Critical Access Hospital Physical Plant

1
Critical Access HospitalPhysical Plant
EnvironmentLife Safety Code Survey(LSC)

• Henry Kowalenko
• Design Standards Unit
• Division of Health Care Facilities and Programs
• March 18, 2009

2
Rules and Regulations

• The following rules and regulations are used when
  surveying a facility.
• Illinois Hospital Licensing Requirements, 77
  IL Admin Code 250
• Center for Medicare and Medicaid Services (CMS)
• CFR 485.623d Standard Life Safety from Fire
• National Fire Protection Association - NFPA 101
  Life Safety Code (2000 Edition)
• Chapter 18, New Healthcare Occupancies
• Chapter 19, Existing Healthcare Occupancies
• Illinois Plumbing Code - 225 ILCS 320 February
  , 2004
• Illinois Accessibility Code - 71 Illinois Admin
  Code 400

3
LSC Survey Process

• The Department inspector will be escorted on a
  tour of the facility. The following items should
  be available
• Keys to all areas
• Ladder
• Flashlight
• Small floor plan which indicate
• Fire barriers and ratings
• Suite designations
• Exits

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LSC Survey Process

• The inspector will conduct a review of the
  following documentation
• Fire drills records
• Fire alarm testing
• Emergency generator testing
• Kitchen hood suppression systems
• Fire extinguishers annual testing and maintenance
• Written fire and emergency policy and procedures
• Interior finish ratings
• History of each building to include
• Construction dates
• Type of occupancy
• Construction type

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LSC Survey Process

• During the inspection, the fire alarm and
  sprinkler systems will be tested.
• Fire alarm system this is a test and not a
  drill. Staff response is not necessary.
• Pull Stations
• Key will need to be available to reset
• Smoke detectors
• Functional test (no magnets), Canned smoke is
  required
• Water flows tamper valves (if sprinklered)
• Verify water flow activation within 90 seconds
• Inspector test pipe to a location than can accept
  full flow

6
LSC Survey Process

• During the exit interview, the inspector will
• identify the deficiencies found
• inform the Provider of the CMS survey process
• answer questions
• The survey is not all inclusive and represents a
  sample of findings. The Provider is responsible
  for compliance with all applicable codes.

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LSC Survey Process

• The Provider will receive a Statement of
  Deficiencies and Plan of Correction (SoD/PoC),
  CMS 2567 form. This form is sent to the Provider
  by certified mail within 15 calendar days of
  survey exit date.
• Call IDPH for clarification if the deficiency is
  unclear, you have questions or you need an
  extension to file the POC.
• The Provider must use the forms provided to
  submit their Plan of Correction (PoC)

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LSC Survey Process

• The Plan of Correction must
• Clearly identify what will be done to correct the
  deficiency
• Indicate who is responsible for the corrective
  action
• No proper names
• Completion dates must be reasonable and formatted
  as mm/dd/yy
• If the corrective action requires a number of
  steps, identify the steps and when they will be
  completed.
• Example
• Obtain consultant Date
• Review solutions Date
• Bid work Date
• Start work Date
• Work complete Date

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LSC Survey Process

• Plan of Correction (PoC)
• The PoC should be submitted to the IDPH within 10
  days of receipt of the SoD.
• If the PoC is deemed acceptable and all
  deficiencies will be corrected within 45 calendar
  days a LSC survey is scheduled, the corrections
  verified and the survey is cleared.
• If the PoC is deemed acceptable and received in a
  timely manner, however, the corrections will not
  be completed by the 55th day, a termination date
  will be established and the Provider notified.
  IDPH monitoring survey schedule will be
  established.

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LSC Survey Process

• If the PoC is received in a timely manner and is
  deemed unacceptable, CMS will notify the Provider
  of a termination date and request the Provider to
  submit an acceptable PoC.
• If the PoC is not submitted in a timely manner,
  IDPH will notify CMS that we are unable to
  receive a PoC. CMS will establish a termination
  date and request the PoC from the Provider.

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LSC Survey Process

• Monitoring surveys are unannounced.
• When monitoring surveys are conducted, it will be
  necessary to provide the same equipment and
  material as the original survey.
• Monitoring surveys are focused on the areas of
  previously identified deficiencies.
• Additional deficiencies can be cited
• If deficiencies are not corrected or new
  deficiencies are cited, a revised SoD will be
  issued to the Provider and a revised PoC will be
  requested.
• The termination date may be adjusted.

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LSC Survey Process

• Fire Safety Evaluation System (FSES) NFPA 101A
  (2001 Edition)
• FSES may be used when prescriptive compliance
  cannot be achieved.
• The FSES is based on a point system.
• The Authority Having Jurisdiction must concur
  that the FSES is reasonable.

13
LSC Survey Process

• When all deficiencies are corrected and no new
  deficiencies are cited, IDPH will forward the
  documentation to CMS to clear the survey.
• CMS will issue a letter indicating the
  termination has been rescinded.

14
Design Standards Unit Staff

• Henry Kowalenko, Supervisor
• Jody Gudgel, Administrative Assistant
• Stephanie Lane, Office Associate
• Architects
• Lynn Manley
• Thomas Busse
• William Bender
• Laura Cramer
• Engineers
• Justin Dammerman
• Don Hall
• Project Designers
• Pam Hastings
• Theresa (Tess) Jimenez

15
Contact Us

• Design Standards Unit
• 525 West Jefferson Street, 4th Floor
• Springfield, IL 62761
• 217-785-4264 Phone
• 217-782-0382 Fax
• dph.design.standards_at_illinois.gov (for general
  information)

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LSC Survey Process

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