Notes From ASHE Conference and

CMS LSC Waiver Summaries

Prepared for HFMADVBy Dennis Rudloff and Dan Campbell

TJC Prep Guide

Preparation OutlineCurrent SOC and status of Previously Accepted

RFI’s, any equivalencies or extensions granted.

Survey team arrives after 7:30AM biographies are on internet; this starts your facilities team into action by calling a code “J” to scour the building within one and a half to two hours.

The surveyor can opt to do the building tour or the document review first. Doing the document review has its advantages.

LSCS surveyor will focus on:EC.02.03.03 Fire DrillsEC.02.03.05 Features of Fire

ProtectionEC.02.05.07 Emergency Power

SystemsEC.02.05.09 Medical gas SystemsHazard Vulnerability Analysis (HVA)Emergency Operations Plan

LSCS surveyor will focus on:And may also survey

LD.04.01.05 EP-4 Accountability (Leaders at the program, service, site, or department level create a culture that enables the hospital to fulfill its mission and meet its goals. They support staff and instill in them a sense of ownership of their work processes. Leaders may delegate work to qualified staff, but the leaders are responsible for the care, treatment, and services provided in their areas.)

LD.04.04.01 EP-2 Hi-Priority (Leaders give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities.)

LD.01.03.01 EP-5 Resources (The governing body provides for the resources needed to maintain safe, quality care, treatment, and services)

ScoringAll findings of less than full compliance are

cited as RFI, RFI resolution is through Evidence of Standards Compliance (ESC).

Score based on the number of times an EP is not met, i.e.: sample size is at least 10 items surveyed. Score of 2 is for 0-1 instance of non-

compliance Score of 1 is for 2 instances of non-

compliance Score of 0 is for 3 or more instances of

non-compliance

Criticality Immediate threat to life (samples on next slide):

Preliminary Denial of Accreditation (PDA) until resolved. PDA can only be issued by TJC President. Follow-up survey required.

Situational Decision Rules: Contingent Accreditation and PDA

Direct Impact Requirements must be resolved within a short time (45Days)

Indirect Impact Requirements must be resolved within 60 days, these generally do not impact the accreditation decision.

Immediate threat to life Triggers (ITL)When these items are significantly compromised:

Fire AlarmSprinkler AlarmEmergency Power Supply SystemMedical Gas Master PanelCompromised ExitsOther situations that place patients, staff, or visitors at

extreme danger. Note:

Any ITL will automatically trigger an RFI at LD.01.03.01 EP-2. (The governing body’s ultimate responsibility for safety and quality derives from its legal responsibility and operational authority for hospital performance. In this context, the governing body provides for internal structures and resources, including staff, that support safety and quality.)

NEW – Time Frequencies Defined:Daily, weekly, monthly are considered calendar references.Quarterly, is once every three months ± 10 days.Semi-Annual, is 6months from the last scheduled event

month ± 20 days.Annual, is 12months from the last scheduled event month ±

30 days3 Years, is 36 months from the last scheduled event month ±

45 days.

Note: Time frames do not apply to required frequencies such as emergency generator testing (see EC.02.05.07 EP-4 and EP-8).

Frequencies required by code may not be modified.

Issues with EC.02.03.05Each device tested is required to be in an

inventory.Lack of an inventory results in a finding at

that EPDocumentation for a specific EP is not

available at time of the survey will result in a finding for that EP.

If a finding is clarified after the survey TJC will review and evaluate for compliance.

But the finding for LD.04.01.05 EP-4 (Staff is held Accountable) will remain

EP.02.03.05 EP-25 Requires the following summary information

Name of the ActivityDate of the ActivityRequired Frequency of the ActivityName, contact information, including

affiliation, of person who performed the activity

NFPA standard(s) referenced for the activityResults of the activity

Interim Life Safety Measures (ILSM)Standard LS.01.02.01ILSM’s are required for EP-1 (notify local fir dept., fire watch and

document it) and EP-2 (post signage to ID exits) regardless of the ILSM policy.

EP-3 must clearly define in writing the ILSM policy including; (No policy Conditional RFI) When to implement What to do to protect patients and other occupants Both construction related and non-compliance with

the LSCEP-4 to 14 aligns with the policy and implementation

strategies.

Life Safety Assessment - SOCCurrent Statement of Conditions Basic Building Information Plan for improvementLadder and flashlightsAccurate Life safety Drawings with

information that shall include. Life Safety Legend that clearly identifies features of LS. (next slide)

Life Safety Assessment – SOC page 2

Identify:Areas that are sprinkleredHazardous storage areasAll Rated barriersAll Smoke barriersSuite boundaries include size, if sleeping (5,000

sq.ft.) or non-sleeping (max 10,000 sq.ft.)Locations of smoke compartmentsLocations of chutes and shaftsAny approved equivalencies or waivers

Management PlansFacilities managers are usually responsible for at least

three possibly more management plans.All plans should be consistent with the organizations

Mission, Values, and Philosophy statements. One way to do this is have them approved annually by the Safety Committee.

Your plan will be assessed base3d on its written program if it exceeds the minimum interpretation of the Elements of Performance.

Your Policies and Procedures are the guidance that defines the programs responses.

Your documentation will ensure the activities being carried out have been pre-planned.

Equipment Survey Process ( 1 of 2 )

Documentation is completed for both Life Support and Non-Life Support devices on the inventory. You must have an inventory with time frames of PM work.

Inventory must be accurate:All Life Support equipment must be on the

inventoryPM frequencies must be clearly defined in

writing.

Equipment Survey Process (cont’d)Surveyor will confirm the work is done as per

schedule activitiesEnsure appropriate work is scheduled based

on maintenance strategies.Evaluate equipment failure and scheduled

action. Do not forget to include ILSM consideration for equipment failures.

Report equipment failures and all follow-up actions to the EOC committee.

CMS LSC Waiver Summaries

CMS LSC Waiver Conditions CMS is granting LSC waivers due to unusual

hardships and no alternatives that provide an equal level of protection.

Applications for the waiver is not required. Waivers elected for use must be documented and

meet all conditions of the waiver. Notify the any LSC survey team and present the

information at the entrance conference of waivers elected. Otherwise your waivers will be accepted.LSC survey team will review information and confirm

you are meeting the circumstances of the waiver.

CMS LSC Waiver Summary ( 1 of 7 )

Medical gas master alarms: Allows substitution of a centralized computer

system for one Category 1 medical gas master alarm.

Code Requirement NFPA 99-2012, 5.1.9.4 and compliance with all other

applicable NFPA 99-1999 medical gas master alarm provisions

Facilities Must Demonstrate that it complies with all other applicable

NFPA 99-1999 medical gas master alarm provisions, as well as with section 5.1.9.4 of NFPA 99-2012

CMS LSC Waiver Summary ( 2 of 7 )

Openings in Exit Enclosures Permits existing openings in exit enclosures to

mechanical equipment spaces if they are protected by fire-rated door assemblies.

Code Reference NFPA 101-2012, 7.1.3.2.1(9)(c) and all other applicable

NFPA 101-2000 exit provisions Mechanical Equipment Space Must

Be in a building protected with an approved supervised automatic sprinkler systems.

Be used only for non-fuel-fired mechanical equipment. Contain NO storage of combustible materials and,Be protected by a fire rated door

CMS LSC Waiver Summary ( 3 of 7 )

Emergency generators and standby power systems Reduces the annual diesel-powered generator

exercising requirement from two (2) continuous hours to one and a half hours.

Code Reference NFPA 110-2010, 8.4.2.3 and all other applicable NFPA

110-1999 operational inspection and testing provisions.

The annual load test is only required when the monthly diesel generator test does not comply with minimum loading requirements to avoid wet stacking.

CMS LSC Waiver Summary ( 4 of 7 )

Door locking arrangements Allows door locking arrangements in areas where

there are clinical needs, security risks or specialized protective measures required for safety.

Code Reference NFPA 101-2012, 18/19.2.2.2.2 through 18/19.2.2.2.6

as well as all other applicable NFPA 101-2000 door provisions.

Facilities staff must make adequate provisions in the rapid removal of occupants by means such as remote control locks or keys carried by the staff at all times.

CMS LSC Waiver Summary ( 4 of 7 part two )

Multiple delayed egress locks Allows more than one delayed-egress lock in the

egress path where the clinical needs require specialized security measures or when a patient requires specialized protective measures for safety.

Code Reference NFPA 101-2012, 18/19.2.2.2.4 and compliance with

all other applicable NFPA 101-2000 door provisions. Facilities Must also use compensating safety

measures specified in those sections that facilitate rapid removal of occupants.

CMS LSC Waiver Summary ( 5 of 7 )Suites Accommodates the use of suites by allowing: (1) one of the required

means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior; and (3) an increase in sleeping room suite size up to 10,000 sq. ft.

Code Reference NFPA 101-2012, 18/19.2.5.7 and compliance with all other applicable

NFPA 101-2000 suite provisions Facility must meet the corridor wall and door requirements for the

outer boundary (perimeter) of the suite and meet the requirements for the smoke zone. One or more egress routes may be required, depending on the size of the

suite. *

CMS LSC Waiver Summary ( 6 of 7 )

Extinguishing requirements Allows for the reduction in the testing

frequencies for sprinkler system vane-type and pressure switch type water-flow alarm devices to semiannual, and electric motor-driven pump assemblies to monthly.

Code Reference NFPA 25-2011, 5.3 and 8.3 and all other applicable

NFPA 25-1998 (as referenced in section 9.7.5 of the NFPA 101-2000)

Facility must meet the code references stated.

CMS LSC Waiver Summary ( 7of 7 )

Clean waste and patient record recycling containers.

Allows the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96 gallons.

Code Reference NFPA 101-2012, 18/19.7.5.7.2

Facility must document that the container has passed an FM fire test.

Miscellaneous Facilities that do not meet all the

requirements of the waiver will be cited. Where do these waivers leave the 2012 LSC?

ASHE believes the agency still wants to adopt the 2012 edition, but because the lengthy adoption process is contingent on other priorities, CMS wanted to give hospitals some relief from burdensome requirements in the meantime.

I personally am skeptical!

Questions ?????