Life Safety Code Surveys · Life Safety Code Presentation 1 Sally Kimbrough-McAuley Licensure &...
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Alabama Department of Public Health October 20, 2011 Life Safety Code Presentation 1 Sally Kimbrough-McAuley Licensure & Certification Supervisor Life Safety Code Unit Alabama Department of Public Health 334-206-5185 Direct 334-206-5890 Fax [email protected] 2 Life Safety Code Surveys • Deemed hospitals -“Validation surveys” validate The Joint Commission (TJC) survey. • Hospitals are selected by CMS in Baltimore after the TJC survey • Unannounced. • Survey reports and variance requests are reviewed and approved by CMS in Atlanta based on the State Agency review 3 Life Safety Code Surveys • Non-Deemed Hospitals not certified by an agency such as The Joint Commission • “Recertification Surveys” approximately every three years • Unannounced • Survey reports and variance requests are reviewed by the state • Variance requests are approved by CMS Atlanta 4 Life Safety Code Surveys • Complaint Survey • Due to serious deficiencies of a complaint investigation may cause a ‘full’ survey • Unannounced • Survey reports and variance requests are reviewed and approved by CMS in Atlanta based on state agency review. 5 CMS Survey Forms – Dated 06/2007 http://www.cms.hhs.gov/cmsforms/downloads/CMS2786 R.pdf 6 [email protected] [email protected] [email protected] [email protected] General phone number 334-206-5177 www.adph.org/facmgmt 7
Transcript of Life Safety Code Surveys · Life Safety Code Presentation 1 Sally Kimbrough-McAuley Licensure &...
Alabama Department of Public Health October 20, 2011
Life Safety Code Presentation 1
Sally Kimbrough-McAuley
Licensure & Certification Supervisor
Life Safety Code UnitAlabama Department of Public Health
334-206-5185 Direct334-206-5890 Fax
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Life Safety Code Surveys• Deemed hospitals - “Validation surveys”
validate The Joint Commission (TJC) survey.
• Hospitals are selected by CMS in Baltimore
after the TJC survey
• Unannounced.
• Survey reports and variance requests are
reviewed and approved by CMS in Atlanta
based on the State Agency review
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Life Safety Code Surveys
• Non-Deemed Hospitals not certified by an
agency such as The Joint Commission
• “Recertification Surveys” approximately every
three years
• Unannounced
• Survey reports and variance requests are
reviewed by the state
• Variance requests are approved by CMS
Atlanta
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Life Safety Code Surveys
• Complaint Survey
• Due to serious deficiencies of a complaint
investigation may cause a ‘full’ survey
• Unannounced
• Survey reports and variance requests are
reviewed and approved by CMS in Atlanta
based on state agency review.
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CMS Survey Forms – Dated 06/2007
http://www.cms.hhs.gov/cmsforms/downloads/CMS2786
R.pdf 6
General phone number
334-206-5177
www.adph.org/facmgmt
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Hold-Open Devices Approved
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Self-Closing Device
►Required
►Must be Operable
Disabled Closing Devices Are Not Permitted39
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Latching Hardware Must be Operable
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K-026 Smoke Compartments
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Locks
K-038 Accessible Means of Egress
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Maintain Clear Corridor Width and Access to Exits
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I’m Glad To Be Here,
But It Is TimeFor My Exit…
Thank You!!!
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IN GOD WE TRUST,
EVERYBODY ELSE SHALL…
DOCUMENT!
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Sally McAuley
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Statement of Deficiencies (SOD)
Due out of the State office within 10 working days
Plan of Correction (POC)
Returned to State within 10 calendar days as stated in letter
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Each deficiency must have 4 elements, with a completion date
not later than the date shown in the ADPH letter.
Correction time is limited to 35 days after the Life Safety Code
Team has left your facility.
Waivers for additional time may be granted.
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� Each deficiency must have a POC
(Plan of Correction), with a completion date not later than the
date shown in the ADPH letter.
� 35 days after the Life Safety Code surveyor has left your facility
� Waivers for additional time may be
granted.
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4 ELEMENTS OF A POC
Specific corrective action.
Identify any other occurrences. This will help you NOT get the same tag next year.
Policies/procedures you have set in place to insure the deficiency will not occur again.
How will you monitor the policies/procedures you have set in place? Who will collect the information? How often will it be collected? What will trigger additional action?
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Waiver Request
� Waivers must be approved by CMS
in Atlanta
� State does not approve waivers, State Agency only recommends
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Waiver Request
�Types
• Continuous
• Time-limited or short-term
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Continuous Waiver
� Corridor used as a return air plenum
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Time-Limited or Short-Term Waiver
� A smoke removal system
� Upgrading a generator
� Replacing fire alarm system
� Installing sprinkler system
� Replacing non-rated ceiling assembly with a UL-listed assembly
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� Request the waiver in writing on letterhead, with justification, including:
� Anticipated start date and completion dates
� Reasons why the additional time is needed
� Approval by Board/Owners
� Bids
� Hire an Architect/Engineer/Contractor
� Send copy of purchase orders
� Include construction milestones or schedule
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� More information provided is better than less information
� All information is sent to CMS for approval
� Weekly or monthly progress reports shall be
provided to the State Agency as determined by CMS or the State Agency
� Revisit will be conducted to verify progress and compliance
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