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Compliance News: More Pending Changes due to CMS 2012 Codes K-Tags

| David Stymiest

During his late afternoon March 14th session at the just-completed 2017 ASHE PDC Conference in Orlando, TJC speaker George Mills (Director of TJC’s Department of Engineering) announced upcoming additions and changes that will supplement the newly-released January 7th Elements of Performance (EPs) and the already-pending July 1st EP changes.  Mr. Mills stated that the required multi-step CMS review process should enable TJC to publish the next list of proposed changes by mid-2017 and schedule them to take effect in January 2018.

Those additional changes emanated from TJC’s intent to further align its EC and LS Chapter EPs with the recently-published CMS 2012 Codes K-Tags.  Those K-Tags were listed in last month’s SSR’s Compliance News article entitled CMS 2012 Codes K-Tags Available.  Refer to that article for the full list of 2012 Codes-related K-Tags.

As we stated last month, CMS published the long-awaited K-Tags that reflect the adoption of the 2012 codes (NFPA 101-2012® Life Safety Code® and NFPA 99-2012 Health Care Facilities Code).  Note that both of these codes also invoke many other NFPA codes and standards that can be between 10 and 15 years newer than the previously-enforced editions.

K-Tags are specific CMS requirements pertaining to the adopted codes and related standards.  They will be scored by state agency surveyors surveying on behalf of CMS.  The Accrediting Organizations will also assess health care organization compliance with the requirements of these K-Tags.

Readers are encouraged to obtain a copy of these K-Tags, which are available from CMS as a document entitled “Form CMS—2786R, 2012, 10/2016” .

The list of proposed future changes is not surprising since the changes within the NFPA requirements have been clear since the adoption of the 2012 codes.  Some of the pending EPs that TJC is submitting to CMS for approval include (note the following is not an all-inclusive list):

  • A requirement for a library of service manuals and related items that support inspection, testing and maintenance (ITM) of equipment and systems. This appears to be a natural outgrowth of the several-years old requirements that formalized the management of ITM activities and frequencies.  Refer to previous Compliance News articles or contact the author for references
  • A new reference invoking NFPA 99-2012 Chapter 15’s fire protection requirements
  • A new reference invoking NFPA 99-2012 Chapter 14’s hyperbaric requirements
  • A new reference invoking NFPA 99-2012 Chapter 4’s risk category requirements
  • Several more proposed EPs containing NFPA 99-2012 details not previously placed into EP-level documentation
  • A proposed new EP requiring continuing education and training for those responsible for operating, inspecting, testing and maintaining medical equipment, utility systems and equipment, fire safety systems and equipment, and the safe handling of hazardous materials and waste. This also appears to be a natural outgrowth of the several-years old requirements that formalize the management of ITM activities and frequencies.  Refer to previous Compliance News articles or contact the author for references.
  • Several proposed LS Chapter EPs containing additional NFPA 101-2012 details not previously placed into EP-level documentation

In an early morning PDC session on March 15th, TJC speakers Jim Kendig and Tim Markijohn, the Field Directors of TJC’s Life Safety Code Surveyors (LSCS), presented the surveyors’ perspective to PDC’s attendees.  Among the topics they discussed were:

  • Parameters for calculating LSCS surveyor-days
  • Recent and potential upcoming changes to the Survey Activity Guide (SAG)
  • The two different LSCS agendas (for a LSCS survey starting on Day 1 vs. a LSCS survey starting on Day 2)
  • How the LSCS prepare for your survey
  • Tips for success during the LSCS-conducted document review
    • Including the long-time expectation about closing all open items and placing the completed work order behind the report for easy retrieval during a survey
  • The impacts of mobile survey technology used by the LSCS and other surveyor team members

Accrediting organizations are surveying now to all associated requirements within or mandated by the adopted 2012 codes.  As an example, TJC LSCS are using the existing broad “wild card” EPs to score findings that do not yet have specific EPs according to the PDC TJC speakers.  It is incumbent on organizations to have the appropriate codebooks and related updated NFPA standards, and to be aware of all changes that result from the 2012 codes.

You may contact the writer at DStymiest@ssr-inc.com if you have questions on this content.

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