Healthcare Life Safety Compliance

The newsletter to assist healthcare facility managers with fire protection and life safety Healthcare Life Safety Compliance P5 P7 P9 P10 P12 Equivalency approval A recent announcement indicated that all approvals sent to The Joint Commission must also be passed on to CMS. What does this mean for your organization? Power strips The use of power strips has been a major topic of discussion recently. What do The Joint Commission and CMS have to say on the matter? Editorially Speaking... This month s editorial discusses recent updates to life safety from the accreditation world. Q&A This month s Q&A looks at cylinders in ambulatory surgery centers, storage in electrical rooms, and more. NFPA Roundup This month s bonus tool provides a Q&A roundup from the recent NFPA conference. Volume 16 Issue No. 8 AUGUST 2014 Changes to the Statement of Conditions PFI list Alterations became effective July 1, 2014 The Joint Commission published an online notice in June 2014 of changes to its survey decision reports, which became effective on July 1, 2014, that may eliminate the strategic advantage of healthcare organizations self-reporting Life Safety Code (LSC) deficiencies on their Plan for Improvement (PFI) list in the Statement of Conditions. The reason for these changes is to align The Joint Commission s survey process with the requirements of CMS. The Joint Commission is in the process of having its renewal application for deemed status from CMS approved, and this action appears to be a direct result of CMS insistence of The Joint Commission to follow CMS rules. CMS has for many years prevented other accreditation organizations (AO) such as HFAP and DNV the ability to have a document similar to the PFI list that provides protection from surveyor findings during a survey. It appears now that by this action, a level playing field with all the AOs has been achieved and any unfair advantage that The Joint Commission had in the past has been eliminated. But sources say this is not the result that HFAP and DNV wanted. They were petitioning the federal agency to allow them to have the same protection for their clients that The Joint Commission offered to its clients in its PFI list. Specifically, the changes that The Joint Commission announced in its online publication stated that while it retained its PFI section of the Statement of Conditions, it eliminated the protection of the deficiency from being identified on the survey report. It now says it will list all open, unresolved PFIs on the survey decision report, which puts it on the same level with the other AOs. In the same online announcement, The Joint Commission declared that it has created a new section in

Healthcare Life Safety Compliance August 2014 the survey decision report called the Opportunities For Improvement (OFI), in addition to the still current Requirement for Improvement (RFI) section. This is significant as currently single observations of Category C elements of performance are not posted on the survey decision report, which is contrary to CMS directive. CMS has stated for years that all deficiencies observed by a surveyor must be cited in the survey decision report. Now, single observations of Category C elements of performance will be cited in the survey decision report under the OFI section, rather than the RFI section. The ability to clarify away surveyor findings after the survey on Category C standards in the OFI section is eliminated. However, the online notice did not say that The Joint Commission is eliminating the ability for healthcare organizations to clarify Category C findings scored under the RFI section. Based on this online notice, it is apparent that CMS convinced The Joint Commission to implement the changes to the survey report, which eliminated the uneven playing field. This action appears to place all AOs on the same level and The Joint Commission no longer has an unfair advantage. But let s remember what the Statement of Conditions PFI list is all about: It is a Joint Commission management tool designed for facility managers to self-report LSC deficiencies in order to manage the resolution of the deficiency. The PFI list is for healthcare organizations to use in order to track the LSC deficiencies to completion. There is no Joint Commission standard that says you must enter all LSC deficiencies into the PFI list that cannot be resolved within 45 days. The Joint Commission does have a Frequently Asked Question on the subject, and the answer they provided is as follows: The Joint Commission allows resolution of a deficiency by either correcting it immediately (preferred), managing it using a corrective maintenance work order system (with tracking capabilities) with resolution within 45 days, or creating a Plan for Improvement (PFI) and managing it using the electronic Statement of Conditions (SOC). This is not a standard requirement of the accreditation organization, but more like a recommendation, and is considered an option for the facility manager. This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Senior Managing Editor Matt Phillion, CSHA mphillion@hcpro.com Follow Us Follow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc Senior Editor Brad Keyes, CHSP Senior Consultant Keyes Life Safety Compliance www.keyeslifesafety.com James R. Ambrose, PE Technical Director, Healthcare Code Consultants, Inc. St. Louis, Missouri Joseph A. Berlesky, CHFM, CHE Director, Plant Facilities Baptist Medical Center Beaches Jacksonville Beach, Florida Frederick C. Bradley, PE Principal FCB Engineering Alpharetta, Georgia Jamie Crouch, Safety and Security Manager Metro Health Hospital Wyoming, Michigan Michael Crowley, PE Senior Vice President, Engineering Manager Rolf Jensen & Associates, Inc. Houston, Texas A. Richard Fasano Manager, Western Office Russell Phillips & Associates, LLC Elk Grove, California Burton Klein, PE President Burton Klein Associates Newton, Massachusetts Henry Kowalenko Supervisor, Design Standards Unit Office of Healthcare Regulation, Illinois Department of Public Health Chicago, Illinois David Mohile President Medical Engineering Services, Inc. Leesburg, Virginia James Murphy President MRF, Ltd. Western Springs, Illinois Thomas Salamone Director, Healthcare Services Telgian Corporationn Atlanta, Georgia Terry Shultz, PE Principal Code Consultants, Inc. St. Louis, Missouri William Wilson, CFPS, PEM Fire Safety Coordinator Beaumont Hospitals Royal Oak, Michigan Healthcare Life Safety Compliance (ISSN: 1523-7575 [print]; 1937-741X [online]) is published monthly by HCPro, a division of BLR, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate is $329 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, P.O. Box 3049, Peabody, MA 01961-3049. Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance, call 781-639- 1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email customerservice@hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be in cluded on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of HLSC. Mention of products and services does not constitute endorsement. Advice given is general and based on National Fire Protection Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Information should not be construed as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter or otherwise. Advisory board members are not responsible for information and opinions that are not their own. 2 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

August 2014 Healthcare Life Safety Compliance The facility manager does not have to enter the LSC deficiencies in the PFI list if he or she does not want to, especially now that there is no protection from a finding on the survey report. But you may be shorting yourself of a useful tool if you do not use the PFI list. It is considered by many that an organization would be at an advantage to list all of its LSC deficiencies that cannot be resolved within 45 days on the PFI list and risk being cited for them, in order to track and manage each deficiency to a successful conclusion. Each organization needs to consider all of the alternatives and make its own decision. At the NFPA annual Conference and Expo held in Las Vegas in June, George Mills, MBA, FASHE, CEM, CHFM, director of engineering at The Joint Commission spoke of the changes to the PFI list. He explained that the Statement of Conditions is another tool that healthcare organizations should use to conduct their own inspections for LSC compliance. We expect the inspection to be conducted annually and that it is tied into your processes to make sure your buildings are life and fire safe at all times, says Mills. During these inspections we want you to identify deficiencies and the best thing to do is repair the deficiency right away. If you can t get it done right away, you write a work order ticket on it and get it fixed within 45 days and that way you manage the process to resolve the deficiency. If it takes more than 45 days, we expect that you write a PFI in the Statement of Conditions. In the PFI list, healthcare organizations are expected to identify the LSC deficiency and explain how they are going to resolve that deficiency. Mills reminded the attendees that the LSC deficiencies identified on the PFI list need to be assessed for interim life safety measures. The PFI list started in 1995 when The Joint Commission created the Statement of Conditions process. Mills says it really was a way to put the assessment of the buildings into the facility manager s hands rather than in the on-site surveyor team s. We thought you could do a far better job on building inspection, says Mills. Then when you identify deficiencies in your PFI list, we would work with you to make sure the deficiency is resolved in time. The Joint Commission has a section in the PFI list called the projected completion date. This is an important part of the PFI and is the date when the organization believes it will have the deficiency completed. There is a certain amount of estimate with that and The Joint Commission does allow a six-month grace period. What that means, when you write your PFI it really is your best guess when the work will be done, says Mills. Well, we will give you an additional six months to get the work done just in case you can t get parts, or you run over. Technically, the projected completion date is a guesstimate and the drop-dead date is six months from then. The Joint Commission Life Safety chapter is the source that permits the healthcare organization to write PFIs. If the deficiency is not in the Life Safety chapter and it is not related to the LSC, then it is not eligible to be listed as a PFI. For example if you have potholes in the parking lot, although they are a trip hazard, they are not considered an LSC deficiency, so you would not write a PFI to repave the parking lot. We want to know specifically what you re talking about with the PFI, so you can t just say you have holes on the third floor, says Mills. We want to know where those holes are that you re managing and taking credit for. Be specific so when we re on survey we can identify where the holes are located. This can be a description in the PFI list, or a reference to a drawing or something that is related back to the location of the deficiency. The Joint Commission does allow you to group and gather similar deficiencies if you need to. For example, if you have a life safety drawing and identify 15 penetrations on the third floor by the locations on the drawing and dated when those were found and type that drawing number into the one PFI and say, See life safety drawing #12 for 15 identified deficiencies, which will be corrected by December 31, 2014, or whatever, that would be acceptable, says Mills. But that PFI cannot be closed until you resolve all 15 identified deficiencies on that list. So be sure that is realistic what you put on the drawing and the projected completion date based on what is associated. According to Mills, all PFIs can be edited by the organization until they are accepted by surveyors during a survey. So if you need to edit the PFI and need more time to resolve the deficiency, as long as The Joint Commission has not accepted your PFI, then you can edit it as much as you need to. Mills does say 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 3

Healthcare Life Safety Compliance August 2014 though, the edits are recorded. It will show on a view-all screen that has been modified that simply shows us that somebody has done some clerical change to the PFI itself, says Mills. On the first day of survey our life safety surveyors will lock down the PFI, which means we accept them and, at that point in time, you can no longer make any edits to the PFI other than the actual completion date. Because when we accept those PFIs is when The Joint Commission is agreeing with you that, Yes, the deficiency exists, and yes, you re managing them appropriately, and yes, you have a projected completion date that is reasonable. The surveyors are being trained to look at all the open PFIs before they accept them to make sure they are LSC-related, and to make sure the projected completion dates are reasonable. Once The Joint Commission accepts the PFIs, it is acknowledging they exist and the accreditor expects that the organization will meet the projected completion date plus the sixmonth grace period that it has given you. Failure to do so could result in an adverse decision, under rule AFS-10, says Mills. The reason for that is once we ve accepted your PFI we are now in agreement with this deficiency and there is a responsibility on both sides. Ours is to make sure the organization gets the work done they say they will, and yours is to make sure you get it done within the time frame you stated. So there is this relationship that is now formed once we accept these and failure to do so breaches that agreement, which is why it could result in an adverse decision rule. Mills explains that a PFI that exceeds the six-month grace period after the projected completion date will cause The Joint Commission to take action. If it is a PFI that we have accepted, and you exceeded the projected completion date by more than six months, then your Statement of Conditions will send me an email, says Mills. What will happen then is we will make a telephone call to you and we will say that we ve identified that you exceeded the projected completion date by more than six months. The conversation is more of a What s going on? discussion. We ll also look down the road a bit and see what PFIs are maturing. Clearly we want to work with you on this process; it s not punitive and it is not going to turn into a negative issue. It s meant to get you back on track and get you fixed up. That s for the first-time offense. Mills says The Joint Commission will also annotate in the History Audit Trail in the Statement of Conditions that it had a discussion with you at that time. If The Joint Commission receives a second automatic email for another PFI that exceeded the projected completion date by more than six months, the conversation is more serious. When the second one happens, we are going to look at the PFI and make a decision, says Mills. The decision may be that we come out and make a re-survey with a life safety surveyor and look at what the deficiency is that caused your PFI to be late. We would then decide whether or not that the failure [late PFI] was reasonable or out of control and whether we should write it as a finding, which could include an adverse decision rule under AFS-10. So the second time the judgment call will be made by The Joint Commission office as to whether or not we will send out an LS surveyor. Mills explained additional changes with the PFI process. Effective July 1st, what we are going to do is import all of your open accepted PFIs into your final survey report, says Mills. Now that will be a two-step process. What will happen is on the last day of survey we re going to import into the one-page summary and it will say how many open PFIs you have and the projected completion date for the oldest one. That will be imported on the last day of survey so your leadership will then see it at that point. It will also be imported into the final survey report. But Mills put a positive spin on the subject of PFIs imported into the final survey report, which some experts considered to be a setback for facility managers. I think this is pretty much in sync with the ASHE [American Society for Healthcare Engineers] movement right now, says Mills. ASHE has a definite movement right now where they are trying to get the facility folks into the C-suite. I think this is a huge proactive way to do that where you can go to your leadership, explain the important PFIs that are in there, what the impact of that is, and how it is a positive thing. It is not similar to other RFIs because you identified the deficiencies and you are managing them appropriately. So it is a good opportunity to get in the C-suite, explain to them your process, justify the dollars that you are asking for. H 4 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

August 2014 Healthcare Life Safety Compliance Approving equivalencies Methods to deal with changes to the process As a result of the June 2014 online announcement by The Joint Commission that identified major changes for the Statement of Conditions Plan for Improvement (PFI) list, it also mentioned that beginning July 1, 2014, all equivalency requests submitted to it will be passed along to the appropriate CMS Regional Office for approval. It appears that this is another situation whereby CMS is encouraging The Joint Commission to change the way it does business with regard to the way equivalencies are approved. CMS has 10 regional offices scattered across the United States, serving the 50 states, American Samoa, Guam, Saipan, Puerto Rico, U.S. Virgin Islands, and the District of Columbia. Under its Conditions of Participation section 482.41(b)(2), CMS has the right to waive specific provisions of the Life Safety Code (LSC) which, if rigidly applied, would result in unreasonable hardship upon the facility, but only if the waiver does not adversely affect the health and safety of the patients. Waivers are different than equivalencies, in that a waiver is a judgment to no longer require compliance with a particular LSC condition. There is no approach involving alternative methods or devices (such as an equivalency would require), and the approval of a waiver is solely based on the organization s ability to convince the Regional Office that compliance would be a hardship. In informal conversations with CMS representatives from Baltimore, they state that they consider waivers to be the same as equivalencies even though the LSC does not mention waivers, but has a specific section under 1.5.2 (2000 edition) that allows for alternative systems, methods, or devices approved as equivalent by the authority having jurisdiction. The trump card that CMS is now playing is it has said (as recently as the April 2014 proposed rule on adopting the new 2012 LSC) that it is the authority having jurisdiction involving healthcare organizations that receive Medicare and Medicaid reimbursements. This means the accreditation organizations (AO) like The Joint Commission, HFAP, DNV, and CIHQ are not the authority having jurisdiction on waiver and equivalency issues for healthcare organizations that are certified by CMS. Essentially, according to the CMS interpretation, the AOs are just agents that have deeming authority to evaluate and assess healthcare organizations on behalf of CMS. During the NFPA annual Conference and Expo held in Las Vegas in June, George Mills, MBA, FASHE, CEM, CHFM, director of engineering at The Joint Commission spoke about The Joint Commission s history of granting equivalencies. We feel granting equivalencies is the right thing to do and makes sense, says Mills. We have been doing this since 1981, and we believe it is a supported process and a safe process. We grant two kinds of equivalencies: Traditional equivalencies and the Fire Safety Evaluation System (FSES) identified in NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 edition. The Joint Commission s traditional equivalency is a process of field verification by identifying alternate methods of fire safety that offset the identified deficiency based on field verification. The Joint Commission requires the field verification to be conducted by one of the following: A registered architect A professional engineer with fire protection experience A Certified Fire Protection Specialist (CFPS) A local AHJ responsible for fire safety Mills explained that field verification must include an on-site assessment by the professional. Many times we are seeing the work done by the facility manager identifying the offsetting feature of life safety, then sending it to somebody off-site who signs off on it but never visited the facility, says Mills. Because we are part of the process of granting these and we are not on-site to verify the conditions, we really are stressing that field verification must be accomplished by the professional. The FSES process calculates the features of life 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 5

Healthcare Life Safety Compliance August 2014 safety and assigns numerical values to them. The LSC deficiencies identified receive a deduction and the mathematical outcome determines whether the building is equivalized based on this process. Mills explained that the entire building needs to be evaluated in this manner. This is not just doing the affected zone, but you need to evaluate the entire building, says Mills. We want to see your submittal in a narrative form that identifies the deficiencies that targeted the equivalency. All of the worksheet forms from NFPA 101A must be completed and all zones are evaluated. If any of these are not happening,we are going to reject it and send it back to you. And we are not doing your math. Mills explained that when The Joint Commission approves an equivalency, it enters the summary of that equivalency into the Statement of Conditions PFI section called the History Audit Trail. Effective July 1, when equivalencies are granted there will be a highlighted section identifying what was equivalized and what supported the equivalency, says Mills. Also, during the building tour our LS surveyor will look and see how you ve done with these. For example, let s say you had unprotected structural steel and your plan was to have sprinkler coverage in that zone. So you re offsetting this deficiency by installing sprinklers in that area. So during the building tour, the LS surveyor will see the unprotected structural steel and look for the sprinklers that offset the deficiency. If you fail to do the things you said you would through the process of the equivalency, we will identify that you have a failed equivalency, and the surveyor will write you for noncompliance for unprotected structural steel. In the final survey report there will be a paragraph that says your equivalency had been reviewed and found to be noncompliant, which resulted in a finding. Mills explained the changes that became effective July 1, that CMS required The Joint Commission to make. For those organizations that use The Joint Commission for deemed status (i.e., they receive Medicare and Medicaid reimbursements), equivalencies will continue to be submitted to our office, says Mills. Our staff will work with you until they are at a point where they can be accepted. Once we get to that level of acceptability, then we will forward your request on to your CMS Regional Office for their final action. So it will delay the process, but it is what CMS has wanted us to do for a long, long time. We pushed back on it until finally, for all sorts of other reasons, we agreed. Effective July 1st, equivalencies that are on our desk and new ones that are coming in will be sent to the Regional Office, provided we can get them to where we believe they are an acceptable equivalency. We expect that the CMS response will be positive, but you need to be aware that this is another step that CMS is posing on all of us, which may delay the approval process. Representatives from HFAP and DNV have said CMS will not accept a waiver request or an equivalency request without the LSC deficiency first being cited during a survey. It requires a copy of the deficiency report and a copy of the Plan of Correction to be submitted, along with the waiver or equivalency request. The Plan of Correction cannot be submitted unless an LSC deficiency is first identified during a survey. This would lead one to believe that this process also applies to The Joint Commission since CMS is trying to level the playing field between the AOs. But that process is not clear to the representatives from The Joint Commission who spoke at the NFPA annual Conference. As far as I m concerned we still want to be proactive and we still want organizations to self-identify and go through this equivalency process to manage their deficiencies, says Anne Guglielmo, CFPS, CHSP, LEED A.P., engineer in the department of engineering at The Joint Commission, who also spoke at the NFPA annual Conference. I have been told I need to forward all my actions on to CMS for their response and I am to understand that the Regional Offices are directed to give me a response. Now, I ve not been told that that response has to be tied to a K-Tag and if that information comes out we will disseminate that information to the field. The K-Tag that Guglielmo refers to is from the form CMS-2786R, which is the CMS version of an LSC deficiency having been cited. There is one silver lining to all of this, Guglielmo says. When you used to submit for an equivalency to our office we would tell you to make sure to submit for waivers from CMS because they are two stand-alone 6 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

August 2014 Healthcare Life Safety Compliance processes, completely independent. But with the new process, if I take your requests and forward them on to your Regional Office for an answer, you ve just killed two birds with one stone. Because the approval will now come from the Regional Office, you re not submitting two separate submittals anymore; you re really sending only one submittal. As far as nuts and bolts are concerned, we are waiting to hear from them, says Mills. We don t know what the turnaround time is from the Regional Offices. We have a lot of questions: What if one region says yes and another region says no to the same type of request? They are in the same system, but we have to live with what the region tells us. Stay tuned. We will let you know when we learn more. It is also understood by the other AOs that CMS will only accept equivalency requests based on the FSES approach described in NFPA 101A. That means the traditional equivalency that The Joint Commission has used for many years may no longer be available. That is unfortunate, as the traditional equivalency is a much more affordable system than the FSES. While Guglielmo and Mills did their best to put a positive spin on this latest change of events, the potential for facility managers to discontinue being proactive is a real possibility. Without the opportunity to seek an equivalency prior to a triennial survey, facility managers may decide to wait and see if the deficiency is cited by the surveyors before they identify the issue. If there is no protection from a survey report finding (see the article on changes to the PFIs on p. 1) for self-identifying LSC deficiencies, then the incentive to self-report seems to have been diminished. If the surveyors fail to identify them, then they likely will not get resolved at all. One other bit of information that CMS apparently failed to inform The Joint Commission of: According to information provided by one of the other AOs, CMS now says waivers and equivalencies are only valid until the next survey. This means where equivalencies used to be good for the life of the building, or until major renovation is performed in the area, now the equivalency will become null and void when the surveyors show up for your next triennial survey. Then the AO will be obligated to cite the LSC deficiency again, and the healthcare organization will be obligated to write another FSES and submit it as part of the Plan of Correction process. There is no guarantee that the CMS Regional Office will approve the same FSES for the second time. H Requirements concerning power strips There has been a lot of discussion over the past few months concerning relocatable power taps (RPT), or power strips as they are commonly called. Apparently, all of the concern started when George Mills, MBA, FASHE, CEM, CHFM, director of engineering at The Joint Commission spoke at the Association for the Advancement of Medical Instrumentation (AAMI) held May 31 June 2 in Philadelphia about a conversation that he had with representatives from CMS in Baltimore. The words that Mills used implied that a change had occurred at CMS whereby it no longer will permit power strips to be used with medical equipment or used in patient care areas. Shortly after the AAMI conference was concluded, informal communications from representatives of CMS stated that, in fact, there was no issuance of a new CMS policy on the use of power strips. They refer to the long-standing requirements in the Life Safety Code (LSC) and NFPA 99 Health Care Facilities (1999 edition) standards that prevent the use of power strips in patient care areas and on medical equipment. Those codes and standards require sufficient outlet receptacles located as to avoid the need for extension cords or multiple outlet adaptors. This seems to be consistent with state agencies that perform validation surveys on behalf of CMS. Many of the state agencies polled indicated they interpret the issue to not allow power strips in patient care areas, or to be used on medical equipment. Florida is even on record of not allowing them anywhere in healthcare 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 7

Healthcare Life Safety Compliance August 2014 organizations, even in non-patient care areas on nonmedical equipment. This issue has been discussed among authorities and accreditors for a long time, as Mills explained during the recent NFPA annual Conference and Expo held in June in Las Vegas. Back in 2007 I brought the issue of power strips to the Healthcare Interpretations Task Force (HITF) because I wasn t sure were we could allow them, says Mills. So we wrestled with it and looked at NFPA 70, 99, and 101 and said these are the regulations that control them in a patient room. We discussed it and no interpretation was issued. So, recently I sent an email to CMS at our counterparts there, asking what their position is on RPTs? And they said RPTs 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, noncritical care areas such as patient rooms, diagnostic areas, exam rooms, etc. Mills was quoting directly from a communication he received from CMS, which seems to be pretty clear. But NFPA 99 (1999 edition), section 7-5.1.2.5, exception #2 does allow the use of power receptacles supplied by a flexible cord in anesthetizing locations if they are an integral part of the equipment assembly. So Mills raised the question to CMS: What does CMS interpret this to mean? I asked them if you took a 4 x 4 electrical junction box and bolt it onto a cart would that meet the intent, says Mills. They said no, that is not what it means. What it means is the receptacle needs to be integrated into the device. They are not relocatable power taps; they are part of the device. In addition, Mills says the ceiling electrical receptacle drops are acceptable according to NFPA 99, but he cautioned that you cannot daisy chain power strips together when used in non-patient care areas. I m not really sure what the solutions are, says Mills. I wish I had better answers for you now, but we are trying to figure this out just as you re trying to figure this out. We do know RPTs cannot be used on medical equipment in patient care areas and that is how the surveyors will enforce it. One result of this decision on the restriction of power strips is the additional extension cords or existing power cords draped across the floor of a procedure area to the wall outlets. The additional cords will create a new trip hazard for those working in the room. We are still trying to clarify what the limits are that they are putting on us, says Mills. I understand that we are creating more problems with this position and I fully understand your frustrations. I see a lot of problems with this. The American Society for Healthcare Engineers (ASHE) is currently working with accrediting organizations, CMS, and the NFPA to develop clarity on the use of RPTs in hospitals. ASHE notes that the 2012 edition of NFPA 99 does allow some flexibility for the use of power strips as described in section 10.2.3.6, which states: Two or more 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 cartmounted, provided all of the following conditions are met: 1.) The receptacles are permanently attached to the equipment assembly. 2.) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. 3.) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. 4.) The electrical and mechanical integrity of the assembly is regularly verified and documented. The change with the 2012 edition of NFPA 99 allows healthcare organizations to use RPTs that are not an integral part of the equipment, which is more in line with current practices in most facilities. The way the new 2012 edition is worded seems to allow the use of RPTs in all locations in the healthcare facility. One of the goals ASHE is working toward is to convince CMS to issue a categorical waiver to allow healthcare organizations to begin using the 2012 edition of the NFPA 99 standard on the above referenced section right away, and to allow their use in patient care areas and on medical equipment. H 8 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

August 2014 Healthcare Life Safety Compliance Editorially Speaking Editor s note: This month, Senior Editor Brad Keyes, CHSP, offers his thoughts, concerns, and comments on issues pertaining to healthcare life safety. If you re an accreditation junkie like me, it seems to be a great time to be alive right now. Well, anytime you re alive would be great, but a lot is going on in the world of accreditation, and I thought I might take a minute to reflect on the changes. The biggest change is that CMS is proposing to adopt the new 2012 Life Safety Code (LSC) and the 2012 NFPA 99 Health care Facilities Code, which probably won t be adopted until after the first of the year in 2015, at the earliest. Along with this decision to adopt the new LSC is the issuance of categorical waivers to allow the use of certain portions of the new LSC and the new NFPA 99. These categorical waivers allow facility managers to use the more user-friendly new standards on issues such as: Humidity limitations in anesthetizing locations Unoccupied rooms opening onto an exit enclosure Suites Door locks Corridor width Cooking locations Decorations Gas-fire fireplaces Medical gas alarms Emergency generator testing Sprinkler system testing Clean waste and patient record recycling containers CMS knows that it cannot just adopt the new 2012 LSC on a moment s notice, but must go through the arduous rulemaking process required of all federal agencies, which takes multiple years to adopt a more current edition of the LSC. Up until a couple of years ago, CMS would not be this flexible in issuing categorical waivers on new codes and standards. Facility managers have ASHE and The Joint Commission to thank for convincing CMS to issue these categorical waivers. Speaking of The Joint Commission, it has been in the news lately identifying many changes in order to comply with CMS requirements. This is the year that The Joint Commission must reapply to CMS for deeming authority to assess and evaluate hospitals that receive Medicare and Medicaid reimbursements. The federal agency is requiring the accreditor to make certain changes to its standards to comply with CMS rules and regulations. Two of the biggest changes involve the changes to the Statement of Conditions PFI list (see the article on p. 1). And the other is the change involving equivalencies, whereby The Joint Commission can no longer approve equivalencies. All equivalency requests that the accreditor receives must be forwarded to the appropriate CMS Regional Office for review and approval. Now that places The Joint Commission on the same level playing field with the other three hospital accreditors (HFAP, DNV, and CIHQ) so it no longer has an unfair advantage. While it really isn t a change according to CMS, power strips will be more regimentally enforced, and it won t be to the facility manager s liking. CMS says power strips are not permitted in patient care areas, or used with medical equipment. The Joint Commission issued another online announcement in late June describing new elements of performance (EP) in the EC chapter to make its standards compliant with the requirements of CMS. Effective July 1, 2014, the new requirements are found under EC.02.04.03, EP 24; and EC.02.05.05, EP 6. These address the requirements for the organization to conduct risk assessments when determining the best equipment maintenance strategy. Additionally, The Joint Commission announced the following new EPs effective July 2, 2014: EC.02.02.01, EP 18: Requires radiation workers to be checked periodically EC.02.02.01, EP 19: Requires procedures for trash storage and disposal Changes to existing EPs include: EC.02.03.01, EP 10: Includes the phrase and report fire alarms EC.02.05.03, EP 6: Adds the rooms intensive care, and emergency rooms In some shape or form, these changes will likely affect all of us in the healthcare industry. Take time to learn about them before you are held accountable to comply with them. H 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 9

Healthcare Life Safety Compliance August 2014 Questions&Answers Editor s note: Each month, Senior Editor Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, answers your questions about life safety compliance. Our editorial advisory board also reviews the Q&A column. Follow Keyes blog on life safety at www. keyeslifesafety.com for up-to-date information. O2 cylinders in ambulatory surgery centers Q Since the Life Safety Code addresses ambulatory surgery centers in chapters 20 21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage of compressed gas cylinders? A According to the CMS S&C-07-10 memo dated January 12, 2007, ambulatory surgery centers (ASC) are included in the scope of that interpretation memo and ASCs are required to abide by the 2005 edition of NFPA 99, section 9.4.3. This allows them the same advantage as hospitals with no storage requirements for 300 cubic feet and less of nonflammable compressed gas per smoke compartment. For storage of non-flammable compressed gas over 300 cubic feet and less than 3,000 cubic feet per smoke compartment, the ASC needs to comply with chapter 13 of NFPA 99, section 13-3.8, which refers back to chapter 8. Section 8-3.1.11.2 provides the requirements for storage of non-flammable compressed gas in quantities less than 3,000 cubic feet, which do not include 1-hour fire rated barriers. However, since the CMS S&C memo grants a special dispensation for ASCs to follow the 2005 edition of NFPA 99, for 300 cubic feet and less of compressed gas, then they are the same as hospitals in regard to storage of compressed gas. According to the CMS S&C memo, cylinders in use are not to be counted as cylinders in storage. Therefore, they are not included in the calculation of cubic feet of compressed gas when considering storage requirements. NFPA 99 requires full compressed gas cylinders to be segregated when stored with empty compressed gas cylinders. Storage in electrical rooms Can cardboard boxes be stored in an electrical Q room that is over 50 square feet, fully sprinklered, and has only dry transformers under 112 1/2 kva? A Yes, only if the room qualifies as a hazardous room under sections 18.3.2.1 or 19.3.2.1 of the 2000 edition of the Life Safety Code, depending if the room is considered new construction or existing conditions. NFPA codes and standards do not prevent storage in electrical rooms as long as it does not obstruct access to the electrical equipment. You must maintain at least 36 inches clearance in front of all electrical panels, and at least 30 inches clearance to the side of electrical panels. Now, other authorities having jurisdiction may have their own rules and interpretation, so I would suggest you check with your accreditation organization and state and local authorities to see if they have any issues with that. Door locks We have been asked to install a lock on a door Q in the path of egress through an office. For security reasons they would like to lock the doors to and from this area. We are thinking of using an electric strike fail safe connected to a fire alarm on both doors. This is not in a patient care area, and the doors would only be used by staff. A In a hospital, there are only three permissible methods to lock a door in the path of egress: 1) delayed egress; 2) access control; and 3) clinical needs. Let s eliminate clinical needs right off the bat, as that refers to a behavioral health unit or an Alzheimer s unit. Delayed egress may be a possibility, but the hospital needs to be fully sprinklered or fully 10 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

August 2014 Healthcare Life Safety Compliance smoke detected, and you cannot have more than one delayed egress lock in the path of egress to the public way. Delayed egress does not provide true security for the doors, just a 15-second delay which, if activated, can be annoying to the staff. I don t see this as a suitable arrangement. The more logical approach is the access-control locks, which allow you to provide security to prevent unauthorized individuals from entering the space, but it does not prevent anyone from exiting the space. Section 7.2.1.6.2 of the 2000 edition of the Life Safety Code describes the requirements for access-controlled egress: A sensor must be installed on the egress side of the door to detect an occupant approaching the door and automatically unlock the door. This sensor must also be wired where a loss of power to the sensor unlocks the door. A loss of power to the access-control system must unlock the door. A manual release Push to Exit button must be installed on the egress side of the door, 40 48 inches above the floor, and within 5 feet of the door. The manual release button must be labeled with a sign that reads Push to Exit. When operated, the manual release button must directly interrupt power to the lock independent of the access-control system, and the door must remain unlocked for a minimum of 30 seconds. Activation of the building s fire alarm system and/or sprinkler system must unlock the door, and remain unlocked until the fire alarm system has been manually reset. Access-control locks do not provide any security in the path of egress. In your question, you stated that the door in question is in the path of egress. If that is truly the case, then there is no way you can legally lock this door. I would advise the hospital to reconfigure its walls and path of egress to allow the office space desired without locking a door in the path of egress. Another issue to consider: Is the door in question required to latch? If so, then access-control locks cannot be used in lieu of latching. Even though the door may be locked by a mag-lock, it still needs to latch (if required). The phrase fail safe means different things to different people. Typically, for locksmiths fail safe means when power is removed, the locks remain locked, but for fire safety people the phrase fail safe means the lock remains unlocked. Equipment room storage I was always under the impression that no Q storage was allowed in mechanical rooms within hospitals. Now I work at a hospital that allows ladders and supplies to be stored in mechanical rooms. Is this allowed? A All I can say is it is not an NFPA violation to store items in mechanical rooms, as long as it is done properly. Obviously, storing combustible or flammable items must be accomplished in approved storage rooms, and the typical mechanical room may not qualify for these hazards. But then again, perhaps a mechanical room could qualify to store combustibles. Sections 18.3.2.1 for new construction and 19.3.2.1 for existing conditions of the 2000 edition of the Life Safety Code describe the requirements for storing combustibles. It does not make sense to store a bunch of cardboard boxes full of paper filters in a mechanical room that also houses fuel-fired equipment. But why can t you store those same boxes of filters in a mechanical room for air handlers that does not have any fuel-fire equipment, and qualifies as a hazardous room under the code sections referenced? The NFPA codes and standards do not prohibit it. Where hospitals get pinched on this issue, is they don t do their homework. A mechanical room that was never designed to double up as a storage room may not qualify as a storage room for combustibles. If you alter (or change) the use of a room or area, the room or area must comply with the requirements for new construction. This means if a hospital decides to start storing combustibles in an AHU mechanical (with no fuelfired equipment), now the room must be protected with 1-hour fire rated barriers, and also be protected with automatic sprinklers. If the room in question does not meet these requirements, then the hospital is exposed for a citation. H 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400. HCPRO.COM 11

Healthcare Life Safety Compliance August 2014 Quick tip Q&A from George Mills on PFIs, equivalencies, and relocatable power taps During the NFPA annual Conference and Expo held in Las Vegas in June, George Mills, MBA, FASHE, CEM, CHFM, director of engineering at The Joint Commission took questions from the audience and provided these answers. Readers are reminded that, although these answers were provided by the director of engineering, they are not considered to be official interpretations or positions of The Joint Commission. Question Answer Statement of Conditions Plan for Improvement (PFI) list In regard to the PFI process, does the deficiency have to be a Life Safety Code deficiency to be a PFI? I frequently see PFIs written for leaky sprinkler systems. What would your surveyors do with that? How soon can you ask for an extension on a PFI when you re pretty sure you re not going to get it done on time? Yes They would not accept that and they would ask that you close the PFI out and mark it other and move it to a corrective work order in your maintenance work order system. You can ask as soon as you want but what we advise you to do is wait until the PFI matures to four months past its projected completion date. It will turn yellow at that time. Once it turns yellow that is really a warning to do something and tells you that you have two months to get this resolved. At that point you should have a much better idea of how much time you will need, because when you ask for a new date, that s a drop-dead date: no more grace period when you ask for an extended period, so wait till you really know what you re asking for so it is an accurate request. Equivalencies What are qualifications for the person who submits the FSES? Does the professional with the CFPS designation who conducts the field verification for a traditional equivalency have to be external to the organization or can he or she be internal? There are no qualifications required in NFPA 101A. But it is pretty obvious when we see the quality of the work being submitted and how he or she interprets the forms whether the person is qualified or not. They can be internal to the organization. Relocatable power taps (power strips) Some of our IV poles come with power strips attached; would they be okay to be used in patient care areas? Understanding that the restrictions on the use of relocatable power taps is a CMS issue, are you going to be enforcing this position in non-deemed organizations? Do these restrictions on relocatable power taps in patient care areas apply to power strips that are UL listed? No; because they are relocatable power taps on wheels. Yes, because it is a NFPA 99 issue, not just a CMS issue and the code is the code. I don t see how I can t. It is what it is. Yes. We asked that question to CMS as well. The components are UL listed, but UL doesn t know what you re plugging into the power strips. You don t know what it is being used for, so UL cannot say it is okay for the application. Source: NFPA annual Conference and Expo, June 10, 2014, Las Vegas. 12 HCPRO.COM 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

Vol. 16 No. 8 August 2014 Healthcare Life Safety Compliance The newsletter to assist healthcare facility managers with fire protection and life safety Quiz Quiz questions August 2014 (Vol. 16, No. 8) 1. (T) (F) The Joint Commission announced in June that open Plan for Improvements (PFI) will now be recorded in the survey report. 2. (T) (F) The Joint Commission also announced that it is creating a new category in the survey report called Opportunities For Improvement. 3. (T) (F) The Joint Commission s standards require that you enter all Life Safety Code (LSC) deficiencies into the PFI list that cannot be resolved within 45 days. 4. (T) (F) Placing an LSC deficiency on the PFI list relieves the organization of the responsibility to assess the deficiency for interim life safety measures. The 2000 edition of the LSC allows clinical needs locks to be used to protect newborn babies and pediatric patients. 5. (T) (F) The projection completion date on the PFI is a guesstimate and the drop-dead date is six months from then. 6. (T) (F) Failure to complete a PFI by the projected completion date could result in an adverse decision, under AFS-10 rule. 7. (T) (F) The Joint Commission has the right to waive specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship upon the facility. 8. (T) (F) As recently as the April 2014 proposed rule to adopt the 2012 LSC, CMS is saying it is the authority having jurisdiction concerning waivers and equivalencies. 9. (T) (F) Beginning July 1, 2014, The Joint Commission will no longer approve equivalencies for healthcare organizations with deemed status, but will send them to the appropriate CMS Regional Office. 10. (T) (F) CMS will allow relocatable power taps in patient care areas as long as they are UL listed. A supplement to Healthcare Life Safety Compliance