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An inside look at a CMS Life Safety CodeĀ® survey


September 1, 2010

Your hospital just completed its Joint Commission survey and now you have another team of surveyors knocking on your door.

It’s a team from your state health department conducting a follow-up or validation survey on behalf of the Centers for Medicare & Medicaid Services (CMS) to ensure your hospital’s compliance with the Conditions of Participation (CoP).

Part of that survey will be a review of your Life Safety Code® (LSC) compliance. So what can you expect? Henry Kowalenko knows firsthand as the supervisor of the Design Standards Unit in the Division of Health Care Regulation at the Illinois Department of Public Health, where he’s been conducting and overseeing LSC surveys for the past 17 years.

Kowalenko shared his experience along with advice on how to have a successful survey at the 4th annual Hospital Safety Center Symposium, May 6 in Las Vegas.

Why CMS conducts surveys

CMS requires compliance with the LSC as one of the CoPs. The Code of Federal Regulations (CFR) outlines all of the CoPs that hospitals must comply with to receive funding through the Medicare program. CFR 482.41(b) requires hospitals to comply with the 2000 edition of the LSC.

CMS adopted the 2000 edition of the LSC as of March 11, 2003. Facilities with plan approvals or that were constructed after that date are considered new buildings under the LSC. If you added on to your original hospital, it can be a gray area, and it’s up to the surveyor whether to survey you as a new or existing occupancy, Kowalenko says.

Hospitals must demonstrate their compliance with all of the CoPs with accreditation by one of three accreditors—The Joint Commission, the American Osteopathic Association, or Det Norske Veritas Health Care, Inc.—or through an inspection by their state survey agencies that includes the department of public health or public safety or the state fire marshal.

The validation survey

If your hospital undergoes a Joint Commission survey, CMS requires validation of accrediting agencies’ findings. Validation surveys are scheduled within 60 days of the accreditation survey; however, only 2% of facilities are surveyed within a fiscal year, so not every hospital receives this follow-up survey. In Illinois, for example, only four hospitals will receive a validation survey per year.

Who gets selected for a validation survey? Kowalenko says the decision is made by CMS, not the states. “All we get is a memo” telling the department which facilities to survey, he says. In his time as a surveyor, he has been in some hospitals three times, whereas others he has never inspected.

If CMS selects your facility for a validation survey, the survey team will review all of the CoPs. These surveys are also provider number–specific, so surveyors can inspect any of your buildings that share your provider number. If the state receives a complaint about one of your buildings, all of your buildings are subject to survey. 

Other occupancies, such as areas for physical or occupational therapy, billing under your hospital’s provider number are subject to an LSC survey for their occupancy classification, Kowalenko says. They may be surveyed as business occupancies under Chapter 38 or 39 of the LSC, depending on whether they are new or existing buildings.

Surveyors will survey facilities built prior to March 11, 2003, under Chapter 19 of the LSC, “existing healthcare occupancies.” Surveyors will survey facilities (buildings, additions, renovations, etc.) completed after that date under Chapter 18, “new healthcare occupancies.”

All CMS surveys are unannounced. However, you know that if you have an accreditation survey, CMS could do a validation survey within 60 days.

The entrance conference

A CMS survey will start with an entrance conference. You will have a whole team of people in your facility, including an LSC specialist who will want to meet with the facility director or manager.

The number of surveyors depends on the size of your organization. A full team of four surveyors—which typically includes a nurse/medical professional, an LSC specialist, a sanitarian, and a nutritionist—will inspect a 500-bed hospital; on the other hand, the state will probably assign only two surveyors to inspect a 100-bed facility, Kowalenko says.

During the survey, the LSC surveyor will test all of your systems—medical gas, fire alarms, and sprinklers. The surveyor will also review documentation for things such as your annual fire alarm testing.

“It’s very important to document,” says Kowalenko. “If it isn’t written down, to me it didn’t happen.”

You will want to provide the following items for the LSC survey:

  • An appropriately sized ladder that is tall enough to reach your ceilings
  • A standard flashlight to see above ceiling panels
  • A small-scale floor plan that includes fire barriers, smoke barriers, exits, and suites
  • Keys or the ability to access all areas

Providing a small-scale floor plan will be very helpful to the surveyor and can answer many questions as he or she tours your hospital, Kowalenko says. For instance, a plan will show the exact location of smoke barriers. Keep the plan up to date.

You will make a good impression by knowing where fire dampers are and by being prepared. You don’t want to be fumbling for keys as the surveyor tours your facility. If the surveyor can’t access an area of the building, he or she will move on to another area and then backtrack. That makes for a longer, more frustrating survey, says Kowalenko, so carrying a master key is helpful.

The facility tour

The LSC surveyor will inspect your entire building. Always have someone from your facilities department accompany the surveyor. You should also have department managers, such as those in surgery, physical therapy, or imaging, tour their departments with the surveyor. Department managers can often answer specific questions about their areas.

The surveyor will verify fire barriers, exits, and rated enclosures. A small-scale plan will help identify these locations. The surveyor will look above ceilings to verify dampers and installation. He or she will trace exit paths to where they discharge from your building and review special locking devices, such as those that provide security in your infant nursery.

If your facility is fully sprinklered, you don’t need smoke dampers under the 2000 edition of the LSC, says Kowalenko. However, if you have them installed in your building, you are not required to keep them because the code will let you take them out.

Surveyors sometimes see problems at exit discharge points,  Kowalenko says. The LSC requires a solid, stable surface at building exits, such as asphalt or concrete, not gravel or mud.

Surveyors will use the tour to review the scope of your facility and then later will review and test your systems. “In Illinois, we do the tour first and get a sense of what your facility looks like,” Kowalenko says.

Testing your systems

The surveyor will test all of your systems, including your fire alarm system. When it comes to your pull  stations, it is not necessary to break the glass rod, and you can use keys to reset them, Kowalenko says. The surveyor will verify a fire department tie with a telephone call.

The surveyor will also test smoke detectors. This involves a functional test using canned smoke. CMS does not allow testing of smoke detectors with magnets, says Kowalenko. Keep one or two cans of canned smoke on hand to test your smoke detectors. Failure to do so will result in a citation, he says.

The surveyor will also activate the sprinkler system. The LSC requires activation of the flow switch within 90 seconds. The inspector’s test orifice must equal the activation of one sprinkler, and the test must drain to a location capable of accepting the full flow.

“You don’t want that water all over the floor,” says Kowalenko. The code requires that it flow someplace where it can accept the full flow, so make sure if you use a slop sink, it will not overflow the basin. You can have that flow go outside your building.

If surgeries are being performed, you need to know whether the fire alarm test is going to shut down your air handling system. Notify the surveyor of a potential fan shutdown if it is going to be a problem, Kowalenko says. 

Exit interview

At the exit interview, surveyors will identify any deficiencies they have cited and answer any questions, as well as discuss the CMS process.

Surveyors typically take notes on what they find as they tour your facility. In Illinois, surveyors cannot let the facility managers make copies of those notes. Thus, it is a good idea to take your own notes, especially when the surveyor is writing something down. You can ask the inspector what he or she is writing as well as ask to have any deficiency repeated.

Remember, the exit interview is not the venue to dispute the findings, Kowalenko says. “Don’t bring out the code books. Your chance to reply comes later,” he says.

The survey should not be considered all-inclusive; it is a sample of findings identifying trends. The provider is responsible for compliance with all the applicable codes.

Editor’s note: Next month, BHS will look at the process for hospitals to correct deficiencies found during an LSC survey.


Document review: What surveyors expect to see

When it comes to document review, Illinois surveyors typically look at a three-year history, says Henry Kowalenko, supervisor of the Design Standards Unit in the Division of Health Care Regulation at the Illinois Department of Public Health. However, that may vary from state to state.

The surveyor will review the following:

  • Fire drills, including fire drill critiques
  • Fire alarm annual testing
  • Annual fire extinguisher testing, including monthly extinguisher inspections during tour
  • Kitchen hood suppression system
  • Emergency generator testing, including weekly visual and monthly load
  • Sprinkler and fire pump testing
  • Written fire and emergency policies and procedures
  • Building(s) history (e.g., construction date, occupancy, construction type)

The surveyor will not want to see that you keep repeating the same mistakes, Kowalenko says. For instance, if your fire drill critiques show that fire doors don’t close or that staff members can’t hear the fire alarms, you need to show a work sheet order proving that you fixed the problem.

With regard to fire alarm annual testing, you should have a list of your devices, which will help the contractor who tests your system find them all. Keep your inventory and compare it to the contractor’s testing to ensure all the devices are tested.

Remember to complete a monthly visual inspection of fire extinguishers. You can indicate this with tags on the extinguisher or with bar coding. Be sure your inspector signs off on these monthly.

Kowalenko recalls conducting a facility survey in March and finding that all the inspection tags indicated the April inspection had occurred. When questioned, a staff member explained that he was on vacation in April and did the inspections early. Kowalenko made clear that the hospital must have someone else do the job during his absence so the inspection would be done during the actual month.

The surveyor will want to see your emergency procedures for events such as evacuations, floods, or tornadoes. If your hospital is part of a large healthcare system, pull out the procedures that don’t apply to your facility. For example, hospitals in Illinois do not need a hurricane policy.

Think of your documents as the building blocks to a solid house, Kowalenko says. They also can give your surveyor a high level of confidence in your facility’s compliance.


CMS may adopt 2012 Life Safety Code®

It’s 2010, but the Centers for Medicare & Medicaid Services (CMS) requires hospitals to comply with the 2000 edition of the Life Safety Code® (LSC). 

However, CMS may look at adopting the 2012 edition of the LSC, says Henry Kowalenko, supervisor of the Design Standards Unit in the Division of Health Care Regulation at the Illinois Department of Public Health.

“My understanding is that if there are enough changes, they will adopt it,” Kowalenko says.

Because of the difficult process of changing federal regulations, CMS is waiting for significant changes in the LSC before adopting a new version of the code, he says. 

But it may be time for that update. “We’re looking at 10-year-old technology now,” Kowalenko says.

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