1. Notes From ASHE Conference and CMS LSC Waiver Summaries
Prepared for HFMADV
By Dennis Rudloff and Dan Campbell

2. TJC Prep Guide

3. Preparation Outline
Current SOC and status of Previously Accepted RFI’s, any equivalencies or extensions granted.
Survey team arrives after 7:30AM biographies are on internet; this starts your facilities team into action by calling a code “J” to scour the building within one and a half to two hours.
The surveyor can opt to do the building tour or the document review first. Doing the document review has its advantages.

4. LSCS surveyor will focus on:
EC Fire Drills
EC Features of Fire Protection
EC Emergency Power Systems
EC Medical gas Systems
Hazard Vulnerability Analysis (HVA)
Emergency Operations Plan

5. LSCS surveyor will focus on:
And may also survey
LD EP-4 Accountability (Leaders at the program, service, site, or department level create a culture that enables the hospital to fulfill its mission and meet its goals. They support staff and instill in them a sense of ownership of their work processes. Leaders may delegate work to qualified staff, but the leaders are responsible for the care, treatment, and services provided in their areas.)
LD EP-2 Hi-Priority (Leaders give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities.)
LD EP-5 Resources (The governing body provides for the resources needed to maintain safe, quality care, treatment, and services)

6. Scoring
All findings of less than full compliance are cited as RFI, RFI resolution is through Evidence of Standards Compliance (ESC).
Score based on the number of times an EP is not met, i.e.: sample size is at least 10 items surveyed.
Score of 2 is for 0-1 instance of non-compliance
Score of 1 is for 2 instances of non-compliance
Score of 0 is for 3 or more instances of non-compliance

7. Criticality
Immediate threat to life (samples on next slide): Preliminary Denial of Accreditation (PDA) until resolved. PDA can only be issued by TJC President. Follow-up survey required.
Situational Decision Rules: Contingent Accreditation and PDA
Direct Impact Requirements must be resolved within a short time (45Days)
Indirect Impact Requirements must be resolved within 60 days, these generally do not impact the accreditation decision.

8. Immediate threat to life Triggers (ITL)
When these items are significantly compromised:
Fire Alarm
Sprinkler Alarm
Emergency Power Supply System
Medical Gas Master Panel
Compromised Exits
Other situations that place patients, staff, or visitors at extreme danger.
Note:
Any ITL will automatically trigger an RFI at LD EP-2. (The governing body’s ultimate responsibility for safety and quality derives from its legal responsibility and operational authority for hospital performance. In this context, the governing body provides for internal structures and resources, including staff, that support safety and quality.)

9. NEW – Time Frequencies Defined:
Daily, weekly, monthly are considered calendar references.
Quarterly, is once every three months ± 10 days.
Semi-Annual, is 6months from the last scheduled event month ± 20 days.
Annual, is 12months from the last scheduled event month ± 30 days
3 Years, is 36 months from the last scheduled event month ± 45 days.
Note: Time frames do not apply to required frequencies such as emergency generator testing (see EC EP-4 and EP-8).
Frequencies required by code may not be modified.

10. Issues with EC
Each device tested is required to be in an inventory.
Lack of an inventory results in a finding at that EP
Documentation for a specific EP is not available at time of the survey will result in a finding for that EP.
If a finding is clarified after the survey TJC will review and evaluate for compliance.
But the finding for LD EP-4 (Staff is held Accountable) will remain

11. EP.02.03.05 EP-25 Requires the following summary information
Name of the Activity
Date of the Activity
Required Frequency of the Activity
Name, contact information, including affiliation, of person who performed the activity
NFPA standard(s) referenced for the activity
Results of the activity

12. Interim Life Safety Measures (ILSM)
Standard LS
ILSM’s are required for EP-1 (notify local fir dept., fire watch and document it) and EP-2 (post signage to ID exits) regardless of the ILSM policy.
EP-3 must clearly define in writing the ILSM policy including; (No policy Conditional RFI)
When to implement
What to do to protect patients and other occupants
Both construction related and non-compliance with the LSC
EP-4 to 14 aligns with the policy and implementation strategies.

13. Life Safety Assessment - SOC
Current Statement of Conditions
Basic Building Information
Plan for improvement
Ladder and flashlights
Accurate Life safety Drawings with information that shall include. Life Safety Legend that clearly identifies features of LS. (next slide)

14. Life Safety Assessment – SOC page 2
Identify:
Areas that are sprinklered
Hazardous storage areas
All Rated barriers
All Smoke barriers
Suite boundaries include size, if sleeping (5,000 sq.ft.) or non-sleeping (max 10,000 sq.ft.)
Locations of smoke compartments
Locations of chutes and shafts
Any approved equivalencies or waivers

15. Management Plans
Facilities managers are usually responsible for at least three possibly more management plans.
All plans should be consistent with the organizations Mission, Values, and Philosophy statements. One way to do this is have them approved annually by the Safety Committee.
Your plan will be assessed base3d on its written program if it exceeds the minimum interpretation of the Elements of Performance.
Your Policies and Procedures are the guidance that defines the programs responses.
Your documentation will ensure the activities being carried out have been pre-planned.

16. Equipment Survey Process ( 1 of 2 )
Documentation is completed for both Life Support and Non-Life Support devices on the inventory. You must have an inventory with time frames of PM work.
Inventory must be accurate:
All Life Support equipment must be on the inventory
PM frequencies must be clearly defined in writing.

17. Equipment Survey Process (cont’d)
Surveyor will confirm the work is done as per schedule activities
Ensure appropriate work is scheduled based on maintenance strategies.
Evaluate equipment failure and scheduled action. Do not forget to include ILSM consideration for equipment failures.
Report equipment failures and all follow-up actions to the EOC committee.

18. CMS LSC Waiver Summaries

19. CMS LSC Waiver Conditions
CMS is granting LSC waivers due to unusual hardships and no alternatives that provide an equal level of protection.
Applications for the waiver is not required.
Waivers elected for use must be documented and meet all conditions of the waiver.
Notify the any LSC survey team and present the information at the entrance conference of waivers elected. Otherwise your waivers will be accepted.
LSC survey team will review information and confirm you are meeting the circumstances of the waiver.

20. CMS LSC Waiver Summary ( 1 of 7 )
Medical gas master alarms:
Allows substitution of a centralized computer system for one Category 1 medical gas master alarm.
Code Requirement
NFPA , and compliance with all other applicable NFPA medical gas master alarm provisions
Facilities Must
Demonstrate that it complies with all other applicable NFPA medical gas master alarm provisions, as well as with section of NFPA

21. CMS LSC Waiver Summary ( 2 of 7 )
Openings in Exit Enclosures
Permits existing openings in exit enclosures to mechanical equipment spaces if they are protected by fire-rated door assemblies.
Code Reference
NFPA , (9)(c) and all other applicable NFPA exit provisions
Mechanical Equipment Space Must
Be in a building protected with an approved supervised automatic sprinkler systems.
Be used only for non-fuel-fired mechanical equipment.
Contain NO storage of combustible materials and,
Be protected by a fire rated door

22. CMS LSC Waiver Summary ( 3 of 7 )
Emergency generators and standby power systems
Reduces the annual diesel-powered generator exercising requirement from two (2) continuous hours to one and a half hours.
Code Reference
NFPA , and all other applicable NFPA operational inspection and testing provisions.
The annual load test is only required when the monthly diesel generator test does not comply with minimum loading requirements to avoid wet stacking.

23. CMS LSC Waiver Summary ( 4 of 7 )
Door locking arrangements
Allows door locking arrangements in areas where there are clinical needs, security risks or specialized protective measures required for safety.
Code Reference
NFPA , 18/ through 18/ as well as all other applicable NFPA door provisions.
Facilities staff must make adequate provisions in the rapid removal of occupants by means such as remote control locks or keys carried by the staff at all times.

24. CMS LSC Waiver Summary ( 4 of 7 part two )
Multiple delayed egress locks
Allows more than one delayed-egress lock in the egress path where the clinical needs require specialized security measures or when a patient requires specialized protective measures for safety.
Code Reference
NFPA , 18/ and compliance with all other applicable NFPA door provisions.
Facilities Must also use compensating safety measures specified in those sections that facilitate rapid removal of occupants.

25. CMS LSC Waiver Summary ( 5 of 7 )
Suites
Accommodates the use of suites by allowing: (1) one of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior; and (3) an increase in sleeping room suite size up to 10,000 sq. ft.
Code Reference
NFPA , 18/ and compliance with all other applicable NFPA suite provisions
Facility must meet the corridor wall and door requirements for the outer boundary (perimeter) of the suite and meet the requirements for the smoke zone.
One or more egress routes may be required, depending on the size of the suite. *

26. CMS LSC Waiver Summary ( 6 of 7 )
Extinguishing requirements
Allows for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type water-flow alarm devices to semiannual, and electric motor-driven pump assemblies to monthly.
Code Reference
NFPA , 5.3 and 8.3 and all other applicable NFPA (as referenced in section of the NFPA )
Facility must meet the code references stated.

27. CMS LSC Waiver Summary ( 7of 7 )
Clean waste and patient record recycling containers.
Allows the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96 gallons.
Code Reference
NFPA , 18/
Facility must document that the container has passed an FM fire test.

28. Miscellaneous
Facilities that do not meet all the requirements of the waiver will be cited.
Where do these waivers leave the 2012 LSC?
ASHE believes the agency still wants to adopt the 2012 edition, but because the lengthy adoption process is contingent on other priorities, CMS wanted to give hospitals some relief from burdensome requirements in the meantime.
I personally am skeptical!

29. Questions ?????