ashe 7 07 emerg mgmt · 2015-06-26 · 7 n answer: 7.10.8 special signs. 7.10.8.1* no exit. any...

Safety, Emergency Management and Security

(SEMS) Education Roundtable

June 26, 2015

Florida Hospital Association 1

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Disclosure Statement

The employees and/or speakers for this presentation have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity.

Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products.

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FHA Update 2015 June 26, 2015

Jim Kendig

Field Director



June 26, 2015


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Learning Objectives

At the conclusion of this presentation, the participant will be able to:

1. Identify the top five (5) compliance issues in LS, EC, and EM.

2. Be able to describe changes when storing “full,” “partially- full,” and “empty e-cylinders.”

3. Be able to describe and implement “tips” for a successful survey.

4. Understand the new survey process changes that were implemented July 1, 2014 and anticipated changes for January 1, 2015

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Trivia

How many light bulbs should you

consider for lighting at the exit?

Only one is required

At least two

More than two



June 26, 2015


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Answer

7.8.1.4 Required illumination shall be

arranged so that the failure of any single

lighting unit does not result in an

illumination level of less than 0.2 ft-

candles (2 lux) in any designated areas.

– Surveyors are looking for two bulbs in the

outside exit area.

– Have you evaluated at night?

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Trivia

In Chapter 7 Means of Egress – 2000

LSC is it:

– A. Not an Exit

– B. No Exit

– C. I don’t care



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Answer:

7.10.8 Special Signs.

7.10.8.1* No Exit. Any door, passage, or stairway that is

neither an exit nor a way of exit access and that is located or

arranged so that it is likely to be mistaken for an exit shall be

identified by a sign that reads as follows:

NO

EXIT Such sign shall have the word NO in letters 2 in. (5 cm) high

with a stroke width of ⅜ in. (1 cm) and the word EXIT in letters

1 in. (2.5 cm) high, with the word EXIT below the word NO.

“No Exit” not to scale.

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Trivia

What is the “maximum” height you can

mount a portable fire extinguisher (per

NFPA)?

– 4ft

– 3 ½ ft

– 3 ft

– 5 ft

http://codesonline.nfpa.org/a/c.ref/2000_ID101_9855/sec



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Answer:

1-6.10 Fire extinguishers having a gross weight not exceeding

40 lb (18.14 kg) shall be installed so that the top of the fire

extinguisher is not more 5 ft (1.53 m) above the floor.

Fire extinguishers having a gross weight greater than 40 lb

(18.14 kg) (except wheeled types) shall be so installed that the

top of the fire extinguisher is not more than 3 1/2 ft (1.07 m)

above the floor

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Trivia

What is the “minimum” distance that a

portable fire extinguisher is mounted off

the floor?

– 4ft

– 3 ft

– 4 inches

– 12 inches



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Answer:

In no case shall the clearance between

the bottom of the fire extinguisher and

the floor be less than 4 in. (10.2 cm).

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Trivia

What is the recommended height to

mount a sharps container?

– 52-56 inches

– 50-54 inches

– 40-46 inches

– It depends

Hint: NIOSH DHHS Publication Number 97-111 Selecting,

Evaluating, and Using Sharps Disposal Containers – 1998



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Trivia

Provide some parameters regarding

the 18” inch storage rule:

– 1.

– 2.

– 3.

– 4.



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Answer:

1 2

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18”

Perimeter

Shelving 18” RULE Perimeter

Shelving

OK OK OK Wrong

Ceiling

Wall

3

4



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The Rule

Sprinklers and storage areas (including perimeter wall shelving)

There must be 18” clear from the bottom of the sprinkler deflector to any storage or shelving. This is measured as a horizontal plane in the room (not conical measurement from the sprinkler head). This is a vertical measurement. Horizontally sprinklers can be as close as 4” (closer in some instances with special installations). (See NFPA 13-2010, 8.6.3.3 “Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.”) and A.8.6.6 regarding shelving

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Trivia

What is the recommended maximum

height to mount ABHR?

– A – <36 inches

– B – <42 inches

– C – <48 inches



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Answer

Dispensers should be mounted so the

operating mechanisms are at a height

less than 48 inches from the floor.

–ADA sections 4.271 – 4.27.3

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Trivia

Why is there mesh at the top of patient-

privacy curtains?



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Answer:

No. 1 nursing answer:

– Light

– Ventilation

To allow sprinkler water to pass

through the mesh. – NFPA 101-2000, 19.5.5 NFPA 13-1999, 5-

6.5.2.3. Both discuss in greater detail in the Annex to avoid the 18” clearance.

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Trivia

Cover plates or receptacles on

emergency system are required to

have or by covered by a:

– Red outlet cover

– Maroon outlet cover

– Distinctive color or marking

– None



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Answer:

NFPA 99-1999

– 3-4.2.2.4 Wiring Requirements

–2.* The cover plates for the electrical

receptacles or the electrical receptacles

themselves supplied from the

emergency system shall have a

distinctive color or marking so as to be

readily identifiable.

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April 2015 Perspectives



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Top Five Compliance

Challenges

EC.02.06.01 – No. 1

– Indoor safety issues

–For example; comingled empty and full

e cylinders; unrestrained cylinders,

compactor safety, etc.

–Clean and free from offensive odors

–CoP: 482.41(a)

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Top Five Compliance

Challenges

Ventilation – Number 2 – EC.02.05.01

– Critical vs. non-critical areas

– “Scott meter”

– Overhead announcement….?

– CLD vs. SLD

– Year space “commissioned.” – The same 2010 FGI Guidelines for Ventilation that LSCS

use are available as a free, read-only document at

http://www.fgiguidelines.org/guidelines2010.php.

– CoP: 482.42 and 482.1(c)(4), respectively

http://www.fgiguidelines.org/guidelines2010.php



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Top Five Compliance Challenges

Corridor clutter – Number 3 – EC.02.01.20

– Except in use “crash,” “chemo,” and “isolation” carts

– Dead end corridors not to exceed 50 sq ft of storage.

– 30 minutes… – NFPA 101: Life Safety Code (Section 18.2) offers guidelines for corridor

clutter. See https://www.inkling.com/read/life-safety-code-handbook -ron-cote-8th/chapter-18/section -18-2-means-of-egress.

– CoP: 482.41

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Top Five Compliance

Challenges

Documentation issues with fire alarm

systems – No. 4 – EC.02.03.05

– Written Inventory

–Reconciled and each device listed

– Meeting testing deadlines and

documentation

– Construction activities and

adding/deleting devices – reconcile! – CoP: All of EC.02.03.05 - 482.41(c)(2) except

EP25. Use CoP 482.41(b)(1)(i) for EP25.

https://www.inkling.com/



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EC.02.03.05 cont.

– LD.04.01.05 EP 5 – staff held accountable

– If 3 or more findings in Eps 1-20

–Documentation not available –

EC.02.03.05 - EP 25

–Primarily NFPA standard and year

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Top Five Compliance

Challenges

Penetrations – No. 5

– EC.02.01.10

– Nearly half of the hospitals surveyed in

2013 did not have adequate building and

fire protection “designed and maintained

to minimize the effects of fire, smoke, and

heat. – Consult NFPA 101: Life Safety Code (Section 8.3) for information

on smoke barriers and penetrations. See

https://www.inkling.com/read/life-safety-code-handbook-ron-cote-

8th/chapter-8/section-8-3-smoke -barriers.

– CoP: 482.41(b)(1)(i)

https://www.inkling.com/read/life-safety-code-handbook-ron-cote-8th/chapter-8/section-8-3-smoke























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Top Five Compliance

Challenges

Door issues (latches, closures, and

gaps)

– Clearance between, below…

– Removal of closer or removal of hardware

for bottom latching due to new floor

– Penetrations in door A guide to door inspections (including a checklist) is available from the

Firestop Contractors International Association at http://www.fcia.org

/articles/KeyBiscayneNov09/documents/DHIFireMarshalPrintVersionS

ept1.pdf/.

CoP: 482.42(b)(1)(i)

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The final few…

LS.02.01.30 – EP 2 & 16-23; hazardous areas and smoke

barriers and doors

LS.02.01.35 – Sprinklers not used to support other items

and sprinklers are not damaged, free from corrosion, or painted, missing escutcheons, ceiling tiles out, mixing of sprinkler types, etc.

EC.02.02.01 – PPE, escorts to hot lab (see July

Perspectives – 2012), lead aprons

http://www.fcia.org/



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Physical Environment Portal

Stay tuned…

Release in July 2014

Purpose

– Support compliance with the top EC and

LS findings

– Partner with ASHE

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Changes to eSOC/PFI/BBI

Reminder

– Bldg construction type

– “Busted” plan (PFI) – RED – call from CO

– Editing vs. “accepted”

– Reminder – CMS Waivers must be

annotated in BBI information

–Last page and credentials of individual

completing eSOC



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eSOC – PFI

Busted plan?

– First time – contact by SIG ENG

– Second time – may involve on-site survey

(AFS 10) an adverse accreditation

decision

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Be careful with “Waivers”



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Waivers

Must be declared on day 1 – morning.

Noted in BBI – last page.

Reminder - New process – TJC must

send (only) approved waivers to CMS

regional office.

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CMS – August 2013

Categorical Waivers Available: (S&C 13-58-LSC) – Medical Gas Master Alarms

– Openings in Exit Enclosures

– Emergency Generators and Standby Power Systems

– Doors

– Suites

– Extinguishing Requirements

– Clean Waste & Patient Record Recycling Containers



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Categorical Waivers cont.

Plus five – S&C 12-21-LSC & Two! – Wheeled equipment in egress corridors

– Fixed seating in egress

– One alternative kitchen cooking arrangement

– Direct or vent gas fire place and solid wood burning fire place

– Combustible decorations on walls, doors, and ceilings

– S&C 14-46-LSC (Sept 26, 2014)

– Power Taps

– S&C 14-41- CAH (Aug 8, 2014)

– Equip Maint (not noted in BBI but in Safety/EC Minutes)

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The Process to adopt CMS

Waivers – Critical!

The CMS categorical waiver would allow organizations to immediately

implement the provision without seeking formal approval.

– The organization must document their decision to apply the

categorical waiver and also declare to a surveyor at the beginning

of a survey their decision.

– Annotating the Statement of Conditions™ in the Basic Building

Information (BBI)”

– Additional Comments field will inform the Life Safety Code

Surveyor (LSCS) at the beginning of survey for the Life Safety

Code issues, and documenting the modified inspection, testing

and maintaining categorical waivers in the environment of care

committee (or equivalent) minutes.

– During survey the Life Safety Code Surveyors will field verify the

conditions of the appropriate code are met and the organization

has documented their decision to implement the categorical

waiver(s).



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Utilities & Equipment Mgmt

Inventory is populated based on one of two strategies: – All equipment inclusion

– Based on physical risks for

– Infection

–Occupant needs

–Systems critical to patient care

All life support equipment is included

All new types of equipment is evaluated for inclusion

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Utility Inventory

The hospital identified high-risk

operating components of utility systems

on the inventory for which there is a

risk of serious harm or death to a

patient or staff member should the

component fail.

– Note: High-risk utility components include

life-support equipment



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High Risk

Utility System as defined in the Accreditation Manuals Glossary and EC.02.05.03 include: – Electrical distribution

– Emergency Power Supply System (EPSS)

– Vertical & Horizontal Transport

– Heating, Ventilation & Air Conditioning

– Plumbing

– Boiler and Steam

– Piped Gases

– Vacuum Systems

– Communication Systems & Data Exchange

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Utility Equipment

Specific Utility Systems include

– Features of Fire Safety (EC.02.03.01)

– Alarm and Notification (LS.02.01.34)

– Suppression Systems (LS.02.01.35)

– Design criteria (EC.02.05.01)

– Power Distribution System (EC.02.05.03)

– Emergency Power Supply Systems (EC.02.05.07)

– Medical Gases (EC.02.05.09)

Specific populations of equipment

– Life support systems (EC.02.05.05)

– Infection Control utility systems (EC.02.05.05)



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Risk Assessment & Inventory

Should Include, but Not Limited To:

Infection control

Air handlers

Air Exchanges

Filtration

Pressurization

Fume hoods

Isolation Rooms

Support of the environment

Boilers

Chillers

Equipment support

Vertical transport

Fire alarm and suppression

Medical air pumps

Communication

Telecom system

Paging system

IT Network

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Time…

Time defined:



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Cylinder Storage Q&A

Segregation:

– All full cylinders must be segregated from

empty cylinders.

– For storage issues, any cylinder that has

been opened is considered to no longer be

full.

– All full cylinders must be segregated from all

open cylinders in storage.

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Medical Gas Safety



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Medical Gas Safety

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Medical Gas Safety



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Cylinder - More

5.3.3.2.5 If cylinders are wrapped when received, the wrappers shall be removed prior to storage (often see DOT plastic wrap used to minimize “clanking” during transport)

5.3.3.2.4 Wooden racks for cylinder storage shall be permitted.

5.3.3.2.3 No flammable materials, cylinders containing flammable gases, or containers containing flammable liquids shall be stored in rooms with medical gas cylinders.

–NFPA 99 - 2005

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What’s wrong with this picture?



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Cylinder Storage

NFPA 99-1999 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). – Combustible materials, such as paper, cardboard,

plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

– So in the example above – five (5) of the tanks are

in violation of this requirement and only one (1) tank is compliant. Scored at EC.02.03.01 – EP 1 as a fire hazard.

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Conducting a Risk Assessment:

Seven Steps

1. Identify the issue

2. Develop arguments in support of the issue

3. Develop arguments against the issue

4. Objectively evaluate both arguments

5. Reach a conclusion

6. Document the process

7. Monitor and reassess the conclusion to ensure it is right conclusion



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Risk Assessments

When to Conduct

Use to evaluate any issue that lacks a clear

decision

Educated guess that drives your

assumptions

Clearly document the process

Determine when to re-assess the issue

Problem solving approach to determine

appropriate response

Preventive strategies to address potential

issues

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RISK ASSESSMENT CYCLE

1

Identify Issue

7

Monitor &

Re-assess

6

Document

5

Reach a

conclusion

4

Objectively

evaluate

3

Disadvantages

2

Advantages

Risk Assessment

Cycle



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New Report Format

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New Report



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New Report

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New Report



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July 1 Updates – Final Report

“c” standards will now be listed on the

report as “opportunities for improvement”

“c’s” will be individually noted

– Example – fire extinguisher – door latching,

etc.

No ESC required

No clarification accepted

Bolded finding

Note 3 or 4 (direct vs indirect)

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Icons – page 13 CAMH



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Approved

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Not Approved



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July 1 updates cont. – Final

Report

Waivers and Equivalencies

– Existing waivers and equivalencies will be

evaluated on-site by LSCS.

– Located in History and Audit Trail icon.

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Most scored EM standards

Top EM standards scored in 2014: – In 1,278 surveys . . .

– 3.91% were out of compliance with EM.01.01.01-Developing

the plan – who? – 4.77% were out of compliance with EM.02.01.01-EOP – .78% were out of compliance with EM.02.02.01 – .47% were out of compliance with EM.02.02.03 – .08% were out of compliance with EM.02.02.05 – .70% were out of compliance with EM.02.02.07 – .23% were out of compliance with EM.02.02.09 – 0% were out of compliance with EM.02.02.11

– 4.46% were out of compliance with EM.02.02.13-Credentialling practitioner

– 1.80% were out of compliance with EM.02.02.15

– 4.69% were out of compliance with EM.03.01.01-Annual Review

– 7.67% were out of compliance with EM.03.01.03-Evaluates

drills



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EM Update

Foundation: 01.01.01

Organization engages in planning activities prior to developing

the EOP EP 1 Leaders participate in planning activities; including

medical staff!

EP 2 Conducts HVA

EP 3 Works with community on HVA

EP 4 Communicates with Community

emergency response agencies

EP 5- 6 Uses HVA in defining mitigation and preparedness activities (NEW - (See also

IM.01.01.03, EPs 1–4 [ see next slide])

EP 7 Integrates incident command structure

into community structure

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IM – LSCS to pull the thread

Elements of Performance for IM.01.01.03 A 1. The hospital has a written plan for managing interruptions

to its information processes (paper-based, electronic, or a mix of paper-based and electronic). (See also EM.01.01.01, EP 6)

The hospital’s plan for managing interruptions to information processes addresses the following:

A 2. Scheduled and unscheduled interruptions of electronic information systems. (See also IM.03.01.01, EP 1; EM.01.01.01, EP 6)

A 3. Training for staff and licensed independent practitioners on alternative procedures to follow when electronic information systems are unavailable. (See also EM.01.01.01, EP 6)

A 4. Backup of electronic information systems. (See also EM.01.01.01, EP 6)



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STANDARD EM.03.01.03 THE HOSPITAL EVALUATES THE EFFECTIVENESS OF ITS EMERGENCY OPERATIONS PLAN.

A 15

of all emergency response exercises and all responses to actual emergencies, are communicated to the improvement team responsible for monitoring environment of care issues and to senior hospital leadership. (See also EC.04.01.03, EP 1; EC.04.01.05, EP 3; LD.04.04.01, EP 25)

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STANDARD EM.03.01.01 THE HOSPITAL EVALUATES THE EFFECTIVENESS OF ITS EMERGENCY MANAGEMENT PLANNING ACTIVITIES.

A 4 The annual emergency management planning

reviews are forwarded to senior hospital leadership for review. (See also LD.04.04.01, EP 25) Note: Senior hospital leadership refers to those leaders with

responsibility for organization wide strategic planning and budgets (vice presidents and officers). The hospital may determine that all senior hospital leaders participate in reviewing emergency management reviews, or it may designate specific senior hospital leaders to review this information.



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STANDARD LD.04.04.01 LEADERS ESTABLISH PRIORITIES FOR PERFORMANCE IMPROVEMENT. (REFER TO THE “PERFORMANCE IMPROVEMENT” [PI] CHAPTER.)

A 25. – Senior hospital leadership directs implementation of selected

hospital wide improvements in emergency management based on the following:

– Review of the annual emergency management planning reviews (See also EM.03.01.01, EP 4)

– Review of the evaluations of all emergency response exercises and all responses to actual emergencies (See also EM.03.01.03, EP 15)

– Determination of which emergency management improvements will be prioritized for implementation, recognizing that some emergency management improvements might be a lower priority and not taken up in the near term

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Problem areas in Field



June 26, 2015


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Endo Rooms

- ASHRAE voted in July 2013 to move endoscopy procedure rooms from positive to N/A.

- Therefore, if an organization had made a documented decision based on risk assessment to no longer monitor endoscopy procedure rooms as per the 2013 ASHRAE action, we would accept this.

- If the organization has not made a documented decision, the room should be evaluated as per the table (see next slide) and construction date.

- No change to bronchoscopy procedure rooms.

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Guidelines Ventilation Table:

Endoscopy & Bronchoscopy



June 26, 2015


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OR Temperature

FGI Guidelines require 68 – 75°F

AORN, CDC, AAMI and APIC also have

different temperature ranges

– AORN range: 60 – 75°F

– APIC range: 68 – 75°F

– CDC range: 68 – 73°F

We survey to the organization policy

Clinical decisions supersede guidelines

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Monitoring Temp and rH

TJC standards are not prescriptive with regard to methods used to maintain temperature and humidity levels suitable for critical spaces.

Room temperature and humidity monitoring can be accomplished remotely by a building automation system, as long as there is a means to efficiently identify an adverse condition (like a person at the monitoring station, an alarming mechanism, a paging system, etc.).

Daily monitoring can also be accomplished at the room site, by the occupants, as long as there is a process to periodically check readings (like a temperature/humidity reading device within the space).

All non-compliant conditions are to be documented with corrective actions described. Logs are not required, unless by organizational policy, but are a common method used to identify non-compliant conditions and document corrective action taken.

S&C 15-27 impact to supplies and equipment less than 30% rH



June 26, 2015


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EC.02.03.05 EP 3

Testing Smoke Detectors

Inventory required

Pass / Fail documentation that testing occurred is acceptable

This is why EP 25 asks for the NFPA standards referenced for the activity

Testing is to comply with the NFPA requirements, such as

Smoke detector sensitivity must be measured

Visual affirmation of the condition of each smoke detector

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LS Drawing Information

A legend that clearly identifies features of fire safety*

Areas of the building that are fully sprinklered (if the building is partially sprinklered)

Locations of all hazardous storage areas

Locations of all rated barriers

Locations of all smoke barriers

Suite boundaries, including the size of the identified suites—both sleeping (max 5,000 sq ft) and non-sleeping (max 10,000 sq ft)

Locations of designated smoke compartments

Locations of chutes and shafts

Any approved equivalencies or waivers

*See April 2014 Errata



June 26, 2015


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Fire Door Gaps

Question: What is acceptable for repairing a gap on a rated fire door?

If the door fit cannot be properly adjusted the only recourse may be replacement doors

Only astragals that are acceptable by the door manufacturer can be field applied to a door to resolve door gap issues

A coordinator may also need to be installed that is compatible with the door assembly

Brush astragals may not need a coordinator

Undercuts may be solved with approved sweeps

You must be able to provide appropriate documentation of materials used

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Dorm Style Refrigerators

Dorm Style Refrigerators

Organizations should not use dorm style refrigerator/freezers for ANY vaccine storage, even temporary storage.

Source: CDC

The environment that vaccines are stored is very important



June 26, 2015


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Relocatable Power Taps (RTPs)

On September 26, 2014 CMS issued S&C: 14-46-LSC, which allows organizations to use a categorical waiver for the use of Special Purpose Relocatable Power Tap and Relocatable Power Taps, with certain restrictions.

First and foremost, the organization must ensure compliance with NFPA 99-2012 (see 10.2.3.6) and NFPA 101-2012.

Next, the organization must document the decision to use the categorical waiver in either Safety Committee or Environment of Care Committee Minutes or equivalent (i.e. Utility Committee).

Finally, the organization must declare the categorical waiver at the beginning of survey. It is certainly acceptable for the Life Safety Code Surveyor to ask, at the beginning of survey, if the organization has adopted any categorical waivers.

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RTPs Cont. “Not a Get out of Jail

Free Card!” Requirements, NFPA 99-2012:

Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section 6.3.2.2.6.2.

Power strips may be used in a patient care vicinity to power rack-, table-, pedestal-, or cart-mounted patient care-related electrical equipment assemblies, provided all of the following conditions are met, as required by section 10.2.3.6:

– 1. The receptacles are permanently attached to the equipment assembly.

– 2. The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles.

– 3. The ampacity of the flexible cord is suitable in accordance with the current edition of NFPA 70, National Electric Code.

– 4. The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.

– 5. Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.

– Power strips may not be used in a patient care vicinity to power non-patient care-related electrical equipment (e.g., personal electronics).

– Power strips may be used outside of the patient care vicinity for both patient care-related electrical equipment & non-patient-care-related electrical equipment.

– Power strips providing power to rack-, table-, pedestal-, or cart-mounted patient care-related electrical equipment assemblies are not required to be an integral component of manufacturer tested equipment. Power strips may be permanently attached to mounted equipment assemblies by personnel who are qualified to ensure compliance with section 10.2.3.6.

– If power strips are used in any manner, precautions as required by the LSC and reference documents are required, including but not limited to: installing internal ground fault and over-current protection devices; preventing cords from becoming tripping hazards; connecting devices so that tension is not transmitted to joints or terminals; no “daisy chaining” power strips; using power strips that are adequate for the number and types of devices, and no overloading power strips with high load devices. In addition, the use of ground fault circuit interruption (GFCIs) may be required in locations near water sources to prevent electrocution.

– Power strips providing power to patient care-related electrical equipment must be Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.

– Power strips providing power to non- patient-care-related electrical equipment must be Relocatable Power Taps (RPT) listed as UL 1363.



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RPTs Cont.

If at any time a RPT is daisy chained, presents a significant trip hazard, or using an under-rated RPT for the types of devices connected will be considered non-compliant. Scoring for this will be EC.02.06.01 EP 1 as unsafe patient conditions would be created by the use of the Relocatable Power Tap.

If the organization fails to document the use of the categorical waiver for the use of RPTs in patient care areas, they are not compliant. However, if the organization is developing an inventory to begin managing the use of RPTs and is not aware of the categorical waiver, we will discuss the S&C with them, although the organization may not create and take advantage of the categorical waiver once survey starts.

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Problem Areas in the Field

EC.02.03.05 EP 5 – quarterly testing of fire alarm system equipment for notifying off-site fire responders – Not a “ping”

– Not required to illustrate the “math” but this is best practice

– Fire drill form – central station received signal within 90 seconds – yes ___ no ___



June 26, 2015


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Forensic Patient Management

– HR.01.04.01 EP 7

– What does “responding to unusual clinical

events and incidents” mean?

– “C” or Finding



June 26, 2015


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EC.02.05.01 EP 6

– Pressure relationships in critical areas

– CLD

– FGI Guidelines – Table 7-1

– Space commissioned…?

Barrier Management – Focus of Annual

Educ LSCS Retreat - 2014

– Penetrations

– Doors

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DOT plastic mesh covering “H” and “e”

type cylinders (mentioned twice in

1999-99 and 99-2005 5.3.3.2.5).

Comingling “full” vs. “empty” cylinders

(noted in 99-1999 and 99-2005

5.3.13.4.3).



June 26, 2015


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Problem Areas in Field

Emergency Showers and Eyewash

Stations

– What resource are you using – ANSI?

What year?

– Risk Assessment?

–(See OSHA’s letters of interpretation)

–29CFR1910.151© and 1048 (i)(II)(i)(III)

–Placement and distance requirements?

–EC.02.02.01 EP 5

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Hazardous Materials & Waste

EC.02.02.05

Who is trained and can sign manifest

(40CFR)

P & U Listed Waste – overuse?

GHS



June 26, 2015


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Barrier Management

Door Security & Safety Foundation – NFPA 80

– Mostly consultative THIS year (not using NFPA 80 – 2007 or later – YET!)

– 1999 edition (and earlier editions) of NFPA 80

– Chapter 15, Care and Maintenance

–– Paragraph 15-2.1.1

– “Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.”

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Top 10 Deficiencies

Swinging Fire Doors

Painted or missing fire door

labels

Poor clearance dimensions

around the perimeter of the

door in the closed position

Kick down door holders

Auxiliary hardware items that

interfere with the intended

function of the door

Fire door blocked to stay in

the open position

Area surrounding the fire door

assembly blocked by

furniture, equipment, and/or

boxes

Broken, defective, or missing

hardware items (e.g., latch

bolts, strike plates, closer

arms, cover plates, etc.)

Fire exit hardware installed on

doors that are not labeled for

use with fire exit hardware

Missing or incorrect fasteners

Bottom flush bolts that do not

project 1/2-inch into the

strikes



June 26, 2015


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Barrier Mgmt Cont.

Firestop Contractors International

Association

– Firestopping for Continuity Products

become Systems

– What are Firestop Systems?

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Firestopping for Safety

Unlisted, Untested Firestop

Systems What “system” is being used?



June 26, 2015


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Joint Compound - NO

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Others…NO



June 26, 2015


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How to deal with Firestopping &

Fire/Smoke Dampers …

Dampers are UL 555, 555S Listed

Systems

– Installed to manufacturer’s written

instructions - (Systems – Angles…no

sealants)

Firestop sealants – UL 1479 –

Improper hole sizing or poor

installation… Consult the Damper

Manufacturer & the

Authority Having

Jurisdiction

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Installing Incorrectly May Void the Fire / Smoke Damper

Manufacturer’s Warranty Graphics – Firestop Solutions



June 26, 2015


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Other considerations….

Barriers With Combustible Penetrants

Joints and Seams

Penetrations in Head of Wall & Bar

Joist Penetrations

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Gypsum Wallboard Compound,

Diluted Firestop Spray =

Unacceptable



June 26, 2015


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Results of Improperly Installed

Mineral Wool = Voids in Firestop

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Well Done Installations



June 26, 2015


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FHA – did you know?

State wide Forensic Patient

Management Policy

– Approved by the FL Police Chiefs Assoc

– Now in FDLE’s corrections and police

academies

State wide emergency codes

– First standardized in 2002/2003

– Added Code Silver in 2010

Workplace violence tool kit

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TIPS



June 26, 2015


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Tips

Who receives Perspectives in your org

– is it circulated?

Subscribe to EC News?

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Tips – PI?

Who can turn off the zone medical gas

valve (NFPA 99 Appendix C)?

How can staff differentiate between a

smoke and fire door and a convenience

door?



June 26, 2015


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Tips

Placing FDC’s on fire drill form?

Placing NFPA 72 requirement on fire

drill form?

Take advantage of “planned” vs.

“unplanned” fire watch duties (EC

News July 2009 page 10-11)

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Tips Written fire response plan…

– LIP role?

– Typically same as staff – Really!

– Volunteers, Students, Contractors? (best practice)

– Forensic patients

– Restrained patients

Stacking diagram

How to illustrate a room has been evacuated? – Pillow in front of the door?

MRI Fire Drill

Monthly generator run – graph?



June 26, 2015


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Stacking Diagram

FIRE DRILL DATE:

FIRE DRILL SUMMARY

D-8

D-7

D-6

D-5

SOUTH

SOUTH

SOUTH

SOUTH

NORTH

NORTH

NORTH

NORTH

TOTAL NUMBER OF SMOKE COMPARTMENTS 3

FIRE POINT OF ORIGIN

AREAS OBSERVED ABOVE OR BELOW,

AND ADJACENT TO ORIGIN

COMMENTS:

SHIFT: 01-24-2010 3

1ST

NUC MED WAITING

EMERGENCY

ROOM

ATRIUM

AU BON PAIN

PATIENT REGISTRATION

OCCUPATIONAL MEDICINE

CARDIO PULM

NUC MED WAITING GIFT SHOP

2ND

OR STORAGE

CARDIAC

ADMIN

OFFICES

O R ROOMS

CATH LAB WAITING

CLINICAL PHAR

PREP & RECOVERY CATH LAB

CARDIO VASCULATOR ICU

CCU WAITING

AU BON PAIN

PREP

3RD

LINEN STORAGE

STORAGE

RESPIRATORY

STAGING

CLINICAL ENG ENVIRONMENTAL

SERVICES

MECHANICAL ROOM

RESPIRATORY

REPORT ROOM

IT OFFICES

CATERING

4TH

CORORARY ICU MEDICAL ICU

One Unoccupied Floor



June 26, 2015


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Performance Improvement

What are your PI’s?

– Examples

–MRI Life Safety

– ICS

–Staff Knowledge

–Smoke Compartmentation

–Medical Gas Zone Valves

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New NCMEC

The 10th edition for healthcare professionals has been published and is available (8/5/14).

Also available on the web site: – Drill Critique Form * fillable

– Self Assessment * fillable

– Nursing Checklist * fillable

– Profile of the Typical Offender

– What Parents Need to Know * English

– What Parents Need to Know * Spanish



June 26, 2015


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Specific to Children’s Hospitals

19.2.2.2.2 Locks shall not be permitted on patient sleeping

room doors.

– Exception No. 1: Key-locking devices that restrict access to

the room from the corridor and that are operable only by

staff from the corridor side shall be permitted. Such devices

shall not restrict egress from the room.

– Exception No. 2: Door-locking arrangements shall be

permitted in health care occupancies, or portions of health

care occupancies, where the clinical needs of the patients

require specialized security measures for their safety,

provided that keys are carried by staff at all times.

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19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side. – Exception No. 1: Door-locking arrangements without

delayed egress

– shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)

– Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

– Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

15 or 30 seconds?



June 26, 2015


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Cameras in stair enclosures?

–7.1.3.2 Exits. (page 101-43 – 2000

LSC)

(e) Penetrations into and openings through an exit enclosure assembly

shall be prohibited except for the following:

(1) Electrical conduit serving the stairway

(2) Required exit doors

(3) Ductwork and equipment necessary for independent

stair pressurization

(4) Water or steam piping necessary for the heating or cooling of the exit

enclosure

(5) Sprinkler piping

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Options?

– “Equivalency” and/or “Waiver”

–Requires local AHJ support

– Re-positioning CCTV



June 26, 2015


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Fire Drills

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Fire Drills Cont.

The only thing relaxed in the Life Safety Code between 9pm and 6am is the audible alarm component.

The fire drill still occurs once per shift per quarter at varying times and varying conditions. The coded announcement provision supplants the horns. Strobes will still activate as that is not excluded.

Some new construction requires strobes in all occupied rooms, but the Life Safety Code never allowed turning the strobes off in patient care areas (or anywhere else). This is why we made a change in our EP, which incorrectly allowed not activating the buildings fire alarm system, when the Life Safety Code only allowed the silencing of the audible alarms.

If the organization does not have the ability to silence the audible alarm then they would still need to exercise the system. I have never encountered a fire alarm system that did not have control over the audible alarm feature, including old Edwards and Simplex systems. The auto-dialer and other features of the fire alarm system should still work.



June 26, 2015


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Surveyor Resources

LSCS and clinical surveyors have access to: – AAMI (ST79)

– FGI 2010 (acquire FGI 2014 in 2015)

– NFPA all access to standards

– JCR book: THE JOINT COMMISSION/NFPA®

LIFE SAFETY BOOK FOR HEALTH CARE

ORGANIZATIONS

By George Mills, MBA, FASHE, CEM, CHFM, CHSP, and James K. Lathrop, FSFPE

– JCR publishing (late 2014) a book for novice quality directors

– Design Guide for the Built Environment of Behavioral Health Facilities 6.2 – April 2014

– More…

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Surveyor Focus on 2015

LSCS Webinars continue – Relevant and contemporary surveyors

80+ Strong

Hiring continues for new business – AHC

– DOD

Educational event – June/July 2014 – NFPA 99 & 101-2012 & 2015

– Surveying psych environment

– IC



June 26, 2015


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New next week

Customer Focus

– New LSCS agenda

–Day 1 and Day 2 options

– New document checklist

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The Joint Commission

Disclaimer These slides are only meant to be cue points, which were expounded upon

verbally by the original presenter and are not meant to be comprehensive

statements of standards interpretation or represent all the content of the

presentation. Thus, care should be exercised in interpreting Joint Commission

requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or

distributed without permission of the content owner or The Joint Commission.

The program may be electronically recorded by The Joint Commission and is

subject to the protection of the copyright laws of the US. No individual or entity

other than The Joint Commission may electronically record any portion of these

programs for any purpose without the written permission of The Joint

Commission and the content owner. Any and all reproduction or publication of

these proceedings and programs are intended for internal field representative

education only and will not be distributed in any other way without written

permission from the content owner

ashe 7 07 emerg mgmt · 2015-06-26 · 7 n answer: 7.10.8 special signs. 7.10.8.1* no exit. any...

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