May 05 2016

Categorical Waivers and the New 2012 Life Safety Code

Category: Blog,Life Safety Code UpdateBKeyes @ 12:00 am
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10112[1]By now most of you have heard that CMS finally adopted the 2012 Life Safety Code, effective July 4, 2016, which is 60 days from the date CMS posted their final rule (May 4, 2016). While nearly everyone is excited and happy that CMS finally published their final rule, it is raising some questions that previously may not have been addressed.

I received an email from a reader that asked the following:

 

 

Since the 2012 edition of the Life Safety Code has now been adopted by CMS, what implications does that have for organizations that have categorical waivers adopted…and are anxiously awaiting our survey.  We are due for survey before August 31, 2016.   I realize we need to comply by July 4th, so we are in an interesting time slot.  Any guidance you could offer would be appreciated.  Basically, do we keep the waivers until July 4th or what?

This adoption of the 2012 Life Safety Code by CMS does not have any effect on the categorical waivers already invoked by the hospital. Since the concept of invoking a categorical waiver is to be in compliance with a particular section of the 2012 LSC, once the 2012 LSC becomes effective, the categorical waivers no longer apply. They simply ‘go away’ or dissolve.

Now… CMS’s final rule will require hospitals to be compliant with the 2012 Life Safety Code by July 4, 2016. But in reality, this should not be a burden for most hospitals since most of the differences between the 2000 LSC and the 2012 LSC are in the favor of the facilities… meaning there are less restrictions rather than more restrictions.

However, there are a few changes that are more restrictive with the 2012 LSC, such as:

  • All swinging fire-rated doors must be tested and inspected annually;
  • Temporary construction barriers must be 1-hour fire rated (or non-rated if the construction area is fully sprinklered; tarps cannot be used);
  • Pressuring reducing valves on sprinkler systems need to be inspected quarterly.

Technically… CMS is saying the hospital needs to be compliant with these ‘more restrictive’ issues by July 4, 2016. But in reality, there will be some unstated ‘adjustment’ time where the accreditation organizations (AOs) will show leniency towards the more restrictive requirements. How much time? No one knows, but if past indicators are predictors of the future, I would not be surprised that the AOs will not enforce the new requirements until August or September, or maybe even the first of the year.

That’s just my opinion, but that is based on the knowledge that the AOs cannot make changes to their accreditation manual until CMS approves it and CMS takes 60 days to review and approve an AO manual. It would take 30 – 60 days for the AO make their changes and submit them to CMS. So… Assuming the AOs submit their revised manuals to CMS in June, and CMS takes 60 days to approve it… It looks like August or September before the AO can enforce the new requirements of the 2012 LSC.

But… I suggest you get started on compliance with these new more restrictive requirements, if you haven’t already. If you start today, you may be in full compliance with the additional requirements by July 4, 2016.

 

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May 04 2016

I’m Sorry…

Category: BlogBKeyes @ 12:00 am
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Dear Readers…

In a recent post I made a comment that architects are making errors and causing facility managers headaches by calling for 20 minute fire-rated doors in smoke barriers. I was wrong to have said that. While NFPA allows non-rated 1.75 inch thick solid-bonded, wood core doors in smoke barriers; the IBC does not.

Architects have to design the facilities to meet not only NFPA requirements, but often times they have to design to meet IBC requirements as well. The most restrictive requirement must be met, and the IBC requires 20-minute fire rated doors in smoke barriers.

My comment was rather derogatory towards architects, and for that I do apologize. I was allowing my frustration with poorly designed hospitals regarding suites-of-rooms to over-shadow my objectivity with the smoke barrier door issue. I will attempt to be more understanding and fair in the future.

Be assured that this website is intended to discuss NFPA codes and standards as it relates to healthcare facilities, and does not attempt to discuss or reference any other codes or standards. This is because once the facility is constructed, the facility manager is under siege with inspections from multiple authorities that hold them accountable to NFPA codes and standards; not the IBC.

Thank you….

Brad Keyes

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May 03 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand 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: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

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
• Changes the 2012 LSC Will Bring • 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: $779.00 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.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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Apr 29 2016

The 2012 Life Safety Code is Nearly Adopted

Category: BlogBKeyes @ 10:33 am
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I received the following message from my friends at Russell Phillips and Associates, LLC:

For those of you that are awaiting the adoption of the 2012 Life Safety Code:  We recently learned that the CMS rule adopting the 2012 LSC passed out of the Office of Management and Budget (OMB) last week.  This final rule is now cleared to be published in the Federal Register and should be out soon. Many years in the making and it is finally very close to being here.  Now we need to see if it was approved in its entirety or if it was modified.

I was told by another source that May is the month that CMS likes to release final rules, and Friday is the day of the week that CMS likes to release notices in the Federal Register.

Keep your eyes posted….

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Apr 29 2016

Which Edition of FGI Guidelines Do We Use?

Category: BlogBKeyes @ 12:00 am
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Q: We were using the 2006 edition of the FGI Guidelines for Design and Construction of Health Care Facilities but we have both the 2006 and the 2010 version of this document. The guidelines are different related to air pressures in Endoscopy and Bronchoscopy procedure rooms. We are trying to determine if air flow should be positive or negative. Can you tell us which edition of this book we are to be using as the current guideline?

A: The ventilation requirements for Bronchoscopy procedure rooms have stayed consistent through the many recent editions of the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities. There have been no changes in the requirement for negative air pressure in relationship to the surrounding areas, and a minimum of 2 outdoor air changes per hour with an overall total of 12 air changes per hour.

However, the same cannot be said for Endoscopy procedure rooms. From the 1996-1997 edition to the 2014 edition, the ventilation requirements seemed to change every edition:

Edition Air-Pressure Requirement Outdoor Air Changes

per Hour

Total Air Changes

per hour

1996-1997 No Requirement 2 6
2001 Negative 2 6
2006 No Requirement 2 6
2010 Positive 2 15
2014 No Requirement 2 6
[It is noted that the 1996 – 1997 edition was written and published by the American Institute of Architects (AIA), and the 2001 and 2006 editions were written by the FGI and AIA together. All subsequent editions are written by FGI and published by the American Society for Healthcare Engineers (ASHE).]

So, depending on when the Endoscopy room was designed, the ventilation requirements fluctuated. You authorities having jurisdiction usually state which edition of the FGI guidelines they are using as a guide. The interpretive guidelines for the Centers for Medicare & Medicaid Services (CMS) standard 482.41(c)(4) says acceptable standards such as the FGI guidelines should be incorporated into the hospital’s policy, but the standard does not say which edition. Likewise, the HFAP standard 11.07.03 says virtually the same thing, but The Joint Commission standard EC.02.06.05, EP 1 does reference the 2010 edition of the FGI guidelines.

For CMS and HFAP purposes, the assumption is clear that they would require the most recent edition, which would be the 2014 edition. For Joint Commission purposes, George Mills, Engineering Director for the accreditor recently stated during a regional ASHE meeting they would allow a health care organization to use the more recent 2014 edition.

The current edition of the FGI guidelines is the 2014 edition, which has no requirement for air pressure relationship to surrounding areas, and requires 2 outdoor air changes per hour and 6 total air changes per hour. But please check with you state and local authorities to determine what their requirements are.

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Apr 26 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand 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: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

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
• Changes the 2012 LSC Will Bring • 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: $779.00 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.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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Apr 22 2016

Frequency of Ventilation Checks

Category: BlogBKeyes @ 12:00 am
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Q: Is there a code or standard that states how frequent the test intervals must be for air-exchange rates and air-pressure relationships in operating rooms, soiled utility rooms, and central sterile supply clean rooms must be conducted? We check air-pressure relationships periodically, but typically we only check air-exchange rates if we suspect or know of a problem.

A: Depending on the particular authority having jurisdiction (AHJ), they may have specific standards that addresses the frequency of air-pressure checks and air-exchange rates, but generally speaking, there is no specific code or standard that addresses this on a national level, that I am aware of. A quick check of the FGI Guidelines (2010 edition) did not identify anything specific on the frequencies of these checks. NFPA, CMS, Joint Commission, HFAP and DNV do not have specific standards that address the frequency of ventilation checks.

When the standards do not specifically state a specific action, then it is up to the AHJ to make an interpretation on this issue. Where the AHJ has not made an interpretation, then it is up to the institution to make an interpretation. But be aware, that most AHJs have their own interpretation and/or rules on the frequency of air-pressure checks and air-exchange rates, whether they publish those interpretations or not. Many of them usually want to see daily checks on basic requirements like air-pressure relationships to surrounding areas. This can be done with a tissue held at the bottom of the door to confirm air-flow in or out of the room; or you can invest into some air-pressure gauges that are mounted on the wall. The air-exchange rates are more difficult to confirm, so this may be done less frequent, such as semi-annual or annual. Check with your operating room nurse manager. I believe their professional organization, the Association of periOperative Registered Nurses (AORN), has published recommendations of daily checks for air-pressure relationship requirements for operating rooms. Make sure all checks are documented.

My best advice for you is to contact all of your AHJs and ask them directly how frequent they expect you to test these ventilation requirements.

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Apr 19 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand 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: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

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
• Changes the 2012 LSC Will Bring • 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: $779.00 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.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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Apr 15 2016

Evacuation Route Maps

Category: BlogBKeyes @ 12:00 am
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Q: Are evacuation route maps required in a hospital? We have them in our facility, but I’ve heard some people say they are not required. If they are not required, why does our facility have them?

A: To quickly answer your question: No they are not required. According to the Life Safety Code (LSC) and other NFPA standards, evacuation route maps are not required, anywhere in your hospital. However, if you have evacuation route maps, the must be accurate and up to date. All too often the evacuation route maps are put into place and then forgotten, and changes and additions to the floor plans are not updated on the evacuation route maps. Also, the orientation of the evacuation route maps must be placed so anyone can easily discerned where they are in relation to the evacuation route map.

There is considerable value in having evacuation route maps. They can be a teaching aid when conducting fire drills on a unit. You can use the evacuation route map to identify the locations of key features of life safety, such as:

  • Smoke compartment barrier doors
  • Exits
  • Fire alarm pull stations
  • Medical gas shutoff valves
  • Fire extinguishers
  • Elevators

You are not alone in wondering why hospitals have evacuation route maps. At one time they were required by the fore-runner of the Centers for Medicare & Medicaid Services (CMS). Someone pointed out to them that the NFPA codes and standards do not require evacuation route maps, and CMS agreed and removed them from the requirements. But hospitals seem to hang onto them, probably because they are a good idea.

The confusion on this issue is from section 19.7.1.1 of the 2000 LSC which requires written copies of a plan for the evacuation to areas of refuge. The LSC is only referring to a written plan, like a management plan, but somehow it got interpreted to mean evacuation route maps.

Now, there may be other codes or standards that could require an evacuation route map that a hospital has to consider, so they should check with the local and state authorities.

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Apr 12 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand 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: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

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
• Changes the 2012 LSC Will Bring • 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: $779.00 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.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

Tags:


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