit access. 57

58 Plan for the LSS Visit LSS = Life Safety Specialist  Remember at of 1/1/2008 all hospitals were scheduled for LSC Specialist visit  Duration was 1 or 2 days depending on size of building(s).  In 2009 includes Critical Access Hospitals  The time frames for CAH are shortened so the LSS can also conduct the EC and EM sessions in that one day visit. 58

59 Plan for the LSS Visit There are four parts to the LSS visit 1. The Facility Orientation which is approximately 30 minutes. 2. The Document Review is 60 – 90 minutes. 3. The building tour is 4 or more hours. 4. The exit conference or briefing. 59

60 Facility Orientation  The LSS meets with appropriate organizational staff to learn about the buildings, etc.  Review BBI data, plans and information about smoke compartments, sprinklered areas, age of buildings  Reviews organization’s policy and process as well as documentation for Interim Life Safety Measures. 60

61 Document Review  The eSOC and ePFI’s are locked down at the onset of the survey team arrival.  Review will include all materials needed to show compliance  EC (fire alarms and systems)  EC (emergency power systems)  EC (medical gas systems)  Items in this review can then be verified on building tour. 61

62 Building Tour LSS will assess several components:  Fire / smoke separations, hazardous areas, exit stairwells, any kitchen grease producing cooking devices  The master alarm panels and if relevant the automatic sprinkler pump  Electrical and medical gas systems  Remember to provide a ladder, flashlight and any keys or opening devices for locked and secured areas. 62

63 Exit Conference or Briefing  LSS will enter all findings into laptop and provide a copy for the team leader.  An interim exit briefing with members of the survey team will be provided to review the LSS observations during the survey.  LSS will leave contact information with team leader in case issue arise later during survey. 63

64 How to AVOID RFI’s.  First rule is “Organization, organization, organization.”  Have all your documents available and have the appropriate staff available to respond to questions.  Everybody needs a wingman  Make sure you have back-ups for staff 64

65 How to AVOID RFI’s.  Make it easy for the surveyor to get the needed information to assure compliance  Train staff them for roles needed in this process  Have up to date floor plans  Mark plans with the appropriate notes, fire walls, smoke compartments, etc. 65

66 Remember to be Proactive  Under 2009 Survey guidelines, there is some leeway in scoring if you fix things during survey.  SIG has trained the LSS to note a condition but indicate that it was corrected during survey.  Not all issues can be resolved and not scored, but you should remain proactive. 66

67 Corrected During Survey Sample Items that can be corrected during survey  Repositioning of ceiling tiles to close gaps  Moving items that block  Medical gas and fire extinguishers or pull stations  A partially burned out exit light  Storage and clutter issues 67

68 What CANNOT be Corrected During Survey Per SIG guidelines, systems issues will still be scored even if corrected during survey:  Penetrations in walls or fire/smoker barriers  Door issues, missing rating labels, lack of latching or closure  Non functioning fire alarm  Missing smoke detectors or fire damper  Missing handrail on exit stairwell 68

69 Let’s Get Organized!  Many organizations receive RFIs because they do not have the specific documentation required by the standard or in the correct time frame.  Most organizations rely on outside contractors to complete much of the required testing, and assume documentation is available 69

70 Let’s Get Organized!  Beware of documentation shortfalls.  Trace the actual document review to see if documentation is available and appropriate in timing to meet the expectations.  Review requirements to know what evidence is needed to demonstrate compliance. 70

71 Let’s Get Organized!  Make sure you refer to the appropriate NFPA codes referenced in the standards.  When you outsource, make sure your contractors apply the correct codes.  Develop checklists and organize you reports.  Prepare for the twelve month period, as well as those items with longer time frames, like dampers and standpipes. 71

72 Let’s Get Organized! 72

73 Let’s Get Organized!  Build in a review process to connect documents with specific standards  Ensure your staff know how to answer questions, such as how they actually test the fire pump  The standards can be cumbersome so practice, practice, practice! 73

74 Health Facilities Magazine February 2009  “The Joint Commission references five separate NFPA documents under standard EC alone. They are the 1998 editions of NFPA 10, 25, 96 and 1962, and the 1999 edition of NFPA 72. Additionally, the 1999 edition of NFPA 99 and the 1996 edition of NFPA 111 are referenced later.”  Although the SOC is based on NFPA 2000 LSC, make sure you comply with the references to other NFPA documents. 74

75 The Statement of Conditions  Remember this is a living breathing document.  The LSS will review the SOC signed off on your last survey, as well as the current one.  Build in checks and updates on your electronic version.  Make sure more than one person in your organization (not just a hired contractor) knows how to update your e-SOC and find issues. 75

76 Managing the PFI’s  Document your work order process and manage the electronic PFI process to avoid more RFI’s.  If you have equivalencies, make sure they are with your documents. Remember the equivalency needs to be signed off by SIG, not just your AHJ.  Make sure all your information on BBI/SOC is correct.  During survey is not the time to plead an error. 76

77 Documents  Make sure you have the proper documents readily available, such as daily checklists for ILSM’s.  Check documents periodically for completion  Example – assure the transfer switches are documented on the generator tests  Make sure all documents are legible.  Don’t fill in blanks, have a correction process.  Make sure you authenticate entries. 77

78 It’s only 1 Day (or 2)!  It’s over fast – you must be prepared and have your documents ready at a moments notice  Make every day survey day and you’ll wow your surveyor  Avoid being argumentative with the surveyor  When conflict arises - use special resolution time 78

79 Are You Ready for This?  And if this isn’t enough, there is talk of expanding the role of the LSS  TJC is considering making LSS visits at least two days for every organization, and longer for larger organizations.  If you practice and walk in the shoes of the LSS before you walk beside them, you win. And you might even become one. 79

80 References  Comprehensive Accreditation Manual for Hospitals, 2009  “Put it in Writing” by S. Spaanbroek, February 2009 Health Facilities Magazine  The Life Safety Organizer, Courtemanche & Associates

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