CMS/Accreditation Surveys The Physical Environment

Transcription

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) ** info@safemgt.com SMS, Inc.,

2 Managing Accreditation in The Physical Environment Accreditation Options What is CMS? - Centers For Medicare/Medicaid Services SMS, Inc.,

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.,

4 Managing Accreditation in The Physical Environment Accreditation Options Why Seek Accreditation? - To Obtain Deemed Status - Residency Program Requirements - Recruitment - Public Image SMS, Inc.,

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.,

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.,

7 Managing Accreditation in The Physical Environment Accreditation Options What is TJC? - The Joint Commission SMS, Inc.,

8 Managing Accreditation in The Physical Environment Accreditation Options What Is AOA? - American Osteopathic Association Healthcare Facilities Accreditation Program (HFAP) SMS, Inc.,

9 Managing Accreditation in The Physical Environment Accreditation Options What is DNV? - Det Norske Veritas National Integrated Accreditation for HealthcareOrganizations (NIAHO) SMS, Inc.,

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.,

11 Managing Accreditation in The Physical Environment Accreditation Options What about DNV & ISO 9001? SMS, Inc.,

12 Managing Accreditation in The Physical Environment ISO Key Elements Quality Management System Documentation Records Internal Auditing Monitoring & Measurement SMS, Inc.,

13 Survey Preparation Opening Day Documents Management Plans Annual Evaluations SOC/PFI esoc/epfi Safety/Security Job Descriptions SMS, Inc.,

14 Survey Preparation Environment of Care Session Documents to be Available Policies & Procedures Sample Documentation Aggregated Documentation Matrices, Charts & Graphs SMS, Inc.,

15 Survey Preparation Tab Set Photo SMS, Inc.,

16 Life Safety Code Documentation Checklist Standard Requirement Frequency Checked Fire Safety Equipment EC EP1 Supervisory Signaling Devices Quarterly EC EP2 Tamper Switches & Water Flow Devices Quarterly EC EP3 Duct Detectors Every 12 months EC EP3 Smoke Detectors Every 12 months EC EP3 Heat Detectors Every 12 months EC EP3 Manual Fire Alarm Boxes Every 12 months EC EP3 Electromechanical Release Devices Every 12 months EC EP4 Audible Devices-Bells, Chimes, Speakers Every 12 months EC EP4 Visual Devices; Strobes Every 12 months EC EP5 Off-site Fire Responders Verification Every quarter EC EP6 Fire Pump Churn Test Every week EC EP7 Water Tank Level Alarms Every 6 months EC EP8 Water Tank Freeze-Up Alarms Every month during cold weather EC EP9 Main Drain Test Every 12 months EC EP10 Fire Department Connections EC EP11 Fire Pump Flow Test EC EP12 Water-Flow Test Standpipe EC EP13 Automatic Fire Extinguishing Systems Inspected - Kitchen (no disch req) EC EP14 Other Gaseous Extinguishing Systems - Inspected (no disch req) EC EP15 Fire Extinguishers - Inspection EC EP16 Fire Extinguishers - Maintenance EC EP17 Hose Test - Hydrostatic 5 years after install, every 3 years after that EC EP18 Dampers-New Installation EC EP18 Dampers- Operational Test EC EP19 Fan Shut Down devices - Operational Test EC EP20 Rolling Dire Doors and Shutters - Operational test Emergency Power Systems Every quarter Every 12 months Every 5 years Every 6 months Every 12 months Monthly Every 12 months 5 yrs. / 3 yrs. 1 year after installation Every 6 years Every 12 months Every 12 months EC EP1 Battery-powered lights required for egress for 30 seconds 30 day intervals EC EP2 Battery-powered lights required for egress for 1 1/2 hours or replacement and random test of 10% of batteries for 1 1/2 hours Every 12 months EC EP3 Stored Emergency Power Supply (SEPSS) - 5 minutes Every quarter EC EP3 SEPSS - full load for 60% of its class or rating for recharge Annually EC EP4 Generator tested - intervals not < 20 or > 40 days apart for 30 continuous minutes with dynamic load at least 30% nameplate rating or 12 times a year manufacturers recommended prime movers' exhaust gas temperature EC EP5 If above not met, supplemental loads of 25% nameplate for 30 min, followed by 50% nameplate rating for 30 min, followed by 75% Every 12 months nameplate rating for 60 min for a total of 2 continuous hours EC EP6 ATS - All Transfer Switches tested not < 20 or > 40 days apart 12 times a year Generator tested for minimum of 4 hours - 30% nameplate rating or EC EP7&8 manufacturers recommended prime movers' exhaust gas temperature EC EP9 If required test fails, interim measures are made until repairs are done EC EP10 Equipment if retested after repairs or corrections are finished Medical Gas and Vacuum Systems Every 36 months EC EP1 Inspects, tests and maintains critical components of piped medical gas defined by hospital EC EP2 EC EP3 Maintains supply valves for purity, correct gas, proper pressure Main as supply zones and valves are accessible and clearly labeled Electronic Statement of Conditions LS EP1 Assign individual to assess compliance with LSC,complete e-soc, manage defic N/A LS EP2 Maintains a current e-soc quarterly? LS EP3 When resolving deficiency through e-soc meets time frames identified in accepted PFI LS EP4 Maintains documentation of any inspections and approvals made by state and local fire control agencies Interim Life Safety Measures (ILSM) Written ILSM policy including criteria for evaluating where and what LS EP3 extent the hospital follows special measures LS EP4-12Implements ILSMs as defined by the policy N/A N/A

17 Life Safety Code Documentation Checklist Standard Requirement Frequency Checked Fire Safety Equipment EC EP1 Supervisory Signaling Devices Quarterly EC EP2 Tamper Switches & Water Flow Devices Quarterly EC EP3 Duct Detectors Every 12 months EC EP3 Smoke Detectors Every 12 months EC EP3 Heat Detectors Every 12 months EC EP3 Manual Fire Alarm Boxes Every 12 months EC EP3 Electromechanical Release Devices Every 12 months EC EP4 Audible Devices-Bells, C himes, Speakers Every 12 months EC EP4 Visual Devices; Strobes Every 12 months EC EP5 Off-site Fire Responders Verification Every quarter EC EP6 Fire Pump C hurn Test Every week EC EP7 Water Tank Level Alarms Every 6 months EC EP8 Water Tank Freeze-Up Alarms Every month during cold weather EC EP9 Main Drain Test Every 12 months EC EP10 Fire Department C onnections Every quarter EC EP11 Fire Pump Flow Test Every 12 months EC EP12 Water-Flow Test Standpipe Every 5 years EC EP13 Automatic Fire Extinguishing Systems Inspected - Kitchen (no disch req) Every 6 months EC EP14 Other Gaseous Extinguishing Systems - Inspected (no disch req) Every 12 months EC EP15 Fire Extinguishers - Inspection Monthly EC EP16 Fire Extinguishers - Maintenance Every 12 months EC EP17 Hose Test - Hydrostatic 5 years after install, every 3 years after that 5 yrs. / 3 yrs. 1 year after EC EP18 Dampers-New Installation installation EC EP18 Dampers- Operational Test Every 6 years EC EP19 Fan Shut Down devices - Operational Test Every 12 months EC EP20 Rolling Dire Doors and Shutters - Operational test Every 12 months 17

18 Life Safety Code Documentation Checklist Standard Requirement Frequency Checked Emergency Power Systems EC EP1 Battery-powered lights required for egress for 30 seconds 30 day intervals EC EP2 Battery-powered lights required for egress for 1 1/2 hours or replacement and random test of 10% of batteries for 1 1/2 hours Every 12 months EC EP3 Stored Emergency Power Supply (SEPSS) - 5 minutes Every quarter EC EP3 SEPSS - full load for 60% of its class or rating for recharge Annually EC EP4 Generator tested - intervals not < 20 or > 40 days apart for 30 continuous minutes with dynamic load at least 30% nameplate rating or 12 times a year manufacturers recommended prime movers' exhaust gas temperature EC EP5 If above not met, supplemental loads of 25% nameplate for 30 min, followed by 50% nameplate rating for 30 min, followed by 75% Every 12 months nameplate rating for 60 min for a total of 2 continuous hours EC EP6 ATS - All Transfer Switches tested not < 20 or > 40 days apart 12 times a year Generator tested for minimum of 4 hours - 30% nameplate rating or EC EP7&8 manufacturers recommended prime movers' exhaust gas temperature EC EP9 If required test fails, interim measures are made until repairs are done EC EP10 Equipment if retested after repairs or corrections are finished Every 36 months SMS, Inc.,

19 Life Safety Code Documentation Checklist Standard Requirement Frequency Checked Medical Gas and Vacuum Systems EC EP1 Inspects, tests and maintains critical components of piped medical gas defined by hospital EC EP2 EC EP3 LS EP1 Maintains supply valves for purity, correct gas, proper pressure Main as supply zones and valves are accessible and clearly labeled Electronic Statement of Conditions Assign individual to assess compliance with LSC,complete e-soc, manage defic LS EP2 Maintains a current e-soc quarterly? LS EP3 LS EP4 When resolving deficiency through e-soc meets time frames identified in accepted PFI Maintains documentation of any inspections and approvals made by state and local fire control agencies Interim Life Safety Measures (ILSM) Written ILSM policy including criteria for evaluating where and what LS EP3 extent the hospital follows special measures LS EP4-12Implements ILSMs as defined by the policy N/A N/A N/A SMS, Inc.,

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.,

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.,

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.,

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.,

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.,

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.,

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 SMS, Inc.,

27 Managing Accreditation in The Physical Environment Questions? SMS, Inc.,

28 Contact Information Safety Management Services, Inc 1502 North Arlington Heights Road Arlington Heights, IL (847) SMS, Inc.,