Presentation Prepared for Healthcare Professionals

1. Presentation Prepared for Healthcare Professionals “Hot Spots in HealthCare”

2. Hot Spots In HealthCare It’s Probably Somewhere Around The Facility Management Office.

3. Facilities Manager’s Moto FMer’sMoto: I Never Get To Drive The Train Or Even Ring The Bell; But Let It Go And Jump The Tracks And See Who Catches Hell.

4. Do you really think a FMer did this?

5. Your new your career ladder?

6. Exits and Corridors • Corridor Clutter Ranks At The Top Of The List! • Locked Egresses • Dead Bolts (On Exit Access Doors) *All Occupancies • More Than One Locked Or Delayed Door In Exit Path • Corridor Door Problems 6

7. Never Acceptable Corridor Storage 7

8. Your Hospital May be Great! 8

9. What's Wrong Here? ▼ ► O ◄ ► ◄ ►

10. Trash Containers >32 Gallons • Toilets are not required to be separated from the corridors but if you have a 40 gallon trash container, the capacity of the trash container would require separation. • Nurses Stations are not required to be separated from the corridor but a lot of them have recycle bins > 32 gallons.

11. Trash Containers >32 Gallons 11

12. What’s Wrong Here?

13. To Easy!

14. Ditto!

15. What’s Wrong Here?

16. What’s Wrong Here?

17. Exits and Corridors 17

18. Something Wrong?

19. What’s Wrong Here?

20. Sprinklers are Suppose to Help!

21. What’s Wrong Here?

22. Fire Safety Equipment Maintenance • Fire damper inspection- “corrective action.” • “Not Accessible” Contractors use this term when they cannot get into a room because it is in use. You (the FMer), think it means that there was no way to get to the damper. You put it on a PFI and then a surveyor checks the list. • Your contractor needs to identify that situation in different terms. • If your contractor identifies a damper situation as “not accessible” you should verify for yourself that the damper is “not accessible.” Surveyors are starting to investigate occurrences of “not accessible” and are finding that the dampers are indeed “accessible.” 22

23. Fire Safety Equipment • If you are TJC accredited and you have failed devices you need to perform a ILSM Assessment at the least and possibly implement a fire watch. • Follow your P&P. 23

24. What’s Wrong Here?

25. What’s Wrong Here?

26. Stairwells • The are rumblings that CMS is circling back to handrails in stairwells. • The rails in the previous slide are not continuous thru turns and they do not return to the wall. • Handrails mounted between 34” and 38” from leading edge of tread (to 42” if part of a guard).

27. Stairwells • Guards on Stairwells which will not allow the passing of a 4 “sphere” up to a height of 34”.

28. Stairwells 28

29. Life Safety Drawings • I just worked with a facility that got 17 K-Tags for Life Safety Drawings. K-048 • Drawings did not indicate Building Construction Types • Drawings did not indicate Occupancy Classifications • Drawings did not indicate Portions of building covered by sprinklers • Drawings did not indicate Fire Barriers and their required resistance • Drawings did not indicate shaft enclosure ratings • Drawings did not indicate ratings of communicating openings between buildings/occupancies • Drawings did not indicate Smoke Compartment size in sq ft 29

30. Life Safety Drawings • Drawings did not indicate • Drawings did not indicate exit access corridors • Drawings did not indicate the limits and areas (in sq ft) of all suites • Drawings did not indicate Hazardous Areas and their fire resistive ratings • Drawings did not indicate locations of Special Locking Devices • Drawings did not indicate any special fire protection elements (fire shutters or window protection) • Drawings did not indicate EXITS 30

31. Life Safety Drawings • Drawings did not indicate Smoke Compartments correctly (to small to accommodate patients relocated from adjacent smoke compartments) • Drawings did not indicate current conditions (as built) • Drawings did not indicate Suites, Suite Boundaries, Suite Area (sq ft), two remote exits from Suites (where required), type of Suite, travel distance within Suites, and egress corridors serving Suites 31

32. Life Safety Drawing Detail 32

33. Life Safety Drawing Detail 33

34. Life Safety Drawing Detail 34

35. Life Safety Drawing Detail 35

36. Life Safety Drawings/Plans Your life Safety Plans/Drawings are the basis for your SOC, Life Safety Program, BMP (Optional), and last but not least your TJC Life Safety Survey. 36

37. SOC Requirements 37

38. When Does the Code Apply? • Depending on your particular circumstances you may be dealing with 3-4 AHJs and each one may have a different opinion/interpretation. • If the AHJ’s cannot agree on the code how can you be expected to understand/translate the basis for one of your 36 “most important” jobs? • If you are accredited by TJC they are your AHJ (along with the Local, State, and CMS).

39. HITF Healthcare Interpretation Task Force (HITF)

40. HITF

41. HITF • STREAMLINING INTERPRETATIONS FOR HEALTHCARE FIRE PROTECTION ISSUES • As a field surveyor, policy administrator, fire marshal or other authority having jurisdiction, how many times have you received different interpretations from different parties, concerning the same problem? Because of the number and variety of groups that evaluate all aspects of the service and performance of a healthcare facility, slight differences in interpretations of applicable codes and standards can arise. The Healthcare Interpretations Task Force (HITF), is now in place to help reconcile organizational differences of opinion. • Formed in July 1998, this Task Force is the by-product of a unique coalition of the major organizations that most impact the healthcare community in terms of fire protection related issues. This coalition, now known as The Authority Having Jurisdiction Committee, is comprised of representatives from: • Agency for Health Care Administration • American Health Care Association (AHCA) • American Society for Healthcare Engineering (ASHE) • Centers for Medicare/Medicaid Services (CMS) • Department of Defense (DoD) • Indian Health Services (IHS) • International Fire Marshals Association (IFMA) • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • National Fire Protection Association (NFPA) • Department of Veterans Affairs (VA)

42. HITF • When this larger coalition was founded in 1996, its purpose was to bring together the key players who must enforce, implement, or evaluate the various fire protection measures found in each healthcare occupancy in the U.S. This group has worked on several initiatives including working to make recognition of the 1997 Edition of the Life Safety Code a reality for CMS. Another area identified where across-the-board communication was deemed important involved interpretation and understanding of the various NFPA codes and standards used in the healthcare environment and how they relate to position and policy views of groups like CMS and JCAHO. • The Healthcare Interpretations Task Force established a mission, purpose, and process by which the Task Force would operate. In essence, the Task Force brings together the seven key organizations (CMS, JCAHO, IFMA, VA, NFPA, ASHE, AHCA, DoD, and IHS), to the table to evaluate and debate, and engage the resources of the talent pool to establish consistent interpretations of specific questions. While the debate and discussions are open to all seven parties, the actual voting by the committee is limited to the four authority having jurisdiction members; IFMA, CMS, JCAHO, VA, DoD, and IHS. In addition, 3 of the 4 voting members must be in agreement about a particular answer to a particular question. • The mission statement, paraphrased below, captures the essence of what this group hopes to establish during its existence: • MISSION: To provide consistent interpretations on national codes and standards referenced by CMS, JCAHO and state and territorial authorities having jurisdiction. This will be accomplished through the evaluation of field conditions, surveyor/inspector/fire marshal interpretations, and questions by consumers of these services generated through a member of the task force.

43. HITF • In this process, nothing the task force does is intended to usurp the power or authority of an NFPA Technical Committee who still has ultimate responsibility for rendering formal interpretations to their respective documents. In fact, the task force will actually recommend forwarding unresolved items to the appropriate NFPA Technical Committee for a formal interpretation, or as individual members, recommending changes to NFPA codes and standards to clarify certain issues. • At the very first meeting of the Task Force, several agenda items were provided for the group to consider and evaluate. As with any code or standard, one's perspective, background and experience may cause a slightly different opinion as to what is intended or meant by a particular requirement. A thorough, thoughtful debate, including some historical perspective, background or case history with a particular issue, results in a cohesive melding of the minds. The result is an interpretation that makes sense and that can be applied by the various enforcement agencies that look at the fire protection features in a healthcare facility. • This process will bring a great deal of consistency to the myriad issues with which a healthcare facility must deal, often times with, multiple, key authorities having jurisdiction - JCAHO, CMS, local and state fire marshals and state health departments. The Task Force, through the publications and information media of their respective organizations, will be publishing the results of their efforts to get the widest possible dissemination of their discussions. • Questions for the Task Force must come in through one of the member organizations. It is anticipated that this group will be meeting on a quarterly basis and will be looking for additional items to review and evaluate. Any questions for this group should be directed to any of these organizations (listed below). Interpretations and answers to questions will be printed in this and other publications in the future.

44. HITF Membership • Current membership includes ten organizations: • Agency for Health Care Administration • JAMES GREGORY – STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (PRINCIPAL) • CHAD BEEBE – WASHINGTON STATE DEPARTMENT OF HEALTH (ALTERNATE) • AMERICAN HEALTH CARE ASSOCIATION (AHCA) • Thomas Jaeger, P.E. – Jaeger and Associates, LLC (Principal) • Dick Strub – American Health Care Association (Alternate) • American Society for Healthcare Engineering (ASHE) • Douglas Erickson, P.E. – American Society for Healthcare Engineering (Principal) • Dave Dagenais – Wentworth Douglas Hospital (Alternate) • Centers for Medicare/Medicaid Services (CMS) • James Merrill, P.E. – Centers for Medicare/Medicaid Services (Principal) • Department of Defense (DoD) • Philip Hogue – U.S. Army Corps of Engineers (Principal) • Indian Health Services (IHS) • Lewis Faulkner– Indian Health Services (Principal) • Joseph Bermes – Indian Health Services (Alternate) • International Fire Marshals Association (IFMA) • Ken Bush – Maryland State Fire Marshal’s Office (Principal) • Kim Osborn – Michigan Department of Labor and Economic Growth (Alternate) • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • George Mills – JCAHO Staff (Principal) • John Fishbeck – JCAHO Staff (Alternate) • National Fire Protection Association (NFPA) • Robert Solomon, P.E. – Chair, NFPA Staff (Principal) • Gregory Harrington, P.E. – NFPA Staff (Alternate) • Nancy McNabb – NFPA Staff • Department of Veterans Affairs (VA) • David Klein, P.E. – Department of Veterans Affairs (Principal) • Peter Larrimer, P.E. – Department of Veterans Affairs (Alternate)

45. HITF - Interpretations

46. HITF 09-10-1998 Interpretations Meeting The following interpretations were discussed and voted on by the members present at their 10 September 98 meeting. 98-1 NFPA 101, All editions prior to the 1988 edition. BACKGROUND: Prior to the 1988 edition of the Life Safety Code, the code only permitted doors in the required means of egress of a health care facility to be locked with time delay type locks or in mental health facilities with keys. The more recent editions of the code now refer to the clinical needs of the patient and do not limit key locking to just mental health facilities. For example, today’s nursing homes have Alzheimer’s units or wings. Alzheimer’s is not a mental health condition and was not identified prior to the mid 1980’s other than through vague terminology such as “senility” or “dementia.”

47. HITF 09-10-1998 Interpretations Meeting • AHJ’s using editions of the Life Safety Code prior to 1988 are not permitting nursing homes to lock Alzheimer’s units other than with time delay locks (special locks) because they are not mental health facilities. Time delay locks are totally inadequate for Alzheimer’s patients. Alzheimer’s patients have no idea that their pressing on the panic bar is the cause for the alarm and the locks eventually open without staff interceding. The constant alarming only causes the staff to disconnect the systems. • QUESTION: Was it the intent of the Life Safety Code prior to the 1988 Edition to permit doors in the means of egress of health care facilities to be locked where the clinical needs of the patients required specialized security, provided staff can unlock the doors at all times? • ANSWER: YES. Locking of these doors is acceptable provided: • The clinical needs of the patients require specialized security measures for their safety; and • Staff can readily unlock such doors at all times.

48. HITF 09-10-1998 Interpretations Meeting • NFPA 101, 1997 Edition. • NOTE: While this interpretation is rendered based upon the 1997 edition of the Life Safety Code, it should be noted that this interpretation is also applicable to the 1985, 1981, 1973 and 1967 editions of the code. • QUESTION 1:Is it the intent of 12-3.6.2.1 and 13-3.6.3.1 to require conformance with NFPA 80, Fire Doors and Windows for non-rated corridor doors? • ANSWER 1: NO. • QUESTION 2:Would a non-rated corridor door, provided with an average 1 inch undercut, be an acceptable arrangement? • ANSWER 2: YES.

49. HITF 09-10-1998 Interpretations Meeting • NFPA 101, 1997 Edition. • QUESTION: Can the normal clinical staff in an area affected by a fire alarm impairment or a sprinkler system impairment be used to satisfy the requirements for a fire watch? • ANSWER: YES. Clinical staff may fulfill this role provided, as determined by the authority having jurisdiction, there is an adequate staffing level to continuously patrol the affected area and that they have the means to make proper notification to other occupants in the event of a fire.

50. HITF 11-28-1998 Interpretations Meeting • 1. 98-4 NFPA 101, 1997 Edition. Section 1-7.5 • NOTE: While this interpretation is rendered based upon the 1997 edition of the Life Safety Code, it should be noted that this interpretation is also applicable to the 1994 Edition of the code. • Background Information: • This section of the Life Safety Code does not specifically address what percentage, if any, of fire drills must be announced or unannounced. This section expects fire drills to be held at both expected and unexpected times but does not specifically require more unannounced drills than announced fire drills. • Recently, JCAHO stated that at least 50% of the fire drills must be unannounced although this requirement is not part of their EC standards. (See Healthcare Fire Protection Newsletter, October 1998, Volume 4, No. 10, page 11 as quoted by Janet McIntyre, spokesperson for the JCAHO). This is their interpretation of section 1-7.5. • Question:Does Section 1-7.5 require that 50% or more of the fire drills conducted be of the unannounced type? • Answer:NO. Each authority having jurisdiction may establish a percentage of unannounced drills as appropriate for the circumstances. For example, JCAHO has recently indicated that at least half of the fire exit drills should be conducted as unannounced drills. Regardless of this, no drill should ever jeopardize the welfare of the patient receiving care.