Categorical CMS Waivers Slide 2 Health Care Hierarchy Who is in
charge? Centers for Medicare & Medicaid Services - AKA: CMS Who
is the babysitter? The Joint Commission - AKA: TJC (formerly JCAHO)
Use their own standards based on CMS regulations Det Norske Veritas
- AKA: DNV Use the ISO:9001 quality principles Is anyone else in
charge, or just CMS? At Kaweah Delta, we must meet the regulations
of: CMS, TJC, CDPH, State of CA Fire Marshal (via OSHPD), local
authority having jurisdiction (in Visalia, this is the Fire
Marshal), OSHA, etc. Whose rules do we have to follow? Whoever is
most strict Slide 3 Health Care Bibles Slide 4 BUREAUCRACY Slide 5
Its never okay to break the rules, except sometimes. Slide 6
Relative humidity in anesthetizing locations Medical gas master
alarms Openings in exit enclosures Emergency generators and standby
power systems Door locking arrangements Multiple delayed egress
locks Suites Extinguishing requirements Clean waste and patient
record recycling containers Items in the corridor Kitchens open to
the corridor Gas fireplaces in common areas Installation of
combustible decorations Bending the Rules Categorical Waivers Slide
7 Relative Humidity in Anesthetizing Locations NFPA 99, 1999
edition: 5-4.1.1 Why is it important? Current requirement is 35%
relative humidity Waiver decreases to 20% relative humidity UPDATE:
S&C: 15-27-Hospital, CAH & ASC Issued by CMS February 20,
2015 What do we do? Monitor relative humidity levels in
anesthetizing locations, take action when needed to ensure that
levels remain at or above 20%. Document, Document, Document. Slide
8 Slide 9 Emergency Generators and Standby Power Systems NFPA 110,
1999 edition: 6-4.2.2 Why is it important? Shorter run times on the
annual generator load bank tests equate a lower cost for testing,
reduction in the use of diesel and reduced negative environmental
impacts. What do we do? Ensure that you are in compliance with ALL
other applicable NFPA 110, 1999, operational inspection and testing
provisions and 8.4.2.3 of NFPA 110, 2010. Document, Document,
Document Slide 10 Door Locking Arrangements NFPA 101, 2000 edition:
18/19.2.2.2.2 18/19.2.2.2.6 Why is it important? Previously, we
were not allowed to have doors that remained locked in the event of
a fire alarm or power outage (if on magnet locks). In units where
the clinical needs of the patient (i.e. psychiatric, Alzheimer,
dementia, neonatal, pediatric) require specialized security
measures for their safety, door locking arrangements are permitted.
What do we do? Ensure that you are in compliance with ALL other
applicable NFPA 101, 2000 door provisions, as well as 18/19.2.2.2.2
18/19.2.2.2.6 of NFPA 101, 2012. Document, Document, Document Slide
11 Suites NFPA 101, 2000 edition: 18/19.2.5 Why is it important?
Prior to the waiver, every habitable room was required to have an
exit access door leading directly to an exit access corridor. Only
allowed exit through another suite under certain circumstances.
Limits the size of sleeping room suites to 5,000 sq. ft. What do we
do? Meet with your local AHJ to ensure that they approve of the
changes. Document, Document, Document One of the two required exits
can be: exit stair, exit passageway, or exit door to the exterior.
Can now exit through another suite. Allows suite size up to 10,000
sq. ft. Slide 12 Clean Waste and Patient Record Recycling
Containers NFPA 101, 2000 edition: 18/19.7.5.5 Why is it important?
Increases the can size of clean waste (bottles, cans, paper) from
32 gallons to 96 gallons. Reduce the number of receptacles, which
creates more room in the corridor. What do we do? Must be compliant
with NFPA 101, 2012 18/19.7.5.7.2 e.g. 96 gallon containers shall
be labeled and listed as meeting the requirements of FM approval
standard 6921, Containers for Combustible Waste.Containers for
Combustible Waste. Document, Document, Document Slide 13 Items in
the Corridor NFPA 101, 2000 (Several Sections) Why is it important?
2000 edition of the Life Safety Code mandates 8 feet of
unobstructed with in Hospital corridors. With todays technological
advancements and the inception of Electronic Medical Records, we
have more equipment that is used in the course of patient care.
What do we do? Ensure that you are in compliance with ALL other
applicable NFPA 101, 2012 18/19.2.3 standards are met. This
includes compliance with 7.3. Meet with your local AHJ to ensure
that they approve of the changes. Document, Document, Document The
2012 code will allow previously restricted items to be in the
corridor. CANNOT USE CORRIDOR FOR STORAGE Slide 14 Installation of
Combustible Decorations
http://osfm.fire.ca.gov/licensinglistings/pdf/flameretardant/chemical/Ch
emicalList.pdfhttp://osfm.fire.ca.gov/licensinglistings/pdf/flameretardant/chemical/Ch
emicalList.pdf NFPA 101, 2000 edition: 18/19.7.5.4 Why is it
important? Previous code had severe restrictions on furnishings,
mattresses and decorations. Combustible decorations shall be
prohibited in any health care occupancy unless they are
flame-retardant. What do we do? Meet with your local AHJ to ensure
that they approve of the changes. Document, Document, Document
Waiver permits following NFPA 101, 2012. Slide 15 How to bend the
rules 2.Document your decision to use a categorical waiver(s). Most
commonly done during an Environment of Care meeting. 4.Notify
surveyors (CMS, TJC, DNV, CDPH) at the beginning of the survey that
they have chosen to declare a categorical waiver. THIS IS CRITICAL.
1.Gather and prepare documentation along with a Categorical Waiver
Declaration. 3.Prepare a binder or file of Categorical Waivers with
back up documentation and a summary to have at the ready. Slide 16
Slide 17 Slide 18 B.there was no bulb in the lamp. An
administrative assistant called in a work request stating that her
desk lamp did not work. When the technician responded to the
request he discovered that: A.the desk lamp was not plugged in.
C.the admin had brought the lamp from her home. Slide 19 Tenant:
When the fire alarm goes off, please send a quick email to let
everyone know if it is a false alarm or if they should actually
start evacuating. Tenant Request: Can the speed bumps be shaved
down? They are too high. I have to go too slow to go over them.
Slide 20 This occurred last week on the first day of the year to
exceed 80 degrees. The occupants of one office complained they were
too hot. I addressed it myself due to the political expediency of
the issue. Upon arriving, the occupants expressed their
dissatisfaction of our department and how we cant get anything
right. The space has two windows. In one of them is mounted a
window A/C. It was set for 60 degrees, and was working beautifully.
The other window was wide open. I informed them that the unit cant
cool the entire outdoors. I then noticed that one of the occupants
had a small portable heater on under the desk. I asked why it was
running, and she complained that her feet were cold. Slide 21 I was
on call one night when at 3 a.m. my pager goes off. I call in to
the hospital and was connected with a nurse who had worked (there)
for 30 years. She says, I have a patient in room 21 and the lights
dont work. I crawl out of bed, get dressed, and drive the eight
miles. I go to the room and turn on the light switch, and all the
lights go on. Puzzled, I step in the hallway and asked her what was
I missing. She said, I didnt try the switch. I just thought that as
it was dark in there that the lights must be burnt out. I didnt say
any bad words until I was in my car on the way back home. Slide 22
We once received an emergency work order (highest priority) to turn
around the toilet paper roll because it was installed backwards.
Our response was, Toilet paper roll direction is a matter of
personal preference and may depend on multiple critical life safety
issues such as whether or not you have a kitten on the loose. Slide
23 Thank you
