2 Health Care Hierarchy Who is in charge? “Centers for Medicare & Medicaid Services” - AKA: CMSWho is the babysitter?“The Joint Commission” - AKA: TJC (formerly JCAHO)Use their own standards based on CMS regulations“Det Norske Veritas” - AKA: DNVUse the ISO:9001 quality principlesIs anyone else in charge, or just CMS?At Kaweah Delta, we must meet the regulations of: CMS, TJC, CDPH, State of CA Fire Marshal (via OSHPD), local authority having jurisdiction (in Visalia, this is the Fire Marshal), OSHA, etc.Whose rules do we have to follow?Whoever is most strictFederal governing branch of health care is named “Centers for Medicare & Medicaid Services.” Referred to as CMS, in our industry.When a hospital accepts patients with Medicare, Medicaid and/or Medical (in CA), we are subject to the rules, regulations, watchful eye, scrutiny, fines, fees, etc. etc. of CMS.The government does not have time to make sure that all of the health care businesses who accept these types of insurance are following all of the rules that have been laid out.Approximately 12 other accrediting organizations in the United StatesBasically – hospitals who meet accreditation through a CMS approved organization are deemed to meet the Medicare “Conditions of Participations” or COPsHospitals pay these organizations to come in every term (3 years for TJC and 1 year for DNV) to ensure that they are following all of the rules.Local Authority for Visalia relies on CA Fire Code – for their last revision, they almost decided to go with NFPA 101, but decided not to at the last minute. Most other states follow NFPA.Health Care Hierarchy
3 Why are we still using the 2000 and 1999 edition you ask? Especially when the National Fire Protection Association releases a new edition every three years, which means that we are 5 editions behind?Health Care “Bibles”
4 BUREAUCRACYMonday, April 14, 2014 – CMS announces it’s proposed adoption of NFPA 101 – 2012 editionPublic comment period for 60 days (ASHE, NFPA, professional groups)After the 60 days, CMS responsesIn the beginning of 2014, when CMS announced this – there was a short period when we all thought that we would be using the 2012 version in early Well, here we are……..After CMS adopts the 2012 edition, the accrediting agencies are expected to follow accordingly. BIG CHANGES! Easier to comply with updated rules when building standards and other organizations use guidelines that are “More Current.”So, what do we do in the mean time? How to we apply these out of date codes to our more current facilities with increasing demands and costs?
5 It’s never okay to break the rules, except sometimes. Categorical Waivers vs. Conventional WaiversCategorical Waivers are different from Conventional Waivers because Categorical Waivers are not related to a survey event, but may be elected at any time.Conventional Waivers are produced when CMS identifies a noncompliant life safety condition during a survey and writes a citation. The organization is required to implement a corrective action. If the organization feels that it will have a difficult time implementing corrective action (or other reasons), it may request a conventional waiver.April 19, 2013 – S&C: LSC & ASC: Relative Humidity: Waiver of Life Safety Code Anesthetizing Location RequirementsS&C LSC is a Memo from CMS: this particular memo addresses requirements from the Life Safety Code. In some cases, compliance with the 2000 edition of the Life Safety Code is costly and impossible to follow. Later editions of this code have identified and aligned requirements with those that are more cost effective while still ensuring patient safety.
6 Bending the Rules – Categorical Waivers Relative humidity in anesthetizing locationsMedical gas master alarmsOpenings in exit enclosuresEmergency generators and standby power systemsDoor locking arrangementsMultiple delayed egress locksSuitesExtinguishing requirementsClean waste and patient record recycling containersItems in the corridorKitchens open to the corridorGas fireplaces in common areasInstallation of combustible decorationsThese are all of the Categorical Waivers that are currently offered by CMS. There are 13.Bending the Rules – Categorical Waivers
7 Relative Humidity in Anesthetizing Locations NFPA 99, 1999 edition: §Why is it important?Current requirement is ≥ 35% relative humidityWaiver decreases to ≥ 20% relative humidityWhat do we do?Monitor relative humidity levels in anesthetizing locations, take action when needed to ensure that levels remain at or above 20%.Document, Document, Document.UPDATE: S&C: Hospital, CAH & ASCIssued by CMS February 20, 2015Drops the requirement from greater than or equal to 35% to greater than or equal to 20%Original intention was to reduce static discharge, which was very important when flammable anesthesia was in use.Saves money, time.On February 20, 2015, after a “Quality Advisory” was issued by: the American Hospital Association, the American Society of Healthcare Engineers and the Association for Healthcare Resource and Materials Management in conjunction withRelative Humidity in Anesthetizing Locations
8 This memo states that <30% RH is not compatible with the instructions for use for some sterile supplies and electro-medical equipment used in operating rooms.Manufacturers will be working toward expanding the lower level of the RH range in which their products may function, however, this will take time.CMS expects hospitals to follow the current Instructions for Use on supplies and equipment, effective immediately.What do we do? We check all instructions for use on sterile supplies and electro-medical equipment and adjust as necessary.
9 Emergency Generators and Standby Power Systems NFPA 110, 1999 edition: §Why is it important?Shorter run times on the annual generator load bank tests equate a lower cost for testing, reduction in the use of diesel and reduced negative environmental impacts.What do we do?Ensure that you are in compliance with ALL other applicable NFPA 110, 1999, operational inspection and testing provisions and § of NFPA 110, 2010.Document, Document, DocumentSection of NFPA 110, 1999 edition requires diesel-powered generators that do not meet the monthly testing requirements under section to be run annually with various loads for a total of two hours.The 2010 edition of NFPA 110 allows for the testing time to be reduced to an hour and half.Emergency Generators and Standby Power Systems
10 Door Locking Arrangements NFPA 101, 2000 edition: § 18/ – 18/Why is it important?Previously, we were not allowed to have doors that remained locked in the event of a fire alarm or power outage (if on magnet locks).In units where the clinical needs of the patient (i.e. psychiatric, Alzheimer, dementia, neonatal, pediatric) require specialized security measures for their safety, door locking arrangements are permitted.What do we do?Ensure that you are in compliance with ALL other applicable NFPA 101, 2000 door provisions, as well as §18/ – 18/ of NFPA 101, 2012.Document, Document, Document2013 CA Fire Code – California Code of Regulations, Title 24, Part 9 - Chapter 10 - Means of Egress, Section “Delayed egress locks.” (Page 206)9 regulations, all 9 must be satisfiedSecond part of that waiver permits more than one delayed-egress lock in the means of egress – compliance with all other applicable 2000 LSC door provisions and all sections of ch. 18/ of the 2012 LSCDoor Locking Arrangements
11 Suites Why is it important? What do we do? NFPA 101, 2000 edition: § 18/19.2.5Why is it important?Prior to the waiver, every habitable room was required to have an exit access door leading directly to an exit access corridor.Only allowed exit through another suite under certain circumstances.Limits the size of sleeping room suites to 5,000 sq. ft.One of the two required exits can be: exit stair, exit passageway, or exit door to the exterior.Can now exit through another suite.Allows suite size up to 10,000 sq. ft.What do we do?Meet with your local AHJ to ensure that they approve of the changes.Document, Document, DocumentIn hospitals, suites are used to create groupings of rooms and spaces that can function more efficiently than individual rooms located off of a corridor. In order to designate a suite, the space must meet certain criteria within the code, such as fire wall ratings, etc.This has other advantages within the Life Safety Code like patient rooms are not required to have doors in a suite, and if they do, they are not required to latch.Have copies of your SOC drawings and any other applicable information that proves that you meet the code.Suites
12 Clean Waste and Patient Record Recycling Containers NFPA 101, 2000 edition: § 18/Why is it important?Increases the can size of clean waste (bottles, cans, paper) from 32 gallons to 96 gallons.Reduce the number of receptacles, which creates more room in the corridor.What do we do?Must be compliant with NFPA 101, 2012 §18/e.g. 96 gallon containers shall be labeled and listed as meeting the requirements of FM approval standard 6921, Containers for Combustible Waste.Document, Document, DocumentUsed to be 32 gallons per 64 square feet. Linen and regular trash must still comply with this.NFPA has deemed that “clean trash and PHI” are less combustible and they must be placed in containers which conform to the FM 6921 standards. Link Attached.Keep proof of approval standard 6921 with your waiver declaration. If you change what you order BE SURE TO KEEP THAT INFORMATION TOOClean Waste and Patient Record Recycling Containers
13 NFPA 101, 2000 (Several Sections) Why is it important?2000 edition of the Life Safety Code mandates 8 feet of unobstructed with in Hospital corridors.With today’s technological advancements and the inception of Electronic Medical Records, we have more equipment that is used in the course of patient care.The 2012 code will allow previously restricted items to be in the corridor.CANNOT USE CORRIDOR FOR STORAGEWhat do we do?Ensure that you are in compliance with ALL other applicable NFPA 101, 2012 §18/ standards are met. This includes compliance with §7.3.Meet with your local AHJ to ensure that they approve of the changes.Document, Document, DocumentPreviously only allowed to leave equipment in the hallway for 30 minutes. Still applies to housekeeping carts and COWs, WOWsA task force developed these changes over 3 years…Patient Lift equipmentSome of the requirements include fire sprinklers, smoke detectors, etc.Items in the Corridor
14 Installation of Combustible Decorations NFPA 101, 2000 edition: § 18/Why is it important?Previous code had severe restrictions on furnishings, mattresses and decorations.“Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.”Waiver permits following NFPA 101, 2012.What do we do?Meet with your local AHJ to ensure that they approve of the changes.Document, Document, DocumentIt is very important to the facilities to create a relaxing environment i.e. decorations.Decorations do not exceed 20 %of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.Decorations do not exceed 30 % of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.Decorations do not exceed 50 % of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons in a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.Our local fire marshal mandates that we keep proof of which fire retardant was used. It must be from the list. We have to identify when the item was treated and it has to be re-treated according to the manufacturer’s instructions.CA Office of the State Fire MarshalInstallation of Combustible Decorations
15 Gather and prepare documentation along with a Categorical Waiver Declaration. Document your decision to use a categorical waiver(s). Most commonly done during an Environment of Care meeting.Prepare a binder or file of Categorical Waivers with back up documentation and a summary to have at the ready.Notify surveyors (CMS, TJC, DNV, CDPH) at the beginning of the survey that they have chosen to declare a categorical waiver. THIS IS CRITICAL.If TJC accredited, must document on the BBI of the SOC. If an EC standard, must document in the Environment of Care minutes.If you do not declare your Categorical Waivers before the survey, anything that is found by the surveyors will be written up as a finding and deficiency regardless.How to bend the rules
18 “An administrative assistant called in a work request stating that her desk lamp did not work. When the technician responded to the request he discovered that:A. the desk lamp was not plugged in.B. there was no bulb in the lamp.C. the admin had brought the lamp from her home.”
19 “Tenant: When the fire alarm goes off, please send a quick to let everyone know if it is a false alarm or if they should actually start evacuating.”“Tenant Request: “Can the speed bumps be shaved down? They are too high. I have to go too slow to go over them.””
20 “This occurred last week on the first day of the year to exceed 80 degrees. The occupants of one office complained they were too hot. I addressed it myself due to the political expediency of the issue. Upon arriving, the occupants expressed their dissatisfaction of our department and how we can’t get anything right. The space has two windows. In one of them is mounted a window A/C. It was set for 60 degrees, and was working beautifully. The other window was wide open. I informed them that the unit can’t cool the entire outdoors. I then noticed that one of the occupants had a small portable heater on under the desk. I asked why it was running, and she complained that her feet were cold.”
21 “I was on call one night when at 3 a. m. my pager goes off “I was on call one night when at 3 a.m. my pager goes off. I call in to the hospital and was connected with a nurse who had worked (there) for 30 years. She says, “I have a patient in room 21 and the lights don’t work.” I crawl out of bed, get dressed, and drive the eight miles. I go to the room and turn on the light switch, and all the lights go on. Puzzled, I step in the hallway and asked her what was I missing. She said, “I didn’t try the switch. I just thought that as it was dark in there that the lights must be burnt out.” I didn’t say any bad words until I was in my car on the way back home.”
22 “We once received an emergency work order (highest priority) to turn around the toilet paper roll because it was installed backwards. Our response was, “Toilet paper roll direction is a matter of personal preference and may depend on multiple critical life safety issues such as whether or not you have a kitten on the loose.””