The Life Safety Specialist Surveyor Preparing for the Life Safety Specialist Documentation Review and Facility Tour Will limit Healthcare Engineering Consultants

The Life Safety Specialist (LSS) It is likely that the LSS will arrive with the team on the first or second day, less likely later in the survey For 2011, the LSS will usually be scheduled for an additional day based on the scheduled time of the previous survey The LSS will spend several hours on dedicated documentation review, but much more time on the facility tour Other responsibilities assigned to the LSS will depend on the survey team member preferences and responsibilities – they may conduct the “EC Interview” and Emergency Management tracers The other survey team members will also observe life safety issues, but not as detailed as the LSS – it is not likely that the nurse and physician will request a ladder and flashlight! If the LSS observes deficiencies outside of their defined responsibility (example: medical records privacy or medication security), they will report it to the other team members Healthcare Engineering Consultants

The LSS Documentation Review Life Safety Specialist (LSS) surveyor documentation responsibilities include at a minimum: LS.01.01.01: SOC and Life Safety Code LS.01.02.01: Interim life safety measures EC.02.03.05: Fire system tests EC.02.05.07: Emergency power systems EC.02.05.09: Medical gas and vacuum systems Note: In 2011, the Life Safety Specialist may be assigned additional responsibilities during the survey Healthcare Engineering Consultants

The LSS Documentation Review LS.01.01.01: SOC and Life Safety Code The SOC completion will be verified through the Joint Commission Connect site (BBI’s and PFI’s) Have the SOC notebook available for review The PFI documents from the previous survey may be reviewed to verify completion of deficiencies (have them available, if requested) The compartmentation drawings will be reviewed to assist in planning the facility tour Life Safety Code compliance will be verified during the facility tour Healthcare Engineering Consultants

The Statement of Conditions How Should the Statement of Conditions (SOC) Document be Completed? Healthcare Engineering Consultants

The Statement of Conditions What is the SOC? The Statement of Conditions (SOC) is a document that is required to be completed by every healthcare facility that applies for accreditation by the Joint Commission. It references the *2000 edition of the Life Safety Code and consists of the following sections: Basic Building Information (BBI) Form – electronic on Connect site Life Safety Assessment (LSA) Form – not electronic Plan for Improvement (PFI) Form – electronic on Connect site BBI’s, LSA’s and PFI’s are *Note: Other LSC editions may be selected, but the entire edition must be followed Healthcare Engineering Consultants

The Statement of Conditions SOC Notebook (Best Practice) A SOC notebook is strongly recommended to contain “hard copies” of the SOC documents The notebook should include at least the following sections: Section 1: The SOC policy and responsibility statement Section 2: Current copies of the downloaded BBI forms Section 3: Accurate, color-coded compartmentation prints Section 4: The latest, completed LSA-type document Section 5: Current and previous, downloaded PFI forms Section 6: Any correspondence with the Joint Commission, including equivalencies, letters and emails Healthcare Engineering Consultants

The Statement of Conditions Why Should I have an SOC Policy? (Best Practice) The SOC policy describes how the Statement of Conditions program is organized for the facility What Should the SOC Policy Include? Who is responsible for completing and maintaining the SOC How often the SOC documents are reviewed Who reviews the SOC documents for timeliness PFI guidelines (when does a work order become a PFI?) Whether a BMP is implemented Whether an above-the-ceiling program is in place How the SOC documents are organized Healthcare Engineering Consultants

Statement of Conditions Document The current Statement of Conditions “hard copy” document is dated 5/2004 and can still be downloaded from JointCommission.org for the LSA form (do not use the BBI or PFI “hard copies” – they are obsolete) Healthcare Engineering Consultants

Statement of Conditions Document Notes About the e-BBI Form List on the e-BBI cover page every occupancy that will be surveyed, even for business occupancies (make sure that the BBI and survey list match!) The e-BBI questionnaires are only required for ambulatory, hotel/ dormitory and healthcare occupancies Fill in the comments section regarding SOC preparer, location of building drawings, mixed occupancies, equivalencies, special building features or local AHJ requirements to the BBI If multiple occupancies are entered, the greatest percentage defaults to the BBI form, so multiple BBI entries are required Be sure to download the electronic version of the BBI form before it is saved so that a “back-up” is available, and place a copy in the SOC Notebook Healthcare Engineering Consultants

Statement of Conditions Document Compartmentation Requirements Mixed Occupancies: (LSC: 19.1.2.1) Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet the following conditions: They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation They are separated from the health care occupancy by a fire rating of at least 2 hours Separation between ambulatory and business occupancies only requires a 1 hour rating (LSC: 21.1.2.1) Healthcare Engineering Consultants

Statement of Conditions Document e-BBI Form – Buildings Be sure to complete for all healthcare and ambulatory facilities Optional for business occupancies, but strongly suggested for the cover page Healthcare Engineering Consultants

Statement of Conditions Document e-BBI Form - Healthcare Refer to instructions related to “stories” in the Life Safety Code Note instructions related to building construction type (occupancy) Building age is important due to significant code changes Healthcare Engineering Consultants

Statement of Conditions Document e-BBI Form – page 2 1991 date significant due to sprinkler requirement Emergency power fuel type important due to “wet stacking” Healthcare Engineering Consultants

Statement of Conditions Document e-BBI Form – page 3 “Previous inspections” data provides valuable information to the survey team! Be sure to list local or regional requirements (example: limited generator testing due to high pollution days) in the “Comments” section at the bottom of the form as well as other requested information Healthcare Engineering Consultants

Statement of Conditions Document LSA Form (is not electronic): Is a voluntary assessment tool, although some assessment is required at least annually Is not required for “Business Occupancies” The Joint Commission surveyor normally expects some type of form, document or evaluation to be completed Dated 5/2004, so a cover sheet that is signed annually is recommended Can still be downloaded from the Joint Commission home page website (search “Statement of Conditions”) Can use PPR form or similar for the LSA document Comments in LSA must match PFI deficiencies Healthcare Engineering Consultants

Statement of Conditions Document Life Safety Building Compartmentation Drawings Blue – smoke barrier Green – 1 hour fire wall (hazardous area) Red – 2 hour fire wall Note: Color-coded drawing is “best practice” Healthcare Engineering Consultants

Statement of Conditions Document Notes About the PFI Forms The forms should not be used for “operational deficiencies”, such as exit lights burned out, doors out of minor adjustment or small penetrations that can be easily filled – these should be completed using the routine work order system The normal “trigger time” from a work order to PFI is 45 days Document the “PFI’s” on a continuing basis – be sure that the PFI log is up-to-date and ready to be reviewed by the surveyor Don’t forget to enter the projected start and completion dates and the actual completion date Failure to meet the completion dates without a delay approval results in Conditional Accreditation 6 months after the projected completion date has passed! If applicable, keep any previously signed PFI copies available Healthcare Engineering Consultants

Statement of Conditions Document The first page for the electronic PFI forms is used to list the deficiencies Notice that a “No Deficiencies” option is available (and should be completed, if applicable) Healthcare Engineering Consultants

Statement of Conditions Document The second page for the electronic PFI forms is used to indicate the deficiency resolutions Don’t forget to complete all of the requested information, including the proposed action, source of funds and the projected start and completion dates The projected completion dates can be altered until they are “frozen” before or during the actual survey! Comments for each PFI should include a note regarding the implementation of ILSM’s! Healthcare Engineering Consultants

Statement of Conditions Document The listing document simply provides a summary of all of the deficiencies that have been recorded on the PFI form for tracking purposes – keep a copy of this in the SOC notebook for reference purposes Healthcare Engineering Consultants

The Life Safety Specialist Documentation Review Should I Implement and Document a Building Maintenance Program (BMP)? Healthcare Engineering Consultants

The Building Maintenance Program (BMP) Is voluntary; no scoring benefit in 2011 No longer requires a measure of effectiveness Measurement system can use random samples Results should be used to determine revisions to inspection or test frequencies Information should be provided to the hospital safety committee if changes are made to the program Is basically a PM program for the buildings Is still considered a Best Practice Healthcare Engineering Consultants

Healthcare Engineering Consultants Fire System Tests Points to Remember Clearly define supervisory devices (fire pump, low air pressure on dry or pre-action systems and water tank level indicators expected) Tamper and flow device test intervals increase to quarterly on 7/1/11 Inventory all doors on magnetic releasing devices and document test results Document tests results for each individual heat and smoke detector, pull box and audible and visual device Healthcare Engineering Consultants

Healthcare Engineering Consultants Fire System Tests Points to Remember Document receipt time of fire alarm signal to local fire department or receiving station Document static and residual pressure readings for main drain tests and time back to static pressure (best practice) Visually inspect fire department connections quarterly The 5-year standpipe test was added to the requirements in 2009 Indicate the day and month of portable fire extinguisher checks Healthcare Engineering Consultants

Healthcare Engineering Consultants Fire System Tests Points to Remember Don’t forget to implement and document “Interim Fire System Measures” (IFSM), when required If the occupant hoses have been removed, keep a copy of the approval letter from the AHJ Place inaccessible smoke and fire dampers on the PFI for a 6-year, renewable period (for tracking purposes only) Document that duct detectors trip the air-handling units Only applies to vertical and horizontal smoke and fire doors, not security doors or curtains Healthcare Engineering Consultants

Fire System Test Monitoring Best Practice for Monitoring Compliance Healthcare Engineering Consultants

Fire System Test Monitoring Healthcare Engineering Consultants

The LSS Documentation Review EC.02.05.07: Emergency Generators Perform and document weekly generator visual checks (NFPA 110) Perform and document monthly generator tests between 20 and 40 days and with at least 30% of the rated load for 30 minutes Document that all automatic transfer switches are exercised monthly Conduct annual load bank tests if the 30% load is not achieved and manifold temperatures are not sufficient (possible change from the 2 hour to a 1.5 hour test in 2011 – not yet approved) Combining the annual and trienniel tests can be performed by starting the load at 30% of nameplate for the first 30 minutes of the test Document the static or dynamic 4-hour trienniel test for all generators Test fuel oil quality annually, unless fuel is consumed from the entire tank (NFPA 110) Utilize “Interim Emergency Power Measures” (IEPM) when necessary Note: Refer to NFPA 99 and 110 for more information Healthcare Engineering Consultants

The LSS Documentation Review EC.02.05.07: Emergency Battery Lights Required in all anesthetizing locations (NFPA 70: 517.63 ) Task Light! “administration of nonflammable inhalation anesthetic agents in the course of examination or treatment” Note: Grandfathering usually permitted in existing OR’s Required in “Level 1 or Level 2 EPS equipment locations” (NFPA 110: 7.3.1) Task Light! Required in business occupancies for egress lighting where emergency power is not required or not available (NFPA 101: 7.9.1.1) Egress Light! Monthly push-to-test required for all battery installations Differentiate between “task lighting” and “egress” lighting Annual battery replacement in lieu of 90-minute discharge test Note: 10% of lights must be tested for 90 minutes annually, even if the batteries are changed. Healthcare Engineering Consultants

The LSS Documentation Review EC.02.05.07: Stored Emergency Power Supply Systems (SEPSS) Standard applies to Level 1 systems (NFPA 111: 4.5.1) Level 1: “failure of the equipment to perform could result in loss of human life or serious injuries” Testing requires: 1. Quarterly functional test (5 minutes or class specification) 2. Annual full-load test for 60% of SEPSS class duration Note 1: NFPA 111 requires a monthly inspection, quarterly functional test and annual full load test for full class duration for Level 1 systems Note 2: The Joint Commission references exit lighting, life support ventilation, fire detection and alarm systems, and public communications systems as Level 1 systems, but most are not SEPPS systems Healthcare Engineering Consultants

The LSS Documentation Review EC.02.05.09: Medical Gas and Vacuum Systems Medical gas and vacuum system preventive maintenance program is required (facility must define PM) and must include: - Bulk medical gas and vacuum system components and source valve - Master signal panels and area alarms - Automatic pressure switches and shutoff valves - Flexible connectors and outlets Testing per NFPA 99 is required for new installation, modification or repair (cross-connections, purity, pressure) Main supply valves and area shut-off valves must be accessible and clearly labeled Utilize “Interim Medical Gas Measures” (IMGM) when necessary Note: Significant changes to NFPA 99 are likely to occur when the next vote occurs at the NFPA Annual Meeting Healthcare Engineering Consultants

The LSS Documentation Review EC.02.05.09: Medical Gas and Vacuum Systems Certification of installers and verifiers per ASSE 6000 series is required Medical air quality must meet NFPA 99 requirements below: Parameter Limit Value Pressure dew point 39 degrees F Carbon monoxide 10 ppm Carbon dioxide 500 ppm Gaseous hydrocarbons 25 ppm (as methane) Halogenated hydrocarbons 2 ppm Healthcare Engineering Consultants

The LSS Documentation Review Medical Gas and Vacuum System PM Recommendations Note: The recommendations provided in the chart to the right are from NFPA 99, the 2005 edition, Appendix C, section 5.2. Tests that are required due to new system installations, renovations or repair are listed in chapter 5 of NFPA 99 Healthcare Engineering Consultants

The LSS Documentation Review Interim Utility System Measures (IFSM, IEPM, IMGM) Best Practice! Strongly recommended to document that interim measures have been implemented to compensate for utility systems that are taken out of service Healthcare Engineering Consultants

Healthcare Engineering Consultants The LSS Facility Tour Typical Tour Sequence Start on the roof, penthouse, mechanical equipment rooms Take the “most traveled stairwell” from the top to the bottom Take the elevator back up to the top patient floor Check smoke/ fire doors and compartmentation features Inspect chutes, storage areas, utility chases, hazardous areas Continue down to the lower and basement levels to specific areas, such as the kitchen, loading dock, fire pump, emergency generators, fire annunciator panel, compressed gas and infectious waste storage Complete checklist, or until problems are found! Healthcare Engineering Consultants

The LSS Facility Tour Smoke and fire doors Checklist for the Facility Building Tour Smoke and fire doors Check: Closure, label rating, gaps, undercuts, warpage, kick plate Smoke and fire compartments Check: Penetrations, proper sealant Roof and penthouse Check: Contractor supplies, smoking, exhaust fans labeled Exit stairwells Check: Door rating, closure, signage, exit discharge Linen/ trash chutes and receiving rooms Check: Door rating, closure, fusible link, chute blockage Healthcare Engineering Consultants

The LSS Facility Tour Checklist for the Hospital Building Tour (cont’d) Hazardous areas Check: Storage of flammables, room rating, door closer Fire pump Check: Controls turned “on”, valves open, tampers OK Fire annunciator panel Check: Bypass, trouble, ground fault or supervisory Soiled linen rooms Check: Proper storage, dirty separated from “clean” Healthcare Engineering Consultants

The LSS Facility Tour Checklist for the Hospital Building Tour (cont’d) Medical waste storage Check: Locked area, secure, sharps not accessible Loading dock Check: Smoking, improper storage, powered equipment Kitchen area Check: Cleanliness, storage, CO2 tanks, refrigerator temps, K-type portable extinguishers within 30’ of fat fryer PFI verification Check: Previous PFI’s have been resolved as listed Healthcare Engineering Consultants

The LSS Facility Tour Checklist for the Hospital Building Tour (cont’d) ILSM verification Check: Construction areas for ILSM implementation Mechanical equipment rooms Check: Storage, unlabeled containers, cigarettes, labeling Emergency generators Check: In “auto” mode, batteries/ charger, fuel leaks Medical gas systems Check: Manifolds, medical air and vacuum pumps Healthcare Engineering Consultants

The LSS Facility Tour Checklist for the Hospital Building Tour (cont’d) Compressed gas storage rooms Check: Full and Empty separation, chained or on racks Egress corridors Check: Equipment “not in use”, containers > 32 gallons Eyewashes, showers and portable fire extinguishers Check: Test dates on log or tag Chapel Check: Candles, open flames Other? Healthcare Engineering Consultants

Healthcare Engineering Consultants The LSS Facility Tour Multiple “Operational” Deficiencies are Likely to be Found During the Facility Tour Healthcare Engineering Consultants

Operational Deficiencies Operating Features A clear space >18 inches below sprinkler heads to the top of storage must be maintained Exception: Perimeter wall shelving, unless below the sprinkler (refer to NFPA 13) Portable space heating devices are only permitted in non-sleeping staff and employee areas, with heating elements that do not exceed 212 degrees F (LSC, 2009 edition, 19.7.8) Combustible decorations are prohibited, unless flame retardant (19.7.5.4) Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity (19.7.5.5) Exception: Attended or in hazardous area Healthcare Engineering Consultants

Operational Deficiencies Operating Features Holiday decoration policy and implementation Candles used in the chapel Furnishings, decorations or other objects may not obstruct access, egress or block the visibility of exits (7.1.10.2.1) Exit doors must be free of mirrors, draperies or hangings that may conceal, obscure or confuse the direction of exit (7.5.2.2), and; Hallway Clutter! Healthcare Engineering Consultants

The Life Safety Specialist Surveyor Questions? Healthcare Engineering Consultants