life safety do-and-don’ts - university of wisconsin life safety do-and-don’ts may 12, 2016...
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Life Safety Do-and-Don’ts
May 12, 2016
Hospital ConferenceWisconsin Dells, WI
David Soens, PE, RALSC Fire Authority
Add C
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Overview
• Fire basics
• Federal enforcement
• State corrections
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CMS
State Agency Provider
Roles
CMS
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• Agreement to comply• Facility governing body
• Reimbursement• Medicare T18 - Medicaid T19
• Agreement to enforce• Wisconsin Department of
Health Services (DHS)
Roles
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Survey
Health Surveyors
hospitals
home health
hospice
ASC
ESRD
complaints
LSC Surveyors
hospitals
hospice
ASC
ESRD
SNF
FDD
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LSC Consistency
Health Staff
100% survey
LSC Staff
40% survey
30% plans
30% onsite
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Wisconsin Facilities
• Healthcare • 158 Hospitals
• 395 Nursing Homes
• 83 Hospice
• Ambulatory Health Care• 77 Ambulatory Surgical Centers
• 117 Dialysis
• Assisted Living• 3580 CBRF / RCAC / AFH
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Survey Tasks
Health Staff
patient interviews
patient records
staff interviews
pharmaceutical
dietary
LSC Staff
plant tours
patient spaces
staff interviews
testing records
equipment
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Survey Types
Health Staff
certification
recertification
validation
complaint
LSC Staff
certification
recertification
validation
complaint
revisit
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Survey Prep
Accurate life safety plan
Organized testing records
Interim life safety measures
Scribe per Surveyor
Prior survey deficiencies
State level construction status
Historical equivalencies
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Hospital Conditions
42 CFR 482 Hospitals
16 required
7 optional
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Conditions
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Conditions
Elements
Standards
Conditions
Hierarchy
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Conditions
Condition of Participation (COP)
Federal requirements which must be met if providers desire to participate
in the Medicare or Medicaid programs
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Interpretive Guidelines
Written clarification
Assist determinations
Authoritative
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Survey Findings
Health Staff
conditions
standards
elements
LSC Staff
conditions
standards
elements
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Focus
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11
Def
icie
ncie
s
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Hospital Condition
42 CFR 482.41
Physical Environment
1 – Condition
15 - Standards
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Hospital Condition
A700 Physical Environment
The hospital must be constructed, arranged, and maintained to ensure the
safety of the patient, and to provide facilities for treatment appropriate to the
needs of the community
42 CFR 482.41
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Hospital Standard
A709 Life Safety from Fire
The hospital must meet the NFPA Life Safety Code
CMS may waive specific provisions
42 CFR 482.41(b)
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Hospital Standard
A709 Life Safety from Fire
• Hospitals, regardless of size or number of beds, must comply with the hospital / healthcare Life Safety Code requirements for all inpatient care locations
• Hospital departments and locations such as emergency departments, outpatient care locations, etc. must comply with hospital / healthcare Life Safety Code requirements
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2000 Edition of NFPA 101
Life Safety Code (LSC)
Federal, state and accreditation
Code
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LSC Surveyor Reporting Form
K-tag Summary
Internet Search
CMS-2786R
Resource
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Top 10 – FY15
# 1 sprinkler testing K-62# 2 fire drills K-50# 3 general electrical K-147# 4 hazardous areas K-29# 5 sprinkler installation K-56# 6 fire alarm testing K-52 & 54# 7 exit access K-38# 8 corridor doors K-18# 9 fire alarm installation K-51#10 generator testing K-144
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Purpose
The purpose of the Life Safety Code is to
provide minimum requirements, for the
design, construction, operation, and
maintenance for safety from life from
______ ?
NFPA 101 s 1.3.1
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Fire Triangle
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Hazards of Fire
• Toxic smoke
• Flames and heat
• Oxygen depletion
• Building structural failure
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Estimate
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Sources of Ignition
• Radiant (heat)
• Friction
• Chemical
• Sparks
• Electrical
• Construction
• Tools
• Equipment
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Fire Transmission
conduction
convection
radiation
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Fire Extinguishment
• Remove one or more element of the fire triangle ….
– starving it of fuel
– smothering it to exclude oxygen
– cooling it to reduce temperature
• Fire-fighting revolves around these principles
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Surgical
Fuel?
Oxygen?
Heat?
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Wisconsin
Fire Events
Surgery – November 2014
Emergency Dept – January 2015
Patient room - January 2015
Patient room - April 2015
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Minimize Fire
• PREVENTION
– make sure fires don’t start
• PRECAUTIONS
– minimize the damage from fire
• PROCEDURES
– action to take in the event of fire
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Code Rules
Read code
Understand use
Code in effect remains
Nothing in the code guarantees it will work
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Complex
Shall / Should
And / Or
Exceptions
It Depends….
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Universe
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Future Change
2012 Edition of NFPA 101Proposed Rule
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Future Change
Emergency Preparedness Proposed Rule
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Total Concept
All health care facilities shall be
designed, constructed, maintained, and
operated to minimize a fire event
requiring evacuation…
… the safety of health care occupants
cannot be ensured by dependence on
evacuation of the building…
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Total Concept
Healthcare occupants protection from
fire shall be provided by
• Appropriate facilities
• Trained staff
• Effective Testing
• Proactive Maintenance
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Total Concept
1) Construction
2) Fire protection systems
3) Fire prevention, planning, and
training
NFPA 101 s 18.1.1.3
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Total Concept
Passive
Active
Operations
NFPA 101 s 18.1.1.3
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CMS
Active
Operations
Total Concept
Passive
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Code Questions
• Relationship to active systems?
– alarm, sprinkler, or essential power
• Relationship to passive systems?
– walls, floors, or doors
• Relationship to operations?
– training, testing, and maintenance
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All healthcare facilities
Total Concept
Passive
Designed
Constructed
Compartments
Active
Detection
Alarm
Extinguishment
Operations
Prevention
Planning
Training
18.1.1.3 and 19.1.1.3
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CMS Policy
Facility agrees to be certified and follow federal rules then….
CMS rules apply to a facility regardless of the patient census
More restrictive thanNFPA 101 s 3.3.188.7
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LSC Policy
Facility agrees to be certified and follow NFPA 101 ….
LSC rules apply to the patient regardless of their location
“customary access”NFPA 101 s 18.1.3.3
Patient Patterns
• Inpatients?
– admission, treatment to recovery
• Outpatients?
– admission, treatment to recovery
• Intangibles?
– emergency department
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Passive Systems
Wall Purposes
• Privacy - audible or visual?
• Infection control - sterile?
• Radiation - shielding?
• Fire resistance – fire or smoke?
• Access – occupant control?
• Suite – department or ward?
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Help
Life Safety Plan
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Box Concept
walls, floors, and decks
K11 K12 K17 K25 K29
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Correction
Numerous rated wall assemblies
Numerous mechanical penetrations
Numerous electrical penetrations
10-15 different vendor repairs
VS
1 fire stopping professional
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Active Systems
• Fire alarm system
• Sprinkler system
• Emergency lighting
• Emergency power
K46 K51 K56 K144
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Active Systems
Inspection & Testing records– Fire alarm system
– Sprinkler system
– Emergency lighting
– Emergency power
K46 K51 K56 K144
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Active Systems
Number of binders is not important
Compliant inspection records
Accuracy
Accuracy
Accuracy
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Master Plan
Annual Semi-An Quarterly Monthly Weekly
Fire alarm X X X
Sprinkler X X X
Hood X
E – lights X
E – power X X
Extinguish X X
Fire pumps X X
Elevators X
Hydrants X
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Active Systems
• Inspection and Testing– What, Who and When
• Action taken– How, Who and When
• Facility record guru- Can find or get any record
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Quote
Why are we relying on contractors to tell us what is in
our buildings?
“ Know your own buildings ”
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Operational
• There is a written plan for the protection of all patients
• Fire drills are held at unexpectedtimes under varying conditions
• All health care personnel shall be instructed
K50
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Operational Example
Fire Drill Primer
• Time - start to all clear?
• Staff - response to stations?
• Patient - relocation?
• Corridor - removal of clutter?
• Doors - compartment & sleeping?
• Participation level?
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Fire Drill Participation
Operational Example
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Correction Options
• I’m going to fix
• I can’t fix
• I don’t need to fix
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Correction Option I
• I’m going to fix
• Who, When, Steps
• Design and state agency plan review
• Interim life safety measures
• Fire watch
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Correction Option II
• I can’t fix– Waiver
• Two key criteria
• Not automatic
• Recite exposure
• Limitations
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Correction Option III
• I don’t need to fix– FSES
• NFPA standard 2001
• Benefits unsprinklered buildings
• Credits offset deficiencies
• Entire building analysis
• Recite exposure
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Waivers
• Criteria No adverse affect on patient health
and safety
Correction of the deficiency would impose an unreasonable financial hardship on the facility
Both required to be substantiated by the facility not the surveyor
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Waivers
• Process
• Deficiency
• Plan of Correction
• State Agency Recommendation
• CMS RO Adjudication
• Facility Notification
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Waiver Lessons
• Financial Hardship SOM 2480C
• Estimated cost of the new installation
• Extent and duration of the new construction disruption
• Remaining useful life of the building
• Estimated period over which cost would be recovered
• Availability of financing
• Facility budgetary summary
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Waiver LSC Factors
• Fire Load (inventory combustible quantities)
• Fire Containment – 4 levels Room, smoke compartment, floor, building
• Fire Extinguishment (extent) Sprinkler coverage, kitchen hood, portable
• Evacuation Drills, staff participation, refuge areas
• Operating Features Staffing levels on all shifts
Proactive or reactive maintenance
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Waiver Lessons
• Additional Fire Safety Measures
• Relevant attestations
• Updated records
• Long-term reliability
• Accountability
• Signatures
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Survey Close-out
Revisit
• LSC deficiencies are common
• Facility correction takes months– Fire extinguisher 1 month
– Fire door 8 months
– Sprinkler upgrade 10 months
• Facility should proactively update LSC team leader on status
• Expect LSC revisit surveys
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Best Practice - 1
Roles & Responsibilities
Initial Contact
Lean process improvement
Roles and responsibilities
State level plan review
Proactive
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Best Practice - 2
Accountability
Case Study
State level plan reviewer “John”
Fully trained state and federal
Private sector experience
Licensed professional
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Best Practice - 2
Accountability
Case Study
Hospital campus A
Hospital campus B
Hospital campus C
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Best Practice - 2
Accountability
Case Study
A & C share challenges
Disagreements
Conflicting code interpretations
Delays in responses
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Best Practice - 2
Accountability
Case Study
Facility B projects
Minimal to no disagreements
Code directives are understandable
Timely responses
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Best Practice - 2
Accountability
Case Study
Department contacts B
Describe your relationship with Dept.
How do you manage your projects?
Why no complaints?
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Best Practice - 2
Accountability
Case Study
Facility B
Culture of accountability
Facility is accountable to designers
Designers are accountable to facility
Contractors & subcontractors
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Best Practice - 3
Budget Contingency
Case Study
CMS authorized a validation survey
Department surveyors onsite AM
Break, lunch and return
PM begins with design professionals
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Best Practice - 3
Budget Contingency
Case Study
Design professionals – not interns
Long term relationship – not short term
Developed updated LSC plans
Diverse survey sub-teams
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Best Practice - 3
Budget Contingency
Case Study
Department manager
How did you get these resources here on such short notice?
How is it they are knowledgeable about the building prior to the survey?
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Best Practice - 3
Budget Contingency
Case Study
Budget funding each year
Not tied to a specific construction project
Facility to designer commitment
Payback
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Best Practice - 4
Primary Contact
Complex process
Numerous stakeholders
DQA establishes a primary
Facility establishes a primary
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Best Practice - 5
Schedule Transparency
Lean Process evaluation
Known construction schedule
Advance notice to Department
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Best Practice - 6
Construction Process Literacy
Hospital executives
Hire a team of professionals
Evaluate operations
Goal is an effective facility
Not another hotel
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Best Practice - 7
Performance
Building performance
Operational performance
Assist or deter
People are your primary asset
Not the bricks and mortar
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Thank You
Wisconsin Department of Health Services
www.dhs.wisconsin.gov
David Soens
(608) 266-8016