George Mills, Sr. Engineer Standard Interpretation Group

2011 Joint Commission Findings , Impact & Update Joint Commission & CMS: Issue Resolution
George Mills, Sr. Engineer Standard Interpretation Group The Joint Commission 1

Top 5 Most Cited Standards in 2010
Critical Access Hospitals Hospitals 62% RC 50% LS 44% LS 38% EC 37% LS 47% EC 44% LS 40% EC 33% LS 27% EC

#2: LS (50%) The hospital maintains the integrity of the means of egress. EP 13 Corridor Clutter EP 12 Projections EPs 16 – 22 Suites issues Equivalize > 5000 sq ft EP 1 Doors locked in means of egress

Corridor Storage “If the corridor looks cluttered…it probably is”
Corridor clutter is not a PFI issue Carts Allowed: Crash Carts Isolation Carts Chemo Carts Based on a HITF Interpretation (TJC, CMS & other AHJs) the following carts are not allowed: Linen Hampers Latex Carts Anything in the egress corridor more than 30 minutes is storage

Corridor Storage Dead end corridors may be used for storage
Less than or equal to 50sqft space Converting patient room: Long term include door closure Surge issue: based on policy patients may be treated in the egress corridor during surge conditions

#3: LS (44%) Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. EP 9 Penetrations EPs 5 – 7 Door issues EPs 1 & 2 Building Type issues EP 8 Duct issues

NOTE: #1 for Critical Access Hospitals
#4: EC (38%) The hospital maintains fire safety equipment and fire safety building features. Features of fire protection NOTE: #1 for Critical Access Hospitals

#5: LS (37%) The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. EPs 16 – 23 Smoke Barriers & Doors EP 2 Hazardous Areas

Life Safety Code Specialist
LSCS Background Facilities or Environment of Care based Prefer CHFM certification LSCS Agenda On-Site Two Days Interfaces with survey team member(s) LSCS Survey Focus Life Safety Chapter EC EC EC Other “Observations”

Life Safety Code Specialist
May also survey LD EP 4 Accountability LD EP 2 Hi-Priority LD EP 5 Resources All HAP and CAH will be surveyed for a minimum of 2 days by a LSCS Greater than 1.5 million sq ft will be surveyed for a third day by the LSCS An additional day is added for every three buildings that are classified as healthcare Example: for a HAP organization with 2 million square feet of healthcare occupancy and 5 buildings classified as healthcare occupancy: the number of LSCS days would be 4

LD.04.01.05 EP 4: What to do when the documentation isn’t there…
During survey specific documentation is reviewed If the documentation is not available write the observation as non-compliant Also score LD EP 4 If the documentation becomes available later in the survey to the survey team, the team can: Consider removing the previous finding if documentation confirms the activity was completed as per the EP LD EP 4 may also be removed during survey If the survey team would prefer not to evaluate the documentation the organization can submit clarification If the organization clarifies after survey: SIG Engineers will review and evaluate compliance LD EP 4 remains 11

What Triggers ITL (Immediate Threat to Life)
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

What Triggers AFS 13 AFS 13 is only related to previously accepted PFIs Failure to make sufficient progress (LS EP 2) Failure to implement appropriate ILSMs (LS EP 3) Failure to manage previously accepted PFIs affects the Joint Commission Both organizations are aware of deficiencies that have been managed using the PFI process

Deficiency Resolution
Resolution to a deficiency: Resolve it immediately Correct it within 45 days: Management process that documents the deficiency and actions to resolve ILSM must be considered Plan For Improvement located in the Statement of Conditions™ Corrected within 6 months of the Projected Completion Date

45 Day Corrective Action Documented Origination date Completion date
Kept available for rolling 3 years Life Safety deficiencies Must not exceed 45 days If greater than 45 days create a Plan For Improvement (PFI) If originally a work order, close out as complete and generate the PFI Must be made available to the Joint Commission During survey to confirm management of the deficiency During CMS/Joint Commission validation process upon request

How Many Open PFIs Are Too Many?
The PFI process was created to allow organizations to self assess and create a Plan for Improvement The self disclosure has never defined how many is too many The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation

How Many Open PFIs Are Too Many?
Survey Process: Evaluate both closed and currently open PFIs in the View All screen Spot check during building tour both some closed and open PFIs to evaluate how well the organization is managing the PFI process Evaluate the scope of PFI entries Are there life safety deficiencies Are they greater than maintenance items (i.e. screws missing from a door hinge)

Statement of Conditions: PFI
PFIs should be related to the LS Chapter Corridor clutter is not a legitimate PFI PFIs should provide specific information No blanket statements “…penetrations on 3rd floor” Specific references to Life Safety Drawings is acceptable 32 penetrations as identified on LS Drawing 3rd Floor, Center Tower dated 3/3/2010 Projected Completion Date is for all listed items (i.e. “32 penetrations”)

Equivalencies The Joint Commission accepts two forms of equivalencies
Traditional Equivalency A process of field verification identifying alternative methods of fire safety that off-set the identified deficiency Fire Safety Evaluation System (FSES) A process of calculating the features of life safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES

History Audit Trail The History Audit Trail is used by SIG Engineers when considering extensions or other activities related to an organization Prior to surveying, the surveyor must preview the History Audit Trail to discover if equivalencies or other actions have occurred by SIG Engineers When surveying, brief but accurate information entered in the File Room is important

Building Maintenance Program (BMP)
The BMP is no longer available to offset findings during survey, but is considered “best practice” All EPs related to the original ten BMP items are ‘C’ categories

Contingency Planning Utilities exist to provide a safe and comfortable environment of care Failure of utilities could directly impact patient care delivery Activities associated with managing utilities are designed to ensure the reliability of the systems day to day Contingency plans are developed to ensure reliability of utilities systems Contingency plans address at least two issues: Utility/Equipment failure or disruption Emergency related failures or disruption

Contingency Planning: Survey
Organizations ensure their contingency plans are current and accurate Discuss the organization Memorandum of Understanding and its impact in the community Evaluate against Standards & Elements of Performance Suggest the organization include exercising these contingency plans with their Emergency Exercise

EC Utilities Mgmt. EP 7 The hospital maps the distribution of utility systems EP 8 The hospital labels controls for a partial or complete emergency shutdown EP 9 The hospitals has procedures for responding to utility system disruptions EP 10 The hospitals' procedures address shutting off the malfunctioning system and notifying staff in affected areas EP 11 The hospitals procedures address performing emergency clinical interventions during utility systems disruptions EP 12 The hospitals procedures addresses the following: How to obtain emergency repair services EP 13 The hospital responds to utility system disruptions as described in its procedures

EM.02.02.09: Utility Disruption
Emergency Operations Plan identifies alternative means of providing: EP 2 electricity EP 3 water needed for consumption and essential care activities EP 4 water needed for equipment and sanitary purposes EP 5 fuel required for building operations or essential transport activities EP 6 medical gas/vacuum systems EP 7 Utility systems defined as essential, such as Vertical & horizontal transport Heating & cooling systems Steam for sterilization EP 8 Utility needs identified in the HVA

Time Defined The Joint Commission EC chapter defines time as:
Daily, weekly, monthly and quarterly are calendar references Semi-annual is 6 months from the last scheduled event +/- 20 days Annual is 12 months from the last scheduled event +/- 30 days 3 years is 36 months from the last scheduled event +/- 45 days NOTE 1: The above does not apply to required frequencies such as emergency generator testing (see EC EP 4 & 8) NOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable

Semiannual: +/- 20 days Annual: +/- 30 days
Due Date + Due Date + 20 20 20 20 Scheduled Month Scheduled Month 30 30 30 30 Semiannual June July Aug Sept Oct Nov Dec Annual Jan F M A M J J A S O N D Jan Frequencies required by Code may not be modified (i.e. EC EP 4 & 8)

Does Every mean Every ? EC EP 13 Every 6 months the hospital inspects any automatic fire extinguishing systems in a kitchen. The completion date of the test is documented. Every 6 months +/- 20 days EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented. Every 12 months +/- 30 days At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented. Tested within the calendar month

PRA EC.02.06.05 EPs 2 & 3 Preconstruction Risk Assessment (PRA)
Construction or renovation in occupied healthcare facilities can result in environmental problems such as: Noise Vibration Creation or spread of contaminants Disruption of essential services Emergency Procedures Air quality 29

Interim Life Safety Measures
Order of Standards (LS ) EP 1 & 2 regardless of ILSM policy EP 3 must clearly define the ILSM policy including AFS 13 Process When to implement What to do to protect occupants Both construction related and non-compliance with the LSC EPs 4 – 14 align with policy and implementation strategies

Fire Watch An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable. In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled. A scheduled activity would be an event known to and under the knowledge of and control of organization staff a construction project servicing or upgrading the fire alarm system or sprinkler system. 31

ILSM Evaluation Required?
Service Situation Fire Watch Required? ILSM Evaluation Required? Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours No Recommended Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area. Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational Yes Rationale: During a controlled event the organization is managing the deficiency. The area would be continually monitored, and ILSM should be implemented as per policy. Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours ● Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system) Not in all cases Yes (emphasis on occupant notification) Rationale: During a controlled event, the organization is managing the deficiency. The area would be continually monitored, and ILSM would be implemented as per policy. ● Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure) 32

EC EP 1 Effective 1/1/2011 the Joint Commission will recognize the Facilities Guidelines Institute (FGI) Guidelines for Design & Construction of Health Care Facilities ASHRAE 170 has been attached to the Guidelines Ventilation Table 20 – 60 % RH requirement of relative humidity in seven affected areas of the Surgical Environment, and one in Diagnostic & Treatment. NOTE CMS has not adopted this, but remains at 35 – 60%RH The established 60% upper range however should be maintained for issues such as mold growth.

RH% Treatment Areas Class A Operating/Procedure room
Class B and C operating rooms Operating/surgical cystoscopic rooms Delivery room (Caesarean) Treatment rooms Trauma room (crisis or shock) Laser eye room Diagnostic & Treatment: Gastrointestinal Endoscopy Procedure Room

General Life Safety Interpretations
ASHRAE 188 Prevention of Legionellosis Associated with Building Water Systems This 29 page DRAFT document provides guidance related to Legionella mitigation Site survey to identify risk points i.e. water towers Mitigation strategies Water treatments what to do if contamination occurs, such as secondary treatment

Central Sterile Layout
Physically separated soiled and clean work rooms Soiled Work Room: Work surface, sink, washer/sterilizer decontaminators Soiled room is not to have direct contact with the OR Clean assembly /work room Hand washing station Sufficient workspace and equipment Self-closing door or pass through is acceptable between soiled and clean work rooms Storage provisions for humidity, temperature, and ventilation Location of storage may be within the clean assembly/ workroom in a permanently designated space Guidelines for Design & Construction of Health Care Facilities FGI edition

Pressure Relationship All Room Air Exhausted Directly Outdoors
Ventilation (Table 7-1) Function Pressure Relationship Min Outdoor ACH Minimum Total ACH All Room Air Exhausted Directly Outdoors Relative Humidity Design Temp. °F Equip. Room Negative N/R 10 Yes Soiled or Decontam 2 6 72 – 78 Clean Work Room Positive 4 Max 60 Sterile Storage ANSI/ASHRAE/ASHE Standard Table 7-1

Changes to EC EP 2 Existing: Every six months the hospital tests valve tamper switches and water-flow devices. The completion date of the tests is documented. NOTE: for additional guidance on performing tests see NFPA (Table 7-3.2)

Changes to EC.02.03.05 EP 2 Revised:
EP2 For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly the hospital tests water-flow devices. Every 6 months the hospital tests valve tamper switches. The completion date is documented. NOTE: For additional guidance on performing tests see NFPA (Section & 2.3.3) and NPFA (Table and Section 7-5.2).

Changes to EC EP 2 EP 2 (continued) For hospitals that do not use accreditation for deemed status purposes: Every 6 months, the hospital tests valve tamper switches and water-flow devices. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2).

NEW: EC EP 25 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following: Next Slide for Contents Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)

NEW: EC.02.03.05 EP 25 Continued Text: Name of the activity
Date of the activity Required frequency of the activity Name and contact information, including affiliation, of the person who performed the activity NFPA standard(s) referenced for the activity Results of the activity

NEW: EC EP 25 For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following: Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)

Fire & Smoke Damper Inspections
Ensure inaccessible dampers truly are by random sampling Confirm ILSM policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers Evaluate adequacy of damper accessibility plan

LS.02.01.34 EP 2 Master Alarm Panel
The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and ¾ hour fire rated doors) that is continuously occupied OR in an area with a smoke detector. NFPA &

Fire Extinguisher: Dating
Month, day year and initials of inspector as per NFPA EC EP 15 4-3.4 Inspection Recordkeeping. Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action. At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record. DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION 46

Perimeter shelving and sprinkler provision: Are perimeter wall shelving that extends to the ceiling required to be fastened to the wall? NO Shelving is not required for storage There is no correlation between Shelving Clearance The need to secure any shelving

18” rule Perimeter Shelving Perimeter Shelving Ceiling 18” 18” Wall
OK OK OK Wrong

Rated doors must have legible labels on the door and jambs Jambs prior to 1966 may not have a rating label Are ILSM in place where non-compliant door assemblies are found? 49

Firestop: Existing application is acceptable when It was installed in a manner consistent with original design specifications It is in acceptable condition currently If the firestop is cracking, etc, then it is to be removed and repaired using current technologies 50

Expanding foam used for insulation purposes is NOT an acceptable firestop in any fire or smoke barrier This product does have a UL label: for insulation properties Easily ignited Toxic gases may occur when burned NOTE: There are several acceptable fire stop products that expand when installed

Non Flammable Medical Gas Volume & Storage: Scoring
Score EC EP 1 …fire risk 12 ‘E’ cylinders (<300ft³) per smoke compartment (22,500ft²) may be open to the egress corridor in a rack or appropriate holders Between 300 and 3000ft³ must be stored in a room that is limited construction with doors that can be locked “In use” verses “in storage” Properly secured to a gurney is considered “in use” Properly racked is “in storage” Empty are NOT considered part of the 12 in storage Empty and full must be stored (racked) separately 52

Non-Flammable Gas Storage: NFPA 99-2005
NFPA edition has additional language regarding O2 storage requirements, specifically: Storage of nonflammable gases: 9.4.1 > 3000 cubic feet – 3000 cubic feet cubic feet Other: design and construction ventilation of locations for manifolds ventilation for motor driven equipment ventilation for outdoors NOTE: CMS also recognizes reference 53

Non-Flammable Medical Gas Unsafe Conditions: Scoring
Score EC …unsafe condition Unsecured cylinders Laying on top a gurney mattress; leaning against the wall Free standing Transfilling liquid oxygen Transfer of any gases from one cylinder to another in patient care areas of health care facilities is prohibited. Transfilling of liquid oxygen shall be performed in an area that is mechanically ventilated sprinklered ceramic or concrete flooring separated with at least 1 hour construction from any patient care areas 54

Tank Farm EC EP 1 states the hospital tests, inspects and maintains critical components of the piped medical gas systems. Tank Farm is included in this EP The bulk storage tank(s) and associated systems are critical components of the piped medical gas system Tanks above ground, not on roofs No electrical service above tanks 10’ Clear from vehicles & sidewalks 50’ from wood frame buildings At least 1’-0” from other buildings At least 10’ form any opening in wall of adjacent structures Concrete pads at all spill points (3’ min) Permanent signage: OXYGEN – NO SMOKING – NO OPEN FLAMES Access controlled (i.e. locked) 55

Q. Is a UPS used to condition power or supply power when normal power is interrupted until emergency power is established a SEPSS? A. The UPS in this application is a bridging device, and is not a SEPSS

NFPA 110: Emergency & Standby Power Systems
Automatic Transfer Switches (ATS) are self-acting devices that have normal electrical power entering and leaving the ATS The power continues on to distribution panels When a ATS senses a disruption in power it sends a signal to the alternative power source seeking power This start circuit initiates the emergency generator starter The ATS is also equipped with a test switch to simulate the power disruption Recommended practice is to rotate which ATS initiates the start circuit to the emergency generator

Generator Loading The 30% requirement assures the diesel engine achieves correct operating temperature The output of the EPSS is not as critical as the operating temperature during the generator tests Two common ratings on the nameplate: KW & Amps The diesel engine drives the alternator, creating electrical charge Power factor and the nameplate ratings With a static load the power factor is 1.0 With a dynamic load the power factor is .8 The nameplate rating measures the capacity of the system with a diesel engine driving the alternator The 30% is taken from the nameplate without calculating the power factor EPs 5 & 8: …uses a dynamic or static load that is at least 30% of the nameplate rating…

Electrical Unlocked distribution panels in patient care areas Based on policy Consider risk assessment Score EC EP 1 Open junction boxes Score at EC EP 1 Risk: arcing resulting in fire or loss of service

Supervisory Signals: EC EP 1 At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2). Table actually only states that Supervisory Signal Devices must be tested quarterly The Table does not actually define the specific devices

EC EP 1: NFPA , 2-9 lists Supervisory Signal Initiating Devices: 2-9.1 Control Valve Supervisory Signal Initiating Devices 2-9.2 Pressure Supervisory Signal Initiating Devices 2-9.3 Water Level Supervisory Signal Initiating Devices 2-9.4 Room Temperature Supervisory Signal Initiating Devices This is further reinforced by the listing in NFPA , Table 7-2.1, 13.h as devices addressed in NFPA

Staff Safety EC EP 3: Precautions & PPE EP 4: Spill procedures EPs 5 – 10: minimizes risk EC EP 1: Monitoring & Reporting EPs 2 – 11: Specifics Manifests: EP 11 DOT training for those signing

Unsafe Conditions & Suicide Risk EC EP 1: Interior Spaces meet the need of the patient population and are safe and suitable to the care, treatment and services provided. Any unsafe condition can be scored here, provided it is in the patient care interior spaces Suicide risk may be addressed by clinical interventions or policies Work with other survey team members

Outdoor Safety EC EP 5 The hospital maintains all grounds and equipment Grounds includes Sidewalks Parking lots Park ways Picnic and patio areas Play structures

Outdoor Safety EC EP 5 The hospital maintains all grounds and equipment Equipment includes Lawn maintenance equipment Snow removal equipment Maintenance equipment Paving Road repair Lighting

CE: Lessons Learned from 2010
Scope issues Contamination issues Alarm Hazards Disabled or otherwise compromised Telemetry Infusion pumps Surgical Site Fires Sentinel Event Alert

Defibrillators: FAQ Q. Are defibrillators considered life support equipment? YES. Maintenance activities then must be identified for equipment on the inventory A maintenance strategy for defibrillators could include a range of activities from a visual inspection of the single-use AED (automatic external defibrillator) to the scheduled PM maintenance of a defibrillator Note: the daily and weekly observations are assessed as per policy (see PC EP2) 67

Emergency Management: Key Concepts
All hazards approach Collaboration with community partners Situational awareness Active mitigation and preparation, not just a written plan Monitor and evaluate

Pre-Session documents
Emergency Operations Plan All hazards approach Addresses the six critical areas Inventory of resources and assets Hazard Vulnerability Analysis (HVA) Mitigation and preparedness activities for the top 2 or 3 events Disaster drill and real event evaluations Monitors and evaluates the six critical areas

Hazard Vulnerability Analysis
Conducted by EM Committee/Team Use Multi-disciplinary Approach Experts within your facility Community Share information with: Community-prioritizes events Hospital Leadership For each emergency, the organization defines Mitigation, Preparation, Response, Recovery Directs the survey process related to EM

Staff Responsibilities Utilities Management
Six Critical Areas Communication Resources & Assets Safety & Security Staff Responsibilities Utilities Management Patient Clinical & Support Activities

Overview of the 2011 EM Changes
Stand alone EM session Up to 90 minutes Focus on mitigation and preparedness No disaster scenarios; use hospital disaster critiques Data collection tool and EM Tips document Focused discussion on six critical areas Look at resources and assets inventory; appropriate storage, expirations, training

Questions?

SIG Engineers: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer SIG Michael Chisholm, CPE, CHFM Engineer SIG Anne Guglielmo, CFPS, LEED, A.P., CHSP Engineer SIG 74

The Joint Commission Disclaimer
These slides are current as of 4/22/ 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. 75

Maintenance Strategies Medical Equipment Utilities Systems
Surveying Maintenance Strategies Medical Equipment Utilities Systems