Top 10 physical environment findings

Health care facilities professionals should develop a greater understanding of the requirements that apply to their organizations.

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Health care facilities are under continual scrutiny by various regulatory authorities, most notably the Centers for Medicare & Medicaid Services (CMS). CMS allows health care facilities to be accredited by third-party organizations that are deemed by CMS to have requirements that are comparable and at least as stringent as the CMS Conditions of Participation (CoPs).

DNV Healthcare USA Inc., Katy, Texas, is one such accreditation organization. DNV’s accreditation requirements include eight physical environment areas, including facility, life safety, safety, security, hazardous materials and waste, emergency management, medical equipment and utility management. In addition to meeting the CMS CoPs, DNV’s physical environment systems also cover requirements of the Occupational Safety and Health Administration, Environmental Protection Agency and Department of Transportation.

Traditionally, when an organization was cited for nonconformance, many would merely fix an issue (such as repairing a door latch) rather than doing a deep dive into the cause of the issue and applying a sustainable corrective action. As health care facilities management has matured over the years and embraced processes such as risk-based “Plan, Do, Check, Act” cycles and the International Organization for Standardization’s ISO 9001:2015 Quality Management Systems, more sustainable corrective action processes are being implemented.

Top 10 findings

Despite these maturing processes, many organizations still have recurring nonconformances, which repeatedly appear on DNV Healthcare’s annual listing of top 10 physical environment findings. These findings, listed here from most to least frequent, represent the top physical environment nonconformances cited by DNV Healthcare in 2023:

1. Compressed gas cylinders not individually secured (DNV National Integrated Accreditation for Healthcare Organizations (NIAHO^®) accreditation standards). The individual securing of compressed gas cylinders is a DNV-specific requirement that exceeds the requirements of the 2012 edition of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, which requires central supply cylinders to “be provided with racks, chains or other fastenings to secure all cylinders from falling, whether connected, unconnected, full or empty” and oxygen cylinders to “be protected from abnormal mechanical shock.” DNV’s requirement at PE.5 (SR.5) states, “All compressed gas cylinders in service and in storage shall be individually secured and located to prevent abnormal mechanical shock or other damage to the cylinder valve or safety device.”

When a health care organization is first surveyed by DNV, this subtle difference often is missed by health care personnel. More concerning, though, are health care organizations that continue to be observed with cylinders that are not individually secured.

Often, organizations have found that while they have installed the infrastructure to secure cylinders individually, they have not been able to overcome the human factor — staff and vendors placing the cylinders in storage rooms often neglect to properly secure the cylinders. Some successful corrective action plans have included more frequent rounding of cylinder storage areas, education of delivery personnel and occasionally something as simple as instructional signage in the storage areas. (This nonconformance ranked third in 2022.)

2. Fire sprinklers loaded or contaminated with foreign material (NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition). NFPA 25-2011 states that fire sprinklers shall be inspected from the floor level annually and that any sprinkler that shows signs of leakage, corrosion, physical damage, loss of fluid in the glass bulb, loading or painting not performed by the sprinkler manufacturer is to be replaced.

When surveyors observe loaded sprinklers, one of the first questions asked relates to the annual inspection of sprinklers. Often, the organization will confirm through their documentation that their contractor did inspect the sprinklers. So why are loaded heads being observed?

Assuming they were cleaned properly, a few factors can come into play. Given ambient conditions, some sprinklers may be in locations that are more susceptible to dust being deposited onto the sprinkler heads. While sprinklers in kitchens and laundry areas will often load quicker than those elsewhere, sprinklers located adjacent to heating, ventilating and air conditioning (HVAC) diffusers often collect dust at a more rapid rate, as well as those located near entrances to buildings or those located outside and susceptible to spider webs, wasps and even bats. (This nonconformance ranked seventh in 2022.)

3. Penetrations of fire and/or smoke barriers (NFPA 101^®, Life Safety Code^®, 2012 edition). According to the NFPA, smoke inhalation is the leading cause of fire deaths. Preventing the spread of the products of combustion is a key factor in protecting patients, staff and visitors, yet issues with the protection of fire and smoke barriers remain high on the list of nonconformances. Some of the issues observed by surveyors include unprotected openings or penetrations, damaged fire-stopping and improper installation of firestop materials or devices.

Penetration issues are occasionally observed in new construction, but most nonconformances are found in existing construction and are often related to work being done that results in penetrations of smoke and fire barriers. To help organizations with this issue, DNV’s NIAHO accreditation standard requires them to implement barrier protection programs. This program requires written permission for any individual (e.g., staff, vendor or contractor) who penetrates a smoke or fire barrier wall, ceiling or floor assembly. Furthermore, it requires the implementation of a monitoring process to ensure all work is completed correctly. (This nonconformance ranked sixth in 2022.)

4. Items improperly supported by sprinkler piping and hangers (NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, and NFPA 25-2011). NFPA 13 and 25 generally prohibit fire sprinkler piping from supporting any non-system components. While DNV surveyors still observe this nonconformance, they do not cite organizations for items in incidental contact with sprinkler piping. The sprinkler piping must actually be supporting the items for a citation to be issued. While this is easy to see during the annual inspection of piping visible from floor level, there is not a requirement that concealed spaces, such as those above ceilings, be routinely inspected. Nonetheless, no matter the location, if a surveyor observes non-system components being supported, it will likely be cited.

To deal with this issue, many organizations are including the prohibition of items on sprinkler piping in above-ceiling permits, which, when properly managed, have reduced the occurrence of new items being supported by sprinkler piping. To deal with existing items on sprinkler piping, a few organizations have added into their processes that anytime someone is above the ceiling, they are to document the conditions they observe, including items supported by sprinkler piping. The organization then determines and implements the proper corrective action to deal with the issue. This quick above-ceiling look has also resulted in the self-identification of other issues, such as electrical issues and undetected leaks. (This nonconformance ranked first in 2022.)

5. Monthly owner’s inspection of wet chemical kitchen hood suppression system (NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition). Most kitchen hoods and cooking appliances are protected by a wet chemical suppression system that complies with the requirements of NFPA 17A, which covers the design, installation, acceptance and testing of these systems. It also requires that an inspection of the system be conducted every month in accordance with the owner’s manual as well as a minimum verification of eight items listed in NFPA 17A.

These monthly inspections can be conducted by hospital staff. This inspection is instrumental in ensuring that the system will operate as designed. Often in conjunction with the failure to conduct the monthly owner’s inspection, it is found that cooking equipment has been relocated and is no longer properly protected (the 2011 edition of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, requires an approved method be used to ensure that an appliance is returned to its approved design location) or that nozzles have been moved and are no longer properly directed at the appliance they are protecting.

Organizations report that they were not familiar with the requirement to conduct a monthly owner’s inspection, or they confused it with a monthly fire extinguisher inspection. Proper education in the NFPA 17A requirements and owner’s instructions has allowed organizations to maintain compliance. (This nonconformance ranked fourth in 2022.)

6. Battery-powered lighting units not installed where required (NFPA 99-2012 and DNV NIAHO Accreditation Standards). NFPA 99-2012 requires that battery-powered lighting units be installed in locations where deep sedation and general anesthesia is administered. The DNV NIAHO standard modifies the requirements so that it applies not only to new construction but also to existing construction.

Battery-powered lighting provides an added level of safety for procedures being performed under deep sedation and general anesthesia. It provides nearly instantaneous illumination, addressing the up to 10-second delay before generator power becomes available during a power failure. In the rare event of generator failure during a power outage, the battery-powered lighting ensures at least 1.5 hours of light. This lighting is designed to provide sufficient brightness to safely conclude any ongoing procedure in the area.

Surveyors will commonly observe this nonconformance in existing facilities even though the requirement predates even the 1999 edition of NFPA 99. In more recent construction, the battery-powered lighting units are usually present; most nonconformances in newer construction involve locations where deep sedation and general anesthesia were not originally contemplated. (This nonconformance is new to the top 10 list.)

7. Improper air pressure relationships (NFPA 99-2012 and American National Standards Institute (ANSI)/ASHRAE/American Society for Health Care Engineering (ASHE) Standard 170, Ventilation of Health Care Facilities, 2008 edition). A basic infection control premise is that the flow of air is supposed to be from clean to less clean. Chapter 9 of the 2012 edition of NFPA 99 references the 2008 edition of ANSI/ASHRAE/ASHE 170. Over the years, many of the design parameters for spaces have changed, but one fairly constant parameter has been the pressure relationship between adjacent areas.

Surveyors have been making observations where the opposite is occurring: the airflow direction is from less clean to clean. For example, there was an observation of airflow from a semi-restricted operating room (OR) corridor into the central sterile clean work room. In this situation, it was found that the airflow was “switchable” between positive and negative — and the feature was accessible on the monitor located at the door to the workroom. It had been switched to negative, and the alarm had been silenced.

Other causes of improper airflow direction have included the degradation of ventilation equipment, HVAC changes outside of the protected area inadvertently affecting the balance and too many doors to ORs left open. The main question asked of facilities personnel is how they validate that proper air pressure relationships are being maintained.

Corrective and preventive actions have included continuous electronic monitoring through building automation systems, periodic air balance testing, periodic checks with handheld manometers and even daily “calibrated tissue” tests. The current standards do not specify a method to validate the relationships, so an organization can choose the process that works best for its situation. (This nonconformance ranked ninth in 2022.)

8. Ligature risks in behavioral health settings (DNV NIAHO accreditation standards and CMS CoPs). Throughout the beginning of 2023, based on guidance from CMS in reference to care in a safe setting, strict enforcement of ligature-free behavioral health settings continued to be enforced as it had been in previous years. In mid-2023, CMS released new guidance that still emphasized care in a safe setting, but rather than strictly calling any ligature risk a nonconformance, it allowed for proper mitigations to be in place without necessarily calling for the complete elimination of the ligature risk. This balance of mitigation and risk allows for more flexibility and an environment that appears to be less institutionalized while still providing for the safety of patients.

From the physical environment perspective, the more successful programs utilize a multi-disciplinary environmental risk and safety assessment. The assessment details every risk observed on the unit, with an assignment of risk along with mitigations that are needed for the risks. More severe risks will likely need physical modifications to the environment, whereas more minimal risk may be allowed to remain with proper mitigation. It is important that this is not a static assessment and needs to be updated at least once a year and when any changes occur in the unit. (This nonconformance ranked fifth in 2022.)

9. Testing of fire-alarm panel batteries (NFPA 72, National Fire Alarm and Signaling Code, 2010 edition). There are a multitude of tests required by NFPA 72, but one of the more common findings observed by surveyors is the lack of documentation of the semiannual load voltage test of fire alarm panel batteries. This test is required for traditional lead acid, nickel cadmium and sealed lead acid batteries. Surveyors are seeing documentation of the annual test but not of the semiannual test.

Organizations have related varying causes for this. The reasons given include that they assumed their contractor was conducting all required tests and that contractors had stated they were only contracted to conduct an annual test of the fire alarm system.

Organizations need to understand the systems that they have in their facilities and what the inspection, testing and maintenance requirements are. Some codes, such as NFPA 72, provide tables that can simplify the review of the requirements against what the contractor is doing. One of the clauses of ISO 9001:2015 requires organizations to ensure that contracted services are provided in accordance with requirements of the organization — the health care organization needs to understand the requirements so the contractor knows what they are being held to. (This nonconformance ranked 10th in 2022.)

10. Annual fire door inspections (NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition). As part of the passive fire protection of health care facilities, fire doors serve as a component of compartmentation and help to limit the spread of fire. Proper compartmentation is key to a health care organization’s ability to shelter in place and avoid an evacuation for every fire alarm activation. NFPA 80 requires that fire doors be inspected on an annual basis. For swinging doors, there are at least 11 items that, if present, need to be verified.

Surveyors have been observing, usually after identifying a nonconforming door, that many door inspections do not include all the components present on the door. Without verifying the proper operation, there is uncertainty if the door will operate as designed.

Surveyors are also identifying instances when an organization has conducted or contracted door inspections but has not taken actions to repair the doors and has failed to conduct an alternative life safety assessment to determine if alternative life safety measures (ALSMs) need to be implemented.

For organizations that inspect their own doors, proper education is key. For those that contract these services, often a contractor will provide a seemingly endless list of nonconformances after conducting their inspections. Organizations need to be sure that the doors that are inspected need to be inspected; some organizations have found that the contractor was working from outdated drawings. Lastly, any deficiency related to life safety likely needs an ALSM assessment to determine if any additional measures need to be taken. (This nonconformance is new to the top 10 list.)

Knowledge is key

The takeaway from this article shouldn’t be for facilities professionals to specifically look at these 10 areas. The best advice is to seek out educational opportunities and develop a greater understanding of the requirements that apply to the facility, whether they be accreditation requirements, NFPA requirements or building code requirements.

An organization does not have to spend exorbitant amounts of money on education. Instead, it can take advantage of training and education opportunities through ASHE and its local chapters or webinars offered through many different organizations. Knowledge is one of the keys to successful and sustainable compliance. 

RELATED ARTICLE: An overview of DNV Healthcare

DNV Healthcare USA Inc., Katy, Texas, is part of an international accredited registrar and classification society headquartered in Oslo, Norway. The company currently has about 15,000 employees and 270 offices and laboratories operating in more than 100 countries and provides services for several fields, including maritime, oil and gas, renewable energy, electrification, food and beverage, decarbonization, sustainability, cybersecurity and health care.

In 2008, when DNV received deeming authority from the Centers for Medicare & Medicaid Services (CMS) to accredit health care facilities in the United States, it forever changed how health care accreditation is performed. Instead of making one-time, short-term corrections after a finding from a survey, the DNV approach allows health care organizations to develop their own processes that comply with the CMS-approved DNV National Integrated Accreditation for Healthcare Organizations (NIAHO^®) accreditation standards to focus on long-term sustainable preventive action processes to mitigate and minimize adverse and sentinel patient events.

DNV Healthcare has grown to become the second-largest hospital accreditation organization in the U.S. Its scope of services includes the accreditation of acute care, critical access and psychiatric hospitals. It also provides certification services for four levels of stroke and several other certifications. DNV anticipates final approval from CMS to accredit ambulatory surgical centers later this year.

DNV surveys are not pass/fail tests. There are no traditional scoring systems and no tipping points. Errors happen once, twice is a coincidence and three times is a pattern. There are exceptions, but for the most part, this is how DNV Healthcare surveyors evaluate the effectiveness of the process approach.

Successful accreditation of a health care organization is not based solely on the volume and type of nonconformances (i.e., findings) identified but also on the successful implementation of sustainable corrective action processes to emphasize continual improvement and prevent similar nonconformances in the future. 

About this article

This article is one of a series contributed to Health Facilities Management by DNV Healthcare USA Inc. 

Clinton Butts, CFPS, CHOP, is standards application and interpretation specialist for health care accreditation services at DNV Healthcare USA Inc., Katy, Texas. He can be reached at clinton.butts@dnv.com.