The Life Safety Specialist Surveyor

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The Life Safety Specialist Surveyor
Preparing for the Life Safety Specialist
Documentation Review and Facility Tour

• Will limit

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The Life Safety Specialist (LSS)

• It is likely that the LSS will arrive with the
  team on the first or second day, less likely
  later in the survey
• For 2011, the LSS will usually be scheduled for
  an additional day based on the scheduled time of
  the previous survey
• The LSS will spend several hours on dedicated
  documentation review, but much more time on the
  facility tour
• Other responsibilities assigned to the LSS will
  depend on the survey team member preferences and
  responsibilities they may conduct the EC
  Interview and Emergency Management tracers
• The other survey team members will also observe
  life safety issues, but not as detailed as the
  LSS it is not likely that the nurse and
  physician will request a ladder and flashlight!
• If the LSS observes deficiencies outside of
  their defined responsibility (example medical
  records privacy or medication security), they
  will report it to the other team members

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The LSS Documentation Review
Life Safety Specialist (LSS) surveyor
documentation responsibilities include at a
minimum LS.01.01.01 SOC and Life
Safety Code LS.01.02.01 Interim
life safety measures EC.02.03.05 Fire
system tests EC.02.05.07 Emergency
power systems EC.02.05.09 Medical gas
and vacuum systems Note In 2011, the Life Safety
Specialist may be assigned additional
responsibilities during the survey
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The LSS Documentation Review

• LS.01.01.01 SOC and Life Safety Code
• The SOC completion will be verified through the
  Joint Commission Connect site (BBIs and PFIs)
• Have the SOC notebook available for review
• The PFI documents from the previous survey may
  be reviewed to verify completion of deficiencies
  (have them available, if requested)
• The compartmentation drawings will be reviewed
  to assist in planning the facility tour
• Life Safety Code compliance will be verified
  during the facility tour

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The Statement of Conditions
How Should the Statement of Conditions (SOC)
Document be Completed?
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The Statement of Conditions

• What is the SOC?
• The Statement of Conditions (SOC) is a document
  that is required to be completed by every
  healthcare facility that applies for
  accreditation by the Joint Commission. It
  references the 2000 edition of the Life Safety
  Code and consists of the following sections
• Basic Building Information (BBI) Form
  electronic on Connect site
• Life Safety Assessment (LSA) Form not
  electronic
• Plan for Improvement (PFI) Form electronic on
  Connect site
• BBIs, LSAs and PFIs are
• Note Other LSC editions may be selected, but
  the entire edition must be followed

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The Statement of Conditions

• SOC Notebook (Best Practice)
• A SOC notebook is strongly recommended to
  contain hard copies of the SOC documents
• The notebook should include at least the
  following sections
• Section 1 The SOC policy and responsibility
  statement
• Section 2 Current copies of the downloaded
  BBI forms
• Section 3 Accurate, color-coded
  compartmentation prints
• Section 4 The latest, completed LSA-type
  document
• Section 5 Current and previous, downloaded
  PFI forms
• Section 6 Any correspondence with the
  Joint Commission, including equivalencies,
  letters and emails

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The Statement of Conditions

• Why Should I have an SOC Policy? (Best Practice)
• The SOC policy describes how the Statement of
  Conditions program is organized for the facility
• What Should the SOC Policy Include?
• Who is responsible for completing and
  maintaining the SOC
• How often the SOC documents are reviewed
• Who reviews the SOC documents for timeliness
• PFI guidelines (when does a work order become a
  PFI?)
• Whether a BMP is implemented
• Whether an above-the-ceiling program is in
  place
• How the SOC documents are organized

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Statement of Conditions Document

The current Statement of Conditions hard copy
document is dated 5/2004 and can still be
downloaded from JointCommission.org for the LSA
form (do not use the BBI or PFI hard copies
they are obsolete)
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Statement of Conditions Document

• Notes About the e-BBI Form
• List on the e-BBI cover page every occupancy
  that will be surveyed, even for business
  occupancies (make sure that the BBI and survey
  list match!)
• The e-BBI questionnaires are only required for
  ambulatory, hotel/ dormitory and healthcare
  occupancies
• Fill in the comments section regarding SOC
  preparer, location of building drawings, mixed
  occupancies, equivalencies, special building
  features or local AHJ requirements to the BBI
• If multiple occupancies are entered, the
  greatest percentage defaults to the BBI form, so
  multiple BBI entries are required
• Be sure to download the electronic version of
  the BBI form before it is saved so that a
  back-up is available, and place a copy in the
  SOC Notebook

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Statement of Conditions Document

• Compartmentation Requirements
• Mixed Occupancies (LSC 19.1.2.1)
• Sections of health care facilities shall
  be permitted to be classified as other
  occupancies, provided that they meet the
  following conditions
• They are not intended to serve health care
  occupants for purposes of housing, treatment, or
  customary access by patients incapable of
  self-preservation
• They are separated from the health care occupancy
  by a fire rating of at least 2 hours
• Separation between ambulatory and business
  occupancies only requires a 1 hour rating (LSC
  21.1.2.1)

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Statement of Conditions Document

e-BBI Form Buildings
Be sure to complete for all healthcare and
ambulatory facilities Optional for business
occupancies, but strongly suggested for the cover
page
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Statement of Conditions Document

e-BBI Form - Healthcare
Refer to instructions related to stories in
the Life Safety Code Note instructions related
to building construction type (occupancy)
Building age is important due to significant
code changes
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Statement of Conditions Document

e-BBI Form page 2 1991 date significant due to
sprinkler requirement Emergency power fuel
type important due to wet stacking
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Statement of Conditions Document

e-BBI Form page 3 Previous inspections
data provides valuable information to the survey
team! Be sure to list local or regional
requirements (example limited generator testing
due to high pollution days) in the Comments
section at the bottom of the form as well as
other requested information
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Statement of Conditions Document

• LSA Form (is not electronic)
• Is a voluntary assessment tool, although some
  assessment is required at least annually
• Is not required for Business Occupancies
• The Joint Commission surveyor normally expects
  some type of form, document or evaluation to be
  completed
• Dated 5/2004, so a cover sheet that is signed
  annually is recommended
• Can still be downloaded from the Joint
  Commission home page website (search Statement
  of Conditions)
• Can use PPR form or similar for the LSA document
• Comments in LSA must match PFI deficiencies

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Statement of Conditions Document
Life Safety Building Compartmentation Drawings

Blue smoke barrier Green 1 hour fire wall
(hazardous area) Red 2 hour fire wall
Note Color-coded drawing is best practice
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Statement of Conditions Document

• Notes About the PFI Forms
• The forms should not be used for operational
  deficiencies, such as exit lights burned out,
  doors out of minor adjustment or small
  penetrations that can be easily filled these
  should be completed using the routine work order
  system
• The normal trigger time from a work order to
  PFI is 45 days
• Document the PFIs on a continuing basis be
  sure that the PFI log is up-to-date and ready to
  be reviewed by the surveyor
• Dont forget to enter the projected start and
  completion dates and the actual completion date
• Failure to meet the completion dates without a
  delay approval results in Conditional
  Accreditation 6 months after the projected
  completion date has passed!
• If applicable, keep any previously signed PFI
  copies available

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Statement of Conditions Document

The first page for the electronic PFI forms is
used to list the deficiencies Notice that a No
Deficiencies option is available (and should be
completed, if applicable)
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Statement of Conditions Document

The second page for the electronic PFI forms is
used to indicate the deficiency resolutions Dont
forget to complete all of the requested
information, including the proposed action,
source of funds and the projected start and
completion dates The projected completion dates
can be altered until they are frozen before or
during the actual survey! Comments for each PFI
should include a note regarding the
implementation of ILSMs!
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Statement of Conditions Document

The listing document simply provides a summary
of all of the deficiencies that have been
recorded on the PFI form for tracking purposes
keep a copy of this in the SOC notebook for
reference purposes
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The Life Safety Specialist Documentation Review
Should I Implement and Document a Building
Maintenance Program (BMP)?
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The Building Maintenance Program (BMP)

• Is voluntary no scoring benefit in 2011
• No longer requires a measure of effectiveness
• Measurement system can use random samples
• Results should be used to determine revisions to
  inspection or test frequencies
• Information should be provided to the hospital
  safety committee if changes are made to the
  program
• Is basically a PM program for the buildings
• Is still considered a Best Practice

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Fire System Tests

• Points to Remember
• Clearly define supervisory devices (fire pump,
  low air pressure on dry or pre-action systems and
  water tank level indicators expected)
• Tamper and flow device test intervals increase
  to quarterly on 7/1/11
• Inventory all doors on magnetic releasing
  devices and document test results
• Document tests results for each individual heat
  and smoke detector, pull box and audible and
  visual device

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Fire System Tests

• Points to Remember
• Document receipt time of fire alarm signal to
  local fire department or receiving station
• Document static and residual pressure readings
  for main drain tests and time back to static
  pressure (best practice)
• Visually inspect fire department connections
  quarterly
• The 5-year standpipe test was added to the
  requirements in 2009
• Indicate the day and month of portable fire
  extinguisher checks

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Fire System Tests

Points to Remember Dont forget to implement and
document Interim Fire System Measures (IFSM),
when required

• If the occupant hoses have been removed, keep a
  copy of the approval letter from the AHJ
• Place inaccessible smoke and fire dampers on the
  PFI for a 6-year, renewable period (for tracking
  purposes only)
• Document that duct detectors trip the
  air-handling units
• Only applies to vertical and horizontal smoke
  and fire doors, not security doors or curtains

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Fire System Test Monitoring
Best Practice for Monitoring Compliance
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Fire System Test Monitoring
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The LSS Documentation Review

• EC.02.05.07 Emergency Generators
• Perform and document weekly generator visual
  checks (NFPA 110)
• Perform and document monthly generator tests
  between 20 and 40 days and with at least 30 of
  the rated load for 30 minutes
• Document that all automatic transfer switches
  are exercised monthly
• Conduct annual load bank tests if the 30 load
  is not achieved and manifold temperatures are not
  sufficient (possible change from the 2 hour to a
  1.5 hour test in 2011 not yet approved)
• Combining the annual and trienniel tests can be
  performed by starting the load at 30 of
  nameplate for the first 30 minutes of the test
• Document the static or dynamic 4-hour trienniel
  test for all generators
• Test fuel oil quality annually, unless fuel is
  consumed from the entire tank (NFPA 110)
• Utilize Interim Emergency Power Measures
  (IEPM) when necessary
• Note Refer to NFPA 99 and 110 for more
  information

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The LSS Documentation Review

• EC.02.05.07 Emergency Battery Lights
• Required in all anesthetizing locations (NFPA
  70 517.63 ) Task Light!
• administration of nonflammable inhalation
  anesthetic agents
• in the course of examination or treatment
  
• Note Grandfathering usually permitted
  in existing ORs
• Required in Level 1 or Level 2 EPS equipment
  locations (NFPA 110 7.3.1) Task
  Light!
• Required in business occupancies for egress
  lighting where emergency power is not required or
  not available (NFPA 101 7.9.1.1) Egress Light!
• Monthly push-to-test required for all battery
  installations
• Differentiate between task lighting and
  egress lighting
• Annual battery replacement in lieu of 90-minute
  discharge test
• Note 10 of lights must be tested for 90 minutes
  annually, even if the batteries are changed.

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The LSS Documentation Review

• EC.02.05.07 Stored Emergency Power Supply
  Systems (SEPSS)
• Standard applies to Level 1 systems (NFPA 111
  4.5.1)
• Level 1 failure of the equipment to
  perform could result in
• loss of human life or serious injuries
• Testing requires
• 1. Quarterly functional test (5 minutes or
  class specification)
• 2. Annual full-load test for 60 of SEPSS
  class duration
• Note 1 NFPA 111 requires a monthly inspection,
  quarterly functional test and annual full load
  test for full class duration for Level 1 systems
  
• Note 2 The Joint Commission references exit
  lighting, life support ventilation, fire
  detection and alarm systems, and public
  communications systems as Level 1 systems, but
  most are not SEPPS systems

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The LSS Documentation Review

• EC.02.05.09 Medical Gas and Vacuum Systems
• Medical gas and vacuum system preventive
  maintenance
• program is required (facility must define
  PM) and must include
• - Bulk medical gas and vacuum system
  components and source valve
• - Master signal panels and area alarms
• - Automatic pressure switches and shutoff
  valves
• - Flexible connectors and outlets
• Testing per NFPA 99 is required for new
  installation,
• modification or repair (cross-connections,
  purity, pressure)
• Main supply valves and area shut-off valves
  must be
• accessible and clearly labeled
• Utilize Interim Medical Gas Measures (IMGM)
  when necessary
• Note Significant changes to NFPA 99 are likely
  to occur when the next vote occurs at the NFPA
  Annual Meeting

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The LSS Documentation Review

• EC.02.05.09 Medical Gas and Vacuum Systems
• Certification of installers and verifiers per
  ASSE 6000 series is
• required
• Medical air quality must meet NFPA 99
  requirements below

Parameter Limit Value
Pressure dew point 39 degrees F
Carbon monoxide 10 ppm
Carbon dioxide 500 ppm
Gaseous hydrocarbons 25 ppm (as methane)
Halogenated hydrocarbons 2 ppm
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The LSS Documentation Review

• Medical Gas and Vacuum System PM Recommendations

Note The recommendations provided in the chart
to the right are from NFPA 99, the 2005 edition,
Appendix C, section 5.2. Tests that are required
due to new system installations, renovations or
repair are listed in chapter 5 of NFPA 99
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The LSS Documentation Review
Interim Utility System Measures (IFSM, IEPM,
IMGM)
Best Practice! Strongly recommended to
document that interim measures have been
implemented to compensate for utility systems
that are taken out of service
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The LSS Facility Tour

• Typical Tour Sequence
• Start on the roof, penthouse, mechanical
  equipment rooms
• Take the most traveled stairwell from the top
  to the bottom
• Take the elevator back up to the top patient
  floor
• Check smoke/ fire doors and compartmentation
  features
• Inspect chutes, storage areas, utility chases,
  hazardous areas
• Continue down to the lower and basement levels to
  specific areas, such as the kitchen, loading
  dock, fire pump, emergency generators, fire
  annunciator panel, compressed gas and infectious
  waste storage
• Complete checklist, or until problems are found!

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The LSS Facility Tour

• Checklist for the Facility Building Tour
• Smoke and fire doors
• Check Closure, label rating, gaps,
  undercuts, warpage, kick plate
• Smoke and fire compartments
• Check Penetrations, proper sealant
• Roof and penthouse
• Check Contractor supplies, smoking,
  exhaust fans labeled
• Exit stairwells
• Check Door rating, closure, signage, exit
  discharge
• Linen/ trash chutes and receiving rooms
• Check Door rating, closure, fusible link,
  chute blockage

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The LSS Facility Tour

• Checklist for the Hospital Building Tour (contd)
• Hazardous areas
• Check Storage of flammables, room rating,
  door closer
• Fire pump
• Check Controls turned on, valves open,
  tampers OK
• Fire annunciator panel
• Check Bypass, trouble, ground fault or
  supervisory
• Soiled linen rooms
• Check Proper storage, dirty separated from
  clean

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The LSS Facility Tour

• Checklist for the Hospital Building Tour (contd)
• Medical waste storage
• Check Locked area, secure, sharps not
  accessible
• Loading dock
• Check Smoking, improper storage, powered
  equipment
• Kitchen area
• Check Cleanliness, storage, CO2 tanks,
  refrigerator temps, K-type portable extinguishers
  within 30 of fat fryer
• PFI verification
• Check Previous PFIs have been resolved
  as listed

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The LSS Facility Tour

• Checklist for the Hospital Building Tour (contd)
• ILSM verification
• Check Construction areas for ILSM
  implementation
• Mechanical equipment rooms
• Check Storage, unlabeled containers,
  cigarettes, labeling
• Emergency generators
• Check In auto mode, batteries/ charger,
  fuel leaks
• Medical gas systems
• Check Manifolds, medical air and vacuum
  pumps

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The LSS Facility Tour

• Checklist for the Hospital Building Tour (contd)
• Compressed gas storage rooms
• Check Full and Empty separation, chained
  or on racks
• Egress corridors
• Check Equipment not in use, containers
  gt 32 gallons
• Eyewashes, showers and portable fire
  extinguishers
• Check Test dates on log or tag
• Chapel
• Check Candles, open flames
• Other?

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The LSS Facility Tour
Multiple Operational Deficiencies are Likely to
be Found During the Facility Tour
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Operational Deficiencies

• Operating Features
• A clear space gt18 inches below sprinkler heads to
  the top of storage must be maintained
• Exception Perimeter wall shelving, unless
  below the sprinkler (refer to NFPA 13)
• Portable space heating devices are only permitted
  in non-sleeping staff and employee areas, with
  heating elements that do not exceed 212 degrees F
  (LSC, 2009 edition, 19.7.8)
• Combustible decorations are prohibited, unless
  flame retardant (19.7.5.4)
• Soiled linen or trash collection receptacles
  shall not exceed 32 gallons in capacity
  (19.7.5.5)
• Exception Attended or in hazardous area

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Operational Deficiencies

• Operating Features
• Holiday decoration policy and implementation
• Candles used in the chapel
• Furnishings, decorations or other objects may not
  obstruct access, egress or block the visibility
  of exits (7.1.10.2.1)
• Exit doors must be free of mirrors, draperies or
  hangings that may conceal, obscure or confuse the
  direction of exit (7.5.2.2), and
• Hallway Clutter!

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The Life Safety Specialist Surveyor
Questions?
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