Jan 17 2017

Keyes Life Safety Boot Camp – April 3 & 4, 2017

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Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: April 3 & 4, 2017

Location: Hilton Garden Inn, 45 Lockwood Drive, Charleston, SC (843) 637-4074

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Challenges in Implementing the New Requirements of the 2012 LSC • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $879.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion / AIA CEU’s pending.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 843-637-4074

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or go to: https://www.eventbrite.com/e/keyes-life-safety-boot-camp-charleston-sc-registration-29783435056

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or March 6, 2017

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:

fire-door-solutions-logo-1-002

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Jan 03 2017

Keyes Life Safety Boot Camp – April 3 & 4, 2017

Category: BlogBKeyes @ 12:00 am
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Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: April 3 & 4, 2017

Location: Hilton Garden Inn, 45 Lockwood Drive, Charleston, SC (843) 637-4074

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Challenges in Implementing the New Requirements of the 2012 LSC • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $879.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion / AIA CEU’s pending.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 843-637-4074

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or go to: https://www.eventbrite.com/e/keyes-life-safety-boot-camp-charleston-sc-registration-29783435056

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or March 6, 2017

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:

fire-door-solutions-logo-1-002

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Jan 02 2017

Addressing Common Misconceptions Regarding Corridor Doors

Category: BlogBKeyes @ 12:00 am
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Corridor doors are one of the most common components of the means of egress, yet their significance is often overlooked, possibly because there are so many of them in a hospital. This article will address the different concerns and issues surrounding corridor doors in a healthcare occupancy that may not be considered common knowledge.

The Life Safety Code (LSC) does not require corridor doors to patient rooms to have closers, but if they do have closers, then they can have the type that have hold-open friction-catch closer arms, that requires someone to physically close them.  Hospitals are defend-in-place facilities, so the question asked by some is why do we rely on people to accomplish the closing of the door rather than allow a closer to do it?

As mentioned, corridor doors to patient rooms are not required to have closers, and this is in accordance with section 19.3.6.3.11 of the 2012 LSC. But the Annex section of 19.3.6.3.5 says the concept of having corridor doors to patient rooms without closers allows staff to visibly see into the room to detect any fire or smoke condition. If the door had a closer, then the Annex section recommends the room be protected with a smoke detector. The basic premise of a healthcare occupancy is there is adequate staff on hand to make these observations.

Which brings us to the issue of those patient room corridor doors that have signage added, and coat hooks applied; would they be considered acceptable?

Coat hooks on a non-fire rated patient room corridor doors would be allowed. But a coat hook on a fire-rated door typically would not be acceptable (even if it is applied with adhesives) because any garments hanging from the coat hook would likely contribute to the fuel load of the door. But signage that was informational (i.e. contact precautions; oxygen administered; diet restrictions, etc.) would be permitted, even if they were combustible.

Are corridor doors that are located in a 1-hour fire barrier permitted to be only fire-rated for 20 minutes and not ¾-hour? The answer is no. If a corridor door is part of a fire-rated barrier that serves some other function, such as a vertical opening, exit, or hazardous area, then it must meet the most restrictive requirements of either. But where corridor doors are located in a 1-hour fire-rated barrier the corridor door must be at least a ¾ hour fire rated door, mounted in a fire-rated frame, with self-closing and positive latching hardware. Vertical openings are elevator shafts, mechanical shafts, stairwells, and the like. Exits are direct exits, horizontal exits and exit passageways. Hazardous areas are storage rooms >50 sq. ft. containing combustibles, soiled utility rooms, fuel-fired heater rooms, laundries >100 sq. ft., paint shops, repair shops, trash collection rooms, laboratories, and medical gas rooms (storage rooms with >3,000 cubic feet of compressed gas).

There is one exception to the above rule where a corridor door located in a 1-hour fire rated barrier must be ¾ hour fire rated: When the corridor door is also located in a 1-hour barrier separating the corridor from an atrium. According to section 8.6.7 (1) of the 2012 LSC, the atrium must be separated from adjacent areas with a 1-hour fire rated barrier, but the openings in the 1-hour fire rated barrier are only required to be same as is required for corridors. This means the doors in the atrium separation could be non-rated and only required to resist the passage of smoke, since atriums are only permitted in fully sprinklered buildings.

However, I don’t see where a patient room door would be part of any of these fire-rated barriers, although a patient room door could be part of a smoke barrier, separating smoke compartments. Even though the smoke barrier is required to be 1-hour rated, it is not a fire rated barrier, because the doors in a smoke barrier are only required to be 1¾ inch thick, solid-bonded, wood core doors, or of such construction to resist fire for at least 20 minutes, and must be self-closing. They are just like corridor doors in a non-sprinklered smoke compartment, but must have closers on them.

It’s important to realize that not all corridor doors have to meet the NFPA 80 requirements for fire-rated doors. However, if the corridor door is a fire-rated door, it must be compliant with the requirements of NFPA 80. If the door has a fire rated label, then it is a fire-rated door, and it must be mounted in a fire-rated frame, equipped with a self-closing device, and have positive latching hardware.  The problem that I observe in many hospitals is they installed labeled fire-rated doors in walls and barriers that are not fire rated. Therefore, even though the wall or barrier is not required to have a fire-rated door, the fact that the door is fire-rated means the organization must maintain it as such, according to section 4.6.12.3 of the 2012 edition of the LSC. So, if you have a fire-rated door in a corridor wall, and the corridor wall is not required to be fire-rated, then you must still maintain the fire-rated door to the requirements of NFPA 80, which includes annual testing.

Where I often find this problem in hospitals is the smoke compartment. Some designer/architect sees that smoke barriers are required to be 1-hour rated so they specify ¾ hour fire rated doors. Again, a smoke compartment barrier wall is not a fire-rated wall; therefore, the conditions of 19.3.7.6 apply where 1¾ inch thick, solid-bonded, wood-core doors are allowed. Also, some designers/architects see that smoke barrier doors that are of such construction that resists fire for at least 20 minutes are permitted, so they specify 20-minute fire rated doors for smoke barrier openings. Again, this is not required to have fire-rated doors, but since the 20-minute fire-rated doors was installed, you must maintain it to NFPA 80 requirements, which means it must be mounted in a fire rated frame, be self-closing, and positive latching. I see a lot of 20-minute fire rated doors in smoke compartment barriers that do not have positive latching hardware, which is non-compliant with NFPA 80. The organization must maintain the door to NFPA 80, or simply remove the fire rated label, then the door is no longer a fire-rated door that is obvious to the general public, and does not need to be maintained as such.

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Dec 19 2016

Keyes Life Safety Boot Camp – April 3 & 4, 2017

Category: BlogBKeyes @ 12:00 am
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keyes_logo_lg_nobackUnderstand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: April 3 & 4, 2017

Location: Hilton Garden Inn, 45 Lockwood Drive, Charleston, SC (843) 637-4074

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Challenges in Implementing the New Requirements of the 2012 LSC • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $879.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion / AIA CEU’s pending.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 843-637-4074

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or go to: https://www.eventbrite.com/e/keyes-life-safety-boot-camp-charleston-sc-registration-29783435056

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or March 6, 2017

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:

fire-door-solutions-logo-1-002

 

 

 

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Dec 09 2016

Incorrect Interpretations on Smoke Door and Fire Door Testing

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I just found out yesterday that CMS is teaching their state agency LS surveyors that smoke barrier doors need to be tested in healthcare occupancies. This interpretation of the 2012 Life Safety Code from CMS is incorrect, but your state agency on behalf of CMS may be expecting you to do this.

Yes… section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested. But that conflicts with the occupancy chapter for healthcare and section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing). Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies.

Now… you may have a state agency that believes differently. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but ultimately they are an authority and if they say you have to test smoke doors, then you have to test smoke doors.

But it is not required in healthcare occupancies according to the 2012 LSC.

Also, CMS has instructed their state agency LS surveyors that healthcare occupancy doors in 7.2.1.15.1 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 7.2.1.15.1 do not apply to healthcare occupancies so they are exempt from having to be tested. Only doors in assembly occupancies and residential board & care occupancies need to comply with 7.2.1.15.1.

But be aware: If you have areas of your healthcare facility that qualify as assembly occupancy, even if you do not declare that area as assembly occupancy, then you must comply with 7.2.1.15.1 and test those doors. This would include doors in assembly occupancies that:

  • Have panic hardware or fire-rated hardware;
  • Are located in an exit enclosure;
  • Are electrically controlled egress doors;
  • Delayed egress, access-control, and elevator lobby locked (per 7.2.1.6).

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Dec 03 2016

A New Form Has Been Posted on Changes With the 2012 LSC

Category: BlogBKeyes @ 12:00 am
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Hello all…

This fall has been a very busy time for me. I am thankful that I completed my task of reading all 651 pages of the new CMS Final Rule on Emergency Management standards that will become effective November 15, 2017. I re-wrote the HFAP EM chapter to align with the new requirements and it will soon be sent to CMS for review and approval.

But what I wanted to bring to your attention is I have posted a new document under “Tools” on this website that explains most of the changes that healthcare facilities need to know in regards with the new 2012 LSC. Click on “Tools”, then go to the bottom of the page and click on “Changes the New 2012 Life Safety Code Will Bring”, and open the document called “Changes to the Life Safety Code that the 2012 Edition Will Bring”.

I hope you will find this helpful. If you like it, pass it on to someone who you feel could benefit from it.

Thanks…

Brad Keyes, CHSP

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Oct 11 2016

Save The Date…. Another Keyes Life Safety Boot Camp!

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Web 2April 3 & 4, 2017 is the date of the next Keyes Life Safety Boot Camp, to be held in Charleston, SC.

  • This two-day boot camp on the 2012 Life Safety Code is designed for healthcare organizations that want to:
  • Understand practical applications of the Life Safety Code
  • Learn from actual Life Safety surveyors on what to prepare for during surveys
  • Recognize how the new 2012 Life Safety Code will impact your organization
  • Appreciate key requirements of the 2012 Life Safety Code as they apply to health care facilities and related occupancies

Who should attend:

  • Facility managers
  • Safety officers
  • Chief operating officers
  • Accreditation coordinators
  • Architects / Engineers
  • Consultants
  • AHJs

Watch for further announcements on information to register.

This boot camp is co-presented by Brad Keyes (Keyes Life Safety Compliance, LLC) and Alise Howlett (Codenity, LLC), and is sponsored by:

fire-door-solutions-logo-1-002

 

 

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Sep 22 2016

Oops! Brad Made a Mistake…

Category: BlogBKeyes @ 12:00 am
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I need to apologize to you, as I made an error in an earlier post where I stated the expected dates for the new testing/inspection requirements of the new 2012 Life Safety Code.

Previously, I said healthcare organizations needed to get their first quarterly, annual, 3-year, and 5-year test/inspection completed by November 1, 2016, which is the date CMS said the requirements of the new 2012 LSC will be enforced.

That wasn’t quite true… I received an email from a friend who also is a reader of my blog and said that is not what Joint Commission said at the annual ASHE conference. So, I contacted CMS directly in Baltimore, and communicated with the people who make these interpretations, and they told me this:

Although CMS will begin surveying to the new 2012 LSC on November 1, 2016, the regulation still requires the facility to be in compliance with the 2012 LSC and the 2012 NFPA 99 as of July 5, 2016.

Therefore, when CMS begins to survey on November 1, 2016, the healthcare facility should be able to verify compliance with any new daily, weekly, or quarterly requirements as it has been over 3 months since July 5th. But a facility would not yet be required to meet the new annual, 3-year, or 5-year requirements.

The email from CMS went on to explain that the first annual test/inspection activity that is a new requirement of the 2012 LSC is due July 5, 2017. Similarly, the first 3-year activity is due July 5, 2019, and the first 5-year is due July 5, 2021.

Just as a refresher, here is a list of the new testing/inspecting requirements of the 2012 LSC and the 2012 NFPA 99:

  • Quarterly main drain test on one system riser downstream of the backflow preventer where the sole water supply to the sprinkler system is through a backflow preventer;
  • Quarterly inspection of fire hose valves;
  • Annual test/inspection of all fire-rated door assemblies;
  • Annual test of the 2.5 inch fire hose valves;
  • 18-month test of non-stationary medical gas booms and articulating assemblies using flexible connectors for medical gas outlets;
  • 3-year test of the 1.5 inch fire hose valves;
  • 5-year internal inspection of sprinkler pipe.

So… according to the information provided by CMS, when they begin surveying to the 2012 LSC on November 1, 2016, you need to have your first quarterly main drain test conducted and your first quarterly inspection of fire hose valves. However, the annual, 18-month, 3-year, and 5-year new requirements are not due until their respective anniversary from the July 5, 2016 effective date.

I apologize for this miscommunication…. And I’m glad my friend took the time to point that out to me.

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Sep 19 2016

A Reader Questions Brad’s Comment…

Category: BlogBKeyes @ 12:00 am
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I had a reader question one of my postings on this blog, that I thought you might be interested in reading…

Oxygen Cylinder Storage

The reader wanted to know if the yellow fire cabinets could be used to store oxygen cylinders in lieu of storing them in a designated room, when the accumulative quantity per smoke compartment reaches the 300 cubic feet mark. I said no, according to NFPA 99-2012, section 11.3.2.1 requires an enclosed interior space of non-combustible or limited-combustible construction.

The reader said “I contacted my accreditation organization’s standards interpretation group and asked them the question, and they said it was all-right to store the O2 cylinders in the yellow fire cabinets because they meet the definition of 1/2 hour fire rating.”

A check with one of the manufacturers of the yellow fire cabinets says their cabinets are NOT UL rated for 1/2 hour fire rating. They stated there is not any approved test parameters for the cabinet’s fire rating to be verified with the gypsum material installed in the cabinet’s wall cavity.

To be safe, it is best to not use the yellow fire cabinets for storage of O2 cylinders unless you know for sure the cabinet carries a UL (or similar) test laboratory fire rating of at least 1/2 hour.

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Sep 15 2016

Comments and Observations in the CMS EM Final Rule – Part 1

Category: BlogBKeyes @ 12:00 am
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I have started to review the new CMS Final Rule on Emergency Preparedness. Here are some of the highlights, along with my comments…

Comments and Observations in the CMS EM Final Rule

1) CMS says there are three key essential requirements for maintaining access to healthcare services during emergencies:

  • Safeguarding human resources
  • Maintaining business continuity
  • Protecting physical resources

2) CMS has identified four core elements that are central to emergency preparedness program:

  • Risk assessment and emergency planning: CMS requires all facilities to perform a risk assessment that uses an “all hazards” approach prior to establishing an emergency plan. (NOTE: This is the HVA currently required)
  • Policies and procedures: CMS requires the facility to develop and implement policies and procedures that support the execution of the emergency plan.
  • Communication plan: CMS is requiring the facility to develop and maintain an emergency preparedness communication plan.
  • Training and testing: CMS is requiring the facility to develop and maintain an emergency preparedness training and testing program. (NOTE: This applies to all staff and must include annual refresher training).

3) CMS states in their Final Rule that “Currently, in the event of a disaster, healthcare facilities across the nation will not have the necessary planning and preparation in place to adequately protect the health and safety of the patients. In addition, we believe that the current regulatory patchwork of federal, state, and local laws and guidelines, combined with various accrediting organizations’ emergency preparedness standards, falls short of what is needed for healthcare facilities to be adequately prepared for a disaster.” (OUCH! CMS is saying The Joint Commission’s EM standards and HFAP’s EM standards are inadequate and ‘falls short’ for healthcare facilities to be adequately prepared for a disaster. I don’t agree with that comment.)

4) CMS defines an “emergency” or a “disaster” as an event that can affect the facility internally as well as the overall target population or the community at large. Emergencies can be internal, man-made, or natural events, and can be small or large events.

5) CMS states that their new emergency preparedness requirements focus on continuity of operations, not recovery of operations. Facilities may choose to include recovery of operations planning in their emergency preparedness plan, but they have not made recovery of operations planning a requirement.

6) CMS states facilities are required to track the location of patients and staff in the facility’s care during the emergency.

7) CMS says individual physicians are not required, but are encouraged, to develop and maintain emergency preparedness plans. In addition, physicians that are employed by the facility and all new and existing staff must participate in emergency preparedness training and testing. CMS has not mandated a specific role for physicians during an emergency or disaster event, but they expect facilities to delineate responsibilities for all of their facility’s workers in the emergency preparedness plans and to determine the appropriate level of training for each professional role.

8) Based on a response they received during the public comment period, CMS has changed their proposed rule to allow integrated health systems to have a coordinated emergency preparedness program. CMS revised their proposed requirements by adding a separate standard to the CoPs and CfCs. This separate standard will allow any separately certified healthcare facility that operates within a healthcare system to elect to be a part of the healthcare system’s unified emergency preparedness program.

 

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