Apr 20 2018

Eye-Wash Risk Assessment

Category: BlogBKeyes @ 12:00 am
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Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document?

A: There is no set form to use for risk assessments. You can just get a group of stakeholders together and discuss the issue and the proposed solution and then write down what you discussed.

If you want a form that is based on the seven (7) steps recommended by The Joint Commission, go to my website, click on “Tools” and download the risk assessment form.

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Apr 19 2018

Strange Observations – Part 22

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things I have seen while consulting at hospitals…

I used to work in the construction trades. I like to think that workers in the construction trades know better than to do something silly like this.
The sprinkler pipe is suspended from the frame-work for the overhead door. All sprinkler pipe has to be suspended from the building structure.

Oh well…. I seem to remember I didn’t know how to install a fire damper properly for a long time.

Keep an eye on those construction people… they don’t always know what the code and standards require.


Apr 18 2018

Means of Egress Illumination

Category: BlogBKeyes @ 12:00 am
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Q: We have a chapel/activity room that is used for bingo and worship services. Can you please tell me what the minimum illumination of the walking surface in foot-candles is required for this area?

A: Section 7.8.1 of the 2012 Life Safety Code discusses the requirements for the illumination of the means of egress. Keep in mind that the means of egress includes aisles and is not limited to just corridors. Therefore, the aisles inside the chapel/activity room would be required to meet the minimum illumination requirements. Normally, the minimum illumination requirement at the floor level (other than stairwells) is 1-foot candle according to section 7.8.1.3 (2), but a chapel/activity room would qualify as an assembly occupancy and the LSC allows less lighting levels of 0.2-foot candle during periods of performances or projections involving direct light. But 1-foot candle is not very much illumination and is about the brightness of a lit match. So, maintaining the minimum illumination requirements in the means of egress is achievable. Check with other governmental regulations to see if there are greater requirements for illumination of the means of egress. I’ve been told that OSHA requires a minimum of 5-foot candles of illumination for the means of egress.

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Apr 17 2018

Second Chance to Attend a Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed… Did you want to attend this educational event but missed your chance to register??

Not to worry…. Now you can attend another Keyes Life Safety Boot Camp scheduled for May 22 & 23, 2018 in Kalamazoo, MI. It’s the very same content, the very same presenters, but is sponsored by Compliance One.

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.

Date: May 22 & 23, 2018

Location: Downtown Kalamazoo Michigan

600 E. Michigan Ave., Suite A, Kalamazoo, MI 49007

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; and former Joint Commission LS surveyor.

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

Cost: $889.00 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.

Register: To register for this event, go to www.complianceonebootcamp.com.

Register Early: Seating is limited – Previous boot camps have sold out.  Registration will close on May 2.

Bring your own copy of the 2012 Life Safety Code!

Questions? Contact Ali Rogers, Marketing Manager, ali.rogers@complianceonegroup.com; 866-779-3235

Exclusively sponsored by:

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Apr 16 2018

Un-Sprinklered High Rise Hospital

Category: BlogBKeyes @ 12:00 am
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Q: I am a consultant and I have a client who has a new high rise hospital that is not fully sprinklered. The plans for this hospital were approved and stamped by the local building officials after 2003 and the building construction completed in 2010. Would the entire building have been required to be fully sprinklered when it was constructed?

A: I would say so. Depending on who they are accredited by, and what state they are in, they could be cited for not being 100% sprinklered, since the building design was approved after the 2000 Life Safety Code was adopted. For example, if they are Joint Commission accredited, Joint Commission had been adopting the new editions of the Life Safety Code soon after NFPA published them, up to and including the 2000 edition. So, that means since the 1991 edition of the Life Safety Code was the first edition to require all new construction healthcare occupancies to be fully protected with sprinklers, this building would have been required to be sprinklered if they were Joint Commission accredited. Also, most states adopt new versions of the LSC as they are published, so from a state viewpoint this building would likely have been required to be 100% sprinklered as well.

CMS adopted the 2000 edition of the LSC in March, 2003. Previously they were on the 1985 edition which did not require new construction to be protected with sprinklers. So, for CMS certified hospitals, the start date for new construction required to be sprinklered was March, 2003. For Joint Commission accredited hospitals, it would have been when they adopted the 1991 edition of the Life Safety Code. So, it is apparent someone did not get the word that a newly constructed high-rise hospital that had their design stamped by the local authorities after 2003, is required to be fully sprinklered.

Yep… that is a citation waiting to be written. Could even be a Condition Level Finding. Better advise them to get started in completing the sprinkler installation as soon as possible.

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Apr 13 2018

Refrigerators

Category: BlogBKeyes @ 12:00 am
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Q: Generally, is it permitted to use a refrigerator in offices in healthcare facilities when considering fire safety? I ask because more and more offices are starting to request refrigerators.

A: The Life Safety Code does not regulate where appliances like refrigerators may be placed, other than they may not obstruct the required width of the means of egress. I would think refrigerators in an office should not be any problem, other than temperature control of the office.

 

But check with your state and local authorities to see if they have other restrictions.

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Apr 12 2018

Strange Observations – Part 21

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things I have seen while consulting at hospitals…

This looks like an adjunct corridor, one that is not used by patients. It doesn’t have a finished ceiling, so that implies it is located in a support services area.

Just because the exit is not used very often is no reason you obstruct access to it.

I know storage space is a premium in hospitals, but this is just plain sad.


Apr 11 2018

Environmental Tours

Category: BlogBKeyes @ 12:00 am
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Q: I have read, or thought I read, that the environmental tours were no longer required with the adoption of the life safety code. Is this correct?

A: No… The NFPA codes and standards referenced by the Life Safety Code never did require environmental tours. When the 2012 Life Safety Code was adopted by CMS (and the accreditation organizations) last year, it made no changes regarding environmental tours because the 2012 LSC does not require it. The 2000 LSC did not require it either. Environmental tours are required… by the accreditation organizations (at least some of them). Joint Commission, HFAP and DNV all require that you evaluate your physical environment on a periodic basis. Some require semi-annually, and some only require annually. CMS does not have any Condition of Participation or standard that specifically requires a periodic tour of the physical environment, although they do require that your physical environment be maintained in a safe manner, which implies a routine inspection would be required to achieve that. So, if you’re accredited by one of the major accreditation organizations, you need to continue to perform environmental tours.

 

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Apr 10 2018

Second Chance to Attend a Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed… Did you want to attend this educational event but missed your chance to register??

Not to worry…. Now you can attend another Keyes Life Safety Boot Camp scheduled for May 22 & 23, 2018 in Kalamazoo, MI. It’s the very same content, the very same presenters, but is sponsored by Compliance One.

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.

Date: May 22 & 23, 2018

Location: Downtown Kalamazoo Michigan

600 E. Michigan Ave., Suite A, Kalamazoo, MI 49007

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; and former Joint Commission LS surveyor.

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

Cost: $889.00 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.

Register: To register for this event, go to www.complianceonebootcamp.com.

Register Early: Seating is limited – Previous boot camps have sold out.  Registration will close on May 2.

Bring your own copy of the 2012 Life Safety Code!

Questions? Contact Ali Rogers, Marketing Manager, ali.rogers@complianceonegroup.com; 866-779-3235

Exclusively sponsored by:

 

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Apr 09 2018

Medical Equipment Contractor

Category: BlogBKeyes @ 12:00 am
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 Q: When I came into this new position the medical equipment program was run by a third party managing our own Bio-med technicians. We changed the 3rd party contractor and we still have a problem as far as the PM’s not being done by the new contractor (huge back log). We think with good reason that the hospital is at risk.   We put pressure on the contractor by mentioning our concerns regarding an upcoming accreditation survey, or the state public health department survey, and CMS (which could happen at any time), not to mention the safety of our patients. The contractor’s answer is we should not be concerned since the accreditation organization and CMS will accept the fact that we are “in transition” and that it is commonly accepted to experience a backlog in this type of situation. We asked them to provide documentation to support their position, but we have not heard anything yet. What are your thoughts?

A: I think that is faulty logic. There is nothing in the accreditation standards or the CMS CoPs that allows non-compliance based on a change in contractors. Either you are or you are not compliant. Most surveyors will not care why you’re not compliant.

It is likely that the contractor who told you this was provided misleading information. Perhaps they were part of a survey where the surveyor was benevolent said something like that. If so, then that is an individual surveyor’s preference and is not the policy of the accreditor or the CMS. The chances are you will have a surveyor in your upcoming survey who may be sympathetic, but still cite you if you’re not compliant.

Get cracking on that contractor… You’re the boss, not them.  If they fail to perform, withhold payment and find a new contractor, or better yet, use this situation as a validation to your leadership that you need to manage this important process in-house, and no longer have outside contractors manage your Bio-med services.

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