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© SMS, Inc., 2013 1
CMS/Accreditation Surveys
The Physical Environment
Critical Aspects for 2013
Presenter
Robert H. Bartels, CHFM CHSP CHEP SASHE President – Safety Management Services, Inc.
A program presented by:
SAFETY MANAGEMENT SERVICES, INC.
Arlington Heights, IL
(877) 577-6550 ** [email protected]
© SMS, Inc., 2013 2
Managing Accreditation in
The Physical Environment
Accreditation Options
What is CMS?
- Centers For Medicare/Medicaid Services
http://www.cms.hhs.gov/
© SMS, Inc., 2013 3
Managing Accreditation in
The Physical Environment
Deemed Status
What is Deemed Status?
How does one receive deemed status?
- Meet CMS Conditions of Participation (COP)
- Be Surveyed & Approved by an Authorized
Accrediting Body
© SMS, Inc., 2013 4
Managing Accreditation in
The Physical Environment
Accreditation Options
Why Seek Accreditation?
- To Obtain Deemed Status
- Residency Program Requirements
- Recruitment
- Public Image
© SMS, Inc., 2013 5
Managing Accreditation in
The Physical Environment
Accreditation Options
What Is the Benefit of Accreditation?
- Leads to “Deemed Status”
- Allows Collection of Medicare / Medicaid Funds
© SMS, Inc., 2013 6
Managing Accreditation in
The Physical Environment
Accreditation Options
Who Can Grant Deemed Status?
- Centers For Medicare/Medicaid (CMS)
- The Joint Commission® (TJC)
- American Osteopathic Association (AOA)
- Det Norske Veritas (DNV)
© SMS, Inc., 2013 7
Managing Accreditation in
The Physical Environment
Accreditation Options
What is TJC?
- The Joint Commission®
http://www.jointcommission.org/
© SMS, Inc., 2013 8
Managing Accreditation in
The Physical Environment
Accreditation Options
What Is AOA?
- American Osteopathic Association
Healthcare Facilities Accreditation Program (HFAP)
http://www.osteopathic.org/
© SMS, Inc., 2013 9
Managing Accreditation in
The Physical Environment
Accreditation Options
What is DNV?
- Det Norske Veritas
National Integrated Accreditation for
HealthcareOrganizations – (NIAHO)
http://www.dnv.com/
© SMS, Inc., 2013 10
Managing Accreditation in
The Physical Environment
Accreditation Options
What are the Differences?
Owner/Board Requirements Inspection Cost Survey Type
CMS Federal
Government
COP Triennial Free Unannounced
TJC AHA/AMA/ACS AMH Triennial $$ Unannounced
AOA AOA Board HFAP Triennial $$ Unannounced
DNV Det Norske
Veritas
NIAHO
ISO 9001
Bi-Annual $$ Unannounced
© SMS, Inc., 2013 11
Managing Accreditation in
The Physical Environment
Accreditation Options
What about DNV & ISO 9001? http://www.iso.org/
© SMS, Inc., 2013 12
Managing Accreditation in
The Physical Environment
ISO Key Elements
Quality Management System
Documentation
Records
Internal Auditing
Monitoring & Measurement
© SMS, Inc., 2013 13
Survey Preparation
Opening Day Documents
Management Plans
Annual Evaluations
SOC/PFI – eSOC/ePFI
Safety/Security Job Descriptions
© SMS, Inc., 2013 14
Survey Preparation
Environment of Care Session – Documents to be Available
Policies & Procedures
Sample Documentation
Aggregated Documentation
Matrices, Charts & Graphs
Standard Requirement Frequency Checked
Fire Safety Equipment
EC.02.03.05 EP1 Supervisory Signaling Devices Quarterly
EC.02.03.05 EP2 Tamper Switches & Water Flow Devices Quarterly
EC.02.03.05 EP3Duct Detectors
Every 12 months
EC.02.03.05 EP3 Smoke Detectors Every 12 months
EC.02.03.05 EP3 Heat Detectors Every 12 months
EC.02.03.05 EP3 Manual Fire Alarm Boxes Every 12 months
EC.02.03.05 EP3 Electromechanical Release Devices Every 12 months
EC.02.03.05 EP4 Audible Devices-Bells, Chimes, Speakers Every 12 months
EC.02.03.05 EP4 Visual Devices; Strobes Every 12 months
EC.02.03.05 EP5 Off-site Fire Responders Verification Every quarter
EC.02.03.05 EP6 Fire Pump Churn Test Every week
EC.02.03.05 EP7 Water Tank Level Alarms Every 6 months
EC.02.03.05 EP8 Water Tank Freeze-Up Alarms Every month during cold weather
EC.02.03.05 EP9 Main Drain Test Every 12 months
EC.02.03.05 EP10 Fire Department Connections Every quarter
EC.02.03.05 EP11 Fire Pump Flow Test Every 12 months
EC.02.03.05 EP12 Water-Flow Test Standpipe Every 5 years
EC.02.03.05 EP13 Automatic Fire Extinguishing Systems Inspected - Kitchen (no disch req) Every 6 months
EC.02.03.05 EP14 Other Gaseous Extinguishing Systems - Inspected (no disch req) Every 12 months
EC.02.03.05 EP15 Fire Extinguishers - Inspection Monthly
EC.02.03.05 EP16 Fire Extinguishers - Maintenance Every 12 months
EC.02.03.05 EP17 Hose Test - Hydrostatic 5 years after install, every 3 years after that 5 yrs. / 3 yrs.
EC.02.03.05 EP18 Dampers-New Installation1 year after
installation
EC.02.03.05 EP18 Dampers- Operational Test Every 6 years
EC.02.03.05 EP19 Fan Shut Down devices - Operational Test Every 12 months
EC.02.03.05 EP20 Rolling Dire Doors and Shutters - Operational test Every 12 months
Emergency Power Systems
EC.02.05.07 EP1 Battery-powered lights required for egress for 30 seconds 30 day intervals
EC.02.05.07 EP2Battery-powered lights required for egress for 1 1/2 hours or
replacement and random test of 10% of batteries for 1 1/2 hoursEvery 12 months
EC.02.05.07 EP3 Stored Emergency Power Supply (SEPSS) - 5 minutes Every quarter
EC.02.05.07 EP3 SEPSS - full load for 60% of its class or rating for recharge Annually
EC.02.05.07 EP4
Generator tested - intervals not < 20 or > 40 days apart for 30
continuous minutes with dynamic load at least 30% nameplate rating or
manufacturers recommended prime movers' exhaust gas temperature
12 times a year
EC.02.05.07 EP5
If above not met, supplemental loads of 25% nameplate for 30 min,
followed by 50% nameplate rating for 30 min, followed by 75%
nameplate rating for 60 min for a total of 2 continuous hours
Every 12 months
EC.02.05.07 EP6 ATS - All Transfer Switches tested not < 20 or > 40 days apart 12 times a year
EC.02.05.07 EP7&8Generator tested for minimum of 4 hours - 30% nameplate rating or
manufacturers recommended prime movers' exhaust gas temperatureEvery 36 months
EC.02.05.07 EP9 If required test fails, interim measures are made until repairs are done
EC.02.05.07 EP10 Equipment if retested after repairs or corrections are finished
Medical Gas and Vacuum Systems
EC.02.05.09 EP1 Inspects, tests and maintains critical components of piped medical gas defined by hospital
EC.02.05.09 EP2 Maintains supply valves for purity, correct gas, proper pressure
EC.02.05.09 EP3 Main as supply zones and valves are accessible and clearly labeled
Electronic Statement of Conditions
LS.01.01.01 EP1Assign individual to assess compliance with LSC,complete e-SOC,
manage deficN/A
LS.01.01.01 EP2 Maintains a current e-SOC quarterly?
LS.01.01.01 EP3When resolving deficiency through e-SOC meets time frames identified
in accepted PFI
LS.01.01.01 EP4Maintains documentation of any inspections and approvals made by state
and local fire control agencies
Interim Life Safety Measures (ILSM)
LS.01.01.01 EP3Written ILSM policy including criteria for evaluating where and what
extent the hospital follows special measuresN/A
LS.01.01.01 EP4-12Implements ILSMs as defined by the policy N/A
Life Safety Code Documentation Checklist
17
Standard Requirement Frequency Checked
Fire Safety Equipment
EC.02.03.05 EP1 Supervisory Signaling Devices Quarterly
EC.02.03.05 EP2 Tamper Switches & Water Flow Devices Quarterly
EC.02.03.05 EP3Duct Detectors
Every 12 months
EC.02.03.05 EP3 Smoke Detectors Every 12 months
EC.02.03.05 EP3 Heat Detectors Every 12 months
EC.02.03.05 EP3 Manual Fire Alarm Boxes Every 12 months
EC.02.03.05 EP3 Electromechanical Release Devices Every 12 months
EC.02.03.05 EP4 Audible Devices-Bells, Chimes, Speakers Every 12 months
EC.02.03.05 EP4 Visual Devices; Strobes Every 12 months
EC.02.03.05 EP5 Off-site Fire Responders Verification Every quarter
EC.02.03.05 EP6 Fire Pump Churn Test Every week
EC.02.03.05 EP7 Water Tank Level Alarms Every 6 months
EC.02.03.05 EP8 Water Tank Freeze-Up Alarms Every month during cold weather
EC.02.03.05 EP9 Main Drain Test Every 12 months
EC.02.03.05 EP10 Fire Department Connections Every quarter
EC.02.03.05 EP11 Fire Pump Flow Test Every 12 months
EC.02.03.05 EP12 Water-Flow Test Standpipe Every 5 years
EC.02.03.05 EP13 Automatic Fire Extinguishing Systems Inspected - Kitchen (no disch req) Every 6 months
EC.02.03.05 EP14 Other Gaseous Extinguishing Systems - Inspected (no disch req) Every 12 months
EC.02.03.05 EP15 Fire Extinguishers - Inspection Monthly
EC.02.03.05 EP16 Fire Extinguishers - Maintenance Every 12 months
EC.02.03.05 EP17 Hose Test - Hydrostatic 5 years after install, every 3 years after that 5 yrs. / 3 yrs.
EC.02.03.05 EP18 Dampers-New Installation1 year after
installationEC.02.03.05 EP18 Dampers- Operational Test Every 6 years
EC.02.03.05 EP19 Fan Shut Down devices - Operational Test Every 12 months
EC.02.03.05 EP20 Rolling Dire Doors and Shutters - Operational test Every 12 months
Life Safety Code Documentation Checklist
© SMS, Inc., 2013 18
Standard Requirement Frequency Checked
Emergency Power Systems
EC.02.05.07 EP1 Battery-powered lights required for egress for 30 seconds 30 day intervals
EC.02.05.07 EP2Battery-powered lights required for egress for 1 1/2 hours or
replacement and random test of 10% of batteries for 1 1/2 hoursEvery 12 months
EC.02.05.07 EP3 Stored Emergency Power Supply (SEPSS) - 5 minutes Every quarter
EC.02.05.07 EP3 SEPSS - full load for 60% of its class or rating for recharge Annually
EC.02.05.07 EP4
Generator tested - intervals not < 20 or > 40 days apart for 30
continuous minutes with dynamic load at least 30% nameplate rating or
manufacturers recommended prime movers' exhaust gas temperature
12 times a year
EC.02.05.07 EP5
If above not met, supplemental loads of 25% nameplate for 30 min,
followed by 50% nameplate rating for 30 min, followed by 75%
nameplate rating for 60 min for a total of 2 continuous hours
Every 12 months
EC.02.05.07 EP6 ATS - All Transfer Switches tested not < 20 or > 40 days apart 12 times a year
EC.02.05.07 EP7&8Generator tested for minimum of 4 hours - 30% nameplate rating or
manufacturers recommended prime movers' exhaust gas temperatureEvery 36 months
EC.02.05.07 EP9 If required test fails, interim measures are made until repairs are done
EC.02.05.07 EP10 Equipment if retested after repairs or corrections are finished
Life Safety Code Documentation Checklist
© SMS, Inc., 2013 19
Standard Requirement Frequency Checked
Medical Gas and Vacuum Systems
EC.02.05.09 EP1 Inspects, tests and maintains critical components of piped medical gas defined by hospital
EC.02.05.09 EP2 Maintains supply valves for purity, correct gas, proper pressure
EC.02.05.09 EP3 Main as supply zones and valves are accessible and clearly labeled
Electronic Statement of Conditions
LS.01.01.01 EP1Assign individual to assess compliance with LSC,complete e-SOC,
manage deficN/A
LS.01.01.01 EP2 Maintains a current e-SOC quarterly?
LS.01.01.01 EP3When resolving deficiency through e-SOC meets time frames identified
in accepted PFI
LS.01.01.01 EP4Maintains documentation of any inspections and approvals made by state
and local fire control agencies
Interim Life Safety Measures (ILSM)
LS.01.01.01 EP3Written ILSM policy including criteria for evaluating where and what
extent the hospital follows special measuresN/A
LS.01.01.01 EP4-12Implements ILSMs as defined by the policy N/A
Life Safety Code Documentation Checklist
© SMS, Inc., 2013 20
Survey Preparation
Life Safety Document Review-1
Surveyor will ask you to provide:
6’ stepladder
Strong/bright flashlight
Keys to open all doors
Tape Measure
Any special tools needed to open access panels, air handler doors, inspections doors, etc.
© SMS, Inc., 2013 21
Survey Preparation
Life Safety Document Review-2
After the building tour, have documents gathered together in order to expedite the review. These documents should be collected in a separate room from the general meeting room designated for The Joint Commission survey team.
Please have individuals available to answer any questions that might arise pertaining to these documents.
© SMS, Inc., 2013 22
Survey Preparation
Life Safety Document Review-3
The original SOC from the last survey, with the list of PFI items that were approved during the last TJC survey
The current SOC and the current list of PFI items
Drawings of the hospital showing all of the rated walls, smoke compartments, suites-of-rooms & occupancy separations (carry them with you during the building tour)
© SMS, Inc., 2013 23
Survey Preparation Life Safety Document Review-4
Any equivalencies or Fire Safety Evaluation System
(FSES) pre-approved by Accrediting Body
Building Maintenance Program documentation (if used)
Fire Alarm Test Reports, including: • Supervisory Signals
• Tamper Switches & Water Flow devices
• Duct, heat, smoke detectors; pull stations, releasing devices, interface devices
• Emergency services notification transmission equipment
• Smoke Detection Shut-down devices for HVAC
© SMS, Inc., 2013 24
Survey Preparation Life Safety Document Review-5
Fire Pump Test Reports (Weekly & Annual)
Fire Protection Systems Test & Inspection records, including:
• Main Drain tests
• Fire Department Connections
• Kitchen fire suppression systems
• CO2 and/or Clean Agent suppression systems
• Portable Fire Extinguishers
• Standpipe Occupant Use Fire Hoses
• Water Storage Tank high & low level alarms (if used)
• Water Storage Tank low water temp alarms (if used)
© SMS, Inc., 2013 25
Survey Preparation
Life Safety Document Review-6
Interim Life Safety Measures (ILSM) Policy & Implementation documents
Fire & Smoke Damper Testing (4-year test)
Horizontal & Vertical sliding/rolling doors
© SMS, Inc., 2013 26
Survey Preparation Life Safety Document Review-7
Emergency Power System, including: • Generator Testing
• Automatic Transfer Switch (ATS) testing
• Battery Powered Lights
• Stored Emergency Power Supply Systems (SEPSS)
Medical Gases & Vacuum Systems, including: • Maintenance Program & testing documentation
• Documentation for testing of cross-contamination during installation
• Purity & Pressure documentation
Contact Information
Safety Management Services, Inc
1502 North Arlington Heights Road
Arlington Heights, IL 60004
(847) 577-6550
www.safemgt.com
© SMS, Inc., 2013 28