C A & Courtemanche & Associates HEALTHCARE SYNERGISTS

C & A Environment of Care – Life Safety Code Specialist

C & A Life Safety Code Specialist  Initial group of 50 specialists  Joined existing surveyors for January 2005 training –Collaborative education with ASHE  Reserved for Hospitals with 200 or more beds (as identified on application) –One Day Survey –For organizations with multiple buildings, target will be one with most beds

C & A Life Safety Code Specialist Target Areas  Life Safety Code / Statement of Conditions  Features of Fire Protection  Interim Life Safety Measures  Emergency Power Systems  Piped Medical Gases and Vacuum Systems

C & A Life Safety Code / SOC  Current Statement of Conditions  Organization needs to make “sufficient progress” towards previously approved corrective actions –If “sufficient progress” has not been made, organization could face CONDITIONAL ACCREDITATION  TIP – Let surveyor know of any LSC equivalency immediately

C & A Features of Fire Protection  Portable Fire Extinguishers  Water-based fire protection systems  Fire alarms  Fire doors / windows  Air conditioning and ventilation systems  Fire hoses  Life Safety Code  TIP – Make sure there is no debris or equipment leaning on fire extinguishing systems

C & A Interim Life Safety Measures (ILSM)  ILSM Policy in place  Criteria to identify deficiencies and hazards –When and to what extent all 10 components apply  TIP – Be proactive and be ready to share this information with your surveyor

C & A Emergency Power Systems  Generator Testing  Transfer switches  Battery powered lights  Stored Emergency Power Supply System  REMEMBER – Generator testing – No more than 40 days after last test, and not less than 20 days

C & A Medical Gas and Vacuum Systems  Maintenance Program  Testing Documentation –Cross-connection –Pipe security –Pressure  TIP = Policy and Procedure or Plan for installation of new and replacement piping

C & A Life Safety Code Specialist Agenda  Facilities Maintenance Review –Focused Document Review  Facility Orientation –Statement of Conditions / PFI –Building Plans  Surveyor Planning Session  LSC Building Tour  Meeting with Survey Team

C & A Other Links to Survey Process  Sharing of information with survey team –Focus review of items at other buildings by other surveyors –Environment of Care Tracers  Focus is on Life Safety Code, but also will review closely related EC standards