# Presentation: 482930

## 2009The Physical Environment Overview Environment of Care Emergency Management Life Safety Chapter

- George Mills, Sr. Engineer
- Standard Interpretation Group
- The Joint Commission

## Overview

- Standards Improvement Initiative (SII)

## Standards Improvement Initiative  

- The Standards Improvement Initiative (SII) did not create any new requirements
- Replaced bulleted lists with expanded Elements of Performance
- Enhance clarity and objectivity of standards and EPs
- 3 chapters of the Physical Environment:
- Management of the Environment of Care
- Emergency Management Chapter
- Life Safety Chapter
- Management of these chapters is up to the organization

## Re-structuring

- Environment of Care (EC)
- Merging Safety & Security
- Training moved from HR to EC
- Life Safety Chapter (LS)
- Compliance with the Life Safety Code
- Moved ILSM from EC
- Emergency Management (EM)
- Major changes in 2008
- Hazard Vulnerability Analysis (HVA)
- Emergency Operations Plan (EOP)

## Managing EC, LS, and EM

**Environment **
**of Care**

**Life Safety**

**Emergency **
**Mgmt.**

- ICES

- Exercises

- SOC

**Healthcare**
**Environment**

- Physical
- Environment

## Standards Improvement Initiative  

- No new requirements for 2009
- Improved language
- No more ‘hard to measure’ words like “appropriate”
- Improved structure of the manual
- Hard copy (6 x 9)
- Electronic (CD)
-  Decisions more accurately reflect organizational performance
- New numbering conventions
- EC.02.04.03 EP 2 The organization inspects, tests & maintains all life support equipment.  These activities are documented. (See also EC.02.04.01 EPs 3 &4; PC.02.01,11 EP 2)

## Naming of Chapter

- EC.  [Environment of Care]
-  This is the chapter title designator
- EM.  [Emergency Management]
-  This is the chapter title designator
- LS.   [Life Safety Chapter]
-  This is the chapter title designator

## Numbering of the Standards

- EC.01 [Plan]
- The organization plans activities to minimize risk in the Environment of Care.
- EC.02 [Implement]
- The organization manages safety and security risks.
- EC.03 [Educate/Train]
- Staff and LIP are familiar with their roles and responsibilities relative to the EC.
- EC.04 [Information, Collection Evaluation System (ICES)]
- The organization collects information to monitor conditions in the EC.

## Numbering of the Subject

- EC.02.01
- Safety & Security
- EC.02.02
- Hazardous Materials & Waste
- EC.02.03
- Fire Safety
- EC.02.04
- Medical Equipment
- EC.02.05
- Utilities Management
- EC.02.06
- Safe, Functional Environment

## Numbering of the Subject (cont.)

- LS.01.01
- Administrative | Management of Life Safety
- LS.01.02
- Administrative | ILSM
- LS.02.01
- Healthcare Occupancy | One Building Type
- LS.03.01
- Ambulatory Occupancy | One Building Type
- LS.04.01
- Residential Occupancy | Rooming & Lodging
- LS.04.02
- Residential Occupancy | Hotel & Dormitory

## Numbering of the Issues

- EC.02.03.05
- Implementation | Fire Safety | Maintains Fire Safety Equipment & Fire Safety Building Features
- LS.02.01.34
- Healthcare | One Building Type | [3] Protection [4] Fire Alarm Systems
- EM.02.01.01
- Develop Emergency Operations Plan | Overview Administrative Features in the Emergency Operations Plan | Response Procedures and Capabilities
- EM.02.02.09
- Emergency Operations Plan | Addresses One of the six (6) Critical Functions | Utilities

## Elements of Performance 

- EC.02.01.01
- Implementation | Safety & Security | Safety & Security Issues
- EP 3 The organization takes action to minimize or eliminate identified safety and security risks in the physical environment
- EC.02.01.01
- Implementation | Safety & Security | Safety & Security Issues
- EP 4 The organization maintains all grounds and equipment
- EC.02.01.03
- Implementation | Safety & Security | Smoking Prohibited
- EP 1 The organization develops a written policy prohibiting smoking in all buildings.  Exceptions for patients in specific circumstances are defined.

## Scoring 

## Scoring & Decision Process

- Scoring Scale
- 0 = Insufficient Compliance
- 1 = Partial Compliance
- 2 = Full Compliance
- Requirement for Improvement (RFI)
- All findings of less than full compliance will be cited as a RFI
- All RFIs require resolution through an Evidence of Standards Compliance (ESC)
- This includes findings scored partial
- “Supplemental Findings” (2008 term) are eliminated

## EP Scoring Categories

- A: Structural requirements
- EP’s scored yes (2) or no (0)
- May address issues requiring full compliance
- C: Based on number of times an EP is not met
- Score 2:  0-1 instances of non-compliance
- Score 1:  2 instances of non-compliance
- Score 0:  _**>**_ 3 instances of non-compliance
- Above is based on a sample of 10
*NOTE: The ‘B’ Category has been eliminated*

## Example:  Category A

- EC.02.04.02 EP 2:
- The hospital inspects, tests & maintains all life support equipment.  These activities are documented.
- Did you do it?  Yes or No   [100%]
- Is there documentation?

## Example:  Category C

- EC.02.04.02 EP 3:
- The hospital inspects, tests & maintains all non-life support equipment identified on the medical inventory.  These activities are documented.
-  How many times did you _not_ do it?
-  Is there documentation?

## Criticality of Findings & 	Immediacy of Risk

- The amount of time for submitting the ESC is based on the criticality of the finding and the immediacy of risk as follows:
- Direct Impact		45 Within Days
- Indirect Impact	60 Within Days

## Criticality

- Criticality defined as *“the immediacy of risk to patient safety or quality of care as a result of noncompliance with a Joint Commission requirement.”*
- 4 Levels of Criticality
- 1. Immediate Threat to Life (ITL)
- PDA until resolved
- 2. Situational Decision Rules
- Based on specific situations at time of survey
- 3. Direct Impact Requirements
- Noncompliance may create an immediate risk to patient safety or quality of care
- 4. Indirect Impact Requirements
- Based on planning and evaluation or care processes

## 2009 Scoring Decision Model

## Immediate Threat to Life 
Situations, identified during survey, which have or may potentially have a serious adverse effect on patient health and safety.
The Joint Commission President can issue an expedited Preliminary Denial of Accreditation (PDA) decision.
PDA remains until corrective action is demonstrated, via an on-site validation review.
PDA changes to Conditional Accreditation which includes a follow-up review to assess sustained implementation of corrective action.
Examples:
Inoperable fire alarm system
Lack of Master Alarms for Medical Gas System

_*Immediate Threat to Life*_
- Situations, identified during survey, which have or may potentially have a serious adverse effect on patient health and safety.
- The Joint Commission President can issue an expedited Preliminary Denial of Accreditation (PDA) decision.
- PDA remains until corrective action is demonstrated, via an on-site validation review.
- PDA changes to Conditional Accreditation which includes a follow-up review to assess sustained implementation of corrective action.
- Examples:
- Inoperable fire alarm system
- Lack of Master Alarms for Medical Gas System

- 2009 Scoring Decision Model

## 2009 Scoring Decision Model

_*Situational Decision Rules*_
- Situations in which a decision of PDA or CON is recommended to the Accreditation Committee
- Demonstration of resolution through submission of Evidence of Standards Compliance (ESC).
- Onsite review to validate implementation of corrective action.
- Examples:
- Failure to implement corrective action in response to accepted PFI
- unlicensed facility

## 2009 Scoring Decision Model

_*Direct Impact Requirements*_
- Non-compliance results in direct impact on quality of care and patient safety
- “Implementation” based requirements
- Non-compliant requirements must be addressed via ESC submission process
**Short time-frame (45 days)**
- Decision is pending submission of ESC within established timeframe
- Failure to resolve results in  progressively more adverse decision (e.g., Provisional, Conditional, PDC)
- Example:
- Inspects, tests & maintains Life Support Systems

## 2009 Scoring Decision Model

_*Indirect Impact Requirements*_
- Initially less immediacy of risk; failure to resolve non-compliance increases risk
- “Planning” and “Evaluation” based requirements
- Non-compliant requirements must be addressed via ESC submission process
**Longer time-frame (60 days)**
- Decision is pending submission of ESC within established timeframe
- Failure to resolve  = progressively more adverse certification decision (e.g., Provisional, Conditional, PDC)
- Examples:
- Piping used for AASS is not used to support any other item
- Hospital provides storage space to meet patient needs

## Direct Impact Count

- Environment of Care
- 38 Direct Impact
- Life Safety Chapter
-  7 Administrative (LS.01)
- 20 Healthcare (LS.02)
- 56 Total (62 ‘z’ items in 2008)
- Emergency Management
-  3 Direct Impact

## Survey Issues

## Unannounced Survey Expectations

- Make full use of the Periodic Performance Review process (annual event)
- Statement of ConditionsTM
- Current (LS.01.01.01 EP 2)
- Previously accepted SOC status
- Equivalencies on file and accessible
- Extensions on file and accessible

## Unannounced Survey Expectations

- Documentation
- Current
- EC/Safety Committee Minutes
- EC Management Plans
- Annual Evaluations of EC Plans
- EC.04.01.01 EP 15
- Inspect, Test & Maintain
- EC.02.05.05
- EC.02.05.07

## Life Safety Code Specialist 

- LSCS Background
- Facilities or Environment of Care based
- Prefer CHFM certification
- LSCS Agenda
- On-Site one day (typically on day 1 or day 2)
- Interfaces with survey team member(s)
- LSCS Focus
- EC.02.03.05 Fire Protection Systems
- EC.02.05.07 Emergency Power
- EC.02.05.09 Medical Gas and Vacuum
- LS.01.01.01 Life Safety Code
- LS.01.02.01 Interim Life Safety Measures (ILSM)
- Other EC “Observations”

## Life Safety Code Specialist Update

- May also survey
- LD.04.01.05 EP 4
- LD.03.03.01 EP 4
- LD.04.04.01 EP 2
- Greater than 750,000 sq ft second survey day for the LSCS
**Critical Access Hospitals **_**ONLY**_**:**
- LSCS will survey all of the EC
- In 2009 will survey EC, LS and EM

## 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:
- 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.02.05.01 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

## Emergency Power Distribution

- Emergency power provided as listed in EC.02.05.03 EPs 1 – 6
- Alarm systems
- Exit route illumination
- Emergency communication
- Elevators
- Life support systems
- Where loss of power could harm patients (i.e. OR)
- Emergency Power Systems are maintained as described in EC.02.05.07
- See Sentinel Event Alert #37

## Medical Gas & Vacuum EC.02.05.09

- Inspects tests & maintains
- Maintains main supply valves and area shut off valves accessible and clearly identifies what the main valves control

## Emergency Management 

- EM.01.01.01 HVA
- EP 1 identify potential emergencies
- EP 3 prioritize the HVA
- EP 5 mitigate
- EP 6 preparedness
- EP 8 Documented inventory of resources & assets
- Fuel
- PPE
- Water
- Medical/surgical supplies

## EM.02.02.09

- 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

## Environment of Care 

## Environment of Care: Structure 

- Plan (EC.01.01.01)**  **
- Implement
- Safety and Security (EC.02.01.01, 02.01.03)**  **
- Hazardous Materials and Wastes (EC.02.02.01)**  **
- Fire Safety (EC.02.03.01, 02.03.03, 02.03.05)
- Medical Equipment (EC.02.04.01, 02.04.03)
- Utilities (EC.02.05.01, 02.05.03, 02.05.05, 02.05.07, 02.05.09)
- Other Physical Environment Requirements (EC.02.06.01, 02.06.05)
- Staff Demonstrate Competence (EC.03.01.01)
- Monitor and Improve (EC.04.01.01, 04.01.03, 04.01.05)

## Environment of Care: Issues 

- EC.01.01.01: The hospital *plans* activities to minimize risks in the environment of care.
- Note: One or more persons can be assigned to manage risks associated with the management plans described in this standard.
- EP 3 The hospital has a *written plan* for managing: environmental safety of everyone who enters the hospitals facilities
- EP 4 The hospital has a *written plan* for managing: security of everyone who enters the hospitals facilities

## EC.02.01.01 EPs 1 & 3

- 1 The hospital identifies safety & security risks associated with the environment of care.  Risks are identified from internal sources *such as* ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high risk processes, and from credible external sources *such as* Sentinel Event Alerts.
- 3 The hospital takes actions to minimize or eliminate identified safety and security risks in the physical environment.

## Does Every mean Every ?

- For the Physical Environment the Joint Commission has defined time in the Introduction of all 3 chapters:
- Daily, weekly, monthly and quarterly are calendar references
- Semi-annual is 6 months from last occurrence +/- 20 days
- Annual is 12 months from last occurrence +/- 30 days

## Does Every mean Every ?

-   EC.02.03.05
- EP 2 Every 6 months the hospital tests valve tamper switches and water-flow devices. 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

## Medical Equipment

- EC.04.01.01  The hospital manages medical equipment risks.
- EP 1 The hospital solicits input from individuals who operate and service equipment when it selects and acquires equipment.
- EP 2 The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory. (see also EC.01.01.01 EP 7)

## Utilities Management

- EC.02.05.01 EP 3
- The hospital *identifies in writing* inspection and maintenance activities for all operating components of utility systems on the inventory. (See also EC.02.05.05 EPs 3 – 5 and EC.02.05.09 EP 1)
- NOTE: Hospitals may use different approaches to maintenance.  For example, activities *such as* predictive maintenance, *reliability-centered maintenance*, interval based inspections, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.

## Utilities Management

- EC.02.05.07 EP 4
- Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each generator for at least 30 continuous minutes.  *The completion date of the tests is documented. *

## Utilities Management

- EC.02.05.01, EP 4
- The [organization] defines in writing intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory based upon criteria such as manufacturers’ recommendations, risk levels, and current hospital experience.

## Life Safety Chapter 

## Life Safety Chapter

- Based on the Life Safety Code®
- NFPA 101-2000
- Format to be consistent with NFPA
- CMS K-Tags reconciled
- Three occupancies
- Healthcare
- Ambulatory
- Residential
- Exception language accepted
- Annual Life Safety Assessment will occur as part of Periodic Performance Review

## Life Safety Chapter	

- Removed optional Building Maintenance Program (BMP)
- Standards & Elements of Performance
- LS.01.01.01 Administrative
- LS.01.02.01 Interim Life Safety Measures
- LS.02 - .04
- LS.02	Healthcare
- LS.03 	Ambulatory
- LS.04	Residential
- LS.04.01 _<_ 16 Rooming & Lodging
- LS.04.02 _>_ 17 Hotel & Dormitory

## 	     LS .02 .01 .34

- 	 LS        .02             .01           .3           4
-  Life    Healthcare   Building   Protection   Fire
- Safety 	 	        Type		        Alarm
-  EPs are sequentially listed
-  Exception language accepted
-  Interim Life Safety Measures (ILSM) applies to LSC deficiencies
- Construction and non-construction

## Life Safety Process

- Overview: When an [organization] finds that it is out of compliance with Standards LS.02.01.10 through LS.04.02.05, the hospital either resolves the deficiencies immediately or manages it through one of the following options:
-  a maintenance management process that documents the deficiency and corrective resolution within 45 days; or
-  a Plan For Improvement derived from the *Statement of Conditions*TM; or
-  a Life Safety Code Equivalency approved by The Joint Commission.

## Life Safety Process

- Note: Equivalency approval by The Joint Commission is required even if approval of an equivalency or waiver has been granted by other regulatory bodies.
- Submit extension requests using the PFI
- PFI menu, select PFI Change Request
- Complete the webmail request form

## Equivalencies

- Traditional Equivalency
-  Alternative means of complying with the LSC
-  Confirmed by one of the following:
- Fire Protection Engineer
- Registered Architect
- Local AHJ (over enforcement of fire safety)

## Traditional Equivalencies

- In the SOC select PFI
- Select PFI Change Request
- This routes the user to a Web Request page
- Identify deficiency using specific Life Safety Code references
- Identify alternative solution
- Provide timeline of actions
- Have one of the following certify proposed actions:
- Fire Protection Engineer
- Registered Architect
- Local AHJ (over enforcement of fire safety)

## FSES Equivalencies

- Submit in writing
- Include the following:
- Completed FSES evaluation
- Identify all deficiencies that are being addressed
- Use specific Life Safety Code references
- Identify why the equivalency is being made
- Confirmation that all open PFIs will receive high priority resolution
- Provide summary of FSES findings

## Life Safety Chapter 

- LS.01.01.01 (Administrative)
- EP 3
- When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frame identified in the PFI accepted by The Joint Commission.

## Life Safety Chapter

- LS.01.02.01 (ILSM) EP 3
- The hospital has a written Interim Life Safety Measures (ILSM) policy that covers periods of construction or situations when the Life Safety Code deficiencies cannot be immediately corrected or when The Joint Commission has not granted an equivalency.  The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased risk.

## Life Safety Chapter

- LS.02.01.20
- The organization maintains the integrity of the means of egress
- EP 13 Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice.  (For full text and any exceptions, refer to: NFPA 101-2000, 18/19.2.3.3.)

## Electronic Statement of Conditions (eSOC)

## Electronic Statement of Conditions 

- No paper as of 9/1/2007
- Security levels of access now available
- Color bars indicate Projected Completion Date status
- Enhanced Sites & Building page

## Security Administrator

## Sites & Buildings: Before 

## Sites & Buildings: Revised

## Government Suspension

## BBI Enhancements

## After Gov’t Suspension

## Sites & Building Page

## 	Occupancy Page: BBI 

## Emergency Management 

## Overview

- Is now an accreditation manual chapter
- All Standards and Elements of Performance from 2008 are incorporated into the 2009 Emergency Management Chapter
- No new Standards or Elements of Performance in 2009
- This new chapter contains some standards that were in HR, EC and MS
- Survey Process is similar to 2008

## Rationale

- The revised standards emphasize a “scalable” approach that can help manage the impact on a single organization, multiple organizations, an entire community, or region
- Consider
- Variety of events
- Intensity of events
- Duration of the disasters
- The revisions also stress the importance of planning, and testing response plans for emergencies during conditions when the *local community cannot support* the healthcare organization

## History of Disasters 

-    Hospital/Community Debriefings:
- Tropical Storm Allison-June 2001
- Terrorist Attacks-September 2001
- Power Outage- Summer 2003
- S. California Wild Fires-Summer 2003
- SARS (Asia/Toronto)-Spring 2003
- Florida Hurricanes (Frances, Charley, Jeanne) - Aug/Sept 2004
- Hurricane Katrina, Rita, Wilma- Aug, Sept & Oct 2005

- G

## Assessment Conclusions

- Major Issues Began to Surface:
- Problems with Communication
- Inadequate emergency generator backup
- Faulty Incident Command Systems
- Lack of Involvement with Emergency Operations Center (EOC)
- The extend of an organization’s planning is dictated by the impact of their worst _recent_ disaster

## Chapter Outline

- Foundation for the Emergency Plan [EM.01.01.01]
- Plan for Emergency Operations Plan
- General Requirements [EM.02.01.01]
- Specific Requirements
- Evaluation
- Evaluating the planning [EM.03.01.01]
- Evaluating the plan through exercises [EM.03.03.03]

## Emergency Management 

- Emergency Program

- Evaluate & Exercise

- Emergency Operations Plan

- HVA  and
- 6 Critical Areas

- Annual Evaluation
- Exercises

- Planning & Leadership

## Conduct a Hazard Vulnerability Analysis

- Documented
- Annual Review
- Site specific: one or many
- Organization and community partners prioritize HVA
- Includes disclosing to community needs and vulnerabilities
- HVA to plan mitigation
- HVA to plan preparedness
- EP 8 Documented inventory of resources & assets
- Fuel
- Personal Protective Equipment (PPE)
- Water
- Medical/surgical supplies
- Other

## Emergency Operations Plan 

- Emergency Operations Plan (EOP) describes response procedures
- Written plan
- Capabilities to self-sustain for up to 96 hours
- EOP describes
- Recovery strategies
- Initiation and termination of response and recovery phases
- Defines authorities
- Alternative care sites
- Actual implementation is documented

## Six Critical Components 

- Communication 			[EC.02.02.01]
- Resources & Assets 		[EC.02.02.03]
- Safety & Security 		[EC.02.02.05]
- Staff responsibilities		[EC.02.02.07]
- Utilities Management		[EC.02.02.09]
- Patient, clinical & support activities 							[EC.02.02.11]

## Emergency Management Development

- EM.02.02.01 Communication
- EP 14 establishes backup communication systems and technologies for communication activities identified in EPs 1 - 13
- EM.02.02.03 Resources & Assets
- EP 3 replenish non-medical supplies
- EP 6 process to monitor quantities of its resources and assets during an emergency
- EM.02.02.05 Safety & Security
- EPs 4 & 5 manage hazardous materials
- EPs 6 & 7 controls access and movement

## Emergency Management Development

- EM.02.02.07 Staff Roles & Responsibilities
- EP 3 Define staff assignments
- EP 7 Provide training for staff assignments
- EM.02.02.09 Utilities
- EM.02.02.11 Patient Care Issues
- EP 3 Evacuation strategies
- EP 11 Evaluate advance preparedness based on HVA
- EM.03.01.01 Annual Evaluation
- EM.03.03.03 Exercise Emergency Management Plan
- EP 3 Escalating component

## Surveying Emergency Management

- Review of the organizations Emergency Operations Plan
- Two themes:
- Discussion
- Prefer to conduct in ICS
- Observation
- Tour based on Discussion
- The subject matter will be based on a review of the Hazard Vulnerability Analysis

## Survey Process – Discussion 

- Discussion Phase (40% of session)
- Compliance with EM Standards
- EOP
- Six Critical Functions
- Discuss Emergency Operations Plan
- Surveyor is evaluating Team Dynamics

## Survey Process – Discussion

- Surveyor examines:
- Six Critical Functions
- Organization’s overall EM structure
- Operations
- Planning activities

- Surveyor initiates discussion around the four EM categories:
- Mitigation
- Planning
- Response
- Recovery

## Survey Process – Observation 

- Surveyor concentrates on:
- How the facility handles actual emergencies
- Evaluated with the organization
- Availability of supplies & equipment
- Training efforts that accompanied EOP
- Effectiveness of communication systems
- Contingency Planning
- Patient care

## Relief: until 12/31/2008

- The following 15 EPs will not impact your accreditation status
- These EPs will be cited but not aggregated
- EC.4.11, EP 9 & 10
- EC.4.12 EP 6
- EC.4.13 EP 7
- EC.4.14 EP 8 & 10
- EC.4.15 EP 2, 3 & 5
- EC.4.16 EP 2 & 3
- EC.4.17 EP 4
- EC.4.18 EP 4, 5, & 6

***NOTE:**** EC.4.20 has until the end of 2008 to show compliance, so they are not included here*

## Issue Resolution& Clarification

*Corridor Clutter & Other Life Safety Code Interpretations  *

## Dampers

- Effective 1/1/2008:
- The Joint Commission will allow a hospital to begin the 6 year frequency effective 1/1/2008
- 6 year cycle of damper inspections for hospitals
- Hospitals may add 2 years to current 4 year inspection practice
- Any new damper installed after 1/1/2008 must be inspected one year after installation
- Any dampers that are inaccessible may be tracked using the electronic Statement of Conditions, with an initial *Projected Completion Date* of 6 years from date of discovery

## Damper Inspection: Actual EP Language: 	EC.02.05.05  EP 18

- The hospital operates fire and smoke dampers one year after installation and then at least every six years to verify that they fully close.  The completion date is documented.1
- Note: The initial test that must occur one year after installation applies only to dampers installed on and after January 1, 2008.
- 1For additional guidance, see NFPA 80-2007 (19.4.1.1) and NFPA 105-2007 (6.5.2).

## NFPA Standards

- NFPA 80-2007 Chapter 19, Installation, Testing and Maintenance of fire dampers
- 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
- NFPA 105-2007 Chapter 6, Installation, Testing and Maintenance of smoke dampers
- 6.5.2 Each damper shall be tested and inspected one year after installation.  The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

## LD.04.01.05 EP 4:  What to do when the documentation isn’t there...

- During survey documentation is reviewed
- If the information is not readily available, but will be available later in the survey this may result in a finding at LD.04.01.05 EP 4
- The requested information should be utilized by the organization, so not having the information may indicate a lack of responsibility by the organization
- If the documentation arrives late, non-compliance has already been established
- Scored at LD.04.01.05 EP4
- Leaders hold staff accountable for their responsibilities

## Corridor Clutter

- If the corridor looks cluttered, it probably is
- Carts with wheels that are not parked and forgotten (not longer than 30 minutes), but are actively used are allowed provided they are "in use"
- Crash Carts are always considered "in use" and allowed with staff understanding that in an emergency situation the cart is moved out of the corridor
- Isolation carts, located outside a occupied patient room & required would be “in use”

## Computers on Wheels

- Computers on Wheels and other wheeled carts may be stored in a corridor for not more than 30 minutes
- Computers on Wheels may be charging in the corridor while being used
- Computers on Wheels may be stored in alcoves
- The corridor width must not be compromised

## Computers on Wheels

- What about the Batteries?
- Battery and charging systems must meet the following design requirements to ensure safe operation:
- Sealed Lead-Acid Batteries:
- Absorbed Glass Mat design and
- Sealed Case (Sealed Lead-Acid)
- All Battery Systems (SLA, NiMH, Li+ Ion, Li+ Ion Polymer):
- Smart Charging system with overcharge protection and
- Shorted cell protection that shuts down upon detecting a shorted cell

## General Life Safety Interpretations

- Rated doors must have legible labels on the door and jambs
- Doors installed prior to 1967 may have jambs without rating labels
- Missing labels may be equivalized if evidence of compliance is provided to central office
- Alternative is to have third party testing agency re-label doors
- Are ILSM in place where non-compliant door assemblies are found?

## General Life Safety Interpretations

- Fire stop: existing application is acceptable if:
- 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
- JC does not accept the expanding foam used for insulation in any fire or smoke barrier
- This product does have a UL label, for insulation properties
- Easily ignited
- Toxic gases when burned
- Testing has confirmed foam alcohol based hand rub (ABHR) is equivalent to gel

## General Life Safety Issues

- Fully sprinklered buildings
- Not required in elevator mechanical rooms if state codes do not allow (i.e. Ohio, Massachusetts)
- Ensure sprinkler piping is not used to support wiring or other material
- Score as life safety code deficiency (LS.02.01.35 EP 4)
- Piping supports are not damaged or loose (LS.02.01.35 EP 3)

## Non Flammable Medical Gas Storage:  General Issues

-  <300 ft3: **12** ‘e’ cylinders per smoke compartment, in rack or appropriate holders
- Each ‘e’ cylinder is 24.96 ft3
- Smoke Compartment is limited to 22,500 ft2
-  Between 300 and 3000 ft3 must be stored in a room that is limited construction with doors that can be locked
-  “In use” verses “in storage”
-  On gurney is considered “in use”
-  In rack is “in storage”
-  limited to 12 unprotected, racked per smoke compartment (i.e. open to egress corridor)
-  “Empty” are NOT considered part of the 12 “in storage”
- Process to remove empties in a timely manner

**  **

## Non-Flammable Gas Storage:	 NFPA 99-2005

- NFPA 99-2005 edition has additional language regarding O**2** storage requirements, specifically:
- Storage of nonflammable gases:
- 9.4.1	_>_ 3000 cubic feet
- 9.4.2	300 – 3000 cubic feet
- 9.4.3	0 - 300 cubic feet
- Other:
- 5.1.3.3.2 		design and construction
- 5.1.3.3.3		ventilation of locations for manifolds
- 5.1.3.3.3.2	ventilation for motor driven equipment
- 5.1.3.3.3.3	ventilation for outdoors
- NOTE: CMS also uses NFPA 99-2005, 9.4.3

** **

## Questions?

## SIG Support: 630 792 5900

- Jerry Gervais, CHSP, CHFM
- Engineer       SIG

- George Mills, MBA, FASHE, CEM, CHFM
- Senior Engineer     SIG

- John Maurer  CHFM, CHSP
- Engineer       SIG

- Charles “Skip” Wilson, MBA
- Engineer       SIG