Transcript Things to Watch for in 2009

Understanding the Life
Safety Code
Scoring Impact
& Interim Life Safety
Measures
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Disclosures
 “Courtemanche
& Associates Healthcare Synergists is an Approved
Provider of continuing nursing education by the North Carolina Nurses
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 Continuing Education Contact Hours will be awarded upon full
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Session Objectives
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At the conclusion of the session, participants will
be able to:
Identify 2009 TJC expectations for LS Document
Review
Obtain an overview in Interim Life Safety
Measures (ILSM)
Learn why and when ILSM and ICRA are used
Discuss the impact on the increase in standards
and elements of performance
Speak to the challenge of the LSS tour
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Glossary
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EC/EOC – Environment of Care
EM – Emergency Management
LS – Life Safety
LSC – Life Safety Code
LSS – Life Safety Specialist
e-SOC – Electronic Statement of
Conditions
e-PFI – Electronic Plans for Improvement
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The 2009 Standards

Let’s review the 2009 standards.

There was a total revision and increase in
standards in this area.
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There has been increased scoring since
2008
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The Evolution of EC
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Since the inception of the Life Safety
Specialist in 2004/2005, the focus on the
Environment of Care has shifted to Life
Safety
As of 1/1/2008, all Hospitals, regardless
of size, were scheduled for a LSS
focused visit
This was in answer to continued
disparities in CMS look back surveys
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The Evolution of EC

The Environment of Care chapter and
scoring process changed for 2009
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EC evolved to three separate chapters
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Environment of Care (EC)
Emergency Management (EM)
Life Safety (LS)
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The Evolution of EC
Environment
of Care
EC
Emergency
Management
Life Safety
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The Evolution of EC

Where are we now - it’s 2009?

EOC issues are scoring more in recent
surveys
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There has been an increase in scoring
for Immediate Threat to Life and
Conditional Accreditation rules
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Thresholds – January –
Serve as “Screens”
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Thresholds:
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The number of RFIs will not
automatically trigger a decision
Decision for review is based on number
of non-compliant direct impact
standards and surveyor days
Will serve as a “screen” for more
intensive review by TJC central office –
Standards Interpretation Group &
Division of Accreditation & Certification
Operations Management
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Screens = Surveyor Days & Direct
Impact RFIs (for Hospital)
Band Category
Surveyor Days
RFIs (NonCompliant Direct
Impact Standards)
Band 1
1-4
7
Band 2
5-6
8
Band 3
7-9
9
Band 4
10-13
11
Band 5
≥14
13
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Central Office Review
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Were “situational” rules actually triggered but
not identified during survey?
Do “systemic” problems exist in the
organization – based on magnitude & nature
of findings?
Would findings result in CMS “Condition”
level deficiency for those programs having
deemed status?
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What is Condition-Level
Deficiency?
CMS Finding:
 Standard Level or Condition Level
Based on nature (how severe, dangerous,
critical) and extent (how prevalent,
often, pervasive, how many)
 Condition Level:
 Non-compliance with single standard or
several within a CoP representing severe
or critical safety or health breach
 Standard Level:
 Does not substantially limit ability to give
good care nor jeopardizes patient health
or safety
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2009 Chapters & Standards
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EC chapter now has
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EM chapter now has
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20 standards
143 elements of performance
12 standards
111 elements of performance
LS chapter now has
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17 standards
194 elements of performance
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Let’s Compare
2008 Manual
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1 Chapter
33 Standards
234 Elements of
Performance
2009 Manual
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3 Chapters
49 Standards
448 Elements of
Performance
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More Impact for 2009
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There are four tiers in the scoring model
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Immediate Threat
Situational Decision Rules
Direct Impact Standards
Indirect Impact Standards
The new chapters reflect this scoring
There are automatic rules in some areas,
such as LS
BEWARE: Failure to implement ILSMs!
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Direct Impact Standards
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In the three new chapters, there are
several direct impact standards.
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LS has 20 direct impact standards
EC has 43 direct impact standards
EM has 3 direct impact standards
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Get Ready for 2009
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There is an increase in the number of
chapters
There is an increase in the number of
standards
There is an increase in the elements of
performance
The LSS surveys all hospitals
The CMS disparity rate for physical
environment has increased to 29 %!
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Top Scoring Issues
TJC 2007
(final #s)
MM.2.20
(43%)
NPSG 2C
(36%)
TJC – 1st
Quarter 2008
Issue
 (31%)
Storage of medications
No Data
Critical test/results data requirements
EC.5.20 (29%)  (45%)
Life Safety Code (now LS 01.01.01)
IM.6.10 (26%) = (24%)
Completeness of medical record
IM.6.50 (25%)  (35%)
Telephone & verbal orders
NPSG 2B
(25%)
No Data
Unapproved abbreviations
UP 1C (21%)
No Data
Time out
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Comments
 from prior
year
 from prior
year
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Top Scoring Issues
TJC 2007
(final #s)
TJC – 1st Quarter
2008
Issue
Comments
NPSG 8A (19%)
No Data
Medication reconciliation on admission
 from prior year
NPSG 3D (18%)
No Data
Medication labeling on & off sterile field
 from prior year
EC.5.40 (18%)
 (30%)
Maintenance of fire equipment & building
features (now EC 02.03.05)
PC.13.20 (18%)
=
Pre-anesthesia assessment
EC.7.40 (16%)*
Testing emergency power systems (now EC
02.05.07)
 Early ‘08
numbers show 50%
increase
EC.7.50 (14%)*
Testing medical gas & vacuum systems (now
EC 02.05.09)
 Early ‘08
numbers show over
50% increase
* While not ranking in TJC’s final Top 14 Compliance Issues, preliminary TJC data had
indicated that EC.7.40 had been scored in 8% of organizations surveyed and EC.7.50% had
been scored in 6% of organizations
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Interim Life Safety Measures
What are Interim Life
Safety Measures?
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Additional measures for fire prevention
Required when:
1.
2.
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There are Life Safety Code deficiencies
There is construction that may interrupt normal
exit pathways, fire prevention systems or
create potential for explosion.
Based on proactive risk assessment (PRA)
Consider PRA for any project, renovation or
life safety deficiency that could impact life or
fire safety in the organization.
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What are the Additional
Measures?
Providing free and unobstructed access to
emergency services and for fire, police, and
other emergency forces
 Providing fire alarm, detection, and suppression
systems are in good working order.
 When system impaired, must use a
temporary but equivalent system
 Must inspect and test temporary
systems monthly
 Use temporary construction partitions that are
smoke-tight and built of noncombustible or
limited combustible materials that will not
contribute to the development or spread of fire

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What are the Additional
Measures?
Institute additional fire-fighting equipment and staff
training staff in its use
 NO SMOKING ! throughout the hospital’s
buildings and in and near construction areas
(INCLUDES CONSTRUCTION WORKERS)
 Keep the building’s flammable and combustible
fire load to the lowest feasible level
 Create and enforce storage, house
keeping, and debris-removal practices
 Perform a minimum of two fire drills per shift per
quarter
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What are the Additional
Measures?
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Heighten surveillance of buildings, grounds,
and equipment, with special attention to
excavations, construction areas, construction
storage, and field offices
Provide staff training to compensate for
impaired structural or compartmentalization
features of fire safety
Provide organization wide safety education
programs to promote awareness of fire
safety building deficiencies, construction
hazards, and ILSMs
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The Process
Consider ILSM’s when:
 Out of compliance with LSC
 For any renovation or construction project
 For above ceiling work – i.e., removing more than
4 -5 ceiling tiles may constitute the need for an
assessment to be done
 Loss of certain utilities
 Any interruption in the fire alarm/sprinkler system
for 4 or more hours
 Any change in exit/egress pathways
 Medical gas system compromised
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What is the ILSM Process?

This process is activated to reduce potential
risk by setting procedures in place to
enhance awareness of threats and to
protect patients, staff, visitors and everyone
during construction or times when not in
compliance with the Life Safety Code.
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What is the ILSM Process?
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The assessment process for ILSM’s
Analyzes the project
Identifies the risks
Implements strategies and safeguards
Protects against those risks
Now Let’s Examine ICRA
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ICRA is Infection Control Risk Assessment
When is it needed?
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Whenever the environment may be
compromised with unintended infectious
risk due to demolition, renovation,
construction, or other reason i.e.,
ventilation system failure
Must always be considered when you
undergo construction, demolition or
renovation
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Why is ICRA Important?
During Demolition, Construction,
and Renovation, infection risks
may present.
 Release of mold, spores,
dormant infectious agents
 Release of contaminated air,
water, materials
 Introduction of bacteria,
viruses, molds and fungi
 Creation of reservoirs to
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Where do ICRAs and
ILSMs Meet?
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As discussed earlier, whenever your
organization is considering or involved in
demolition, renovation or construction, you
should proactively assess for the potential for
compromise related to life safety (fire safety)
and infection
Using a combined approach to assess for
both creates an ongoing approach to
consider multiple hazards in one process
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ILSMs and ICRA –
A Renewed Focus
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Interim Life Safety Measures have been around for
years
Infection Control Risk Assessment (ICRA) is always
required when you consider construction, demolition
or renovation.
Both are used to assess risk to ensure the safety
and well being of everyone in the facility, patients,
staff, visitors, etc.
Everyone needs to know roles and responsibilities,
not only the staff in the area of the project - includes
staff, volunteers, students, LIP’s, contractors,
construction workers, and each of you.
YOU are the first line to ensuring the safety here!
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ILSM and ICRA Process
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While most of the responsibility falls to
Facilities/ Engineering and Infection
Control, everyone needs to be involved
Policies and procedures for ILSM and
ICRA should be available for ready review
Develop a comprehensive risk assessment
policy, ICRA, Hot Works Policy, and other
related policies for routine review when
you consider facilities projects
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Once Activated, What is
Required?
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Ongoing assessment and monitoring to
assure safe conditions
1.
2.
3.
4.
5.
Conduct pre-assessment
Assure activation of appropriate
measures
Provide ongoing assessment
Do daily or more often checks as
needed
Document on checklist
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What Does Checking Entail?
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For ILSM’s checking includes:
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Checking for exit egress
Clear evacuation paths
Marked routes
Is fire alarm and suppression system
functioning and operable in the area?
Clear Emergency Access for Police/Fire
Management of combustible load
New risks emerging during project
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What Does Checking Entail?
For ILSMs checking includes:
 Is there adequate fire fighting
equipment, working fire extinguishers?
 When fire suppression or alarm system
out of service for 4 or more hours, are
fire authorities notified? Is fire watch
implemented? And documented?
Watch out for other issues, such as hot work
issues, welding, etc.
Assuring use and availability of PPEs
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What Does Checking Entail?
For ILSMs checking includes:
 Limit debris and clutter
 Test staff education for roles and
responsibilities
 Can everyone get out safely? Do they
know the routes?
 If an exit is blocked or out of service,
show them the way, map alternate route
 Make sure construction barriers are sealed
based on needs in area.
Remember “No Smoking” in any area under this rule.
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What Does Checking Entail?
For ICRA checking includes:
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Preventing unintended spread of dust,
debris, and other potential sources of
infection
Assuring containment of area under work
Lock down ventilation systems connected
to work
Awareness of potential for release of
airborne pathogens
Awareness of patients with special needs
or who are immunocompromised
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What Does Checking Entail?
For ICRA checking includes:
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Daily or more frequent checking to
assure safety of area and containment of
potentially pathogenic organisms
Ventilation systems and protection of
patients in other parts of organization
Are construction barriers intact?
Use of appropriate PPE, such as
respirators during demolition
Dust, debris and particulate matter
compromising adjacent patient care
areas
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What Does Checking Entail?
When you implement ILSM’s and the ICRA
process, you need to document your
efforts.
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Daily ( 7 days a week) rounds to ensure these
details.
Additional fire drills are also needed.
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When in ILSM’s you need to increase
awareness and drills (two per shift, per quarter).
Staff and all involved (that means you!) need
training.
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How Does the Process Happen?
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Training needs to address fire fighting and
infection prevention roles
Can you use a fire extinguisher?
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Remember P-A-S-S, pull the pin, aim low, squeeze
the handle, spray or sweep side-to-side (pass)
If you see dust from the construction site in
your area – do something about it!
You are all that stands between the project
and the patient
Step up, listen and take action to provide a
safe environment
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Safety is Everyone’s Job!
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Take your safety role seriously
YOU can prevent unintended fires and infections
with vigilance and activation of appropriate
measures
Failure to respond and implement ILSM’s not only
can harm those in your facility
Failure can impact your accreditation (TJC and
CMS)
Safety matters! YOU can make a difference!
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Your Role in Fire Safety
and Infection Prevention
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Not only do you need to understand the why’s
and when’s, you need to know you can report
concerns.
If you think any renovation project or construction
issue, or any loss of utility, or service might
impact the safety of the population service in this
healthcare facility, SPEAK UP!
Talk to your supervisor or contact
Facilities/Engineering and/or Infection Control
Even the little jobs can cause big issues – report
a safety concern
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Life Safety Code
Issues and Responses
Stay Alert – Challenges in 2009
e-SOC
 ILSMs
 Life Safety Specialist
 Situational Decision Rules

 Insufficient progress on e-SOC
 Failure to implement ILSMs
More Standards;
 More Potential for Scoring
 More Pressure from CMS

Things to Watch for in 2009

Control and use your eSOC
 It is color coded
 Heed the orange – you’re past expected
date of completion
 Heed the red color – you’re past the 6
month window
 Expect TJC to come knocking!
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Things to Watch for in 2009

Beware of situational decision rules
 CON04 The organization has failed to
implement or make sufficient progress
toward the corrective actions described in
a Statement of Conditions™, Part 4, Plan
for Improvement, which was previously
accepted by The Joint Commission, or has
failed to implement or enforce applicable
interim life safety measures. (LS.01.02.01,
EP 3; LS.01.01.01, EP 3)
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Things to Watch for in 2009
What is an accepted ePFI ?
 These are PFI’s that are “signed off” by
TJC during a survey
 These are the ones you need to track
progress on, watch the colors
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Things to Watch for in 2009
If its out of compliance you have 4 choices:
1. Fix it right away
2. Put on a work order system
3. Repair within 45 days
4. Enter on ePFI, or ask for an equivalency
and document with TJC
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Things to Watch for in 2009
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All other ePFI’s are under your control, you
can change the expected completion dates
and manage internally until “signed off and
accepted.”
Once accepted you can automatically get
one six month extension
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Things to Watch for in 2009
The Building maintenance Program
 The BMP scoring advantage is gone
 The BMP is still a “good PM” program
 You need to manage your compliance with
the LS Code and your SOC
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Things to Watch for in 2009
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Increased focus on ILSM’s this year
HCO’s should consider ILSM’s with
multiple PFI’s
Also look at any areas you are not in
compliance with LSC and EC, not just for
construction
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Things to Watch for in 2009
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If your organization has findings on a CMS
validation survey, you should consider
entering in ePFI’s or manage within the
timeframes (> 45 days and work order
system)
TJC wants to know about your process
here in dealing with CMS
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Things to Watch for in 2009
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Acceptable projected completion dates are
within the 3 year survey time frame or less
Only exception is inaccessible dampers.
SIG now granting “six year” projected
completion date, with possible six year
extension
Dates should be reasonable for deficiency
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Things to Watch for in 2009
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TJC is still using the 2000 edition of the
Life Safety Code
If you want to use a more current code,
you need to get an equivalency from TJC
Only exception is 2005 NFPA 99 code
(# 9.4.3) for medical gas storage issues
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2005 NFPA 99 (#9.4.3) for
Medical Gas
Three Levels
 0-300 cu.ft. limit in smoke zone with no protection

300-3000 cu.ft. if 1 hour wall & 45 min door for the
storeroom, no ventilation required, but
combustible storage next to O2 tanks limited to
5 feet if sprinklered or 20 feet if no sprinklers.
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Over 3,000 cu.ft. has lots of requirements
including ventilation
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More on Medical Gases
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An individual container of medical gas
placed in a patient room for “as needed” (but
regular) individual use is not required to be
stored in an enclosure, when properly
secured.
Oxidizing gases such as oxygen and nitrous
oxide should not be stored with any
flammable gas, liquid or vapor.
All storage areas should be secured to limit
access.
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Plan for the LSS Visit
LSS = Life Safety Specialist
 Remember at of 1/1/2008 all hospitals were
scheduled for LSC Specialist visit
 Duration was 1 or 2 days depending on size
of building(s).
 In 2009 includes Critical Access Hospitals
 The time frames for CAH are shortened so
the LSS can also conduct the EC and EM
sessions in that one day visit.
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Plan for the LSS Visit
There are four parts to the LSS visit
1. The Facility Orientation which is
approximately 30 minutes.
2. The Document Review is 60 – 90
minutes.
3. The building tour is 4 or more hours.
4. The exit conference or briefing .
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Facility Orientation
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The LSS meets with appropriate
organizational staff to learn about the
buildings, etc.
Review BBI data, plans and information
about smoke compartments, sprinklered
areas, age of buildings
Reviews organization’s policy and process
as well as documentation for Interim Life
Safety Measures.
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Document Review
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The eSOC and ePFI’s are locked down at the
onset of the survey team arrival.
Review will include all materials needed to show
compliance
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EC 02.03.05 (fire alarms and systems)
EC 02.05.07 (emergency power systems)
EC 02.05.09 (medical gas systems)
Items in this review can then be verified on
building tour.
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Building Tour
LSS will assess several components:
 Fire / smoke separations, hazardous areas,
exit stairwells, any kitchen grease producing
cooking devices
 The master alarm panels and if relevant the
automatic sprinkler pump
 Electrical and medical gas systems
 Remember to provide a ladder, flashlight and
any keys or opening devices for locked and
secured areas.
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Exit Conference or Briefing
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LSS will enter all findings into laptop and
provide a copy for the team leader.
An interim exit briefing with members of the
survey team will be provided to review the
LSS observations during the survey.
LSS will leave contact information with team
leader in case issue arise later during
survey.
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How to AVOID RFI’s.
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First rule is “Organization, organization,
organization.”
Have all your documents available and
have the appropriate staff available to
respond to questions.
Everybody needs a wingman
Make sure you have back-ups for staff
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How to AVOID RFI’s.
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Make it easy for the surveyor to get the
needed information to assure
compliance
Train staff them for roles needed in this
process
Have up to date floor plans
Mark plans with the appropriate notes,
fire walls, smoke compartments, etc.
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Remember to be Proactive
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Under 2009 Survey guidelines, there is
some leeway in scoring if you fix things
during survey.
SIG has trained the LSS to note a
condition but indicate that it was corrected
during survey.
Not all issues can be resolved and not
scored, but you should remain proactive.
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Corrected During Survey
Sample Items that can be corrected
during survey
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Repositioning of ceiling tiles to close
gaps
Moving items that block
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Medical gas and fire extinguishers or pull
stations
A partially burned out exit light
Storage and clutter issues
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What CANNOT be Corrected
During Survey
Per SIG guidelines, systems issues will still
be scored even if corrected during survey:
 Penetrations in walls or fire/smoker barriers
 Door issues, missing rating labels, lack of
latching or closure
 Non functioning fire alarm
 Missing smoke detectors or fire damper
 Missing handrail on exit stairwell
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Let’s Get Organized!
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Many organizations receive RFIs
because they do not have the specific
documentation required by the standard
or in the correct time frame.
Most organizations rely on outside
contractors to complete much of the
required testing, and assume
documentation is available
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Let’s Get Organized!
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Beware of documentation shortfalls.
Trace the actual document review to see
if documentation is available and
appropriate in timing to meet the
expectations.
Review requirements to know what
evidence is needed to demonstrate
compliance.
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Let’s Get Organized!
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Make sure you refer to the appropriate
NFPA codes referenced in the standards.
When you outsource, make sure your
contractors apply the correct codes.
Develop checklists and organize you
reports.
Prepare for the twelve month period, as well
as those items with longer time frames, like
dampers and standpipes.
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Let’s Get Organized!
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Let’s Get Organized!
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Build in a review process to connect
documents with specific standards
Ensure your staff know how to answer
questions, such as how they actually test
the fire pump
The standards can be cumbersome so
practice, practice, practice!
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Health Facilities Magazine
February 2009
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“The Joint Commission references five
separate NFPA documents under standard
EC.02.03.05 alone. They are the 1998
editions of NFPA 10, 25, 96 and 1962, and
the 1999 edition of NFPA 72. Additionally,
the 1999 edition of NFPA 99 and the 1996
edition of NFPA 111 are referenced later.”
Although the SOC is based on NFPA 2000
LSC, make sure you comply with the
references to other NFPA documents.
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The Statement of Conditions
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Remember this is a living breathing
document.
The LSS will review the SOC signed off on
your last survey, as well as the current one.
Build in checks and updates on your
electronic version.
Make sure more than one person in your
organization (not just a hired contractor)
knows how to update your e-SOC and find
issues.
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Managing the PFI’s
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Document your work order process and
manage the electronic PFI process to avoid
more RFI’s.
If you have equivalencies, make sure they
are with your documents. Remember the
equivalency needs to be signed off by SIG,
not just your AHJ.
Make sure all your information on BBI/SOC
is correct.
During survey is not the time to plead an
error.
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Documents
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Make sure you have the proper documents
readily available, such as daily checklists
for ILSM’s.
Check documents periodically for
completion
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Example – assure the transfer switches are
documented on the generator tests
Make sure all documents are legible.
Don’t fill in blanks, have a correction
process.
Make sure you authenticate entries.
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It’s only 1 Day (or 2)!
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It’s over fast – you must be prepared and
have your documents ready at a moments
notice
Make every day survey day and you’ll wow
your surveyor
Avoid being argumentative with the
surveyor
When conflict arises - use special
resolution time
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Are You Ready for This?
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And if this isn’t enough, there is talk of
expanding the role of the LSS
TJC is considering making LSS visits at
least two days for every organization, and
longer for larger organizations.
If you practice and walk in the shoes of
the LSS before you walk beside them, you
win. And you might even become one.
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References

Comprehensive Accreditation Manual for
Hospitals, 2009
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“Put it in Writing” by S. Spaanbroek ,
February 2009 Health Facilities Magazine
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The Life Safety Organizer, Courtemanche &
Associates 2009
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Questions ??
Contact us!
[email protected]
(704) 573-4535