Mar 17 2014

Life Safety Code Surveyor

Category: Life Safety Code,Questions and AnswersBKeyes @ 6:00 am
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Q: Is the Life Safety Surveyor a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and various areas of survey?”

A: No, the Life Safety Code Surveyor that the accreditation organizations use is not a mandate or a requirement by the Centers for Medicare & Medicaid Services (CMS), or any other arm of the government. It is more of an indication that evaluating the hospital’s compliance with the Life Safety Code requires specialized skills that previous surveyors simply did not have. In 2004, the Government Accountability Office (GAO) published a report that indicated The Joint Commission needed improvement in the assessment of hospitals for compliance with the Life Safety Code. To their credit, the Joint Commission agreed and decided to hire Life Safety Code specialists and make them surveyors and put them on the survey team. The new LSC surveyors began surveying in January, 2005, for hospitals with 200 beds or more, and it was a huge success. Hospitals actually liked being inspected by knowledgeable surveyors and in 2008 the LSC surveyors were expanded to survey all hospitals, including Critical Access hospitals. When Det Norske Veritas Healthcare, Inc. (DNV) started surveying hospitals in 2008, they immediately recognized the need for surveyors with specialized skills in the Life Safety Code and included them in their surveyor compliment. And Healthcare Facilities Accreditation Program (HFAP) has decided to include surveyors with life safety skills as well.


Jan 06 2014

The New 2012 Life Safety Code

Q: When will we know if CMS will adopt the 2012 version of the NFPA LSC book?

A: You will not have to worry about that… Nearly everyone will be writing about it and there will be public announcements made in every industry newsletter and blog across the country. First, CMS will publish an announcement of the rule change to adopt the 2012 LSC in the Federal Register; then membership organizations like ASHE will alert their members of the news; then accreditation organizations like Joint Commission will issue statements and press releases about the adoption; then industry newsletters and blogs (like this one) will be talking about it. It will not go un-noticed. The good news is CMS has already said in the 2013 spring Unified Agenda that they intend to propose a rule that will require compliance with the 2012 edition of the LSC; the bad news is we don’t know when they will issue the final rule. I suspect it will be at least another 6 – 12 months if not longer as CMS must first publish a proposed rule change in the Federal Register, then allow 60 days for public comment; then take the time to review and respond to all the public comments; then they will issue the final rule change to adopt the 2012 LSC, again in the Federal Register. The length of time between CMS reviewing the public comments and issuing a final rule could be 12 months or longer (based on the last time they adopted a newer edition of the LSC). I don’t expect the effective date for the adoption of the 2012 LSC to be until early 2015. The misconception that seems to be very common is the myth that Congress needs to approve the rule change to adopt the 2012 LSC, which is not true. Congress has 60 days to review the final rule and if they don’t like it, they can only challenge it through the federal court system. This is all based on the Administrative Procedure Act of 1946 that limits how federal agencies make changes to their rules. There have even been comments by industry experts that CMS should change the rule, to allow them to adopt a newer edition of the LSC without having to go through the due diligence process of proposed rules and public comments. That does not seem to be a good decision for the public, as then there would be no process for us to make comments on a proposed change to a newer edition of the LSC. All in all, the way they are doing it now is a good system. Not very fast, but what part of government is?


Jun 17 2013

Who is the Authority?

Category: Life Safety Code,Questions and AnswersBKeyes @ 6:00 am
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Q: We recently had a survey where we were cited for not having a paved sidewalk from the exit door of a stairwell, to the parking lot. The surveyor said the path to the public-way needed to be a smooth walking surface. Our architect said this is not true, and provided us with a document from the city building authorities approving the design without the sidewalk. Who do we have to follow, the surveyor from the accreditation organization or the city building authorities?

A: You definitely must follow the most restrictive of all the authorities who inspect your facility. If the city says you do not need a sidewalk but the accreditation organization says you do, then you must follow the accreditation organization, since their interpretation requires a smooth walking surface and is more restrictive. Keep in mind: they are an authority as well. You always have the right to appeal the surveyor’s decision through the clarification process, but whatever the result is of that decision, is what you must do. There are many different authorities having jurisdiction (AHJ) who inspect hospitals and tell them how to operate them. The typical hospital has 5 or 6 different AHJs who may inspect the hospital according to the requirements of the Life Safety Code:

  • Accreditation organizations (Joint Commission, HFAP, DNV)
  • CMS
  • State department of public health
  • State fire marshal
  • Local fire inspector
  • Insurance carrier

Any one of these AHJs can make an interpretation of the code, and the hospital would need to comply with it. No single AHJ can over-rule another AHJ’s decision, however, any of the AHJs can order you (within reason) to comply with their own interpretation, even when it differs with an interpretation from some other AHJ. But the local architects rarely, if ever, deal with accreditation organizations, so that why he felt the surveyor was wrong. It is perfectly within the right of the accreditation organizations to interpret the code to require a paved sidewalk at the exit discharge even though the local AHJs do not require that.


Feb 21 2013

Offsite Locations

Q: We have many offsite locations that are not hospitals but are clinics for diagnostic imaging, testing and physician’s offices. What, if any Life Safety Code standards apply in these locations?

A: The Life Safety Code is a document that needs to be adopted by some authority in order for it to become an enforceable standard. Normally, for free standing offsite clinics and physician’s offices, they are regulated by state and/or local authorities. For construction, the local building code would apply, and for fire safety, either the Life Safety Code or the International Fire Code would apply, depending on which document is used by the local fire inspector. For ambulatory surgical centers, dialysis centers, and other facilities where there may be more than 3 patients incapable of self-preservation, there could be multiple authorities having jurisdiction, such as the Centers for Medicare & Medicaid Services (CMS), Joint Commission, and your state oversight agency on public health. CMS and Joint Commission do enforce the Life Safety Code at these types of facilities, but your state agency may enforce the International Fire Code. If you are unsure of which code or standard that complies, I suggest you contact your local and state authorities and ask them. In regards to the Life Safety Code, there are applicable standards to follow depending on the occupancy classification.