Center for Improvement in Healthcare Quality Newsletter
June 2022

News You Can Use

June’s Compliance Tip of the Month

“Scab Patch” in a Fire Barrier

June’s compliance tip of the month is focused on an issue that could start to be cited during survey. One of the new hot topic areas around life safety code compliance is around “scab patches” in fire rated barriers. Some of you are asking what in the world is a scab patch. I will do my best to describe what it is. Imagine you look above the ceiling at a fire rated barrier. You see a round open hole that is about 3-inches in diameter. You decide to fix the opening by cutting out a square piece of fire rated gypsum board and placing it over the 3-inch round hole opening. You apply it with dry wall screws and then put fire caulk around the exterior of the patch. This is called a scab patch (it has other names as well). The proper way to have corrected the opening would have been to cut out the square opening in fire wall and place the patch flush with the existing fire wall.
So, what is the big fuss about you ask? The issue is that this type of patch work does not meet any UL listed system to seal a penetration in a fire rated barrier. Fire rater barriers are tested to withstand a burn test set forth in ASMT E119 and UL 263. Once the barrier has passed this burn test it is subject to a hose stream test based on UL1479 and ASTM E814. The scab patch would not have been included in the testing standards listed above and therefore could not be verified if it would work. Therefore, it is not an approved system to seal penetrations. There are numerous penetration systems and products on the market that were developed and tested to meet these requirements. These are the types of products that will need to be used.
Now the big questions that will come from organizations who have these types of patches will be am I required to fix these if they are existing to the building. This will be dependent upon your Authority Having Jurisdiction (AHJ). I believe that most AHJ’s would require you to fix these patches since they have more than likely not been approved/tested as a UL system. Unfortunately, the burden of proof will be placed on the hospital to show that these types of patches would meet the UL system requirements for sealing a penetration. The hospital would need to have documentation to prove this if they have any. If not, the AHJ may require you to correct these patches with an appropriate UL system. My advice to hospitals is to evaluate your barriers and determine if you have any of these types of patches. If so, I would recommend starting the process to correct them before an AHJ identifies them.


§482.41 Condition of Participation: Physical Environment
§482.22(b)(1)(i)(ii) Standard: Compliance to the Life Safety Code
(1) Except as otherwise provided in this section—
(i) 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.
(ii) 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.


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.
A. 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

CIHQ publishes standard revisions ahead of CMS renewal effort

The Center for Improvement in Healthcare Quality (CIHQ) has updated its hospital accreditation standards as it finalizes its reapplication to CMS to remain as one of the four accreditation organizations (AO) for hospitals.
The most significant change is the addition of a new Infection Prevention and Control (IC) standard, IC-13: COVID Vaccination of Healthcare Workers, with the new requirements from CMS.
The standard is taken directly from information provided by CMS to its own surveyors in the hospital attachment to the Quality, Safety and Oversight (QSO) memo outlining the requirements for vaccinating healthcare workers against COVID-19.
All of the changes have already been approved by CMS and are in the most recent April 2022 standards, which are posted on CIHQ’s website along with their accreditation policies, FAQs and pricing information.
CIHQ rarely changes its standards unless required to by CMS, says Traci L. Curtis, RCP, HACP, CIHQ’s Executive Director of Survey Operations. “People don't need a moving target, you know, and we don't do quarterly updates,” says Curtis.
First approved as an AO in 2013, CIHQ was approved for renewal in 2017 for six years, which was longer than any other AO at the time. Curtis says she hoping for another six-year extension.
While The Joint Commission, DNV Healthcare and HFAP have all taken criticism in recent CMS reports to Congress, CIHQ has escaped that critique but mostly because it has so few hospitals to survey year to year.
However, Curtis says CIHQ is also trying to increase the number of hospitals it accredits. Starting off with only three hospitals in 2013, CIHQ now represents 176 with 21 hospital applications pending, says Curtis.
The AO should have its application for renewal into the AO by this spring or early summer, she says. Their current approval runs through July 26, 2023.
Curtis says she is not expecting more changes to the standards. But CMS’ review process often includes recommendations for more changes.
Some of the changes in the April 2022 standards are minor additions. For instance under Medical Staff MS-4: Appointment and Reappointment of Medical staff, revisions add that prior education, training and experience is required only at initial appointment and that a separate credential file must be maintained for each practitioner.
However, under Medical Staff, sections MS-12: Appraisal of Practitioners and MS-13: Peer Review are completely new and will be effective July 1.
Those additions are not necessarily new requirements but were not specifically outlined, says Curtis. The additions now outline what surveyors were already looking for, she says.


Here are the highlights of the revisions:
  • CE-1: Provision of Facilities: There is a newly added requirement for hospitals to implement a water management program that “considers AHSRAE industry standard and the CDC toolkit,” which have been CMS requirements since 2016. The revisions include conducting a facility risk assessment and specifying testing protocols and acceptable ranges for control measures.
  • CE-2: Construction & Renovation: Adds a notation that hospitals will assure construction or renovation is done in accordance with the NFPA 101 Life Safety Code® and NFPA 99 Healthcare Facilities Code for “rehabilitation, alteration, renovation and modernization.”
    While most hospitals are required to adhere to the 2012 versions of those NFPA codes, organizations should also be aware of local or regional authorities having jurisdiction that require other versions, says Richard Curtis RN, MS, HACP, CIHQ’s chief executive officer.
    In cases where requirements are different, hospitals will be surveyed to the most stringent of them, he says.
  • Emergency systems and preparedness: Several revisions concerning emergency power systems are broken up under CE-12, CE-13 and CE-14 and are primarily to make section headings clearer or are outlining specific requirements under NFPA codes, with specific citations. Again, these are not necessarily new requirements, but CMS wanted them to be more precise, said Traci Curtis. Similarly, revisions under Emergency Preparedness were to clarify what the standards were about.
  • IC-5: Management of Communicable Disease Outbreaks: A fourth requirement has been added that is specific to the COVID-19 outbreak, and outlines the specific information that hospitals must report to HHS. Again, the requirement is not new but has not been specifically outlined in the standards before, says Curtis.
  • Targeted Quality and Safety Practices: QS-10: Protecting Patients from Self-Harm has be reorganized under specific headings to reflect care for patients and assessment of environmental risk as well as staff training. The expectations are much the same but the section has been beefed up to ensure that hospitals understand exactly what applies to what sort of setting, says Curtis.
  • SB-17: Discharge Summary: This is a new addition to the Swing Beds chapter outlines what is expected when the facility anticipates discharging a resident. The discharge summary must include, among other things, information about the patient’s stay, a final summary of status, reconciliation of all pre-discharge medications with the residents post-discharge medications, and a post-discharge plan that is developed with the patient or patient representative.

CIHQ Joined Soleran’s Compliance Think Tank Webinar Panel

CIHQ’ own Senior Facility Specialist Billy Kinch and Soleran’s Compliance Think Tank Webinar panel joined forces to discuss their perspectives on current and upcoming changes for a facility’s water management program. Strategies and mitigation concepts were discussed as well as the difference in ASHRAE 188 concepts compared to your accrediting agency requirements. A current water management program was also be provided to help the attendee relate with real-time operations.
The Webinar was held live on May 12, 2022 at 1:00pm Central Time. It is not too late to watch it, view the Q&A session, or ask the experts a question.

CIHQ Participated in TORCH Spring Conference 2022

CIHQ attended the Texas Organization of Rural & Community Hospitals (TORCH) Spring conference for the first time. TORCH serves as a model organization and voice in the nation’s capital for rural healthcare. Their mission is to be the principal advocate, to provide leadership, and to preserve rural and community hospitals so healthcare can remain local.