And an update of 2012 Life Safety Code and Joint Commission Standards.

Slides:



Advertisements
Similar presentations
NFPA-101, LIFE SAFETY CODE, 2003 EDITION Chapter 15 Existing Schools
Advertisements

2009 Edition – NFPA 101 Steve Hornyak, DAHC, CDT, FDAI
Classroom Safety. Fire & Life Requirements as per State Education Dept The following list relates to the classrooms and adjacent areas. They are provided.
Facilities Management and Design Chapter 4 Safety and Security systems.
Emergency Preparedness and Response
Regulations (Standards - 29 CFR) Flammable and Combustible liquids
Flammable and Combustible Liquid & Compressed Gas Handling and Storage
NFPA 72 and NFPA 101 Supervised Automatic Sprinkler System Overview
Fired And Unfired Pressure Vessels
DEPARTMENT OF DEVELOPMENT SERVICES BUILDING DIVISION Ronald L. Lynn, Director/Building Official Gregory J. Franklin, Assistant Director Neil Burning, Manager.
CMS Proposed Rule § CMS: 2012 Life Safety Code Adoption Advocacy Liaison Meeting
 Please mute your line to reduce background noise  Do not put us on hold if you have background music on your hold line.  At the end of the presentation.
High-Rise Hotels New Codes General Fire Safety Information Ted Erb Fire Prevention Officer Bellevue Fire Department April
Michigan Department of Licensing and Regulatory Affairs Bureau of Construction Codes.
N.F.P.A. 13R Justin Bohlmann FIR-204.
Doug Hohbein Chief Plans Examiner Nebraska Fire Marshal Agency
The Life Safety Surveyor Facility Tour
January 16, 2014 Brad Keyes, CHSP Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance.
Zone Valves.
NSHE Annual Trade Show & Conference Brad Taylor, CHFM ASHE Region 8 Board Representative May 2, 2014.
2014 TWIN STATE SEMINAR JULY 18, 2014 Impact of CMS’ Adoption of 2012 NFPA 101 & 99 Dave Dagenais, CHFM, CHSP, FASHE.
Indiana Federation of Ambulatory Surgical Centers September 27, 2013 To promote and provide essential public health services.
Fire Protection John Giefer. Statistics In the Drilling Industry In the Drilling Industry 25% of all inspections found violations of (21 inspections.
Child Care Fire Safety Program North Carolina Fire Prevention Code 2000 International Fire Code with NC amendments. North Carolina Building Code Council.
Ted “Smitty” Smith  This slide show contains multiple timed questions. All questions can be answered using the International Fire Code, The National.
CNG STATION & GARAGE MODIFICATION CODES & STANDARDS Graham Barker Business Development Manager.
Emergency Action Plans
Presented by Gene Cable, PE, FPE Dave Dagenais, BS, SASHE, CHFM, CHSP Friday, March 19, 2010.
EGRESS AND FIRE PROTECTION
Health Facilities Planning Seminar Plan Review Division Irvin J. Poke, AIA, Chief Todd Y. Cordill, NCARB, Assistant Chief Providing for Michigan’s Safety.
HVACR311 – Electrical for Refrigeration International Mechanical Code Relating to Refrigeration.
Flammable and Combustible Liquids
The Second Survey Point of Vulnerability How Should I Prepare for the Facility Tour? Healthcare Engineering Consultants.
The Physical Environment Tracers How Should I Prepare for the Physical Environment Tracers? Healthcare Engineering Consultants  Will limit.
© 2008 Delmar, Cengage Learning Property Security, Emergency Response, and Fire Protection Systems Chapter 13.
Flammable and Combustible Liquids. Introduction !The two primary hazards associated with flammable and combustible liquids are explosion and fire !Safe.
© 2015 American Society for Healthcare Engineering, a personal membership group of the American Hospital Association 155 N. Wacker Drive, Suite 400 | Chicago,
MINNESOTA CHAPTER AUTOMATIC FIRE ALARM ASSOCIATION Requirements of the 2003 Minnesota State Fire Code relating to Group R Occupancies September 14, 2006.
1 HVACR318 – Refrigeration II International Mechanical Code Relating to Refrigeration.
Engineering Analysis of NFPA 285 Tested Assemblies
Neil Cooper Fire Safety Residential Implementing the Changes.
Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities.
Exit Routes and Fire Protection
Presented by: Brad Keyes, CHSP Senior Consultant Keyes Life Safety Compliance, LLC.
Maine State Fire Marshals Office1 Laws and Codes Relating to Existing Apartment occupancies in the State of Maine Mark Stevens CFI-II, CFPS, CFPE Inspections.
Part 5: Meeting the Challenge of the “EC Tracers” Healthcare Engineering Consultants How Should I Prepare for the “EC Tracer” Part of the Survey?
NFPA 2 Overview Susan Bershad, Staff Liaison, NFPA.
COMMON DOH SURVEY CITATIONS UPDATE RANDY BENSON WHS HEALTHCARE QUALITY SERVICE JANUARY 2016.
Subpart F - Fire Protection & Prevention ( ) Flammables/combustibles - Approved containers Fire protection program/equipment 2A fire extinguishers.
Work Area Method Level 3 Alterations – Chapter 9 prescribes requirements. 50% of Building Area Rule.
Presented by John Lewandowski and Mike Larabel Inspection, Testing, and Maintenance of Kitchen Hood Systems Michigan Fire Inspectors Society Winter Educational.
The role of the IHS Environmental Health Officer in Healthcare Facility Plan Review CDR Ricardo Murga, CSP, RS, MPH Institutional Environmental Health.
Flammable Liquids Directorate of Training and Education
Safety Rule #1 Open flames are not allowed without first obtaining a permit. The exception to this rule is during a period of closely supervised instructions,
Exit Routes, Emergency Action Plans, Fire Prevention Plans, and Fire Protection.
CIHQ - All Rights Reserved 2017
Earthquake effects on health care facilities
Fire Alarm Systems for Emergency Operations of Elevators
Table of Contents for Subpart E Coverage and Definitions
ARCHITECTURAL SAFETY FEATURES –Exit Separations –Continuation of Exit Stairs from lower to upper floors –Discharge from Exits FIRE PROTECTION FEATURES.
Flammable and Combustible Liquids
Florida Building Commission Lightning Protection Workgroup
Fire Door Inspections Qualified Training
29 CFR NFPA Life Safety Code
Brad Keyes, CHSP HFAP Engineering Advisor Jamie Crouch, BSBM, MHA
Texas Department of State Health Services
THROUGH A SURVEYOR’S EYES
National Fire Protection Association Update
2008 Code Drills Health Care Facilities
Presentation transcript:

And an update of 2012 Life Safety Code and Joint Commission Standards

2015 Ranking CFRTagJC Standard% of Non- Compliance #1§ (a) § (c)(4) A-0701 A-0726 EC %  Interior Spaces  Lighting  Ventilation, temperature & humidity levels  Clean and free of odors  Emergency Access  Keeps furnishings in good repair

2015 Ranking CFRTagJC Standard% of Non- Compliance #2§ (c)(2) § (a) § (b) A-0144 A-0748 A-0951 IC %  Cleaning of medical equipment and supplies  Storing medical equipment and supplies

2015 Ranking CFRTagJC Standard% of Non- Compliance # 3§ §482.41(a) §482.41(c)(2) A-0700 A-0701 A-0144 EC %  Inventory of operating components  Manufactures’ recommendations or alternative maintenance  Maintenance records  Written criteria  Labels controls for partial or complete shutdown  Written procedures for disruptions and emergency repairs  Clinical interventions during utility failures  Minimize biological agents in water systems, cooling towers  VENTILATION SYSTEMS, PRESSURE RELATIONSHIPS AIR EXCHANGES

2015 Ranking CFRTagJC Standard% of Non- Compliance # 4 §482.41(b)(1) (i) A-0710LS %  Door locking arrangements  Exit discharge continuous to public way  Wall projections  Corridor clutter  Exit discharge lighting (failure of single fixture will not leave area dark)  Stairwell signage  Exit signs (visible when path is not readily apparent)

2015 Ranking CFRTagJC Standard% of Non- Compliance #5§ (b)(1)(i)A-0710LS %  Hazardous areas (1 hour or rated)  Door gaps and coverings  Smoke barrier penetrations (existing ½ hour, new 1 hour)  Smoke barrier doors  Positive latching hardware

2015 Ranking CFRTagJC Standard% of Non- Compliance #6§ § (b) A-0431 A-0438 RC %  Completeness of medical record  Continuity of care among providers  Date and time of record

2015 Ranking CFRTagJC Standard% of Non- Compliance #7§482.41(b)(1)(i)A-0710LS %  Sprinklers  Fire wall penetrations  Fire door protective plates (16 inches)

2015 Ranking CFRTagJC Standard% of Non- Compliance #8§482.41(b)(1)(i)A-0710LS %  Piping is not used to support any other item  18 inches or more of space below sprinkler deflector  Fire extinguisher travel distance (75 ft)  K-type fire extinguisher (within 30 ft. of grease devices)

2015 Ranking CFRTagJC Standard% of Non- Compliance #9§482.23(c) § § A-0405 A-0431 A-1081 PC %  Physician orders  Most recent order  Read back and verify

2015 Ranking CFRTagJC Standard% of Non- Compliance # 10§482.26(b)(1) §482.41(a) §482.53(b) A-0536 A-0701 A-1025 EC %  Written inventory  Written procedures for spills / exposures  Hazardous gases ( glutaraldehyde, laser gas, nitrous oxide)  Waste manifests

* EC EP2 A Identify Individuals to intervene * EC EP4 A Designate Smoking physically separate from care * EC EP2 A3 If Patient are permitted to smoke, hospital takes measures to minimize fire risk * EC EP1 A Solicits input from individuals who operate and service equipment

* EC EP 9 A3 If Emergency Power test fails, hospitals implements measures * EC EP10 A Performs re-test * EC EP 3 A Annually recommends one or more priorities for improving EOC * EC EP 3 A Report PI to those responsible for analyzing EOC

* This final rule will amend the fire safety standards for Medicare and Medicaid participating hospitals, critical access hospitals (CAHs), long-term care facilities, intermediate care facilities for individuals with intellectual disabilities (ICF-IID), ambulatory surgery centers (ASCs), hospices which provide inpatient services, religious non-medical health care institutions (RNHCIs), and programs of all-inclusive care for the elderly (PACE) facilities. Further, this final rule will adopt the 2012 edition of the Life Safety Code (LSC) and eliminate references in our regulations to all earlier editions of the Life Safety Code. It will also adopt the 2012 edition of the Health Care Facilities Code, with some exceptions.

* The 2012 edition of the LSC classifies a “Health Care Occupancy” as a facility having 4 or more patients on an inpatient basis. We proposed that the LSC exception for health care occupancy facilities with fewer than four occupants/patients would be inapplicable to the Medicare and Medicaid facilities; all health care occupancies that provide care to one or more patients would be required to comply with the relevant requirements of the 2012 edition of the LSC.

* Sections and —Recycling * This new provision requires that containers used solely for recycling clean waste be limited to a maximum capacity of 96 gallons. If the recycling containers are located in a protected hazardous area, container size will not be limited.

* Sections and —Roller Latches * Roller latches will be prohibited in existing and new Health Care Occupancies for corridor doors and doors to rooms containing flammable or combustible materials. These doors will be required to have positive latching devices instead.

* Sections and —Sprinklers in High-Rise Buildings * This provision requires buildings over 75′ (generally greater than 7 or 8 stories) in height to have automatic sprinkler systems installed throughout the building. The 2012 LSC allows 12 years from when the authority having jurisdiction (which in this case is CMS) officially adopts the 2012 edition of the LSC for existing facilities to comply with the sprinkler system installation requirement. Therefore, those facilities that are not already required to do so will have 12 years following publication of this final rule, which adopts the 2012 LSC, to install sprinklers in high-rise buildings.

* Sections and —Door Locking * Where the needs of patients require specialized protective measures for their safety, door-locking arrangements are permitted by this section. For example, locked psychiatric facilities are designed such that the entire facility is secure and obstructs patients and others from improperly entering and exiting. This provision allows interior doors to be locked, subject to the following requirements: (1) All staff must have keys; (2) smoke detection systems must be in place; (3) the facility must be fully sprinklered; (4) the locks are electrical locks that will release upon loss of power to the device; and (5) the locks release by independent activation of the smoke detection system and the water flow in the automatic sprinkler system.

* Sections and —Alcohol Based Hand Rubs (ABHRs) * This provision explicitly allows aerosol dispensers, in addition to gel hand rub dispensers. The aerosol dispensers are subject to limitations on size, quantity, and location, just as gel dispensers are limited. Automatic dispensers are also now permitted in health care facilities, provided that the following requirements are met: (1) They do not release contents unless they are activated; (2) the activation occurs only when an object is within 4 inches of the sensing device; (3) any object placed in the activation zone and left in place must not cause more than one activation; (4) the dispenser must not dispense more than the amount required for hand hygiene consistent with the label instructions; (5) the dispenser is designed, constructed and operated in a way to minimize accidental or malicious dispensing; and (6) all dispensers are tested in accordance with the manufacturer's care and use instructions each time a new refill is installed. The provision further defines prior language regarding “above or adjacent to an ignition source” as being “within 1 inch” of the ignition source.

* Sections and —Extinguishment Requirements * Based on comments received from the industry, we are withdrawing our proposal and adopting the requirement as specified by NFPA for an evacuation of a building or the instituting of an approved fire watch when a sprinkler system is out of service for more than 10 hours in a 24-hour period until the system has been returned to service.

* Section and —Anesthetizing Locations * This provision requires that anesthetizing locations be protected in accordance with the 2012 edition of NFPA 99, Health Care Facilities Code. Separate from the requirements of the NFPA 99, we proposed that dedicated supply and exhaust systems for windowless anesthetizing locations must be arranged to automatically vent smoke and products of combustion to prevent the circulation of smoke originating from within and outside the operating rooms.

* Sections and —Corridors * This provision allows for wheeled equipment that is in use, medical emergency equipment not in use, and patient lift and transportation equipment be permitted to be kept in the corridors for more timely patient care. This provision also allows facilities to place fixed furniture in the corridors, although the placement of furniture or equipment must not obstruct accessible routes required by the ADA. See section of the 2010 Standards.

* Sections and —Cooking Facilities Cooking facilities are allowed in a smoke compartment where food is prepared for 30 individuals or fewer (by bed count). The cooking facility is permitted to be open to the corridor, provided that the following conditions are met: Show citation box The area being served is limited to 30 beds or less. The area is separated from other portions of the facility by a smoke barrier. The range hood and stovetop meet certain standards— ++ A switch must be located in the area that is used to deactivate the cook top or range whenever the kitchen is not under staff supervision. ++ The switch also has a timer, not exceeding 120-minute capacity that automatically shuts off after time runs out. Two smoke detectors must be located no closer than 20 feet and not further than 25 feet from the cooktop or range.

* Sections and —Furnishings & Decorations * This provision allows combustible decor in any health care occupancy as long as the décor is flame-retardant or treated with approved fire-retardant coating that is listed and labeled, and meet fire test standards. Additionally, decor may not exceed—(1) 20 percent of the wall, ceiling and doors, in any room that is not protected by an approved automatic sprinkler system; (2) 30 percent of the wall, ceiling and doors, in any room (no maximum capacity) that is not protected by an approved, supervised automatic sprinkler system; and (3) 50 percent of the wall, ceiling and doors, in any room with a capacity of 4 people (the actual number of occupants in the room may be less than its capacity) that is not protected by an approved, supervised automatic sprinkler system.

* Sections and —Fireplaces * This provision allows direct-vent gas fireplaces in smoke compartments without the 1 hour fire wall rating. Fireplaces must not be located inside of any patient sleeping room. Solid fuel-burning fireplaces are permitted and can be used only in areas other than patient sleeping rooms, and must be separated from sleeping rooms by construction of no less than a 1 hour fire resistance wall rating.

* Outside Window or Door Requirements * Separate from the requirements of the LSC, we proposed that every health care occupancy patient sleeping room must have an outside window or outside door with an allowable sill height not to exceed 36 inches above the floor with certain exceptions, as follows: * Show citation box * Newborn nurseries and rooms intended for occupancy for less than 24 hours have no sill height requirements. * Windows in atrium walls shall be considered outside windows for the purposes of this requirement. * The window sill height in special nursing care areas shall not exceed 60 inches above the floor.

* Federal Register,The Daily Journal of the United States Government * Rule by the Centers for Medicare & Medicaid Services on 05/04/2016 * The Joint Commission’s 2016 Hospital Accreditation Standards * The Joint Commission ‘s 2016 Joint Commission and CMS Crosswalk

Terry Parish SASHE CHFM Director Regulatory Compliance Columbus Regional Health