The Life Safety Specialist Surveyor Preparing for the Life Safety Specialist Documentation Review...

The Life Safety Specialist Surveyor

Preparing for the Life Safety Specialist Documentation Review and Facility Tour

Healthcare Engineering Consultants

Will limit

The Life Safety Specialist (LSS)

It is likely that the LSS will arrive with the team on the first or second day, less likely later in the survey

For 2011, the LSS will usually be scheduled for an additional day based on the scheduled time of the previous survey

The LSS will spend several hours on dedicated documentation review, but much more time on the facility tour

Other responsibilities assigned to the LSS will depend on the survey team member preferences and responsibilities – they may conduct the “EC Interview” and Emergency Management tracers

The other survey team members will also observe life safety issues, but not as detailed as the LSS – it is not likely that the nurse and physician will request a ladder and flashlight!

If the LSS observes deficiencies outside of their defined responsibility (example: medical records privacy or medication security), they will report it to the other team members


The LSS Documentation Review


Life Safety Specialist (LSS) surveyor documentation responsibilities include at a minimum:

LS.01.01.01: SOC and Life Safety Code

LS.01.02.01: Interim life safety measures

EC.02.03.05: Fire system tests

EC.02.05.07: Emergency power systems

EC.02.05.09: Medical gas and vacuum systems

Note: In 2011, the Life Safety Specialist may be assigned additional responsibilities during the survey



LS.01.01.01: SOC and Life Safety Code

The SOC completion will be verified through the Joint Commission Connect site (BBI’s and PFI’s)

Have the SOC notebook available for review

The PFI documents from the previous survey may be reviewed to verify completion of deficiencies (have them available, if requested)

The compartmentation drawings will be reviewed to assist in planning the facility tour

Life Safety Code compliance will be verified during the facility tour

The Statement of Conditions


How Should the Statement of Conditions (SOC) Document be

Completed?



What is the SOC?The Statement of Conditions (SOC) is a document that is required to be completed by every healthcare facility that applies for accreditation by the Joint Commission. It references the *2000 edition of the Life Safety Code and consists of the following sections:

Basic Building Information (BBI) Form – electronic on Connect site

Life Safety Assessment (LSA) Form – not electronic

Plan for Improvement (PFI) Form – electronic on Connect site

BBI’s, LSA’s and PFI’s are

*Note: Other LSC editions may be selected, but the entire edition must be followed



SOC Notebook (Best Practice)

A SOC notebook is strongly recommended to contain “hard copies” of the SOC documents

The notebook should include at least the following sections:

Section 1: The SOC policy and responsibility statement

Section 2: Current copies of the downloaded BBI forms

Section 3: Accurate, color-coded compartmentation prints

Section 4: The latest, completed LSA-type document

Section 5: Current and previous, downloaded PFI forms

Section 6: Any correspondence with the Joint Commission,

including equivalencies, letters and emails



Why Should I have an SOC Policy? (Best Practice)

The SOC policy describes how the Statement of Conditions program is organized for the facility

What Should the SOC Policy Include?

Who is responsible for completing and maintaining the SOC

How often the SOC documents are reviewed

Who reviews the SOC documents for timeliness

PFI guidelines (when does a work order become a PFI?)

Whether a BMP is implemented

Whether an above-the-ceiling program is in place

How the SOC documents are organized

Statement of Conditions Document


The current Statement of Conditions “hard copy” document is dated 5/2004 and can still be downloaded from JointCommission.org for the LSA form (do not use the BBI or PFI “hard copies” – they are obsolete)



Notes About the e-BBI Form

List on the e-BBI cover page every occupancy that will be surveyed, even for business occupancies (make sure that the BBI and survey list match!)

The e-BBI questionnaires are only required for ambulatory, hotel/ dormitory and healthcare occupancies

Fill in the comments section regarding SOC preparer, location of building drawings, mixed occupancies, equivalencies, special building features or local AHJ requirements to the BBI

If multiple occupancies are entered, the greatest percentage defaults to the BBI form, so multiple BBI entries are required

Be sure to download the electronic version of the BBI form before it is saved so that a “back-up” is available, and place a copy in the SOC Notebook



Compartmentation Requirements

Mixed Occupancies: (LSC: 19.1.2.1)

Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet the following conditions:

1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation

2) They are separated from the health care occupancy by a fire rating of at least 2 hours

3) Separation between ambulatory and business occupancies only requires a 1 hour rating (LSC: 21.1.2.1)



e-BBI Form – Buildings

Be sure to complete for all healthcare and ambulatory facilities

Optional for business occupancies, but strongly suggested for the cover page



e-BBI Form - Healthcare

Refer to instructions related to “stories” in the Life Safety Code

Note instructions related to building construction type (occupancy)

Building age is important due to significant code changes



e-BBI Form – page 2

1991 date significant due to sprinkler requirement

Emergency power fuel type important due to “wet stacking”



e-BBI Form – page 3

“Previous inspections” data provides valuable information to the survey team!

Be sure to list local or regional requirements (example: limited generator testing due to high pollution days) in the “Comments” section at the bottom of the form as well as other requested information



LSA Form (is not electronic):

Is a voluntary assessment tool, although some assessment is required at least annually

Is not required for “Business Occupancies”

The Joint Commission surveyor normally expects some type of form, document or evaluation to be completed

Dated 5/2004, so a cover sheet that is signed annually is recommended

Can still be downloaded from the Joint Commission home page website (search “Statement of Conditions”)

Can use PPR form or similar for the LSA document

Comments in LSA must match PFI deficiencies



Life Safety Building Compartmentation Drawings

Blue – smoke barrier

Green – 1 hour fire wall (hazardous area)

Red – 2 hour fire wall

Note: Color-coded drawing is “best practice”



Notes About the PFI Forms

The forms should not be used for “operational deficiencies”, such as exit lights burned out, doors out of minor adjustment or small penetrations that can be easily filled – these should be completed using the routine work order system

The normal “trigger time” from a work order to PFI is 45 days

Document the “PFI’s” on a continuing basis – be sure that the PFI log is up-to-date and ready to be reviewed by the surveyor

Don’t forget to enter the projected start and completion dates and the actual completion date

Failure to meet the completion dates without a delay approval results in Conditional Accreditation 6 months after the projected completion date has passed!

If applicable, keep any previously signed PFI copies available



The first page for the electronic PFI forms is used to list the deficiencies

Notice that a “No Deficiencies” option is available

(and should be completed, if applicable)



The second page for the electronic PFI forms is used to indicate the deficiency resolutions

Don’t forget to complete all of the requested information, including the proposed action, source of funds and the projected start and completion dates

The projected completion dates can be altered until they are “frozen” before or during the actual survey!

Comments for each PFI should include a note regarding the implementation of ILSM’s!



The listing document simply provides a summary of all of the deficiencies that have been recorded on the PFI form for tracking purposes – keep a copy of this in the SOC notebook for reference purposes

The Life Safety Specialist Documentation Review


Should I Implement and Document a Building Maintenance

Program (BMP)?


Is voluntary; no scoring benefit in 2011

No longer requires a measure of effectiveness

Measurement system can use random samples

Results should be used to determine revisions to inspection or test frequencies

Information should be provided to the hospital safety committee if changes are made to the program

Is basically a PM program for the buildings

Is still considered a Best Practice

The Building Maintenance Program (BMP)

Fire System Tests


Points to Remember

Clearly define supervisory devices (fire pump, low air pressure on dry or pre-action systems and water tank level indicators expected)

Tamper and flow device test intervals increase to quarterly on 7/1/11

Inventory all doors on magnetic releasing devices and document test results

Document tests results for each individual heat and smoke detector, pull box and audible and visual device

Fire System Component Test Schedule

Standard Element of Performance Scoring Category

Test Interval

NFPA Reference

EC. 02.03.05

Fire Component Tests

1 Supervisory switches

C Q NFPA 72

2 Tamper switches, flow devices

C S/A NFPA 72

3 Duct detectors, door releasing devices

C A NFPA 72

3 Smoke and heat detectors, pull boxes

C

A NFPA 72

4 Audible and visual alarms

C A NFPA 72

5 Off-premises transmission equipment

A Q NFPA 72

6 Fire pump churn test

C W NFPA 25

7 Water tank level alarms

C S/A NFPA 25

8 Water tank level alarms (cold weather only)

C M NFPA 25

9 Main drain tests on system risers

C A NFPA 25

10 Fire department connections

A Q NFPA 25

11 Fire pumps (flow test)

A A NFPA 25

12

Standpipe test C 5 yr NFPA 25

13 Kitchen extinguishing systems

A S/A NFPA 96

14 Carbon dioxide/ gaseous extinguishing systems

A A NFPA 2001

15 Portable fire extinguishers (visual check)

C M

NFPA 10

16

Portable fire extinguishers (preventive maintenance)

C A NFPA 10

17 Occupant hoses

C 3 yr–hydro 5 yr–new

NFPA 25, 1962

18 Smoke/ fire dampers

C 6 years NFPA 80, 105

19 HVAC smoke detectors w/ shutdown

A A NFPA 90A

20 Horizontal/ vertical fire doors

C A NFPA 80

Fire System Tests


Points to Remember

Document receipt time of fire alarm signal to local fire department or receiving station

Document static and residual pressure readings for main drain tests and time back to static pressure (best practice)

Visually inspect fire department connections quarterly

The 5-year standpipe test was added to the requirements in 2009

Indicate the day and month of portable fire extinguisher checks



Test Interval

NFPA Reference

EC. 02.03.05



C Q NFPA 72


C S/A NFPA 72


C A NFPA 72


C

A NFPA 72


C A NFPA 72


A Q NFPA 72


C W NFPA 25


C S/A NFPA 25


C M NFPA 25


C A NFPA 25


A Q NFPA 25


A A NFPA 25

12



A S/A NFPA 96


A A NFPA 2001


C M

NFPA 10

16


C A NFPA 10

17 Occupant hoses


NFPA 25, 1962




A A NFPA 90A


C A NFPA 80

Fire System Tests


If the occupant hoses have been removed, keep a copy of the approval letter from the AHJ

Place inaccessible smoke and fire dampers on the PFI for a 6-year, renewable period (for tracking purposes only)

Document that duct detectors trip the air-handling units

Only applies to vertical and horizontal smoke and fire doors, not security doors or curtains



Test Interval

NFPA Reference

EC. 02.03.05



C Q NFPA 72


C S/A NFPA 72


C A NFPA 72


C

A NFPA 72


C A NFPA 72


A Q NFPA 72


C W NFPA 25


C S/A NFPA 25


C M NFPA 25


C A NFPA 25


A Q NFPA 25


A A NFPA 25

12



A S/A NFPA 96


A A NFPA 2001


C M

NFPA 10

16


C A NFPA 10

17 Occupant hoses


NFPA 25, 1962




A A NFPA 90A


C A NFPA 80

Points to Remember

Don’t forget to implement and document “Interim Fire System Measures” (IFSM), when required

Fire System Test Monitoring


Regulatory Compliance Dashboard for Fire System Tests

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments Supervisory Devices

1/15 X X X

Tamper Switches

1/15 X X X

Water Flow Devices

1/15 X X X

Duct Detectors

1/22

Door Releasing Devices

X

Smoke Detectors

X

Pull Boxes

1/18 X

Audible Alarms

X

Visual Alarms

X

Signal Time to FD

1/6 X X X

Fire Pump Churn Test

4, 11 25

W W W W W W W W W W W

Fire Pump Flow Test

X

Water Tank Level Alarms

N/A X X X X X X X

Main Drain Riser Test

X

Fire Dept. Connections

1/12 X X X

Standpipe Test

X 5 yr

Kitchen Systems

X X

Best Practice for Monitoring Compliance

Fire System Test Monitoring


Regulatory Compliance Dashboard for Fire System Tests (continued)

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments CO2/ Gaseous Systems

X

Portable Extinguishers

1/23 X X X X X X X X X X X

Portable Extinguishers

X

Occupant Hoses

X 3 yr

Smoke/ Fire Dampers

X 6 yr

HVAC Shutdown

1/25 X

Horiz/ Vertical Fire Doors

X

Key to dashboard symbols: X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required A/R – Indicates that action is required when applicable Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).



EC.02.05.07: Emergency Generators Perform and document weekly generator visual checks (NFPA 110)

Perform and document monthly generator tests between 20 and 40 days and with at least 30% of the rated load for 30 minutes

Document that all automatic transfer switches are exercised monthly

Conduct annual load bank tests if the 30% load is not achieved and manifold temperatures are not sufficient (possible change from the 2 hour to a 1.5 hour test in 2011 – not yet approved)

Combining the annual and trienniel tests can be performed by starting the load at 30% of nameplate for the first 30 minutes of the test

Document the static or dynamic 4-hour trienniel test for all generators

Test fuel oil quality annually, unless fuel is consumed from the entire tank (NFPA 110)

Utilize “Interim Emergency Power Measures” (IEPM) when necessary

Note: Refer to NFPA 99 and 110 for more information



EC.02.05.07: Emergency Battery Lights Required in all anesthetizing locations (NFPA 70: 517.63 ) Task Light!

“administration of nonflammable inhalation anesthetic agents

in the course of examination or treatment”

Note: Grandfathering usually permitted in existing OR’s

Required in “Level 1 or Level 2 EPS equipment locations” (NFPA 110: 7.3.1) Task Light!

Required in business occupancies for egress lighting where emergency power is not required or not available (NFPA 101: 7.9.1.1) Egress Light!

Monthly push-to-test required for all battery installations

Differentiate between “task lighting” and “egress” lighting

Annual battery replacement in lieu of 90-minute discharge test

Note: 10% of lights must be tested for 90 minutes annually, even if the batteries are changed.



EC.02.05.07: Stored Emergency Power Supply Systems (SEPSS)

Standard applies to Level 1 systems (NFPA 111: 4.5.1)

Level 1: “failure of the equipment to perform could result in

loss of human life or serious injuries”

Testing requires:

1. Quarterly functional test (5 minutes or class specification)

2. Annual full-load test for 60% of SEPSS class duration

Note 1: NFPA 111 requires a monthly inspection, quarterly functional test and annual full load test for full class duration for Level 1 systems

Note 2: The Joint Commission references exit lighting, life support ventilation, fire detection and alarm systems, and public communications systems as Level 1 systems, but most are not SEPPS systems



EC.02.05.09: Medical Gas and Vacuum Systems

Medical gas and vacuum system preventive maintenance

program is required (facility must define PM) and must include:

- Bulk medical gas and vacuum system components and source valve

- Master signal panels and area alarms

- Automatic pressure switches and shutoff valves

- Flexible connectors and outlets

Testing per NFPA 99 is required for new installation,

modification or repair (cross-connections, purity, pressure)

Main supply valves and area shut-off valves must be

accessible and clearly labeled

Utilize “Interim Medical Gas Measures” (IMGM) when necessary

Note: Significant changes to NFPA 99 are likely to occur when the next vote occurs at the NFPA Annual Meeting



EC.02.05.09: Medical Gas and Vacuum Systems

Certification of installers and verifiers per ASSE 6000 series is

required

Medical air quality must meet NFPA 99 requirements below:

Parameter Limit Value

Pressure dew point 39 degrees F

Carbon monoxide 10 ppm

Carbon dioxide 500 ppm

Gaseous hydrocarbons 25 ppm (as methane)

Halogenated hydrocarbons 2 ppm



Medical Gas and Vacuum System PM Recommendations

Component Description

Recommended Test Frequency

Gas cylinder manifold pressure

Daily

Gas cylinder manifold changeover signal

Daily

Liquid cylinder manifold pressure

Daily

Liquid cylinder manifold changeover signal

Daily

Liquid cylinder reserve/ in-use signal

Annually

Bulk liquid system contents gauge

Daily

Bulk system pressure gauges

“Regularly” (weekly)

Bulk system master signal

“Periodically” (monthly)

Main line vacuum system gauge

Daily

Medical air intake location

Quarterly

Medical air pressure gauge

Annually

Medical air high level water sensor

Annually

Medical air receiver drain

Daily

Medical compressed air alarms

Annually

Medical air compressors/ vacuum pumps

Per manufacturer specifications

Dew point sensor/ CO monitor

Annually

Warning system components

Annually

Audible/ visual alarms

Monthly

Shut-off valve leak test

“Periodically” (annually)

Outlet leakage and flow

“Periodically” (annually)

Medical air purity

As determined by facility

Note: The recommendations provided in the chart to the right are from NFPA 99, the 2005 edition, Appendix C, section 5.2. Tests that are required due to new system installations, renovations or repair are listed in chapter 5 of NFPA 99



Interim Utility System Measures (IFSM, IEPM, IMGM) Interim Utility System Measures

Project Number: _________________ Date: ____________________ Affected System: Fire System: _____ Emergency Power _____ Medical Gas: _____ Description of Project: ______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Interim Measures Required: _____ Affected staff notified Comments: ______________________________________ _____ Additional Equipment Required Specify: _________________________________ _____ Back-up Procedures in Place Specify: ___________________________________ _____ Emergency Procedures Reviewed Comments: ____________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ Additional Comments: ______________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Date Project Completed: ___________________ Reviewed By: ____________________

Best Practice!

Strongly recommended to document that interim measures have been implemented to compensate for utility systems that are taken out of service

The LSS Facility Tour

Typical Tour Sequence1. Start on the roof, penthouse, mechanical equipment rooms

2. Take the “most traveled stairwell” from the top to the bottom

3. Take the elevator back up to the top patient floor

4. Check smoke/ fire doors and compartmentation features

5. Inspect chutes, storage areas, utility chases, hazardous areas

6. Continue down to the lower and basement levels to specific areas, such as the kitchen, loading dock, fire pump, emergency generators, fire annunciator panel, compressed gas and infectious waste storage

7. Complete checklist, or until problems are found!



Checklist for the Facility Building Tour

Smoke and fire doors

Check: Closure, label rating, gaps, undercuts, warpage, kick plate

Smoke and fire compartments

Check: Penetrations, proper sealant

Roof and penthouse

Check: Contractor supplies, smoking, exhaust fans labeled

Exit stairwells

Check: Door rating, closure, signage, exit discharge

Linen/ trash chutes and receiving rooms

Check: Door rating, closure, fusible link, chute blockage



Checklist for the Hospital Building Tour (cont’d)

Hazardous areas

Check: Storage of flammables, room rating, door closer

Fire pump

Check: Controls turned “on”, valves open, tampers OK

Fire annunciator panel

Check: Bypass, trouble, ground fault or supervisory

Soiled linen rooms

Check: Proper storage, dirty separated from “clean”




Medical waste storage

Check: Locked area, secure, sharps not accessible

Loading dock

Check: Smoking, improper storage, powered equipment

Kitchen area

Check: Cleanliness, storage, CO2 tanks, refrigerator temps, K-type portable extinguishers within 30’ of fat fryer

PFI verification

Check: Previous PFI’s have been resolved as listed




ILSM verification

Check: Construction areas for ILSM implementation

Mechanical equipment rooms

Check: Storage, unlabeled containers, cigarettes, labeling

Emergency generators

Check: In “auto” mode, batteries/ charger, fuel leaks

Medical gas systems

Check: Manifolds, medical air and vacuum pumps




Compressed gas storage rooms

Check: Full and Empty separation, chained or on racks

Egress corridors

Check: Equipment “not in use”, containers > 32 gallons

Eyewashes, showers and portable fire extinguishers

Check: Test dates on log or tag

Chapel

Check: Candles, open flames

Other?


Multiple “Operational” Deficiencies are Likely to

be Found During the Facility Tour




Operating Features

A clear space >18 inches below sprinkler heads to the top of storage must be maintained

Exception: Perimeter wall shelving, unless below the sprinkler (refer to NFPA 13)

Portable space heating devices are only permitted in non-sleeping staff and employee areas, with heating elements that do not exceed 212 degrees F (LSC, 2009 edition, 19.7.8)

Combustible decorations are prohibited, unless flame retardant (19.7.5.4)

Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity (19.7.5.5)

Exception: Attended or in hazardous area

Operational Deficiencies


Operating Features

Holiday decoration policy and implementation

Candles used in the chapel

Furnishings, decorations or other objects may not obstruct access, egress or block the visibility of exits (7.1.10.2.1)

Exit doors must be free of mirrors, draperies or hangings that may conceal, obscure or confuse the direction of exit (7.5.2.2), and;

Hallway Clutter!

Operational Deficiencies

The Life Safety Specialist Surveyor

Questions?


The Life Safety Specialist Surveyor Preparing for the Life Safety Specialist Documentation Review...

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