INSIGHTS

INSIGHTS

We are EXPERTS in complex regulatory and code compliance

Fire drills in a health care occupancy assess staff productivity during an emergency fire plan but what is the protocol for patients that are bedridden?

Patients that are too weak to get out of bed are not required to be moved outside or to a safe area during a fire drill. Staff can simulate the relocation of bedridden patients using empty wheelchairs and replicated patients.

This is true according to the Life Safety Code which is referred to by Centers for Medicare & Medicaid Services (CMS).

There are four (4) critical areas for Healthcare Facility Managers and their team to focus on when it comes to Infection Control.
  1. When the facility is undergoing an addition or renovation, dust and contaminants from construction need to be managed.
  2. Hospital pharmacies need to make sure no contamination of sterile compounds takes place.
  3. Conscious patient areas need to have correct pressurization and ventilation.
  4. Utility and portable water systems need to be checked for Legionella growth.
What classifies in the Life Safety Code as rehabilitation work on existing buildings?
  • Addition: Increase in building area, aggregate floor area, building height or number of building stories
  • Change of Use or Occupancy Classification: Change in the occupancy classification of a building or portion of a building
  • Modification: Arrangement of any area; addition, relocation or eradication of any door or window; addition or eradication of a load bearing element, arrangement or extension of any system; or installation of any additional equipment
  • Reconstruction: Arrangement of a space that alters an exit corridor shared by more than one occupant space; or the arrangement of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems are not consistently managed
  • Renovation: Replacement or upgrading of materials, equipment or fixtures that doesn’t result in an arrangement of building spaces inside
  • Repair: Restoration, patching, or painting of materials, equipment or fixtures in good condition

Do you know what the six domains of Health Care Quality are?
  1. Safe: Making sure harm does not come to patients derived from the care that is meant to help them
  2. Effective: Administering services established from scientific knowledge to everyone who would benefit and ceasing services to people not likely to benefit
  3. Patient-Centered: Maintaining an atmosphere of care that is considerate to individual patient desires, needs and values and making sure patient values influence clinical decisions
  4. Timely: Diminishing wait times and harmful setbacks for those who receive and give care
  5. Efficient: Ward off waste, including waste of supplies, equipment, energy and ideas
  6. Equitable: Provide consistent quality care to all patient regardless of sex, geographical location, ethnicity and socioeconomic status

These six domains come from the Institute of Medicine's definition of quality care in a healthcare setting. Many other organizations use these domains as their general standard such as the Department of Health.

Healthcare occupancies, especially hospitals, have strict guidelines when it comes to the exact location of handrails in certain areas.

Out of all the areas including stairs, enclosures, ramps, corridors and exit passageways, which one does not have strict guidelines for the exact location of handrails? The answer is corridors. Even though there is no guidelines on handrails for corridors, there are other codes to consider including complying with ADA requirements.

Should hospital “out-buildings” and offsite doctor’s offices participate in fire drills?

Yes. Since these offsite locations are usually considered business occupancies, the requirement is once per shift per year, but this also depends on who your facility is accredited by and the entity that is enforcing the Life Safety Code.

If a hospital is undergoing a short-term project and needs some extra storage space during construction, would it be appropriate to store new equipment that is still in the packaging in unused patient rooms until the project is complete?

This all depends on who the authority is that has jurisdiction. If the storage equipment items qualify as construction, alterations, additions or repair, you may be able to store the items in the unused patient rooms. Of course, alternate life safety standards need to be followed and you should be following in accordance with your own policies as well.

When are playrooms and breast-feeding rooms included in a specific part of a healthcare facility's DGSF?

When a play area or breast-feeding room is located near a specific department, they are to be included in the department’s DGSF (Departmental Gross Square Feet). The exception is when play areas and breast-feeding rooms are positioned in a lobby or public space then they would be considered public spaces.

When is emergency lighting required for existing business occupancies?

If the public can access your building, then you are most likely going to need emergency egress lighting. However, based on the Code, the most general rule is emergency egress lighting is needed when you are required to have two or more paths of egress and/or have delayed egress locking on doors.

Need a tip on lead acid batteries for fire alarm systems in hospitals?

Lead acid type batteries used for fire alarm systems need to be replaced every five years after the date of manufacture according to NFPA. This can also be done more frequently if needed.

According to the Life Safety Code, the following departure components are approved means of egress:
  • Ramps
  • Stairs
  • Doors
  • Fire escape ladders
  • Horizontal exits
  • Smokeproof enclosures
  • Exit passageways
  • Areas of refuge
  • Alternating tread devices

Notice that elevators are not mentioned on the list.

What classification does a freestanding Emergency Department fall under out of Health Care Occupancy, Ambulatory Care Occupancy or Business Occupancy?

While Health Care and Ambulatory Care may be acceptable occupancy classifications, a freestanding Emergency Department would never be considered a Business Occupancy. This is because not all patients brought to an Emergency Department are able to walk or speak, so that takes Business Occupancy off the table.

Did you know that waivers and equivalencies are only valid until the next survey?
  • If CMS approved a waiver or equivalency, you should be going through the process repeatedly every three years. This statement is still true even if things have not changed.

Need some advice on how to assess the risk of patients' electronic devices?
  • A risk assessment is beneficial when deciding if patients should be allowed to bring personal laptops, hairdryers and other electronic equipment into the hospital. Healthcare facilities are expected to develop a course of action to recognize patients' personal equipment that would be included in the medical equipment management plan.

Hospital Submissions (Pennsylvania): DOH, DAAC, DLS or Local Code
  • Need a quick guide on whether to send your hospital submissions to DOH, DAAC, DLS or local code? Drawing submissions are required to go to DLS for I-2 and outpatient surgery centers. All hospital based departments, including business occupancies, must submit their narrative in correspondence to DAAC. All additions and alterations are going to be submitted to local code.

Door Decorating Limits Visibility
  • Different holidays and events throughout the year bring forth themed door decorating. It is important to remember that no decorations, accessories or other objects should limit visibly or access to doorways according to Section 7.1.10.2.1 of the Life Safety Code. All fire-rated door decorating should be looked at as a no-go during festivities.

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