OASC | SAFETY

Managing Life Safety Code Compliance

Is your ASC meeting the requirements?

By James Knaub, Contributing Editor

In today’s medical climate, the only constant is change — and your ASC’s compliance with Medicare’s Life Safety Code (LSC) requirements is no exception. The 2000 edition of the NFPA101 Life Safety Code, published by The National Fire Protection Association (NFPA), is currently the version specified in the Code of Federal Regulations and enforced by CMS.

Here are two pathways to LSC compliance, as well as tips you and your staff can use to prepare your ASC for surveys.

Ensuring LSC Compliance: Two Options

The LSC is a “set of fire protection requirements to provide a reasonable degree of safety from fire,” according to the CMS website. Medicare adopts its requirements from recommendations published by the NFPA as NFPA 101 Life Safety Code (2000 edition). The code includes fire safety standards for both construction and ongoing maintenance of buildings, including some requirements specific to ASCs. It encompasses a range of standards, such as fire-resistant construction, alarm systems, sprinkler systems, medical gas systems, electrical systems, emergency exit signs and exit lighting.

There are two pathways to LSC compliance for an ASC. First, an ASC can be inspected by a state official who has been authorized by CMS to conduct LSC inspections. The requirements are defined in Medicare’s State Operations Manual Appendix L, which stipulates compliance with the NFPA 101 Life Safety Code standards. CMS partners with its designated survey agency in each state to assess facilities for LSC compliance. Those agencies either conduct the surveys themselves or subcontract with relevant state officials, such as state fire marshals, to perform them. All unaccredited ASCs are surveyed by their respective state agencies in this manner.

As an alternative path, CMS accepts accreditation from the AAAHC, the Joint Commission, the Healthcare Facilities Accreditation Program, and the American Association for Accreditation of Ambulatory Surgery Facilities to certify compliance. An accreditation relationship with any of these four organizations includes LSC compliance as part of their survey process.

If your ASC is accredited by one of the four deemed organizations, its recurring (every 3 years) surveys and corrections process keep it in compliance. Any changes in the LSC requirements are incorporated into the triennial accreditation surveys.

Some states require accreditation for ASC licensure (and some insurers require it for reimbursement), so many ASCs already have an LSC compliance mechanism in place under the larger umbrella of their accreditation.

“We have a contract with CMS to act as a deeming authority on their behalf,” says Daniel Ross, a field director with the Joint Commission’s Division of Accreditation & Certification Operations. “We’re surveying on behalf of CMS that an ASC is meeting or exceeding the CMS requirements.”

There are both similarities and differences among the four deemed organizations’ survey processes. The organizations offer different resources to assist their customers in developing and implementing compliance plans. For example, Ross says Joint Commission surveyors often have a significant educational role.

“We have content experts in the LSC and safety in general,” Ross says. “They spend a great deal of time, while on site, engaging customers and educating them on best practices.”

When a state agency or accreditation survey finds areas judged out of compliance, the surveyors prepare a plan of correction for what needs to be done and a time frame for completion. The ASC can accept the findings, plan for corrections and move forward, or it can formally challenge the findings.

While accreditation and state agency surveys happen cyclically, CMS reserves the right to conduct surprise validation surveys.

Testing and Maintenance

Though much of LSC compliance is tied to construction and build-out, an ASC operator still needs a set plan for ongoing testing, maintenance and documentation. For example, a schedule should be in place to conduct periodic safety drills. Also, staff should be trained on evacuation and emergency protocols, including the locations of all exits and extinguishers, as well as where emergency shut-off valves and breaker boxes for electrical are located in case of a fire.

In addition, there are many LSC requirements that are often misinterpreted by ASC operators, says William E. Lindeman, AIA, a medical architect and compliance consultant and president of WEL Designs. A few of the most common to watch out for include the following:

• Incomplete record keeping. Detailed records of Life Safety Code requirements your ASC has met must be kept on file. Key systems, such as fire alarms, sprinklers, emergency power generators, and medical gases require inspection and documentation. ASC management should work with the vendors who service the equipment to provide inspection information and then must file it for future surveys.

“It’s best to address this when you first negotiate your contract with a vendor,” Lindeman says. “If that didn’t happen, tell the vendor your ASC needs to comply with the NFPA standards and request their help in deciding what the vendor should inspect and maintain, and what ASC staff can handle and document.”

• Flame-resistant privacy curtains. The privacy curtains separating spaces in patient areas must be rated as flame resistant. Most are, says Lindeman, but they may not be tagged accordingly. A surveyor will require the ASC operator to obtain documentation for the flame-resistant curtain or, if necessary, replace it.

• Unsealed holes in walls or ceilings that are fire barriers. Computer cabling is a common culprit for this problem, Lindeman says. When information technology workers make changes to an ASC’s computer network, they drill holes to place new cables. The LSC requires those holes to be caulked tightly around the cables.

• Inadequate exit directions. Lindeman says it’s common for facilities to have noncompliant exit signage. At any point in a hallway, a person must be able to see an exit sign with a directional arrow toward the nearest exit. Surveyors will check from every section of the hallway.

A Moving Target

Compliance is also a moving target, so staying up to date on LSC requirements is critical. The current Medicare State Operation Manual Appendix L and NFPA101 Life Safety Code documents are available online from CMS and NFPA, respectively. In addition, some accrediting organizations offer checklists, guidebooks and even consulting services to help you maintain a safe environment for staff and patients. ■