What is the Number 1 Question What is the Number 1

Your Next 12 Months?
Joint Commission –
Inspection Preparation/
Compliance Update
William E. Koffel, Jr. P.E.,
FSFPE, President
Expertly Engineering Safety From Fire
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Your Next 12 Months?
What is the Number 1 Question
???
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What is the Number 1 Question?
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What is the Number 1 Question?
• Catergorical Waivers
– 2012
• Wheeled Equipment/Fixed Furniture
• Security
• Suite Arrangement
• Suite Size
• Combustible Decorations
• NFPA 25 – 2011
– Flow switches
– Fire pumps (maybe???)
• Additional Catergorical Waivers???
• Adoption???
• NPRM
– 2012 Edition of NFPA 101,
but….
• “…regardless of the number
of patients served….”
• Window sill height
– June 4th incident
– 2012 Edition of NFPA 99
but…
• Ventilation requirement in
windowless anesthetizing
locations
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Health Care Corridors
Health Care Corridors
•
•
•
•
Wheeled equipment and carts in use
Wheeled medical emergency equipment
Patient lift and transport equipment
Fixed furniture
– 6 ft clear corridor
must remain
Paragraph 18/19.2.3.4(4)
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Locking Arrangements
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Locking Arrangements
• Patient special needs require
specialized protective
measures
• Door Locking
– Cannot Lock Except…
• Clinical or Security Need
Paragraph 18/19.2.2.2.5.2
Paragraph 18/19.2.2.2.4 and 18/19.2.2.2.5
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Suites
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Egress Through Adjoining Suites
• Two mean of egress required
• One can be through adjoining suite
Paragraphs 18/19.2.5.7.2.2(C) and 18/19.2.5.7.3.2(C)
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Suite Intervening Rooms
Sleeping Suites
• Eliminates the limit on the number of intervening rooms in both
sleeping and non-sleeping suites
• 100 ft distance to an exit access door, regardless of the number
of intervening rooms
– May include horizontal exit (clarified in 2015 Edition)
Paragraphs 18/19.2.5.7.2.4(A) and 18/19.2.5.7.3.4(A)
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Sleeping Suite Size - NEW
• Limited to 7500 ft2
OR
• Greater than 7500 ft2 and not exceeding 10,000 ft2 shall be
permitted where both of the following are provided in the suite:
– Direct visual supervision
– Full automatic smoke detection
2000 Edition Sleeping Suite
Sleeping Suite
5,000 sq. ft.
Paragraph 18.2.5.7.2.3
– Direct visual supervision AND
– Total coverage (complete) automatic smoke detection AND
– Sprinkler system protection with QRS or residential sprinklers
Paragraph 19.2.5.7.2.3
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2012 Edition Sleeping Suite
Sleeping Suite
7,500 sq. ft.
2012 Edition Sleeping Suite
Sleeping Suite
10,000 sq. ft.
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Non-sleeping Suites
• No increases in size
Equivalencies and Waivers
Equivalency
Waiver
– Increased in 2015 Edition
• Intervening rooms
• Adjoining suite egress
Paragraph 18/19.2.5.7.3
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Equivalencies and Waivers
Equivalencies and Waivers
Equivalency
Waiver
Equivalency
Waiver
• Paragraph 1.4, NFPA 101
• Paragraph 4.6.5, NFPA 101
• Paragraph 1.4, NFPA 101
• Paragraph 4.6.5, NFPA 101
– Equivalent or superior to Code
requirement
– Approved by AHJ
– Reasonable level of safety
– Compliance with Code is
impractical
– Approved by AHJ
– Equivalent or superior to Code
requirement
– Approved by AHJ
• TJC
– Traditional
– FSES
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Equivalencies and Waivers
Equivalency
Waiver
• Paragraph 1.4, NFPA 101
• Paragraph 4.6.5, NFPA 101
– Equivalent or superior to Code
requirement
– Approved by AHJ
• TJC
– Traditional
– FSES
• CMS
– FSES is an equivalency
– State to review/prepare
– New Code ALONE is not
enough justification
– Reasonable level of safety
– Compliance with Code is
impractical
– Approved by AHJ
• CMS
– Requested after citation
received
– Categorical Waivers
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– Reasonable level of safety
– Compliance with Code is
impractical
– Approved by AHJ
• CMS
– Requested after citation
received
– Categorical Waivers
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Equivalencies and Waivers
• For facilities that use accreditation for “deemed status”
– TJC will review all equivalences the same as has been done in
the past
• Rumor – Traditional Equivalencies will no longer be
accepted
– MHO – Status unknown
– Once approved, sent to CMS Regional Office for approval
• Questions
– Will CMS approve a Traditional Equivalency or will it be
considered a waiver?
– Resource needs to approve equivalencies?
– How long will this take and how will it impact PFI’s?
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Equivalencies and Waivers
Final Report – Equivalency/PFI
Summary Page
• For facilities that use accreditation for “deemed status”
– If approved, CMS will notify facility and TJC
• History Audit Trail will be updated
– If not approved, CMS will notify facility and TJC
• Correct deficiency, OR
• Resubmit an equivalency
– Effective JULY 1, 2014
• TJC surveyors will check History Audit Trail
• TJC surveyors will confirm conditions stated in equivalency
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Final Report – Equivalency/PFI
Summary Page
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Opportunities For Improvement
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Final Report – Equivalency/PFI
Summary Page
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Opportunities For Improvement
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Opportunities For Improvement
• Description for this new section:
– Observations noted within the Opportunities for Improvement
(OFI) section of the report represent single instances of noncompliance noted under a C category Element of
Performance. Although these observations do not require
official follow up through the Evidence of Standards
Compliance (ESC) process, they are included to provide your
organization with a robust analysis of all instances of noncompliance noted during survey.
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Opportunities For Improvement
• Single observations at C category EPs will be included in a
separate section of the accreditation report
• The new section is titled “Opportunities for Improvement” (OFIs)
• OFIs will not require an Evidence of Standards Compliance
(ESC).
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Utility Systems and Medical Equipment
Utility Systems and Medical Eqiupment
• The hospital maintains a written inventory of all operating
components of utility systems or maintains a written inventory of
selected operating components of utility systems based on risks
for infection, occupant needs, and systems critical to patient care
(including all life-support systems). The hospital evaluates new
types of utility components before initial use to determine whether
they should be included in the inventory. For hospitals that use
Joint Commission accreditation for deemed status purposes:
The hospital maintains a written inventory of all operating
components of utility systems. (See also EC.02.05.05, EPs 1, 3-5)
• The hospital identifies the activities and associated frequencies, in
writing, for inspecting, testing and maintaining all operating
components of utility systems on the inventory. These activities
and associated frequencies are in accordance with
manufacturers’ recommendations or with strategies of an
alternative equipment maintenance (AEM) program.
– Note 1: The strategies of an AEM program must not reduce
the safety of equipment and must be based on accepted
standards of practice.
• An example of guidelines for physical plant equipment maintenance is the American Society
for Healthcare Engineering (ASHE) book Maintenance Management for Health Care Facilities.
– Note 2: For guidance on maintenance and testing activities for
Essential Electric Systems (Type I), see NFPA 99, 1999
edition (Section 3-4.4).
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TJC Definition of “Time”
Relocatable Power Taps (RPT’s)
• The Joint Commission EC chapter defines time as:
– Daily, weekly, monthly are calendar references
– Quarterly once every three months +/-10 days
– Semi-annual is 6 months from the last scheduled event month
+/-20 days
– Annual is 12 months from the last scheduled event month +/30 days
– 3 years is 36 months from the last scheduled event month +/45 days
• CMS:
– “RPT’s are not to be used with medical equipment in patient
care areas.
– This includes critical areas such as operating rooms, recovery
areas, intensive care areas, and non-critical patient care areas
such as patient rooms, diagnostic areas, exam areas, etc.”
• Healthcare Interpretation Task Force (12/2007) stated
– NFPA 70, NFPA 99 and NFPA 101 all have regulations that
control the electrical components and equipment in a patient
room. It appears that it is the intent of these documents to
restrict RPT use so that it is not used in conjunction with
medical equipment
– NOTE 1: The above does not apply to required frequencies
– NOTE 2: An alternative of developing either a unique, written policy
or adopting NFPA definitions when available is acceptable
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Relocatable Power Taps (RPT’s)
• RPTs may be used in anesthetizing locations if they are part of
the equipment assembly. See NFPA 99-1999 7-5.1.2.5(2)
• Ceiling drops are acceptable. See NFPA 99-1999 7-5.1.2.5(3)
• RPTs may be used for non-patient care equipment such as
computers/monitors/printers, and in areas such as waiting rooms,
offices, nurse stations, support areas, corridors, etc.
• Precautions needed if RPT’s are used include:
– ensuring they are never “daisy-chained”
– preventing cords from becoming tripping hazards
– installing internal ground fault and over-current protection
devices
– using power strips that are adequate for the number and types
of devices used
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• ASHE Involvement:
– Continuing to seek clarification
– There are UL listed RPT’s for health care
– Do you remove now?
– NFPA 99-2012 language as possible waiver request
• 10.2.3.6 Multiple Outlet Connection. Two or more power
receptacles supplied by a flexible cord shall be permitted to
be used to supply power to plug-connected components of
a movable equipment assembly that is rack-, table-,
pedestal-, or cart mounted, provided that all of the following
conditions are met:
– (1) The receptacles are permanently attached to the equipment
assembly.
– (four additional)
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Maintaining Fire Barriers
Maintaining Fire Barriers
Maintaining Fire Barriers
Maintaining Fire Barriers
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Maintaining Fire Barriers
Maintaining Fire Barriers
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Recycling Containers
Ventilation (#1 TJC Finding)
• Ventilation system is unable to provide appropriate pressure
relationships, air-exchange rates and filtration efficiencies
– Specific areas lack
• negative or positive pressures in relationship to adjacent
areas
– i.e. Endoscopy Processing Room should be negative to
the egress corridor
• the correct number of air changes per hour
• Improper filtration
– MERV= minimum efficiency reporting value
• EC.02.05.01 (over 50% noncompliant since January 1, 2014)
• Recycling containers of
clean waste or for patient
records awaiting
destruction
Paragraph 18.19.7.5.7.2
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Ventilation (#1 TJC Finding)
• Tissue test: only to be used as a pre-screening tool to evaluate if
further investigation needs to occur
– To perform the flutter test take a tissue and let it hang just off
the floor near the bottom edge of a door
– If the tissue indicates incorrect air flow, stabilize the area by
closing doors and windows, wait a few minutes and re-test
– If the organization presents a Testing & Balancing Report the
following questions should be asked
• when was the balancing done (seasonal issues)
• are any specific requirements (such as keeping a door
closed) needed to achieve satisfactory results
Anti-freeze In Sprinkler Systems
• NFPA 25
– All Non-Listed Out by 2022
– Always – Less than 30%
PG and 38% Glycerine
– Never – Above 40% PG
and 50% Glycerine
– Sometimes - When A
Deterministic Risk
Assessment Supports a
Value In Between
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Additional Resources
• Visit www.koffel.com for links to our LinkedIn Discussion Groups
and Ask the Expert
QUESTIONS?
• ASHE
Expertly Engineering Safety50From Fire
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THANK YOU
William (Bill) Koffel
President
[email protected]
410-540-9008
Follow us on LinkedIn
Expertly Engineering Safety From Fire
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