DNV updates physical environment standards
DNV Healthcare USA Inc., has announced updates to its National Integrated Accreditation for Healthcare Organizations (NIAHO®) accreditation requirements with revision 25-0, set to take effect on April 28. The changes include significant updates to the Physical Environment (PE) section. Below is an overview of the revisions.
DNV updates
PE.1 Facility. Previous editions of the NIAHO required compliance with Chapter 12 of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, 2012 edition, related specifically to emergency management. Revision 25-0 exempts Chapter 12 from the requirements, with additional clarifications found in PE.6. It also specifies that Chapter 13, Security Management, is not required by the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoP) but remains a requirement unique to DNV. This means CMS waivers for NFPA 99 cannot be applied to Chapter 13.
Construction and repair activities have new guidance. Designs must adhere to the Facility Guidelines Institute’s Guidelines for Design and Construction documents. The new requirements also state that risk assessments and mitigation processes, including infection control risk assessments and alternative life safety measures (ALSM), are mandatory. These revisions also include references to NFPA 241, Standard for Safeguarding Construction, Alteration and Demolition Operations, for ALSM alongside the 2012 editions of NFPA 101®, Life Safety Code® and NFPA 99, and state and local building and fire codes. When conflicts arise, the most stringent requirements apply.
PE.2 Life Safety Management System. Inspection frequency for portable fire extinguishers has been clarified. They must be checked once per calendar month, not exceeding 31-day intervals. Definitions for longer-term maintenance frequencies have also been standardized:
- Three years: Conducted once every 36 months, with a minimum of 30 months and a maximum of 40 months.
- Five years: Conducted once every 60 months, with a minimum of 54 months and a maximum of 66 months.
PE.3 Safety Management System. A new requirement mandates organizations to establish a respiratory protection program (RPP) in compliance with Occupational Safety and Health Administration regulations.
PE.5 Hazardous Material Management System. Organizations are now required to comply with NFPA 99-2012, 15.13.3, which pertains to fire prevention related to the use of germicides and antiseptics.
PE.6 Emergency Management System. Compliance with NFPA 99, Chapter 12, Emergency Management, is no longer required under revision 25-0, although it remains an acceptable method of compliance as long as all other PE.6 requirements are met. Instead, new requirements align with CMS State Operations Manual, Appendix Z, regarding emergency preparedness. These changes are extensive and warrant careful review.
PE.7 Medical Equipment Management System. The updated requirements clarify that medical equipment management system requirements apply to equipment owned by the organization in addition to rental or physician-owned equipment.
More resources
The updates to DNV's NIAHO Accreditation Requirements in revision 25-0 introduce significant changes across multiple chapters, including increased clarity, new requirements and alignment with CMS CoP. Organizations accredited by DNV are encouraged to carefully review the changes to ensure adherence to the revised requirements.
For more detailed information about these updates, visit the following resources: