Jan 13 2017

Fire Rated Door Frames

Category: Fire Doors,Life Safety Code UpdateBKeyes @ 12:00 am
Share

Q: We have a mechanical room door that is ¾-hour rated. The mechanical room is a 10 foot x 10 foot room with two electrical panels and a small gas fired heating unit. The metal door frame does not have a rating label on it. Does the frame need to be ¾-hour rated?

A: Anytime you have a fire-rated door assembly, the frame needs to be labeled as a fire-rated frame. Door frames typically (but not always) just have a label that says it is a fire-rated frame without any time associated with it. Those frames that are just labeled as being fire-rated are good for 3-hours, according to information that I seen on the manufacturer’s website. After 3-hours, then the frame needs to be labeled with the specific fire-rating needed.

The room that you are describing is required to be classified as a hazardous room since there is a fuel-fired heating appliance in the room. A hazardous room in a healthcare occupancy under existing conditions is required to have 1-hour fire rated walls with a ¾-hour fire-rated self-closing and positively latching door if the room is not sprinklered. However if the existing room is protected with sprinklers then the Life Safety Code allows you to have smoke resistant walls with a non-rated smoke resistant self-closing positively latching door.

If the hazardous room qualifies as new construction (or renovation), then the room must be constructed with 1-hour fire rated walls with a ¾-hour fire-rated self-closing positively latching door and the room must be protected with automatic sprinklers.

Even if the fire rated door that you refer to is not required, you must maintain it as such, which means the frame must also be labeled as being a fire-rated frame.


Jan 06 2017

Liquid Oxygen Transfilling Operation

Category: Life Safety Code Update,Liquid OxygenBKeyes @ 12:00 am
Share

Q: I have portable liquid O2 canisters that need to be refilled from the portable storage dewar. Are there any directions for me to follow in the process to refill these canisters?

A: Yes… There are very restrictive directions that you must follow when transfilling liquid oxygen from one container to another. It is very dangerous work, because if liquid oxygen were to be spilled onto a combustible surface, it would lower the flame point of that material to room temperature and actually burst into flames. Even floors like PVC tile are a danger, because they are combustible.

Sections 18/19.3.2.4 of the 2012 LSC require compliance with NFPA 99 (2012 edition) on all issues of medical gas. Section 11.5.2.2. of NFPA 99 discusses the requirements to follow for the transferring liquid oxygen (transfilling) from one container to another. Here is a summary:

  • Transfilling must be accomplished at a specifically designated location
  • The location must be separated from patient care and treatment areas by 1-hour fire rated construction
  • The location must be mechanically ventilated
  • The location must be sprinklered
  • The location must have ceramic flooring or concrete flooring
  • The location must be posted with signs identifying transfilling is occurring
  • The location must be posted with signs that says No Smoking
  • Transfilling must be accomplished utilizing equipment complying with CGA pamphlet P-2.6
  • The use and operation of small portable liquid oxygen systems must comply with CGA pamphlet P-2.7

My advice is to get the transfilling operation out of the hospital, and contain it to a special location that is not contiguous to the facility, such as a warehouse. If you haven’t already done so, you need to purchase the P-2.6 and P-2.7 pamphlets from the CGA (http://www.cganet.com/customer/publication_detail.aspx?id=P-2.7).

If you are currently not complying with any of the above listed requirements, I strongly recommend that you stop the transfilling process until you can correct what is non-compliant; it is that dangerous.


May 05 2016

Categorical Waivers and the New 2012 Life Safety Code

Category: Blog,Life Safety Code UpdateBKeyes @ 12:00 am
Share

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.

 

Tags:


Jun 06 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #6

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

CMS Logo 2

The following are the final comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

NFPA 101A Guide on Alternative Approaches to Life Safety

Brad’s Comment: The 2012 edition of the LSC references the 2010 edition of the NFPA 101A, Guide on Alternative Approaches to Life Safety. However, the 2010 edition of NFPA 101A is a guide for creating Fire Safety Evaluation System (FSES) equivalencies based on the 2009 edition of the Life Safety Code. The proper guide for creating FSES equivalencies for the 2012 LSC is the 2013 edition of NFPA 101A.

There are significant differences (other than LSC reference numbers) between the 2010 edition of NFPA 101A and the 2013 edition of NFPA 101A, including:

  • Section 4.3.2 “Selection of Zones to be Evaluated”
  • Section 4.6.9.3 “Mechanically Assisted Systems”
  • Section 4.7.10 “Step 10 – Determine Equivalency Conclusion”
  • Worksheet 4.7.11 “Conclusions”

Therefore, I will encourage CMS to adopt the 2013 edition of NFPA 101A, rather than to allow the reference to the 2010 edition.

Plan for Improvement (PFI) List

Brad’s comment: The Joint Commission has as part of their Statement of Conditions document a section called the Plan for Improvement (PFI) list. The purpose of the PFI list is for hospital facility managers to self-identify LSC deficiencies and to record their commitment to resolve the deficiencies. The PFI list includes documentation of the assessment for alternative life safety measures that further demonstrates the hospital’s ability and commitment to provide a safe environment for their patients. The return for the facility manager is the accreditation organization’s surveyors will not cite the hospital for any LSC deficiencies that have already been self-identified and recorded on the PFI list.

 CMS is on record of stating that all LSC deficiencies observed during a survey must be cited on the survey report, and will not permit any PFI lists that provide protection from findings. By denying the use of PFI lists, CMS is inadvertently enabling hospital facility managers to discontinue their self-identification of LSC deficiencies and take the approach of wait-and-see if the surveyors will find the deficiencies. This process leads to a physical environment that is not as safe for the patients, than one where the LSC deficiencies are proactively identified and the resolution managed.

As previously stated, hospital facility managers are basically conscientious individuals who want to do the best job they can. Many facility managers performance reviews are tied to the quantity and type of deficiencies cited during an accreditation survey or a validation survey. By eliminating a very useful tool as the PFI list, CMS is diminishing the incentive for hospitals to self-identify their LSC deficiencies, resulting in physical environments that may not be as safe.

 I will encourage CMS to reconsider this position, and permit all accreditation organizations the ability to operate documents similar to the PFI list, which provides an incentive to hospital facility managers to self-identify their LSC deficiencies, record them on a list, and manage the resolution of the deficiencies, all without receiving a finding or a citation on their survey report.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


Jun 04 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #5

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

CMS Logo 2

The following is one of many comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

CMS statement: “We also propose to add a new requirement at §482.41(b) (10) that would retain the majority of the 36 inch window sill requirement that was in the 2000 edition of the LSC. Newborn nurseries and rooms intended for occupancy for less than 24 hours, such as those housing obstetrical labor beds, and recovery beds would be exempt from the window sill height. The 2000 edition of the LSC allowed for observation beds in the emergency department to be exempt from the 36 inch window sill requirement. However, we do not propose to incorporate an exemption for observation beds, because they are frequently occupied for greater than 24 hours. Therefore, observation beds would be required to meet the 36 inch window sill requirement.”

Brad’s comment:  The physical environment of the ER consists of as many exam rooms and treatment rooms as the space would allow, and still meet applicable codes and standards. Many ERs extend into the interior areas of the facility since windows to the outdoors are not required in exam and treatment rooms. However, if CMS does not allow an exemption for window sill height in rooms containing observation beds, then healthcare facilities will have difficulty in finding space in the emergency department on outside walls for observation beds that will allow a window to the exterior.

Therefore, I will encourage CMS to reconsider their position and include rooms containing observation beds in the exemption for window sill height.

The following comment is not based on any one specific CMS statement:

Existing Non-High-Rise Health Care Occupancies

Brad’s comment:  While the 2012 LSC does not require existing non-high-rise healthcare occupancies to become fully protected with automatic sprinklers, I will encourage CMS to consider making this a requirement for participation in the Medicare & Medicaid program under this proposed rule, or perhaps future proposed rules.

As mentioned earlier, automatic sprinklers are the most effective fire safety system that can be installed for patient safety. Reports provided by NFPA show a significant reduction in the potential for loss of life when a hospital is equipped with automatic sprinklers, as indicated by this excerpt from a NFPA report:

“On January 24, 1993, an incendiary fire occurred at a hospital in Weymouth, Massachusetts.  One sprinkler operated in the room of fire origin, extinguishing the flames before firefighters arrived.  The damage from flame and heat was limited to the room of origin; however, water and smoke spread into the corridor and resulted in some damage.  Six staff were treated and released for smoke-related injuries.  Compliance with fire safety code requirements, training of staff, and the use of automatic sprinklers significantly reduced the potential for loss of life and large property loss during this incident.”

Based on this and other NFPA reports that indicate sprinklers saves lives in health care facilities, I believe mandating existing non-high-rise healthcare occupancies to become fully sprinklered within 6 to 8 years will provide a significant level of safety for patients in those facilities.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


Jun 03 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #4

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

CMS Logo 2

The following is one of many comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

CMS statement: Sections 18/19.3.5 of the 2012 LSC, Extinguishing Requirements: “Because of the increased reliance upon a facility sprinkler protection system in the 2012 edition of the LSC, and to ensure a facility is adequately monitored when a sprinkler system is out of service, we propose to retain the requirement for evacuation or a fire watch when a sprinkler system is out of service for more than 4 hours.”

Brad’s comment:  I fail to see the increased reliance on the sprinkler system that CMS refers to, other than high-rise buildings required to be fully sprinklered. To the contrary, NFPA has indicated a lessening on the reliance of the building sprinkler system as indicated by the changes made to the 2011 edition of NFPA 25 which has reduced the requirement to test vane-style waterflow switches from quarterly to semi-annually; and the same standard reduced the requirement to test electric driven fire pumps from weekly to monthly.

The NFPA technical committee’s rationale to increase the required time period from 4 hours to 10 hours to either evacuate the building or conduct a fire watch when the sprinkler system is impaired, is based on the belief that sprinkler contractors will be working on the sprinkler system during a normal weekday 8-hour daytime work shift. With the extra manpower that contractors can offer, and the maximum staffing that weekday day-time shifts can provide, it makes perfect sense to allow a 10-hour window that the sprinkler system is impaired before a fire watch is required. Otherwise, if the 4-hour time period is retained, then unnecessary extra staff will have to perform a fire watch that is not necessary during the daytime shift.

I will encourage CMS to reconsider this position. Perhaps it would be better to allow the 10-hour window before a fire watch is required for daytime staffing periods during a normal weekday. For other shifts when staffing levels are lower, such as weekends and holidays, then the 4-hour window before a fire watch is required makes more sense. The majority of work conducted on sprinkler systems in healthcare facilities is conducted during the weekday 1st shift.

2012 Edition of the Health Care Facilities Code (NFPA 99)

CMS statement: “In order to ensure the minimum level of protection afforded by NFPA 99 is applicable to all patient and resident care areas within a health care facility, CMS is proposing the adoption of the 2012 edition of NFPA 99, with the exception of chapters 7, 8, 12, and 13.”

Brad’s comment:  In another section of the proposed rule, CMS states the reason to not adopt chapters 7, 8, and 13 is because CMS believes these chapters are not within the scope of the conditions of participation and conditions for coverage. Chapter 7 is on Information Technology and Communication Systems; chapter 8 is on Plumbing; and chapter 13 is on Security Management. Chapter 12 is on Emergency Management and that subject is already covered by a CMS proposed rule issued in December, 2013.

While titled “Information Technology and Communication”, chapter 7 primarily concerns itself with telecommunications, which is critically important when patients need to communicate with nurses through nurse call systems; physicians need to communicate with health care providers; and incident commanders need to communicate with their regional emergency operations centers. Some of the significant requirements concerning telecommunication systems in chapter 7 include:

  • Not less than two physically separate service entrance pathways into the facility are required;
  • Electronic storage with a minimum capacity to store all inpatient records shall be provided at the building
  • Further restrictions and location requirements on the entrance facility for telecommunication and equipment room include:
    • Power requirements
    • Environmental requirements
    • Fire suppression
    • Nurse call systems

Chapter 8 is titled “Plumbing” and does not seem to offer any additional assistance than state or local plumbing codes. It is understandable that CMS would not want to adopt a chapter with little content and what appears to be a duplication of state and local codes.

Chapter 13 is titled “Security Management” and while the initial content of this chapter appears to be a duplication of another accreditation organization’s standards, the chapter does provide significant guidance and standards on critically important security elements and measures that provide a safe environment for the patients, including:

  • Security management plan
  • Security vulnerability assessment
  • Identification of responsible person to manage security activities by leadership
  • Identifying and protecting security sensitive areas
  • Ingress and egress control
  • Media control
  • Crowd control
  • Security equipment
  • Security operations
  • Program evaluation

This chapter covers more content than any accreditation organization standard on security management, and is very useful and appropriate in the overall plan to provide a safe environment for the patients.

I understand CMS’s reluctance to adopt chapter 8 since it has very little content to offer, and I understand that CMS has their own proposed rule on Emergency Management that makes chapter 12 a duplication. But I disagree with CMS in regards to not adopting chapters 7 and 13. The subject matter in these chapters is very much within the scope of the conditions for participation in regards to hospital health care facilities providing a safe environment for patients. The content of chapter 7 and 13 can be very helpful to hospital health care organizations as the accreditation organizations do not have standards on all of this information. I will encourage CMS to reconsider and adopt chapters 7 and 13 in their final rule.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


May 30 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #3

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

 

CMS Logo 2The following is one of many comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

CMS statement: Sections 18/19.4.2 of the 2012 LSC, Sprinklers in High-Rise Buildings: “We would like to solicit public comments regarding the phase-in period of 12 years, including if 12 years is enough time for the installation of sprinklers in high-rise buildings.”

Brad’s comment: As CMS pointed out in their proposed rule, the 2012 LSC allows a 12-year period from the time the authority having jurisdiction adopts the 2012 LSC for existing high-rise healthcare facilities to comply with the requirement to become fully protected with automatic sprinklers. Automatic sprinklers are the number one most effective fire-safety measure an organization can provide that will save lives in the event of a fire. A healthcare facility that qualifies as a high-rise building will need additional time to evacuate their patients (compared to a non-high-rise healthcare facility) in the event of a fire, and sprinklers can contain and/or extinguish a fire and provide the much needed extra time.

Therefore, I believe 12 years is more than sufficient time to become fully sprinklered for high-rise healthcare facilities, and will encourage CMS to consider a more reasonable time period of 6 to 8 years.   

CMS statement: Section 18/19.3.2.6 of the 2012 LSC, Alcohol based hand rubs (ABHRs): [No Statement]

Brad’s comment:  The 2012 edition of the LSC provides for changes in how health care providers use alcohol based hand-rub (ABHR) dispensers in their facility. The 2012 edition of the LSC only discusses healthcare occupancies and ambulatory health care occupancies when it addresses ABHR dispensers, but the 2012 LSC seems to have omitted allowing ABHR dispensers in corridors of business occupancies.

Section 38/39.3.2 of the 2012 edition of the LSC references section 8.7 on the protection of hazards. Section 8.7.3.2 states: “No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure, unless otherwise permitted by 8.3.7.1.”

The mounting of ABHR dispensers in corridors of business occupancies is considered handling of flammable liquids, and according to the 2012 LSC, is not permitted. However, many hospitals have multiple occupancy types in their facility, including business occupancy, and according to this section of the LSC, ABHR dispensers would not be permitted in the corridors.

I will encourage CMS to address this apparent oversight by the NFPA technical committee(s) who omitted allowing ABHR dispensers in business occupancies of healthcare facilities. Whatever risk there is of ABHR dispensers mounted in the corridors of healthcare occupancies, it is the same and no greater risk when mounted in the corridors of business occupancies.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


May 28 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #2

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

The following is one of many comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

CMS statement: Sections 18/19.2.3.4 (2) 2012 LSC Corridor Projections: “Therefore, while the LSC allows facilities to have 6 inch projections, so long as the ADA standard is 4 inches then facilities should only have 4 inch projections to comply with the more stringent requirement set forth by the ADA.”

Brad’s comment:  The Americans with Disabilities Act (ADA) is only applicable to new construction or renovation of existing conditions, and is not retroactive to existing conditions. Many hospitals have constructed their facilities prior to the enforcement of the ADA, and have corridor projections that exceed the ADA limit of 4 inches. I will encourage CMS to consider requiring health care providers to comply with the ADA corridor projection limits of 4 inches for new construction and renovation of existing areas only.

 CMS statement: Sections 18.3.6.3.9.1 and 19.3.6.3.5 of the 2012 LSC, Roller Latches:Many roller latches in fire situations failed to provide adequate protection to residents in their rooms during an emergency. Therefore, roller latches would be prohibited in existing and new Health Care Occupancies, and corridor doors would be required to have positive latching devices.”

Brad’s comment:  I agree with the concept that roller latches are a safety hazard on corridor doors that are required to latch. However, some corridor doors are not required to latch, such as doors to toilet rooms, shower rooms, and bath tub rooms, where no combustibles are stored. There should be no penalty if an organization wants to use roller latches in situations where corridor doors are not required to latch. Also, doors to patient rooms inside a sleeping suite are not required to latch either, and similarly, roller latches should be permitted inside a suite if the organization chooses to use them.

I will encourage CMS to alter their final rule to distinguish that roller latches are not permitted on corridor doors that are required to latch.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


May 27 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #1

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

CMS Logo 2The following is one of many comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

CMS statement: “We do not consider it always necessary for a facility to be cited before it can apply for or receive a waiver. This is particularly the case when we have evaluated specific provisions of the LSC, determined that a waiver would arguably apply to all similarly-situated facilities with respect to the LSC requirement in question, and issued a public communication describing the specifics of such a categorical waiver, including any particular requirements that must be met in order for the waiver to apply to a facility.”

Brad’s comment:  I recognizes CMS as the sole authority to grant waivers, and support and encourage CMS to continue their review of newer codes and standards that may lead to future categorical waivers to the benefit of all health care providers with similar circumstances. However, it has been the practice of CMS to decline to review waiver requests for specific LSC deficiencies that health care providers may have, since they have not been cited during an accreditation survey or a state agency survey on behalf of CMS.

Most health care facility managers are conscientious individuals who seek to perform a credible performance in maintaining their facility safe for their patients. When confronted with a LSC deficiency that presents an unreasonable hardship and cannot be resolved (or would take multiple years to resolve) they seek alternative methods to achieve compliance. For the sake of this discussion, and assuming a Fire Safety Evaluation System (FSES) equivalency is not a valid alternative, a waiver request is the facilities manager last option. It would be advantageous to the health care provider if CMS would allow them to submit waiver requests through their accreditation organization or state agency on behalf of CMS, to the respective CMS regional office for their review and approval.

CMS may consider it acceptable for facility managers to wait until their triennial survey, and then identify the LSC deficiency for which they seek a waiver so it can be cited on the survey report. This is contrary to the way that most (if not all) facility managers reason and operate. First, most facility managers would not identify LSC deficiencies to a surveyor or inspector during a survey. Secondly, many facility managers performance reviews are tied to the quantity and type of deficiencies cited during an accreditation survey or a validation survey. It is natural for these facility managers to remain silent if presented the opportunity to identify LSC deficiencies to a surveyor or inspector.

By not permitting health care providers with the opportunity to submit waiver requests prior to the LSC deficiency being cited during a survey, CMS is inadvertently creating an environment whereby facility managers are becoming passive about LSC compliance, and may likely take the attitude of not attempting to self-identify LSC deficiencies and implement alternative life safety measures.

CMS has already set a precedent of approving categorical waivers for specific issues prior to a health care provider being cited during a survey. While these categorical waivers are based on newer editions of the NFPA codes and standards, the precedent is set where CMS has granted waivers before the organization was cited.

I will strongly encourage CMS to consider this request to allow health care providers the ability to submit waiver requests before they are cited during a survey.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


Apr 14 2014

Yippee! CMS to Publish Proposed Rule to Adopt the 2012 LSC

Category: Blog,Life Safety Code UpdateBKeyes @ 4:15 pm
Share

 10112[1]The Centers for Medicare & Medicaid Services (CMS) today announced a proposed rule on the adoption of updated life safety code (LSC) that CMS would use in its ongoing work to ensure the health and safety of all patients, family and staff in every provider and supplier setting. The updated code contains new provisions that are vital to the health and safety of all patients and staff.

A key priority of CMS is to ensure that patients and staff continue to experience the highest degree of safety possible, including fire safety. CMS intends to adopt the National Fire Protection Association’s (NFPA) 2012 editions of the (LSC) and the Health Care Facilities Code (HCFC). This would reduce burden on health care providers, as the 2012 edition of the LSC also is aligned with the international building codes and would make compliance across codes much simpler for Medicare and Medicaid-participating facilities.

BACKGROUND:

Currently, CMS applies the standards set out in the 2000 edition of the LSC to facilities in order to ensure patients’ and caregivers’ health and safety. CMS is now proposing to adopt the 2012 editions of the LSC and the Health Care Facilities Code. The LSC sets out fire safety requirements for new and existing buildings, and is issued by the NFPA, a private, nonprofit organization dedicated to reducing loss of life due to fire.

The Health Care Facilities Code contains more detailed provisions specific to health care and ambulatory care facilities. Adoption of this code would provide minimum requirements for the installation, inspection, testing, maintenance, performance, and safe practices of health care facility materials, equipment and appliances.

The new edition of the LSC applies to: hospitals, long term care facilities (LTC), critical access hospitals (CAHs), Programs for All Inclusive Care for the Elderly (PACE), religious non-medical healthcare institutions (RNHCIs), hospice inpatient facilities, ambulatory surgical centers (ASCs), and intermediate care facilities for individuals with intellectual disabilities (ICF-IIDs).

Adoption of the new LSC for Health Care Facilities Code (applicable to hospitals, LTC facilities, CAHs, Hospice inpatient facilities, PACE, RNHCIs) would make the following changes:

  • Would allow facilities to increase suite sizes;
  • Would require all high-rise buildings over 75’ are required to be fully sprinklered within 12 years;
  • Would allow controlled access doors to prevent wandering patients;
  • Would address issues of alcohol based hand rub dispensers in  corridors and patient rooms;
  • Would require a fire watch (The assignment of a person or persons to an area for the express purpose of notifying appropriate people during an emergency) or building evacuation if a sprinkler system is out of service for more than 4 hours; and
  • Would require smoke control in anesthetizing locations.

The key changes for ASCs are:

  • Would permit required 2-hour fire rated interior non-bearing walls to be constructed with fire retardant treated wood;
  • Would require all doors to hazardous areas have to be self-closing or automatic closing;
  • Would address the issue of placing alcohol based hand rub dispensers in corridors;
  • Would require a fire watch or building evacuation if sprinkler system is out of service for more than 4 hours; and
  • Would require smoke control in anesthetizing locations.

The major changes for Intermediate Care Facilities for individuals with Intellectual Disabilities (ICF-IIDs) are:

  • Would have expanded sprinkler requirements to include habitable areas, closets, roofed porches, balconies and decks in new facilities;
  • Would require all attics to be sprinklered if they are used for living purposes, storage or housing of fuel fired equipment- if they are not used for these purposes, attics may have heat detection systems instead;
  • Would require all designated means of escape be free from obstruction;
  • New facilities are required to have smoke alarms installed on all levels;
  • Would allow access-controlled egress doors to be equipped with electrical lock hardware to prevent residents from wandering away;
  • Would require hazardous areas to be separated from other parts of the building by smoke partitions; and
  • Would require existing facilities to include certain fire alarm features when they choose to update their fire alarm systems.

 PUBLIC INPUT INVITED:

The proposed rule is currently on display at http://ofr.gov/inspection.aspx and will be published in the April 16, 2014 Federal Register. The deadline to submit comments is June, 16, 2014.

Tags:


Next Page »