cms/accreditation surveys the physical environment · ec.02.05.07 ep10 equipment if retested after...

© SMS, Inc., 2013 1

CMS/Accreditation Surveys

The Physical Environment

Critical Aspects for 2013

Presenter

Robert H. Bartels, CHFM CHSP CHEP SASHE President – Safety Management Services, Inc.

A program presented by:

SAFETY MANAGEMENT SERVICES, INC.

Arlington Heights, IL

(877) 577-6550 ** [email protected]

mailto:[email protected]

© SMS, Inc., 2013 2

Managing Accreditation in


Accreditation Options

What is CMS?

- Centers For Medicare/Medicaid Services

http://www.cms.hhs.gov/

http://www.cms.hhs.gov/

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Deemed Status

What is Deemed Status?

How does one receive deemed status?

- Meet CMS Conditions of Participation (COP)

- Be Surveyed & Approved by an Authorized

Accrediting Body

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Why Seek Accreditation?

- To Obtain Deemed Status

- Residency Program Requirements

- Recruitment

- Public Image

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What Is the Benefit of Accreditation?

- Leads to “Deemed Status”

- Allows Collection of Medicare / Medicaid Funds

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Who Can Grant Deemed Status?

- Centers For Medicare/Medicaid (CMS)

- The Joint Commission® (TJC)

- American Osteopathic Association (AOA)

- Det Norske Veritas (DNV)

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What is TJC?

- The Joint Commission®

http://www.jointcommission.org/

http://www.jointcommission.org/

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What Is AOA?

- American Osteopathic Association

Healthcare Facilities Accreditation Program (HFAP)

http://www.osteopathic.org/

http://www.osteopathic.org/

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What is DNV?

- Det Norske Veritas

National Integrated Accreditation for

HealthcareOrganizations – (NIAHO)

http://www.dnv.com/

http://www.dnv.com/

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What are the Differences?

Owner/Board Requirements Inspection Cost Survey Type

CMS Federal

Government

COP Triennial Free Unannounced

TJC AHA/AMA/ACS AMH Triennial $$ Unannounced

AOA AOA Board HFAP Triennial $$ Unannounced

DNV Det Norske

Veritas

NIAHO

ISO 9001

Bi-Annual $$ Unannounced

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What about DNV & ISO 9001? http://www.iso.org/

http://www.iso.org/

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ISO Key Elements

Quality Management System

Documentation

Records

Internal Auditing

Monitoring & Measurement

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Survey Preparation

Opening Day Documents

Management Plans

Annual Evaluations

SOC/PFI – eSOC/ePFI

Safety/Security Job Descriptions

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Survey Preparation

Environment of Care Session – Documents to be Available

Policies & Procedures

Sample Documentation

Aggregated Documentation

Matrices, Charts & Graphs

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Survey Preparation

Tab Set Photo

Standard Requirement Frequency Checked

Fire Safety Equipment

EC.02.03.05 EP1 Supervisory Signaling Devices Quarterly

EC.02.03.05 EP2 Tamper Switches & Water Flow Devices Quarterly

EC.02.03.05 EP3Duct Detectors

Every 12 months

EC.02.03.05 EP3 Smoke Detectors Every 12 months

EC.02.03.05 EP3 Heat Detectors Every 12 months

EC.02.03.05 EP3 Manual Fire Alarm Boxes Every 12 months

EC.02.03.05 EP3 Electromechanical Release Devices Every 12 months

EC.02.03.05 EP4 Audible Devices-Bells, Chimes, Speakers Every 12 months

EC.02.03.05 EP4 Visual Devices; Strobes Every 12 months

EC.02.03.05 EP5 Off-site Fire Responders Verification Every quarter

EC.02.03.05 EP6 Fire Pump Churn Test Every week

EC.02.03.05 EP7 Water Tank Level Alarms Every 6 months

EC.02.03.05 EP8 Water Tank Freeze-Up Alarms Every month during cold weather

EC.02.03.05 EP9 Main Drain Test Every 12 months

EC.02.03.05 EP10 Fire Department Connections Every quarter

EC.02.03.05 EP11 Fire Pump Flow Test Every 12 months

EC.02.03.05 EP12 Water-Flow Test Standpipe Every 5 years

EC.02.03.05 EP13 Automatic Fire Extinguishing Systems Inspected - Kitchen (no disch req) Every 6 months

EC.02.03.05 EP14 Other Gaseous Extinguishing Systems - Inspected (no disch req) Every 12 months

EC.02.03.05 EP15 Fire Extinguishers - Inspection Monthly

EC.02.03.05 EP16 Fire Extinguishers - Maintenance Every 12 months

EC.02.03.05 EP17 Hose Test - Hydrostatic 5 years after install, every 3 years after that 5 yrs. / 3 yrs.

EC.02.03.05 EP18 Dampers-New Installation1 year after

installation

EC.02.03.05 EP18 Dampers- Operational Test Every 6 years

EC.02.03.05 EP19 Fan Shut Down devices - Operational Test Every 12 months

EC.02.03.05 EP20 Rolling Dire Doors and Shutters - Operational test Every 12 months

Emergency Power Systems

EC.02.05.07 EP1 Battery-powered lights required for egress for 30 seconds 30 day intervals

EC.02.05.07 EP2Battery-powered lights required for egress for 1 1/2 hours or

replacement and random test of 10% of batteries for 1 1/2 hoursEvery 12 months

EC.02.05.07 EP3 Stored Emergency Power Supply (SEPSS) - 5 minutes Every quarter

EC.02.05.07 EP3 SEPSS - full load for 60% of its class or rating for recharge Annually

EC.02.05.07 EP4

Generator tested - intervals not < 20 or > 40 days apart for 30

continuous minutes with dynamic load at least 30% nameplate rating or

manufacturers recommended prime movers' exhaust gas temperature

12 times a year

EC.02.05.07 EP5

If above not met, supplemental loads of 25% nameplate for 30 min,

followed by 50% nameplate rating for 30 min, followed by 75%

nameplate rating for 60 min for a total of 2 continuous hours

Every 12 months

EC.02.05.07 EP6 ATS - All Transfer Switches tested not < 20 or > 40 days apart 12 times a year

EC.02.05.07 EP7&8Generator tested for minimum of 4 hours - 30% nameplate rating or

manufacturers recommended prime movers' exhaust gas temperatureEvery 36 months

EC.02.05.07 EP9 If required test fails, interim measures are made until repairs are done

EC.02.05.07 EP10 Equipment if retested after repairs or corrections are finished

Medical Gas and Vacuum Systems

EC.02.05.09 EP1 Inspects, tests and maintains critical components of piped medical gas defined by hospital

EC.02.05.09 EP2 Maintains supply valves for purity, correct gas, proper pressure

EC.02.05.09 EP3 Main as supply zones and valves are accessible and clearly labeled

Electronic Statement of Conditions

LS.01.01.01 EP1Assign individual to assess compliance with LSC,complete e-SOC,

manage deficN/A

LS.01.01.01 EP2 Maintains a current e-SOC quarterly?

LS.01.01.01 EP3When resolving deficiency through e-SOC meets time frames identified

in accepted PFI

LS.01.01.01 EP4Maintains documentation of any inspections and approvals made by state

and local fire control agencies

Interim Life Safety Measures (ILSM)

LS.01.01.01 EP3Written ILSM policy including criteria for evaluating where and what

extent the hospital follows special measuresN/A

LS.01.01.01 EP4-12Implements ILSMs as defined by the policy N/A

Life Safety Code Documentation Checklist

17


Fire Safety Equipment

EC.02.03.05 EP1 Supervisory Signaling Devices Quarterly

EC.02.03.05 EP2 Tamper Switches & Water Flow Devices Quarterly

EC.02.03.05 EP3Duct Detectors

Every 12 months

EC.02.03.05 EP3 Smoke Detectors Every 12 months

EC.02.03.05 EP3 Heat Detectors Every 12 months

EC.02.03.05 EP3 Manual Fire Alarm Boxes Every 12 months

EC.02.03.05 EP3 Electromechanical Release Devices Every 12 months

EC.02.03.05 EP4 Audible Devices-Bells, Chimes, Speakers Every 12 months

EC.02.03.05 EP4 Visual Devices; Strobes Every 12 months

EC.02.03.05 EP5 Off-site Fire Responders Verification Every quarter

EC.02.03.05 EP6 Fire Pump Churn Test Every week

EC.02.03.05 EP7 Water Tank Level Alarms Every 6 months

EC.02.03.05 EP8 Water Tank Freeze-Up Alarms Every month during cold weather

EC.02.03.05 EP9 Main Drain Test Every 12 months

EC.02.03.05 EP10 Fire Department Connections Every quarter

EC.02.03.05 EP11 Fire Pump Flow Test Every 12 months

EC.02.03.05 EP12 Water-Flow Test Standpipe Every 5 years

EC.02.03.05 EP13 Automatic Fire Extinguishing Systems Inspected - Kitchen (no disch req) Every 6 months

EC.02.03.05 EP14 Other Gaseous Extinguishing Systems - Inspected (no disch req) Every 12 months

EC.02.03.05 EP15 Fire Extinguishers - Inspection Monthly

EC.02.03.05 EP16 Fire Extinguishers - Maintenance Every 12 months

EC.02.03.05 EP17 Hose Test - Hydrostatic 5 years after install, every 3 years after that 5 yrs. / 3 yrs.

EC.02.03.05 EP18 Dampers-New Installation1 year after

installationEC.02.03.05 EP18 Dampers- Operational Test Every 6 years

EC.02.03.05 EP19 Fan Shut Down devices - Operational Test Every 12 months

EC.02.03.05 EP20 Rolling Dire Doors and Shutters - Operational test Every 12 months


© SMS, Inc., 2013 18


Emergency Power Systems

EC.02.05.07 EP1 Battery-powered lights required for egress for 30 seconds 30 day intervals

EC.02.05.07 EP2Battery-powered lights required for egress for 1 1/2 hours or

replacement and random test of 10% of batteries for 1 1/2 hoursEvery 12 months

EC.02.05.07 EP3 Stored Emergency Power Supply (SEPSS) - 5 minutes Every quarter

EC.02.05.07 EP3 SEPSS - full load for 60% of its class or rating for recharge Annually

EC.02.05.07 EP4

Generator tested - intervals not < 20 or > 40 days apart for 30

continuous minutes with dynamic load at least 30% nameplate rating or

manufacturers recommended prime movers' exhaust gas temperature

12 times a year

EC.02.05.07 EP5

If above not met, supplemental loads of 25% nameplate for 30 min,

followed by 50% nameplate rating for 30 min, followed by 75%

nameplate rating for 60 min for a total of 2 continuous hours

Every 12 months

EC.02.05.07 EP6 ATS - All Transfer Switches tested not < 20 or > 40 days apart 12 times a year

EC.02.05.07 EP7&8Generator tested for minimum of 4 hours - 30% nameplate rating or

manufacturers recommended prime movers' exhaust gas temperatureEvery 36 months

EC.02.05.07 EP9 If required test fails, interim measures are made until repairs are done

EC.02.05.07 EP10 Equipment if retested after repairs or corrections are finished


© SMS, Inc., 2013 19


Medical Gas and Vacuum Systems

EC.02.05.09 EP1 Inspects, tests and maintains critical components of piped medical gas defined by hospital

EC.02.05.09 EP2 Maintains supply valves for purity, correct gas, proper pressure

EC.02.05.09 EP3 Main as supply zones and valves are accessible and clearly labeled

Electronic Statement of Conditions

LS.01.01.01 EP1Assign individual to assess compliance with LSC,complete e-SOC,

manage deficN/A

LS.01.01.01 EP2 Maintains a current e-SOC quarterly?

LS.01.01.01 EP3When resolving deficiency through e-SOC meets time frames identified

in accepted PFI

LS.01.01.01 EP4Maintains documentation of any inspections and approvals made by state

and local fire control agencies

Interim Life Safety Measures (ILSM)

LS.01.01.01 EP3Written ILSM policy including criteria for evaluating where and what

extent the hospital follows special measuresN/A

LS.01.01.01 EP4-12Implements ILSMs as defined by the policy N/A


© SMS, Inc., 2013 20

Survey Preparation

Life Safety Document Review-1

Surveyor will ask you to provide:

6’ stepladder

Strong/bright flashlight

Keys to open all doors

Tape Measure

Any special tools needed to open access panels, air handler doors, inspections doors, etc.

© SMS, Inc., 2013 21

Survey Preparation


After the building tour, have documents gathered together in order to expedite the review. These documents should be collected in a separate room from the general meeting room designated for The Joint Commission survey team.

Please have individuals available to answer any questions that might arise pertaining to these documents.

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Survey Preparation


The original SOC from the last survey, with the list of PFI items that were approved during the last TJC survey

The current SOC and the current list of PFI items

Drawings of the hospital showing all of the rated walls, smoke compartments, suites-of-rooms & occupancy separations (carry them with you during the building tour)

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Survey Preparation Life Safety Document Review-4

Any equivalencies or Fire Safety Evaluation System

(FSES) pre-approved by Accrediting Body

Building Maintenance Program documentation (if used)

Fire Alarm Test Reports, including: • Supervisory Signals

• Tamper Switches & Water Flow devices

• Duct, heat, smoke detectors; pull stations, releasing devices, interface devices

• Emergency services notification transmission equipment

• Smoke Detection Shut-down devices for HVAC

© SMS, Inc., 2013 24


Fire Pump Test Reports (Weekly & Annual)

Fire Protection Systems Test & Inspection records, including:

• Main Drain tests

• Fire Department Connections

• Kitchen fire suppression systems

• CO2 and/or Clean Agent suppression systems

• Portable Fire Extinguishers

• Standpipe Occupant Use Fire Hoses

• Water Storage Tank high & low level alarms (if used)

• Water Storage Tank low water temp alarms (if used)

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Survey Preparation


Interim Life Safety Measures (ILSM) Policy & Implementation documents

Fire & Smoke Damper Testing (4-year test)

Horizontal & Vertical sliding/rolling doors

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Emergency Power System, including: • Generator Testing

• Automatic Transfer Switch (ATS) testing

• Battery Powered Lights

• Stored Emergency Power Supply Systems (SEPSS)

Medical Gases & Vacuum Systems, including: • Maintenance Program & testing documentation

• Documentation for testing of cross-contamination during installation

• Purity & Pressure documentation

Contact Information

Safety Management Services, Inc

1502 North Arlington Heights Road

Arlington Heights, IL 60004

(847) 577-6550

[email protected]

www.safemgt.com

© SMS, Inc., 2013 28

mailto:[email protected]

http://www.safemgt.com/