Center for Improvement in Healthcare Quality Newsletter
April 2022

News You Can Use

April Compliance Tip of the Month

Billy Kinch – MHA, HACP-PE has provided April’s tip of the month. It is related to your facilities CIHQ accreditation application regarding the occupancy classifications of your various locations. This is information entered by the facility on page four of the application.
The focus of this this tip is to look at what the requirements are when determining your occupancy classifications of your building. We first need to start by looking at the definitions out of the NFPA 101-2012 Life Safety Code. Here is what it says for the definitions of the following:
  • Ambulatory Health Care Occupancy – An occupancy used to provide services or treatment simultaneously to four or more patients that provides, on an outpatient basis, one or more of the following:
    • Treatment for patients that renders the patient’s incapable of taking action for self-preservation under emergency conditions without the assistance of others;
    • Anesthesia that renders the patient’s incapable of taking action for self-preservation under emergency conditions without the assistance of others;
    • Emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.
    • Annex Note: It is not the intent that occupants be considered to be incapable of self-preservation just because they are in a wheelchair or use assistive walking devices, such as a cane, a walker, or crutches. Rather, it is the intent to address emergency care centers that receive patients who have been rendered incapable of self-preservation due to the emergency, such as being rendered unconscious as a result of an accident or being unable to move due to sudden illness.
  • Business Occupancy – An occupancy used for the transaction of business other than mercantile.
  • Health Care Occupancy – An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants’ control.
The Center for Medicare/Medicaid Services (CMS) does go a little further on the definition as it relates to an Ambulatory Health Care Occupancy. It states that “Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served.”
As you can see, this is a significant change from that of the NFPA definition which would require 4 or more patients. CMS says that it only takes one patient for these types of departments to be considered Ambulatory Health Care Occupancy as opposed to possibly a Business Occupancy.
It is important for organizations to take a very close look at how they are classifying their different locations to ensure they are applying the appropriate code.
Organizations are encouraged to review their CIHQ applications to assure that the various locations are appropriately classified. This will aid CIHQ to plan your next accreditation survey appropriately.
Both the CMS and CIHQ standards/requirements have been included for reference.

CIHQ

CE-15: Compliance to the NFPA Life Safety Code
The hospital must meet the applicable provisions and must proceed in accordance with the NFPA 101-2012 Edition of the Life Safety Code and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4. Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served.
Note: See the glossary for additional information
Note: In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients.
Note: The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals.
  1. The organization must comply with applicable provisions – and referenced codes – of the NFPA 101 2012 Edition of the Life Safety Code for all buildings designated as healthcare occupancy, and/or ambulatory occupancy.
    Note: Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
    Note: A hospital may install alcohol-based hand rub dispensers in its facility if the dispensers are installed in a manner that adequately protects against inappropriate access;
    Note: When a sprinkler system is shut down for more than 10 hours, the hospital must evacuate the building or portion of the building affected by the system outage until the system is back in service, or establish a fire watch until the system is back in service.
    Note: Buildings must have an outside window or outside door in every sleeping room, and for any building constructed after July 5, 2016, the sill height must not exceed 36 inches above the floor. Windows in atrium walls are considered outside windows for the purposes of this requirement.
    The sill height requirement does not apply to newborn nurseries and rooms intended for occupancy for less than 24 hours. The sill height in special nursing care areas of new occupancies must not exceed 60 inches.
  2. Organizations with business occupancies must meet egress requirements for mixed occupancies within the hospital and buildings separated from the hospital in accordance with NFPA 101, Chapter 39 and Chapter 39
  3. The organization must implement temporary life safety measures to compensate for an identified deficiency(s) in the Life Safety Code until the deficiency(s) can be corrected.
    • The organization determines the temporary life safety measures required based on the nature of the deficiency. It is recognized that some deficiencies (minor) may not require temporary measures
    • The organization implements temporary life safety measures as required. The implementation of temporary life safety measures is documented.
  4. The organization shall maintain a current set of fire and life safety drawings for each building classified as a healthcare or ambulatory occupancy. Drawings deemed to meet this requirement shall have the following minimum information displayed:
    • The identification and type of construction of the building
    • The occupancy classification of the building including all use areas, floors and mixed occupancies
    • The areas of the building fully protected by automatic fire sprinkler systems.
    • The locations of all fire rated barriers and smoke barriers
    • The location and limits of corridors and corridor walls
    • The location and boundaries of all suites including the area in square feet and identified as a sleeping or non-sleeping suite.
    • The location and fire rating of all vertical openings including chutes, shafts and exit enclosures.
    • The location of all exits and exterior exits from the buildings – including any horizontal exits
    • The location of all hazardous areas
    • The location and documentation of any approved equivalencies or waivers.
  5. Fire and life safety drawings shall be made available in a minimum readable format of at least 11 inches by 17 inches in size. Drawings shall display standard conventions including:
    • Title
    • Scale or graphic scale
    • North arrow and geographic orientation
    • Author or person who prepared the drawing
    • Date created along with any revisions
    • Legend

CMS

§482.41(b)
  1. Except as otherwise provided in this section—
    1. The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12–1, TIA 12–2, TIA 12–3, and TIA 12–4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served.
    2. Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
  2. In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients.
  3. The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals.
There are tools made available to CIHQ accredited organizations through the ARS provided resources to assist with compliance:

CIHQ Announces New Disease Specific Certification – Primary Heart Attack Center

CIHQ proudly announces the launching of a new disease specific certification program for Primary Heart Attack Center. This certification is designed to recognize the provision of evidence-based best practice to patients experiencing a heart attack requiring interventional cardiac services. The standards for this disease specific certification are based on the 2021 American Heart Association Guideline for Artery Revascularization and the 2020 American Heart Association Acute Coronary Syndrome Algorithm. For more information click on the DSC on your extranet home page. Not accredited by CIHQ you can still become certified in any one of our programs and can get our standards and information at cihq.org/dsc.asp

CIHQ to Attend TORCH Convention in April 2022

Visit CIHQ at Booth #105 TORCH in April
CIHQ is proud to announce our Corporate Membership with the Texas Organization of Rural & Community Hospitals (TORCH) whose vision is to provide rural Texas access to the highest quality healthcare. The mission of TORCH is to be the voice and advocate for rural and community hospitals, and to provide leadership in addressing needs and issues that arise. We believe this partnership will serve CIHQ and TORCH through shared values of providing the best customer service, using data as a basis for setting policy and improving outcomes, and an open dialogue. CIHQ and TORCH strive to be prepared for changes, maintain growth and to build strategic relationships that enhance effectiveness.
Stop by and see CIHQ at Booth 105 during the TORCH Spring Conference & Trade Show in Dallas, April 19-21, 2022. This distinctive event is the premiere source for quality education and networking for rural hospital leaders and decision makers in Texas. Learn about current issues, reinforce old relationships, and build new ones, show your support for rural and community hospitals. Guest speakers include John M. Zerwas, MD, Executive Vice Chancellor for Health Affairs, The University of Texas System, Texas Senator Lois Kolkhorst, and Benjamin Anderson, Vice-President, Rural Health and Hospitals at Colorado Hospital Association.