ASCs must meet environmental safety standards, but they do not always put the most knowledgeable people in charge of this task, which could result in a big mistake.

“The number one problem is when healthcare organizations do not read the standards, or if they read them, they do not understand what is required,” says Brad Keyes, CHSP, an engineering advisor with the AAAHC of Skokie, IL, and the Healthcare Facilities Accreditation Program (HFAP) of Chicago.

“It’s their responsibility to make sure that someone in their organization is knowledgeable on that, and there is no shame or dishonor in asking questions,” Keyes says. “Everyone should have some mentor they could go to to ask a question.”

Some ASCs will contract with experts to conduct their environmental regulatory compliance on a weekly or monthly basis. Others might hire someone they know who has mechanical skills, even if that person does not have the necessary regulatory knowledge and competence, Keyes says.

“I’ve seen where an organization knows someone with a retired husband who can do some things, and everyone thinks he is doing a good job until the survey and he says, ‘I didn’t know I was supposed to do that,’” Keyes explains. “If a person is not working in the life safety industry, sometimes these changes and requirements can be confusing or puzzling.”

Keyes wrote the updated life safety industry standards for HFAP, basing them on the new 2012 Life Safety Code, published in a final version in 2016 by CMS.

CMS had not updated the life safety code since its 2000 edition, so a revised version was no surprise, Keyes notes.

“The National Fire Protection Association [NFPA] publicizes life safety code updates every three years, so there have been four editions since the 2000 edition,” Keyes says. “There were a lot of people lobbying CMS to adopt the new life safety codes in 2011, so they did their due diligence.”

The HFAP environment standards outline what ASCs can do to meet the new rules. The HFAP Accreditation Requirements for Ambulatory Surgical Centers is 33 pages, which includes columns for standard/element, explanation, scoring procedure, and score.

“A big part of code is interpretations,” Keyes says. “In many cases, we have to interpret the life safety code to learn how to apply it, and we’ve done all of that work over the years.”

Keyes spent about a month going through the book and updating the standards.

One of the major changes is that fire pumps can be tested monthly, instead of weekly. Another change is that water flow switches in the sprinkler system now are tested semi-annually, instead of quarterly. This relaxation of requirements is a trend in the updated rules, he notes.

“More changes of the life safety code reduce the amount of work rather than add to the work,” Keyes says.

The following are some of the other significant changes in the code and standards:

  • Side-hinged fire doors. All side-hinged, fire-rated doors must be inspected and tested on an annual basis. This requirement is entirely new, and in some healthcare facilities, it is a big change as they might feature 400-plus such doors, Keyes explains.

“In general, the technical committee that writes the standards realized that in the past, healthcare organizations have abused fire doors and did not have a plan to inspect and replace them,” he explains. “So, previously, the fire doors would be damaged and wouldn’t close and operate properly, and many healthcare organizations did not have a program to inspect them.”

The new rule was created to hold organizations accountable for the safety of their fire doors.

  • All NFPA 99 rules apply. CMS adopted the 2012 edition of NFPA 99, something it hasn’t done previously, Keyes says.

“In the past, some healthcare facilities did not have to comply with NFPA 99, and some of these changes will be a bit of a surprise to them,” he says. “One of the biggest surprises in requirements is that healthcare organizations have to do a risk assessment to categorize, from one to four, the level of risk of a particular mechanical or electrical system.”

The risk assessment shows whether a failing electrical or mechanical system is at serious risk. For example, a failure within an office environment might be rated a low risk, while in an operating room, it could be a high risk. Likewise, an elevator failure in a dental office could be low risk, but high risk in an ICU or ED.

“NFPA 99 is laid out based on the level of risk, rather than based on the occupancy,” Keyes says. “That’s how you have to evaluate your systems.”

  • Performing risk assessments. Chapter four of the NFPA 99 explains how to perform risk assessments. Although anyone can conduct the risk assessment, it’s ideal to employ someone who is knowledgeable and understands the systems. And it’s best to put multiple people on the task, Keyes suggests.

Assessors can use any template, but the rule offers three recommendations of risk assessment templates to use.

“I advise clients to use risk assessments by the American Society for Healthcare Engineering [ASHE], which has done a much better job,” Keyes says. “ASHE’s template is simple and easy to use.”

The risk assessments are performed once a year, or when the ASC adds a new level of service.

For example, if an ASC wants to provide a new service that requires heavy use of the medical gas system, then it might result in a facility change and a risk assessment should be performed, Keyes explains.

“Or if an addition is made and it affects the HVAC system, you need to evaluate that and see if there are any changes to patients’ health and safety,” Keyes says. “It sounds rather ambiguous, but you’d be surprised how many times something changes in the building, and people don’t always think about how it affects the level of safety for patients and for the staff.”

  • Comply with requirements precisely. Unless an organization meets the specifics of an exception, it must comply with the requirements of the standards and life safety code, Keyes says.

“For example, the code does list five exceptions for locking doors, but if you don’t qualify for any of the five exceptions, then it’s a serious issue to not comply,” he says. “You have to evaluate what your building is doing and whether it complies with the life safety code.”

Also, the person who evaluates the building has to be knowledgeable enough to determine whether the building is in compliance.

“If a small ambulatory surgery center doesn’t have a person on staff, then they have to provide that service somehow and go back to get someone to do it,” Keyes says. “The challenge is finding a person who is knowledgeable and competent.” It may help, for example, to consult with the architect or mechanical engineer who designed the ASC or its mechanical and electrical systems. Also, do not hire a contractor to make changes if this vendor has no real knowledge of Medicare and NFPA standards.