2024 DHA Industry Day_Facilities Accreditation Compliance.pdf

Improving Health and Building Readiness. Anytime, Anywhere — AlwaysImproving Health and Building Readiness. Anytime, Anywhere — Always

DHA Industry Day Facilities Operations Branch -

Facilities Accreditation and Compliance

14 Aug 2024 Controlled By: DHA Facility Ops Branch CUI Category: PROPIN

DISTRO/LDC: FEDCON

POC: (210) 831-7684

CUI

Improving Health and Building Readiness. Anytime, Anywhere — Always

Agenda

• Facilities Accreditation and Compliance Team

• DHA Accreditation Program DHA-PM 6025.13, Vol 5, Clinical Quality Management in the Military Health System

DHA Program Memorandum 4140.01 Accreditation and Certification Compliance Management for Defense Health, 13 JUN 22

• Hospital and Ambulatory DHA Accreditation Assist Visit and Triennial Survey Findings

• Operations and Maintenance Contract Supporting Survey Readiness

Facilities Accreditation and Compliance Team

Chief, Facilities Accreditation & Compliance - Maj Ryan Combest Email: ryan.s.combest.mil@health.mil

Comm: (210) 536-6193

Facilities Accreditation and Compliance - Mr. Steven Middlecamp Email: steven.p.middlecamp.civ@health.mil

Comm: (210) 536-6024

Best way to contact us: dha.ncr.j-6.mbx.dha-fe-fob-fac-ac@health.mil

Improving Health and Building Readiness. Anytime, Anywhere — AlwaysImproving Health and Building Readiness. Anytime, Anywhere — Always

DHA Accreditation Program

• DHA-PM 6025.13, Vol 5, Clinical Quality Management in the Military Health System

DHA ACP Accreditation Assistance Visit (Mock Survey – DHA contractor executed)

DHA FAC Ad Hoc Education and Training Visit

The Joint Commission Triennial Survey

• DHA PM 4140.01 Accreditation and Certification Compliance Management for Defense Health, 13 JUN 22

Transition to Life Safety Code 101: 2021

MTF determines based timing of Triennial Survey

Hospital DHA AAV Findings: EC/LS (10 MTFs; 2024) Number of

Occurrences Standard

Chapter/Element of Performance

8 80% The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes penetrating the walls or floors are protected with an approved fire-rated material.

LS.02.01.10 EP14

7 70% The hospital inspects, tests, and maintains the following: Non-high-risk utility system components on the inventory. The completion date and the results of the activities are documented.

EC.02.05.05 EP6

6 60% In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature, and humidity.

EC.02.05.01 EP15

6 60% The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control. Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code

EC.02.05.09 EP11

5 50% In non–critical care areas, the ventilation system provides required pressure relationships, temperature, and humidity. Note: Examples of non– critical care areas are general care nursing units; clean and soiled utility rooms in acute care areas; laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments.

EC.02.05.01 EP16

5 50%Piping for approved automatic sprinkler systems is not used to support any other itemLS.02.01.35 EP4

4 40%

Fire-rated doors within walls and floors have functioning hardware, including positive latching devices and self-closing or automatic-closing devices (either kept closed or activated by release device complying with NFPA 101-2012: 7.2.1.8.2). Gaps between meeting edges of door pairs are no more than 1/8 of an inch wide, and undercuts are no larger than 3/4 of an inch. Fire-rated doors within walls do not have unapproved protective plates greater than 16 inches from the bottom of the door. Blocking or wedging open fire-rated doors is prohibited.

LS.02.01.10 EP11

4 40%

All existing hazardous areas have doors that are self-closing or automatic-closing. These areas are protected by either a fire barrier with one-hour fire resistive rating or an approved electrically supervised automatic sprinkler system. Hazardous areas include, but are not limited to, boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 square feet, paint shops, repair shops, soiled linen rooms, trash collection rooms with containers exceeding 64 gallons, laboratories employing flammable or combustible materials deemed less than a severe hazard, and storage rooms greater than 50 square feet used for storage of equipment and combustible supplies.

LS.02.01.30 EP3

Hospital TJC Findings: EC/LS (5 MTFs; 2024) Number of

Occurrences Standard

Chapter/Element of Performance

5 100% The hospital labels utility system controls to facilitate partial or complete emergency shutdowns. EC.02.05.01 EP 9

4 80% The hospital inspects, tests, and maintains the following: Non-high-risk utility system components on the inventory. The completion date and the results of the activities are documented.

EC.02.05.05 EP 6

4 80%

Fire-rated doors within walls and floors have functioning hardware, including positive latching devices and self-closing or automatic-closing devices (either kept closed or activated by release device complying with NFPA 101-2012: 7.2.1.8.2). Gaps between meeting edges of door pairs are no more than 1/8 of an inch wide, and undercuts are no larger than 3/4 of an inch. Fire-rated doors within walls do not have unapproved protective plates greater than 16 inches from the bottom of the door. Blocking or wedging open fire-rated doors is prohibited.

(For full text, refer to NFPA 101-2012: 8.3.3.1; 7.2.1.8.2; NFPA 80-2010: 4.8.4.1; 5.2.13.3; 6.3.1.7; 6.4.5)

LS.02.01.10 EP 11

4 80%Piping for approved automatic sprinkler systems is not used to support any other item. (For full text, refer to NFPA 25-2011: 5.2.2.2)LS.02.01.35 EP 4

3 60% The ceiling membrane is installed and maintained in a manner that permits activation of the smoke detection system. (For full text, refer to

NFPA 101-2012: 18/19.3.4.1)

LS.02.01.34 EP 9

3 60% Sprinklers are not damaged. They are also free from corrosion, foreign materials, and paint and have necessary escutcheon plates installed.

(For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.5; NFPA 25-2011: 5.2.1.1.1; 5.2.1.1.2; NFPA 13-2010: 6.2.6.2.2; 6.2.7.1)

LS.02.01.35 EP 5

2 40% In non–critical care areas, the ventilation system provides required pressure relationships, temperature, and humidity. Note: Examples of non–critical care areas are general care nursing units; clean and soiled utility rooms in acute care areas; laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments.

EC.02.05.01 EP 16

2 40%

Doors in smoke barriers are self-closing or automatic-closing, constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1/8 of an inch. In new buildings, undercuts are no larger than 3/4 of an inch, and doors in a means of egress swing in the opposite direction

LS.02.01.30 EP 20

Ambulatory Care DHA AAV Findings: EC (23 MTFs; 2024) Number of

Occurrences Standard

Chapter/Element of Performance

13 56%

Documentation of maintenance, testing, and inspection activities for EC.02.03.05, EPs 1–20, 25 (including fire alarm and fire protection features) includes the following: - Name of the activity - Date of the activity - Inventory of devices, equipment, or other items - Required frequency of the activity - Name and contact information, including affiliation, of the person who performed the activity - NFPA standard(s) referenced for the activity

EC.02.03.05 EP28

12 52%The organization minimizes the potential for harm from fire, smoke, and other products of combustion.EC.02.03.01 EP1

12 52%The organization meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15.EC.02.03.01 EP13

9 39% In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, relative humidity, and temperature

EC.02.05.01 EP7

9 39%The organization labels utility system controls to facilitate partial or complete emergency shutdowns.EC.02.05.01 EP9

8 35% Every week, the organization inspects the emergency power supply system (EPSS), including all associated components and batteries. The results and completion dates of the inspections are documented.

EC.02.05.07 EP4

6 26% In non–critical care areas, the ventilation system provides required pressure relationships, temperature, and humidity. Note: Examples of non– critical care areas are general care nursing units; clean and soiled utility rooms in acute care areas; laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments.

EC.02.05.01 EP16

Ambulatory Care TJC Findings: EC (7 MTFs: 2024) Number of

Occurrences Standard

Chapter/Element of Performance

2 29%The organization inspects, tests, and maintains the following: Utility systems. The completion dates and test results are documented.EC.02.05.05 EP 3

1 14%At least monthly, the organization inspects portable fire extinguishers. The results and completion dates are documented. EC.02.03.05 EP 15

1 14%The organization labels utility system controls to facilitate partial or complete emergency shutdowns. EC.02.05.01 EP 9

1 14% Every 12 months, the organization performs a functional test of battery-powered lights on the inventory required for egress and exit signs for a duration of 1 1/2 hours.

EC.02.05.07 EP 2

1 14%At least annually, the organization tests the fuel quality to ASTM standards. The test results and completion dates are documented. EC.02.05.07 EP 8

1 14%

The organization makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control. Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (see NFPA 99-2012: Table 5.1.11), and operating pressure if other than standard. Labels are at intervals of 20 feet or less and are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency.

EC.02.05.09 EP 11

1 14% When the organization has bulk oxygen systems above ground, they are in a locked enclosure (such as a fence) at least 10 feet from vehicles and sidewalks. There is permanent signage stating “OXYGEN – NO SMOKING – NO OPEN FLAMES.”

EC.02.05.09 EP 8

Operations and Maintenance Contract Supporting Survey Readiness

• Keys to a Medical Treatment Facility Survey Success:

TJC Documentation Operations and Maintenance Library Inspection, Testing and Maintenance Infection Prevention / Pre-Construction Risk Assessments (ICRA/PCRA) Interim Life Safety Measures (ILSM)

Performance of Inspection, Testing and Maintenance in accordance with appropriate NFPA code, applicable code and regulations.

Performance Improvement Opportunities Mock Survey

Summary

• Contact us if you have questions

• LSC 101: 2021 Edition

• DHA Mock Surveys/AAVs and TJC Survey Findings are an evaluation of performance!