CLOSE INSPECTION CMS surveyors will be inspecting facilities to ensure emergency preparedness protocols are current.

Medicare surveyors are cracking down on building safety. They've been enforcing the 2012 editions of the National Fire Protection Association's (NFPA) Health Care Facilities Code and Life Safety Code since last November. The codes are intended to ensure facilities have the systems and equipment in place to protect patients and staff in the event of a fire, power failure or other unforeseen emergency. CMS could withhold payments from out-of-code facilities and, in the most severe of cases, even threaten to shut down noncompliant centers. Financial penalties are concerning, but your main motivation should be the safety of your staff and patients. Here are 10 ways to ensure CMS surveyors see nothing worth noting during their visit to your facility.

1. New versus existing construction. If you remodel, you must follow the rules for new construction. You might have a 20-year-old building, but if you decide to renovate a procedure room, everything needs to be done according to the "new" rules.

2. Initial verification testing. Maintain records of your initial verification testing on fire alarms, sprinklers, generators and medical gases. Although a contractor might hold onto this documentation, file it away for safekeeping.

3. Blueprints. Likewise, always have a construction project's blueprints on file at your facility, including any changes to the plans that have been made along the way. Your contractor can provide you with a "clean" set once the work has been completed.

4. Fire doors. An expert must visually inspect and test fire doors for functionality annually. Although a fire marshal could perform the inspection, a fire alarm or sprinkler system vendor will be able to provide this service.

5. Doors to hazardous areas. You must install self-closing or automatic-closing doors at the entrance to any storage areas that house flammable, combustible or other materials that pose a greater than normal hazard. Check all doors that latch until you hear a click as part of a monthly Environment of Care checklist.

COMPLIANCE CRACKDOWN
Make Sure Your Facility Is Up to Code

ALL SYSTEMS GO CMS now requires facilities to assess the risks associated with medical gases and other equipment.

What happens to a facility that fails to comply with the 2012 editions of the National Fire Protection Association's (NFPA) Health Care Facilities Code and Life Safety Code? "The first center to get cited will cut their teeth for the rest of the industry," says Michael A. Crowley, PE, FSFPE, SASHE, vice president of health care for Jensen Hughes, a fire protection and life safety engineering consulting firm in Baltimore, Md. Here's how to ensure your center isn't the example CMS surveyors are seeking.

Assess risks. The newly adopted codes are meant to catch up with the trend of advanced surgical procedures migrating from acute care hospitals to outpatient settings, says Mr. Crowley. He adds that CMS wants facilities to make the safety of patients and staff their No. 1 priority as they take on new building projects.

To that end, CMS is requiring facilities to conduct risk assessments of construction projects to ensure systems and equipment are in place to protect patients and staff in the event of a fire, power outage or other unexpected event. The risk assessments apply to new and existing facilities, according to Mr. Crowley, who shares these scenarios involving 2 different facilities: One has a medical gas system that does not have the necessary redundancies in place to protect the patient from major injury or death (Category 1) in the event of a power disruption; and one has an OR, which is considered a wet procedure location, that is not protected with either isolated power or ground-fault circuit interrupters. "Unless a risk assessment conducted by a healthcare governing body determines otherwise, both facilities would be non-compliant and, as a result, likely necessitate a significant investment to become compliant in accordance with the proper risk category," he says.

What if your facility wants to introduce a new service line? The risk assessment applies here, too. Mr. Crowley says you'd need to upgrade your facility's systems and equipment to comply with the higher risk category.

Seek out experts. The codes are involved and can be confusing. That's why it's important to partner with a healthcare architect or fire protection engineer who can help you navigate the new regulations, says Chad Beebe, AIA, FASHE, the deputy executive director for advocacy for the American Society for Healthcare Engineering of the American Hospital Association.

Be proactive. "Act now to identify where you're not in compliance and develop a strategy to meet the missing requirements," says Mr. Beebe. "If you get surveyed tomorrow, and you haven't done anything, you'll get in more trouble than if you've outlined a 3-year compliance plan." Mr. Beebe says noncompliant facilities have 60 days to correct issues that CMS surveyors identify before Medicare and Medicaid reimbursements are stopped. In some instances, says Mr. Beebe, CMS could seek to recoup fees it paid to noncompliant facilities before doling out additional reimbursements.

— Bill Donahue

6. Alcohol-based hand rub dispensers. Space these no closer than 4 feet apart in corridors that measure at least 6 feet wide. None should be within 1 inch of an ignition source, such as an electrical outlet or light switch. Also, no single dispenser should exceed 18 ounces.

7. Medical gases. Have a precautionary sign on the door where gases are stored that's readable from 5 feet away — a poster-sized sign would do — that reads "Positive Pressure Gases; No Smoking or Open Flame; Room May Have Insufficient Oxygen; Open Door and Allow Room to Ventilate Before Entering." Also, a master alarm that sounds when the gas system fails must be present in an area where it can be continuously monitored.

8. Firewalls. Keep all firewalls "tight" by reminding maintenance personnel to seal any penetrations — holes to accommodate phone lines or cables, for example — with a fire-approved fire stop system or device.

9. Power generators. You must have a shut-off device outside of the generator. If you don't, it's usually relatively inexpensive for an electrician to install. Also, keep on file 2 copies of the generator manufacturer's instructions for use.

10. Electric and HVAC. Review the standards for electrical systems in regard to the labeling of panels. CMS surveyor questions often surround issues related to OR temperature, humidity and airflow, so review your HVAC system to make sure it's working properly and compliant with current standards. OSM