Sep 05 2017

Power Assist Door

Category: BlogBKeyes @ 12:00 am
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Q: We were cited during a recent survey for not having our power assist doors to our ICU suite connected to the fire alarm system. I thought that was only required on fire-rated doors. Is this a requirement for a corridor door?

A: Section 7.2.1.9 of the 2012 Life Safety Code is discussing Powered Door Leaf Operation, and applies to power assist and power operated doors. This section is not limited to any type of door, such as fire-rated, smoke-resistant, etc. This section applies to all doors with power assist and/or power operated. The six criterions listed under 7.2.1.9.2 must all be met in order to comply with 7.2.1.9.2. Subsection (4) under 7.2.1.9.2 discusses the situation where the door leaf is required to be self-closing or positive latching and is equipped with power operation and is left in an open position, there must a smoke detector near the door that would activate and cause the door leaf to close and cease operation. Therefore, the power assist function would have to be connected to the fire alarm system. Subsection (4) says the smoke detector must be placed in accordance with NFPA 72, so there are a couple of options:

  1. A smoke detector within 5 feet on one side of the door if the height of the transom above the door is less than 24 inches.
  2. A smoke detector within 5 feet on both side of the door if the height of the transom is 24 or more inches above the door.
  3. A smoke detector within 14 feet of the door if the entire area on that side of the door (i.e. corridor) is 100% smoke detected.

All of the above applies to any door, regardless of fire-rating, that is required to be either self-closing or positive latching and is equipped with power assist or power operated equipment. Yes… it applies to suite entrance doors, because the suite is a room that is separated from the corridor and according to 19.3.6.3.3, corridor doors must latch.

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Aug 22 2017

Keyes Life Safety Boot Camp – Last Chance To Register!

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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

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-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 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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Aug 19 2017

Please Vote for Michael Crowley

Category: BlogBKeyes @ 12:00 am
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ASHE MEMBERS

Please Vote for Michael Crowley for ASHE Associate Member Director.

Michael (Mike) Crowley has been an active associate member of ASHE for over 20 years, many of which he spent on the exhibit floor representing his company. ASHE fills a great mission in the healthcare field and helps shape the future of health care design, safety, and regulations. Being nominated to run for associate member representative is an honor and Mike believes he can contribute to ASHE’s overall mission while fairly representing his fellow associate members.

Mike is also active in the NFPA code writing process as a technical committee member. He believes sharing updates to NFPA 101, and NFPA 99 at PDC and ASHE annual is very important. Educating the users and the enforcers on Code updates and intention behind the Code develops a common understanding.

ASHE Advocacy is making a major impact on harmonizing NFPA 101 and the International Building Code (IBC). Mike believes there are too many Code and interpretations, highlighting a need for Common requirements. Mike’s focus will be on the education and understanding the impact of the Codes on the day-to-day operations in healthcare facilities.

Fire Protection and Life Safety are important to the operations and accreditation of facilities. Mike’s presence on the Board of Directors will bring his experience in the Code writing process, Life Safety expertise, and a focus on sharing the knowledge, to the ASHE membership.

Mike is looking forward to being the Associate Member representative for the Board of Directors for ASHE. Please vote for Michael Crowley for Associate Member Director.

VOTE for ASHE Board of Directors

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Aug 15 2017

Keyes Life Safety Boot Camp – September 19 & 20, 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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

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-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 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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Aug 08 2017

Keyes Life Safety Boot Camp – September 19 & 20, 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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

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-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 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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Aug 05 2017

Changes to Smoke Barrier Door Testing

Category: BlogBKeyes @ 12:00 am
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The following article was published in HCPro’s Hospital Safety Insider, on August 3, 2017:

More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline would be pushed back nearly six months, giving facilities until New Year’s Day 2018 to comply with an annual testing requirement for certain doors.

David Wright, director of the CMS Survey and Certification Group, made the announcement in a memo to state survey agency directors. He acknowledged that there had been a fair amount of confusion concerning the change, and he offered some pretty consequential clarifications that could affect whether the new requirement applies to your facility at all.

“[C]onsidering the level of reported misunderstanding of this requirement, CMS has extended the compliance date for this requirement by six months,” Wright wrote.

Within the National Fire Protection Association’s (NFPA) 2012 Life Safety Code® (LSC), which CMS adopted last year, there is a requirement that fire doors and smoke barrier doors be tested annually. Officials with CMS had taken the position that the new requirement applies to healthcare occupancies; that position, however, was met with pushback.

A petition objecting to the CMS position was discussed at length in June by members of the NFPA Healthcare Interpretations Task Force (HITF), says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance. That petition objected to the notion that the LSC specifically requires annual inspections of smoke barrier doors in healthcare occupancies.

“The HITF members did discuss the issue and agreed that healthcare occupancies were exempt from complying with section 7.2.1.15.2 … because the healthcare occupancies did not specifically require compliance with that section,” Keyes says in an email.

The committee decided to table its decision on the matter to give CMS an opportunity to review its position, as it did, Keyes says.

“I am pleased that the system worked in favor for the many hospitals that are certified by the Federal agency,” he adds.

Although the LSC does include provisions requiring annual inspections of smoke barrier doors and fire doors alike, section 7.2.1.15.1 states that these standards apply only where required by Chapters 11–43. Since the chapters governing healthcare occupancies make no direct reference to Section 7.2.1.15.1, the door inspection provisions do not apply to healthcare occupancies, Wright acknowledged in his memo.

Based on that conclusion, Wright spells out a few key takeaways:

  1. Fire doors. In healthcare occupancies, all fire door assemblies must be inspected and tested annually in healthcare occupancies, based on section 8.3.3.1 of the 2012 LSC, which applies to all occupancies.
  2. Smoke barrier doors. Non-rated doors (including smoke barrier doors and corridor doors to patient care rooms) aren’t subject to the annual inspection and testing requirements, but they “should be routinely inspected as part of the facility maintenance program.”
  3. Deadline. The compliance deadline has been pushed back from July 6, 2017, to January 1, 2018.
  4. Citations. Any LSC deficiencies related to annual fire door inspections should be cited under K211—Means of Egress—General.

But what if a healthcare organization was already cited at some point during the three-week gap between the original compliance date and the clarifying memo (July 6–28) for a failure to conduct an annual test of its smoke doors? Multiple CMS representatives did not respond to requests for an answer. Keyes says CMS has been a stickler in the past, holding that a finding cannot be removed once it is written on a survey report.

“There was an accreditation organization [AO] that used to allow findings to be removed from their survey report if the hospital could demonstrate compliance at the time of the survey,” Keyes says. “CMS has said that the AOs may no longer remove findings, even if the hospital was compliant at the time of the survey.”

The Joint Commission stated in the July edition of Perspectives that it requires annual testing for fire door and smoke door assemblies alike, despite acknowledging that the healthcare occupancy chapters don’t cite section 7.2.1.15 specifically. (To support the requirement, The Joint Commission noted that Section 18/19.2.2.2.1 references section 7.2.1, and cited a belief that the annual tests are beneficial.)

Keyes adds a word of caution: “The AOs are not locked into complying with everything CMS says or does. The AOs may have standards that exceed what CMS requires.”

That means the guidance in Wright’s memo might not trickle down to the AOs and state agencies that conduct surveys at your facilities, especially considering how widely advertised the original compliance date has been.

“So, I suspect many of the AOs will keep the start date at July 5, 2017, since they are already enforcing that,” Keyes says.

With that in mind, he recommends that all healthcare facilities have their fire doors tested as soon as possible, rather than waiting until the new deadline—because another authority having jurisdiction might keep to the stricter timeline.

 

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Aug 01 2017

Keyes Life Safety Boot Camp – September 19 & 20, 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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

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-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 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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Jul 25 2017

Keyes Life Safety Boot Camp – September 19 & 20, 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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

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-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 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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Jul 22 2017

Follow-Up From an Earlier Post….

Category: BlogBKeyes @ 12:00 am
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I recently posted on documentation retention, and how long you should keep test/inspection records. A reader contacted me and said they attended a recent ASHE regional event where the speaker said the CMS K-Tags require some records to be kept for the life of the building, and the reader wanted to know if I was familiar with this requirement.

I said no, I was not, but I decided to get an answer direct from CMS themselves. I did receive a reply from CMS which is considered an informal non-public response, and here is a summary of what they said:

  • CMS has not issued any formal policy on retention of records for LS test/inspections.
  • Surveyors typically look back one (1) year to establish compliance.
  • However, the extent of the record review would consider the frequency of a particular test/inspection requirement.
  • If the test/inspection requirement was a monthly requirement, the surveyor may review 12-months’ worth of documentation to confirm compliance.
  • If the test/inspection requirement was an annual requirement, then the surveyor may review 3-years’ worth of documentation to confirm compliance.
  • In addition, retention of records would consider any NFPA, State, or manufacturer requirements.

It’s important to point out that there is a special requirement in NFPA 99-2012, section 5.1.14.4.1 that does require ‘permanent’ records of certain medical gas tests. Permanent would mean retention for the life of the building (or system), but section 5.1.14.4.1 only refers to initial system verification test records… not routine annual inspections. And it only applies to medical gas and vacuum systems, not other mechanical or electrical systems identified in NFPA 99.

CMS K-Tags 907 and 908 refer to a routine maintenance program and a test/inspection program for medical gas systems. These K-Tags says records are to be maintained as required. Since the K-Tags are a CMS product, they are obviously saying maintenance records and routine test/inspection records are to be kept long enough to establish a pattern of compliance. For annual test/inspection records, that would mean you must retain the records for 3-years, not necessarily for the life of the building.

Similarly, K-Tag 921 discusses a testing and maintenance program for electrical equipment, and it says records are maintained for a period of time to demonstrate compliance. This is consistent with the CMS informal comment that a ‘period of time’ would be 1-year for monthly requirements and 3-years for annual requirements.

Since accreditation organizations operate with the authority granted to them by CMS, it would be expected that the accreditation organizations would comply with the same requirements and informal policies as CMS.

But, I will fallback on what I believe: You should never throw away any records that demonstrate compliance with a regulatory requirement. That’s Brads opinion.

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Jul 18 2017

Keyes Life Safety Boot Camp – September 19 & 20, 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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

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-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 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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