Industry Update - March 2019

by Joe Brothman, Director, EHS & EM, UCI Health


Click here to access the full PDF version of this month's update.

CMS Revises Guidance on Declaring Immediate Jeopardy


Appendix Q to the State Operations Manual (SOM), which provides guidance for identifying immediate jeopardy, has been revised. CMS has drafted subparts to Appendix Q that focus on immediate jeopardy concerns occurring in nursing homes and clinical laboratories since those provider types have specific policies related to immediate jeopardy. To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.

New Note Clarifies Applicability of Revised NPSG.15.01.01


The Joint Commission added a Note to the recently revised National Patient Safety Goal (NPSG) NPSG.15.01.01, Element of Performance (EP) 1. The Note clarifies the applicability of EP 1 for behavioral health care settings. This Note is effective July 1, 2019, along with the recent revisions to Standard NPSG.15.01.01.

2021 NFPA 99 Open for Public Comments


The 2021 edition of NFPA 99, Health Care Facilities Code, is currently under development. The technical committees that write the document have created a first draft. More than 200 revisions were made to the code, and the following are among the most noteworthy: risk assessments, electrical PM program, responsible facility authority, micro grids, RPTs, and flammables in the OR.

The public comment phase for NFPA 99 is open until May 8. Comments can be made at by selecting the “Submit a Public Comment” link, which will pull up a clean version of the first draft. Any section of the code can then be chosen for comment, and you will be prompted to provide input.

Guide Promotes Cyber-Secure Medical Devices


The Healthcare and Public Health Sector Coordinating Council (HSCC) recently released a consensus-based guide to developing, deploying and supporting cyber - secure medical devices and health information technology across the product life cycle and improving information sharing between manufacturers and health care organizations.

Joint Commission Clarifies Medical Gas Cylinder Storage Requirements


NFPA 99 does not prohibit various medical gas cylinders from being stored in the same room as long as flammable and non-flammable gasses are not comingled. Typical medical gases whose storage can be comingled with oxygen include: Carbon Dioxide, Medical Air, Nitrogen, Nitrous Oxide, Helium, Argon, and Xenon. All criteria as specified in EC.02.05.09 applies as well as NFPA 99-2012 requiring full and empty cylinders to be segregated from each other.

As previously indicated, non-flammable medical gas cylinders cannot be comingled with; flammable materials, cylinders containing flammable gases, or containers containing flammable liquids. Typical flammable gases may include but are not limited to: Acetylene, Butane, Ammonia, Ethane, and Propane. This prohibition is outlined in NFPA 99-2012;

Medical gas cylinders are also not allowed to be stored in an enclosure containing motor driven devices with the exception of cylinders intended for instrument air reserve headers that must comply with NFPA 99 -2012; This reference can be found at NFPA 99-2012;

Recent Door Inspection Findings


ASHE has contracted with the Center for Health Design (CHD) to research why the failure rate of fire doors in hospitals is as high as is being documented during accreditation surveys.

According to ASHE, the most common citations during accreditation surveys has been the failure of doors to properly latch. Doors that were working at the beginning of the survey fail during the surveyor’s test. The problem has existed for decades. During a recent “Focus on Compliance” project, it was discovered that over 30 percent of all door failure citations were due to a latch failure.

Thus far, the CHD research indicates that there may be other noncompliant conditions found during annual inspections that may be more prevalent than door latching failures. It is hoped that researching the cause of fire door failures may provide insight on how to resolve these issues and ensure the reliability of these life safety barriers.

The goal is for the research to be completed and a report presented at the 2019 ASHE Annual Conference.

Internal Inspections Tool for Facilities Staff


Hospitals often rely on vendors for support and expertise to conduct code-specified inspections and testing of various systems. However, health facility managers may be unaware that some inspections and testing specified by code do not have to be conducted by a specially licensed or certified professional.

Many of these procedures can be conducted in-house, such as fire doors and monthly fire extinguisher checks. However, many do not know that this category also includes firefighter elevator recall, fire/smoke damper testing, medical gas alarm panel testing and more.

This new tool, developed by ASHE’s advocacy task force, can help facility managers determine which requirements can be completed in-house and the possible cost benefits of each.