Puzzling Healthcare Environment Architectural Review Group ARG Gerard Van de Werken Chief Architect Houston July 10 2014 The puzzling stares wwwdshsstatetxushfp Oh Boy here we go again ID: 673294
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Slide1
HAAHE Presents
:
Texas
Department of State Health Services (TDSHS) update on Regulations and Healthcare in the State of TexasSlide2
Puzzling Healthcare
Environment
Architectural Review Group (ARG)
Gerard Van de WerkenChief ArchitectHouston – July 10, 2014 Slide3
The puzzling stares
???
www.dshs.state.tx.us/hfp
Oh Boy here we go again!
Already don’t like him. Looks like he’s got
too much
to say.
I hope he’s good!! Don’t want to be
bored.
Okay already let’s get
going. I just want my CEU credit.Slide4
ARG -
2014
Staff
Total FTE’s Currently8 - Architects 8
-
Architects
4 -
Engineers 2 - Engineers
4 - Admin Support 4
-
Admin Support16 - Total FTE’s 14 - Total FTE’s2 Vacant positionsPosting can be found at https://jobshrportal.cpa.texas.govSlide5
Administrative Staff
Ginger Smith
Team LeaderMedicare Administration
Marilyn HessPosting of InspectionsCorrespondenceRobert MartinMail Intake Generate FilesKerry TerryMinor ProjectsFax CorrespondenceSlide6
ARG
Jurisdiction
Review and approve
6 types of Healthcare FacilitiesHospitals – General/Special - 657
End-Stage Renal Dialysis Centers
579
Ambulatory
Surgical Centers
434Freestanding Emergency Medical Care
Facilities
(FEC) ** 101Private Psychiatric Hospitals & Crisis Stabilization Units 45 Special Care Facilities
**
15
Total
Healthcare Facilities
1831Slide7
Texas Administrative Code - Title 25
Chapters
Chapter
133 - Hospital Licensing State RegulationsChapter 117 – End Stage Renal Disease Facilities
Chapter
135
– Ambulatory Surgical Centers
Chapter
134
– Private Psychiatric Hospitals and Crisis Stabilization Units
Chapter 131 – Freestanding Emergency Medical Care Facilities **
Chapter
125
– Special Care Facilities **Slide8
Plan Submittal
ALTERNATIVE SUBMITTAL
In-lieu-of
submitting one complete set of construction documents/final plans and specifications for review and approval, the DSHS Architectural Review Group will accept one complete set of CD’s/DVD’s for these type of facilities:End Stage Renal Disease Facilities Special Care Facilities
Freestanding
Emergency Medical Care
Facilities
Psychiatric
Hospitals and Crisis Stabilization
Units Ambulatory Surgical Centers Submittals for Hospitals
May be provided on CD’s/DVD’s if the project is 15,000 square feet or less Slide9
Plan Submittal
Format requirements on CD’s/DVD’s
The CD’s/DVD’s must have: A complete index page which includes page numbers as the first image.
The CD’s/DVD’s shall be submitted in a hard case cover(s) with a label indicating the name of the facility and name of the project. May request additional documents:The department may request hard copy documents for Life Safety Code plans or any other documents that are necessary for a complete review.Slide10Slide11
Population
- Census Bureau
-2014Second largest population in USTexas
population growth rate - 1.8% 3 cities with 1 million or more – rank in the top 106 cities with ½ million or more – rank in the top 25Projection of population
growth
Current 2013
–
26.5
millionProjection by 2030 – 33.3 million
From 1980 to present - 150% increase
Texas in the
F
utureSlide12
Texas in the Future
2009 Statistical Brief
(DSHS – THCIC – CHS)Greater need of healthcare services Obesity and elderly
residentsMore physiciansCannot continue the cycle of pushing health care to the most expensive settingsWhat this means for Healthcare Changes to the delivery system and physical environment will evolve
Smaller Healthcare facilities - but more of themSlide13
TX Licensing Req
versus
CMS – Medicare
Health and Safety Code – State LawLicense Healthcare FacilitiesPatient rights and quality of
care.
Basic requirements to operate a
healthcare
facility
NPFA
101 - 2003
CMS – Federal Law
Volunteer program
Patient
rights and quality of care. ReimbursementNPFA 101 - 2000Slide14
CMS
Instruments that provide guidance,
clarification
and instruction to state survey agenciesCMS interpretation and adoption of specific event, code, rules ,etc.
Informational instruction to State surveyors how to look at a specific
item(s) ..
code, rules ,
regulations, etc
.
Where to find these CMS - S & C
Memos
What are CMS - S & C Memorandums
Google – CMS
- S & C Memo
Click on - Policy & Memos to States and RegionsSlide15Slide16
CMS – S & C Memo’s
Meet the Condition of Participation (CoP)
Hospital single organized medical staff
Governing Body of Hospital be responsible of services and activities off-campus EDNursing personnel at the Off-Campus ED be part of the hospital's single organized nursing servicesThe medical records of patients seen at the off-Campus Ed must be part of the hospital’s single Medical record system
S & C
- 08-08
Provider-Based
, Off
–campus Emergency Department and Hospital that Specialize in the Provision of Emergency ServicesSlide17
CMS – S & C Memo’s
S & C
- 08-08 - cont.CMS is encountering increasing interest from providers who seek participation in Medicare as a hospital that specialize in emergency services
However “emergency services hospitals” is not a recognized separate category of Medicare – participating hospital. Such applicant must demonstrate that it satisfies the statutory
definition of Hospital
….
t
hat the
provider primarily engage in the provision of services to INPATIENTS
CMS pays particular attention to size of the ED compared to its inpatient capacitySlide18
CMS – S & C Memo’s
S & C
- 08-08 - cont.
CMS interprets the statutory requirements that a hospital be primarily engaged in the provision of inpatient services to mean that the provider devotes 51% or more of the beds to inpatient care
However, CMS considers the burden of proof (to demonstrate that inpatient care is the primary health care service) to reside with the applicantSlide19
CMS – S & C Memo’s
CMS is clarifying that ASC’s interpretive guidelines indicate that an ASC and an
Independent Diagnostic Testing Facility (IDTF) may
NOT share space, even when temporarily separatedSome facilities are equipped to perform both ambulatory surgeries and diagnostic imaging
S & C
- 09-51
Clarification of ASC Interpretive GuidelinesSlide20
CMS – S & C Memo’s
S & C
- 09-51 – cont.
CMS requires an ASC to operate exclusively for the purpose of providing surgical services CMS prohibits IDFF’s that are not hospital-based or mobile from sharing a practice location with another Medicare-enrolled individual or organizationSlide21
CMS – S & C Memo’s
ASC state regulations
require these facilities to be distinct entities
, solely providing surgical services, containing separate waiting areas, and shall meet the LSC requirements for Ambulatory Health care occupancies
S & C
- 10-20
Ambulatory Surgical Center (ASC ) Waiting Area Separation RequirementsSlide22
CMS – S & C Memo’s
S & C
- 10-20 – cont.CMS clarifies ASC Waiting areas, including the prohibition on the sharing waiting areas with other entities
Definition of an ASC – a distinct entity that operates exclusively for the provision of surgical services As a result an ASC may not share space with another entity when the ASC is openSlide23
CMS – S & C Memo’s
S & C
- 10-20 – cont.
According to NFPA 101, 20.3.7.1 and 21.3.7.1 an ambulatory health care facility shall be separated from other tenants and occupancies by walls having not less that an 1-hour fire resistance rating Floor to deck aboveDoors 1 ¾ inch thick solid-bonded wood core or equivalent
Positive latching
Doors shall be self-closing and shall be kept in the closed positionSlide24
CMS – S & C Memo’s
S & C
- 10-20 – cont.
This requirement applies whether or not an ASC is “temporary” distinct, i.e. it shares its space with another occupancy(ies) but does not have concurrent or overlapping hours of operationsExisiting ASCsCMS may waive, for periods deemed appropriateSignage must be posted that clearly identifies the distinct separate ASC waiting areaSlide25
CMS – S & C Memo’s
RH of 20
> Percent Permitted in Anesthetizing Locations: CMS is issuing a categorical LSC waiver permitting new and exisiting ventilation systems supplying hospitals, ASC, etc. Anesthetizing locations to operate with RH od
20 > percent, instead of 35 > percent.
S & C: 13-25-LSC & ASC
Relative Humidity (RH): waiver of LSC Anesthetizing Location Requirements; Discussion of ASC Operating Room Requirements Slide26
CMS – S & C Memo’s
S
& C: 13-25-LSC & ASC – cont.
Categorical Waiver:Facilities are expected to have written documentation that they have elected to use the waiver
At the entrance conference for any survey assessing
LSC compliance,
a
facility that elected to use the waiver must notify the survey teamSlide27
CMS – S & C Memo’s
S
& C: 13-25-LSC & ASC – cont.
Categorical Waiver does not apply:When more stringent RH control
levels are required
by
State or local laws and
regulations
Where reduction in RH would negatively affect ventilation system performanceSlide28
CMS – S & C Memo’s
S & C: 13-25-LSC & ASC – cont.
Ongoing RequirementsFacilities
must monitor RH levels in anesthetizing locationsProvide evidence that the RH levels are maintained at or above 20 %When internal moisture not sufficient - humidification must be provided
Provide evidence that
timely correctiv
e actions are performed successfully in instances when
internal monitoring
determines RH levels are below the permitted rangeSlide29
CMS – S & C Memo’s
2000 Edition NFPA 101 Life Safety Code Waivers
Several Categorical LSC Waivers
Permitted CMS has identified several areas of the 2000 edition of the LSC and 1999 NFPA 99 that may result in unreasonable hardship on a large number of healthcare facilities and for which there are alternative approaches that provide equal level of protection (2013 NFPA 101 ?)
S & C: 13-58-LSC Slide30
CMS – S & C Memo’s
S & C: 13-58-LSC
– cont.Healthcare facilities must elect to use the categorical waivers
Individual waiver applications are not required , but health facilities are expected to have written documentation that they have elected to use a waiver and must notify the survey team at the entrance conference for any survey assessing LSC complianceSlide31
CMS – S & C Memo’s
S & C: 13-58-LSC – cont
.Categorical Waivers Available:
Medical Gas Master AlarmOpenings in Exit EnclosuresEmergency Generators and Standby Power SystemDoorsSuitesExtinguishing Requirements
Clean Waste & patient Record Recycling ContainersSlide32
TX Licensing
Reg
versus CMS – MedicareThe Dilemma
CMS - S & C versus State Licensing Regulations Healthcare Facilities to participate in provider base services, the facility is required to be licensed within that State and the facility shall meet the requirements of that StateHow is ARG going to resolve the differences ?We are not
Slide33
10
Most costly
items needing correction found after inspection
10 Failing a final inspection. The cost of delay and time. Don’t listen to the contractor, verify for yourself if the project is ready. 9 Check to make sure when owner and contractor value engineer the project verify that it will meet rules and regulations.
8
Patient
room window
in hospitals
opening directly to a graveyard. Architect not vetting out the regulations.
Slide34
10
Most costly items
needing correction found after inspection
7 Minor Project. Not verifying requirements. ARG approves on limited information but Architect or Engineer has
not
verified all
the rules
and
regulations.
Example: Hazard area
at inspection, all partitions
not fire rated
.
6 Not checking the Construction Type Limitations. At inspection the fire rating on floor slabs or columns in renovated areas does not meet NFPA 101 construction type. Slide35
10
Most costly items
needing correction found after inspection
4 ICU sliding doors. Finally permissible in NFPA 101, 2006, only for institutional occupancy. Mistake everyone makes … the first slider is not 41.5 inches in clear width opening.
5
Constructing
a new hospital in a existing
MOB
.
Window heights greater
than 3
feet above finish floor. A big problem when it is tilt up wall construction. Slide36
10
Most costly items
needing correction found after inspection
2 Installation of PVC above slab in hospitals. Contractor VE in-lieu-of what was specified.
1
The
essential electrical emergency
system
wiring
is not in EMT. Contractor
or engineer
did
not install what was specified and VE the wiring to hospital grade MC gable. 3 Doors in treatment, diagnostics, and patient sleeping rooms not having 41.5 inch clear width opening in intuitional occupancy. How many times do we see 36 inch doors?Slide37
10 Most repeated infractions at Insp
10 Nurse
call and Medical gas alarms not connected to proper emergency electrical panels
9 In-patient care area - the electrical panels not grounded between normal and emergency panels
8 Renovation project - electrical panel
and ATS
not labeled correctly
7
Critical electrical receptacles not market/labeled
6 Generator Set - no battery powered light
or
receptacle
on life safety panel at generatorSlide38
10 Most repeated infractions at Insp
5 Medical Gas Storage room - ☼ switch (
5’), proper racking /stored, not a rated door, not ventilated
properly4 Clean room, equipment room, shell space, etc.
in hospital over
100
sq. ft.
is considered storage and hazardous
3
Supply and
return air - every room requires air changes
2
Air pressure relationships between rooms1 Penetrations in Fire rated partitions, Smoke partitions, between Floors not sealedSlide39
Open Forum
and
Thank
y’allSlide40
Abaco - Bahamas
if you don’t
do wild things
while you’re young,
you’ll have nothing
to smile about
when you’re old