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As reported on this website last week, CMS issued a formal communication on April 29, 2020, that granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance …
In a formal communication issued April 29, 2020, CMS granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance (ITM). Refer to page 23 of the following …
Q: Has there been an update to the definition of time by TJC/CMS? I'm looking at quarterly fire drills right now, but any changes/clarification on the definition for all intervals …
During this period of COVID-19 crisis, many readers have written asking if they can discontinue conducting routine Life Safety tests and inspections in order to limit service technicians from entering …
Q: Housekeeping products like germicidal, glass cleaner, air freshener are stored in a locked metal box on housekeeping cart. All of our stock of these and other products are stored …
Q: Is there a code requirement for implementing an Interim Life Safety Measure (ILSM) for occupancies other than healthcare (i.e. business occupancies) if a life safety code deficiency has been …
Q: Please clarify if electrical closets and /or electrical rooms can be accessible to anyone. The NFPA70 National Electrical Code seems to require warning signs limiting access to authorized personnel …
Q: I heard a rumor that the accreditation organizations (AO) are going to 18 month visits vs. the 3 years it has been. Is there truth to this? A: No… …
Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion? …
Q: The Joint Commission standard for annual door testing states "The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of …
Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has …
Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the …
Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required …
Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director? A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (ie …
Q: We had our Joint Commission inspection today and they cited us for water coolers and ice machines not being plugged into GFCI (ground-fault circuit interrupter) receptacles. One of our …
Q: My understanding is we should be following the 2010 FGI Guidelines because that’s what is recognized by the 2012 LSC that was adopted by CMS. But I have read …
Q: For clinics that are in a facility classified as business occupancy, is an ICRA required? A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations …
This is a special posting to let you know there are 6 new forms on the 'Tools' webpage for you to download for free: Advantages if the Building is Sprinklered …
Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a …
Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document? A: There is no set form to use …
Q: I have read, or thought I read, that the environmental tours were no longer required with the adoption of the life safety code. Is this correct? A: No… The …
Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient …
If you've been reading my blog postings over the past few months ( see http://keyeslife.wpengine.com/?s=emergency+department), you've read were I have reported that CMS has issued informal, non-public letters to the …
The following article was published today online by the HCPro newsletter 'Healthcare Life Safety Compliance', and is reprinted here with permission. In a rather surprising interpretation by the Centers for …
In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments are now required to be classified as healthcare occupancies only. For most of …
Q: Are Bronchoscopy procedures to be performed in negative pressure rooms under all circumstances, or can they be performed in OR suites? Does the negative pressure rule only apply to …
Q: We were using the 2006 edition of the FGI Guidelines for Design and Construction of Health Care Facilities but we have both the 2006 and the 2010 version of …
I received the following comment from a reader: During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even …
The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that …
The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment …
Recently, the issue of whether or not the FGI guidelines were enforceable in certain situations came up for discussion. To be sure, the FGI guidelines are guidelines: They are not …
Randy Snelling, the Chief Physical Environment Officer, for DNV-GL Healthcare Inc. spoke at the recent ASHE annual conference in Chicago, and I thought his views on corridor clutter were worth …
I’m no expert on the differences between a Critical Access Hospital (CAH) and an Acute Care Hospital (hospital), but I’m learning. Having been an advisor to American Osteopathic Association/Healthcare Facilities …
A surveyor recently cited an organization for having potential suicide hanging points in a behavioral health unit, in the form of door hinges and other hardware issues in the patient …
Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define …
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