Presented by David Stepelevich Vice President, Healthcare Building Solutions, Inc.

Essential Facility Compliance for the New Healthcare Executive

Today's Presenter

David Stepelevich

Vice President, Healthcare Building Solutions, Inc.

As Vice President, David assists in the leadership and

management of the company’s facilities and compliance

programs. David has over 32 years of direct healthcare

experience and has led the facility, compliance, and project

management programs for some of the largest healthcare

systems in the country. Prior to HBS David was the Director of

Projects and Facilities for MedCath,Inc. and was the Director of

Facilities and Projects for Universal Health Services. He has

developed and marketed nationally recognized facility

compliance software that is currently in use at over 50

healthcare facilities around the United States.

He is a 27 year member of the American Society of Healthcare

Engineers, is a Certified Healthcare Facilities Manager, and has

presented seminars nationally on many subjects from

compliance to disaster response.

Presenters picture here

HBS is dedicated to providing healthcare

facilities and facility managers expert

consultation in the area of accreditation,

survey preparation and regulatory affairs to

achieve optimal performance on your next

inspection.

Our accreditation preparation includes an

Organizational Assessment, Customized

Survey Preparation Plan, Standards Training,

Survey Process Training, Mock Surveys, and

Environment of Care, Emergency

Management & Life Safety Code Review.

Who is required to be compliant in healthcare?

Any healthcare operator who wants to be

reimbursed for providing a healthcare services.

• Hospitals

• Nursing Homes

• Surgery Centers

• Home Health Agencies

Who inspects for facility compliance to

healthcare providers?

• The Joint Commission.

• C.A.R.F.

• Others with deemed status.

• State Department of Health.

• City, Local.

What standards are the inspections based on?

• NFPA 101Life Safety Code – Edition?

• NFPA 99 Healthcare Facilities.

• AIA Guidelines for Healthcare Facilities.

• Centers for Medicare and Medicaid.

• The Joint Commission Guidelines.

When does my facility get inspected for

compliance?

• Annual for Medicare inspection.

• Annual for local inspection.

• Every three years for The Joint

Commission.

You can be inspected at anytime for any

reason with or without cause.

• Complaint

• Construction Project

• Pop Visit

You must be prepared at all times!

How do you know if your facility is compliant?

• Self-assessment and meet compliance using

Form CMS-2786R

• Meet the Joint Commission Guidelines and

Standards

• Third Party Review, Analysis, and Assessment

Initial Assessment

Essential Facility Compliance Review

• What’s really important to you, as an executive, on what’s going on with your physical plant.

• Important non-compliance items in your environment of care plan.

• What to look for during your building tour.

• How to verify compliance and avoid accreditation disaster.

The Joint Commission

372 scoring decisions in Environment of Care, Life Safety, and Emergency Management

Sections of the Guidelines but only a few will result in non-accreditation.

The Joint Commission

Immediate Denial of Accreditation

• Threat to Health and Safety

• Fire alarm or extinguishing system.

• Emergency power system.

• Medical gas master panel.

• Serious Life Safety deficiencies.

The Joint Commission

Preliminary Denial of Accreditation

or

Conditional Accreditation

• Failure to implement interim life safety measures.

• Failure to meet PFI timelines on SOC.

Challenging Physical Environment Standards

Most challenging standard • LS.02.01.20 57% (means of egress)

• LS.02.01.10 57% ( fire compartment)

• LS.02.01.30 47% ( smoke compartment)

• ES 02.03.05 42% ( fire device testing)

• IC 02.02.01 36% (equipment infections)

• LS 02.01.35 33% ( extinguisher, systems)

60% of “Top 10” citations are PE related.

Fire Alarm • Find master fire alarm panel. Verify panel is

not in “TROUBLE”.

• Ask for annual fire alarm testing report executive summary and show proof of the corrective actions taken.

• Monitored 24 hours?

ARE EXITS BLOCKED?

• Are exit doors blocked so that, in the event of an emergency, there is no impediment to exit. This includes both the patient side and the construction side.

• If exits are required to be blocked during construction, is there marked alternative exits identified?

• G. Site condition?

Welding

Is there welding activities occurring at the project?

• Permit in place?

• Extinguisher in place?

• Alarm deactivated or gloved detector?

Construction

• Is there any construction projects going on at your facility?

• Project size doesn’t matter.

• Are there any obvious threat to patients, staff or visitors?

Air Flow and Air Disposal

A. Construction barrier walls deck to deck.

B. Return air system closed off.

C. Negative Air machine in use.

D. Daily inspection and checklist.

E. Can air from construction site leak into patient area?

Infection Control Risk Assessment (ICRA)

• Has the Infection Control Department been involved and approved the class of hazard for the project?

• Have all ICRA requirements been developed, installed and maintained?

Infection Control Risk Assessment

Form is available from ASHE at:

http://www.ashe.org/advocacy/organizations/CDC/pdfs/assessment_icra.pdf

Interim Life Safety Measures (ILSM)

LS.01.02.01

Interim Life Safety Measures

1. Fire Department notification.

2. Exit signs indicating alternative exits.

3. Written ILSM policy and compensation for deficiencies.

4. Daily inspections.

5. Temporary but equivalent Fire Alarm System

Interim Life Safety Measures

6. Additional fire extinguishers. 7. Smoke tight temporary partitions. 8. Increased surveillance. 9. Routine trash removal. 10. Additional fire alarm and extinguishing training.

11. Additional fire drills.

12. Monthly temporary alarm testing.

13. Staff training of deficiencies and measures.

14. Staff training regarding compensation of deficiencies.

Generator Testing

EC.02.05.07

Emergency Generator Testing

• Is testing current?

• 12 times a year >20days apart but< 40 days.

• 30 continuous minutes.

• Loaded generator >30% nameplate

• Documented.

Emergency Generator Transfer Switches

• Is testing current?

• 12 times a year >20 days apart but <40 days.

• Documented

Automatic Transfer Switch A.T.S.

Emergency Generator Testing

• Generator Load Bank test

• Every three years

• 4 continuous hours

• 30% nameplate load

• Documented

Medical Gas Testing EC.02.05.09

• Go to master panel and verify that there is power to panel and press alarm test button.

• Ask for Medical Gas Inspection report executive summary and follow up report.

• Verify approval stamp on report (P.E. stamp)

Medical Gas Testing

• Are time frames for inspection identified by the hospital?

• All components included in inspection?

• All supply valves and area shutoff valves identified?

• New installations?

• Panel must be located in a 24 hour accessible location

Statement of Condition

Plan for Improvement

Were promises made that are now broken?

Statement of Condition

• Depending on what promises were made.

• How long past the due date?

• How many extensions?

• How serious was the infraction that it required a plan for improvement?

• Continued non-compliance?

• Should be considered as conditions of employment.

WHY?

• Safety to patient that is incapable of self- preservation.

• Hospital reputation.

• Your reputation.