Understanding the Life Safety Code Scoring Impact & Interim Life Safety Measures 1

Understanding the Life Safety Code

Scoring Impact & Interim Life Safety Measures

1www.courtemanche-assocs.com

Disclosures

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Session Objectives

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 tour3www.courtemanche-assocs.com

Glossary

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


The 2009 Standards

Let’s review the 2009 standards.

There was a total revision and increase in standards in this area.

There has been increased scoring since 2008


The Evolution of EC

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


The Evolution of EC

The Environment of Care chapter and scoring process changed for 2009

EC evolved to three separate chapters Environment of Care (EC) Emergency Management (EM) Life Safety (LS)


The Evolution of EC


The Evolution of EC

Where are we now - it’s 2009?

EOC issues are scoring more in recent surveys

There has been an increase in scoring for Immediate Threat to Life and Conditional Accreditation rules


Thresholds – January – Serve as “Screens” Thresholds:

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


Screens = Surveyor Days & Direct Impact RFIs (for Hospital)


Band Category Surveyor Days RFIs (Non-Compliant 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

Central Office Review

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?


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


2009 Chapters & Standards EC chapter now has

20 standards 143 elements of performance

EM chapter now has 12 standards 111 elements of performance

LS chapter now has 17 standards 194 elements of performance


1 Chapter 33 Standards 234 Elements of

Performance

3 Chapters 49 Standards 448 Elements of

Performance

2008 Manual 2009 Manual


Let’s Compare

More Impact for 2009

There are four tiers in the scoring model 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!


Direct Impact Standards In the three new chapters, there are

several direct impact standards.

LS has 20 direct impact standards EC has 43 direct impact standards EM has 3 direct impact standards


Get Ready for 2009

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 %!


Top Scoring Issues


TJC 2007 (final #s)

TJC – 1st Quarter 2008

Issue Comments

MM.2.20 (43%)

(31%) Storage of medications

NPSG 2C (36%)

No DataCritical test/results data requirements

from prior year

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 from prior year

UP 1C (21%) No Data Time out

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

Interim Life Safety Measures

What are Interim Life Safety Measures? Additional measures for fire prevention Required when:

1. There are Life Safety Code deficiencies

2. 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.


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


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


What are the Additional Measures?

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


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


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.


What is the ILSM Process?

The assessment process for ILSM’s Analyzes the projectIdentifies the risks Implements strategies and safeguardsProtects against those risks

Now Let’s Examine ICRA

ICRA is Infection Control Risk Assessment When is it needed?

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


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 enhance

growth of infectious organisms Release of dust, debris, airborne hazards


Where do ICRAs and ILSMs Meet?

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


ILSMs and ICRA – A Renewed Focus 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!


ILSM and ICRA Process 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


Once Activated, What is Required? Ongoing assessment and monitoring to

assure safe conditions1. Conduct pre-assessment2. Assure activation of appropriate

measures3. Provide ongoing assessment4. Do daily or more often checks as

needed5. Document on checklist


What Does Checking Entail? For ILSM’s checking includes:

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


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


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.


What Does Checking Entail?For ICRA checking includes:

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


What Does Checking Entail?For ICRA checking includes:

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


What Does Checking Entail?When you implement ILSM’s and the ICRA

process, you need to document your efforts.

Daily ( 7 days a week) rounds to ensure these details.

Additional fire drills are also needed. 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.


How Does the Process Happen? Training needs to address fire fighting and

infection prevention roles Can you use a fire extinguisher?

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


Safety is Everyone’s Job! 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!


Your Role in Fire Safety and Infection Prevention 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


Life Safety Code

Issues and Responses

Stay Alert – Challenges in 2009

e-SOC ILSMs Life Safety Specialist Situational Decision Rules

Insufficient progress on e-SOCFailure 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!


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)


Things to Watch for in 2009What 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


Things to Watch for in 2009If 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


Things to Watch for in 2009

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


Things to Watch for in 2009The 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


Things to Watch for in 2009 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


Things to Watch for in 2009 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


Things to Watch for in 2009 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


Things to Watch for in 2009 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


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.

Over 3,000 cu.ft. has lots of requirements including ventilation


More on Medical Gases

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.


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.


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 .


Facility Orientation

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.


Document Review

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

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.


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.


Exit Conference or Briefing 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.


How to AVOID RFI’s.

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


How to AVOID RFI’s.

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.


Remember to be Proactive 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.


Corrected During SurveySample Items that can be corrected

during survey Repositioning of ceiling tiles to close

gaps Moving items that block

Medical gas and fire extinguishers or pull stations

A partially burned out exit light Storage and clutter issues


What CANNOT be Corrected During SurveyPer 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


Let’s Get Organized!

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



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.



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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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!


Health Facilities Magazine February 2009 “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.


The Statement of Conditions 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.


Managing the PFI’s

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.


Documents

Make sure you have the proper documents readily available, such as daily checklists for ILSM’s.

Check documents periodically for completion

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.


It’s only 1 Day (or 2)!

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


Are You Ready for This? 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.


References

Comprehensive Accreditation Manual for Hospitals, 2009

“Put it in Writing” by S. Spaanbroek , February 2009 Health Facilities Magazine

The Life Safety Organizer, Courtemanche & Associates 2009


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