Feb 14 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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Feb 07 2017

Cardboard Shipping Boxes

Category: BlogBKeyes @ 12:00 am
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I have been receiving quite a few questions regarding cardboard shipping boxes and whether or not they can be used for general storage in storage rooms throughout the hospital. We’re not talking sterile environments, like an OR storage room, but just general utility rooms in various locations in the facility.

To look at the over-all picture, there are two different standards at play, here. From a Life Safety Code point of view, the boxes could be compliant. Cardboard boxes are combustible, and having multiple cardboard boxes stored in a room requires the room to be maintained as a hazardous area. According to section 19.3.2.1 of the 2012 Life Safety Code, the room would have to be 1-hour fire-rated or be sprinklered. If the room is 1-hour fire-rated with 3/4-hour rated door assemblies that are self-closing and positive latching, then you would be compliant with the Life Safety Code. There are no other Life Safety Code requirement that would prevent the storage of cardboard boxes in that room.

However, as I said, there is another standard at hand here. From an Infection Control point of view, cardboard boxes used for shipment presents many problems:

  • The boxes are dirty. They have been riding in the back of trucks for days, and they have been sitting on receiving docks which is a very transient environment. These boxes are not acceptable from an Infection Control consideration to be stored in a clean environment, let alone a sterile environment.
  • The boxes may contain insects or vermin. In some cases, you have no idea where these boxes came from. Insects can make a home in the cardboard boxes and then be shipped to your facility. Vermin have been known to hide in a cardboard box and also be transferred to other places.
  • If left on the floor, the boxes may become wet. A wet cardboard box becomes soggy and falls-apart and leaves a trail of contaminants that provides a place for mold or mildew to grow.

While there may not be a specific standard in the accreditation organization’s manual, or a CMS CoP standard that prohibits cardboard shipping boxes from being stored in a clean environment (i.e. pharmacy storage room), it is generally understood that most surveyors and inspectors will cite an organization for doing so. This is due to the perceived Infection Control issues described above. They would typically cite the facility under a general duty standard that requires the organization to maintain a safe environment for their patients and staff.

My advice is to remove the cardboard shipping boxes from the facility at the point where you receive them (i.e. receiving dock) and discontinue storing any paper or cardboard container on a floor that has the potential to be wet. Discuss this issue with your Infection Control specialist. I’m sure they have an opinion on cardboard shipping boxes.

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Jan 31 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 24 2017

Emergency Departments: Healthcare Occupancy Only

Category: BlogBKeyes @ 12:00 am
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In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments are now required to be classified as healthcare occupancies only. For most of the hospitals this will not be a problem, but for those hospitals that have already classified their ERs as ambulatory healthcare occupancy, they will have to make a change back to healthcare occupancy. This also affects those free-standing Emergency Departments that were designed and approved as ambulatory healthcare occupancies; they also must meet the requirements for a healthcare occupancy.

This all came-about when the accreditation organizations (AO) submitted their revised and updated standards for the change to the new 2012 Life Safety Code. One particular AO created an introduction to their Life Safety chapter and explained the differences in occupancies and gave an ER as an example of an ambulatory healthcare occupancy. CMS wrote back and said no, ERs cannot be ambulatory healthcare occupancies because they provide sleeping accommodations for patients who are on 24-hour observation.

Many of the AOs objected to this change and pointed out that the ER does not provide sleeping accommodations and besides there are situations where there are less than 4 patients under 24-hour observation. CMS would not budge on this issue, and it is their (CMS’) position that the ER does provide sleeping accommodations for 4 or more patients and therefore they must be classified as healthcare occupancies.

This rather severe interpretation by CMS was communicated with the AOs, however it has yet to be released by CMS to the general public. Be aware: It appears that the AOs are prepared to enforce this decision by CMS, because if they do not, and CMS conducts a validation survey after the AO survey, then the AO can be held accountable for not citing the issue.

It is important to understand that there were advantages for a healthcare organization to claim their ER is an ambulatory healthcare occupancy. If the ER was too large to qualify as a suite under the healthcare occupancy requirements, then it may qualify as a suite under the ambulatory healthcare occupancy requirements because under the ambulatory healthcare chapters, suites are unlimited in size. Also, if the ER cannot qualify as a suite, there are no requirements for corridor doors to the exam rooms in an ambulatory healthcare occupancy.

So, for some healthcare organizations, re-classifying their ERs back to be a healthcare occupancy may be a serious challenge.

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Jan 17 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 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

Category: BlogBKeyes @ 12:00 am
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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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