Dec 26 2017

Fully Sprinklered Buildings

Category: Questions and Answers,Sprinklers,WaiversBKeyes @ 12:00 am
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Q: Our facility is a four story facility, and is a combination of different structures built in different years. All of the different structures are protected with sprinklers except for our power plant. Our power plant is 24 hours manned and has Fire Alarm System devices installed or equipped. Do we need to ask for a waiver as per the new NFPA 101 2012 edition that is to be implemented this year?

A: Existing healthcare occupancy buildings are not required to be fully protected with sprinklers. There is no requirement with the new 2012 LSC to install sprinklers in existing buildings (unless the building is a high-rise) so there is no need to ask for waivers.

Now, it is very desirable for healthcare occupancy buildings to be fully sprinklered because if they are, it allows you to do many terrific things. Take a look at the following 2012 Life Safety Code references, which describes the many advantages of having a fully sprinklered building:

  • 7.2.1.6.1 – Delayed egress locks are allowed only if the entire building is protected with sprinklers or smoke detectors
  • 7.3.3.1 – Capacity factors for egress components improve if entire building is sprinklered
  • 7.7.2 – No more than 50% of required exits may discharge through the level of exit discharge if area is sprinklered
  • 8.7.1.1 – A hazardous area may not have to have 1-hour fire rated walls if protected with sprinklers (Note: This does not supersede section 18/19.3.2.1.)
  • 10.2.8.1 – Class C interior finishes are permitted in locations where Class B is permitted, and Class B interior finishes are permitted in locations where Class A is permitted, provided the area is protected with sprinklers. (Note: This does not supersede section 18/19.3.3.2.)
  • 10.2.8.2 – Class II interior floor finish is permitted in locations where Class I is permitted providing the area is protected with sprinklers.
  • 10.3.3 – Upholstered furniture must meet the requirements in accordance with NFPA 260 and NFPA 261, unless the furniture is located in rooms protected by sprinklers.
  • 10.3.4 – Mattresses must meet the requirements in accordance with Part 1632 of the CFR 16, and NFPA 267, unless the mattresses are located in a room that is protected with sprinklers.
  • 19.1.6.1 – Lesser levels of Construction Types are permitted if the entire building is protected with automatic sprinklers.
  • 19.2.6.2.2- Travel distances between any point in a room and the exit increases by 50 feet if the entire building is protected with automatic sprinklers
  • 19.3.2.1- Hazardous areas are not required to be 1-hour fire rated if the walls are smoke resistant and area is protected with automatic sprinklers
  • 19.3.3.3 – No interior floor finish requirements apply in smoke compartment protected with automatic sprinklers
  • 19.3.6.1 – Areas open to the corridor are afforded exceptions if the smoke compartment is protected with automatic sprinklers
  • 19.3.6.2.4 – Corridor walls are not required to be ½ hour fire rated provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • 19.3.6.3.2 – Corridor doors do not have to be 1 ¾ inch thick, solid-bonded wood core or of construction that resists fire for not less than 20 minutes provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • 19.3.7.3 – Smoke dampers are not required in fully ducted penetrations of smoke barriers provided both smoke compartments served by the barrier is protected with automatic sprinklers.

By the way, CMS will not consider a waiver request until such time the Life Safety Code deficiency has been cited in a report. So, don’t plan on submitting a waiver request until after you have been cited.


Oct 31 2017

CMS Waiver Approval

Category: CMS,Questions and Answers,WaiversBKeyes @ 12:00 am
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Q: If a building changes ownership, do waivers stay active with their 1-year window or do the new owners have to resubmit if the building is cited the same deficiency?

A: Interesting question… I’ve never had this issue come up before.

My guess would be the waivers would be valid only to the organization for which they were approved. The way that CMS writes their approval letters is the approval of the waiver is addressed to the healthcare organization, and not to the building owner. In other words, CMS grants approval to the healthcare organization to not have to comply with a particular section of the Life Safety Code. This approval would not appear to be transferrable, since it is addressed to the healthcare organization.

But if the ownership of the healthcare organization changes hands, then I could see where the waiver approval would follow the healthcare organization. CMS tracks the waiver requests and the subsequent approvals via their own CMS Certification Number (CCN), which is assigned to healthcare organizations, not their owners.

To answer your question, if a deficiency is cited and the healthcare organization chooses to submit a waiver request rather than resolve the deficiency, then yes, a new waiver request would have to be submitted.

 


Sep 04 2017

Waiver and Equivalency Validation

Category: Equivalencies,Questions and Answers,WaiversBKeyes @ 12:00 am
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Q: During a recent webinar, the presenter said waivers and equivalencies are only valid until the next triennial survey.   Does that really mean if CMS approved a waiver or an equivalency we need to go through that same process again even if things have not changed in 3yrs and get this reapproved?

A: Yes it does. Once a waiver or equivalency request is approved by CMS, it is only valid until the next survey, regardless if the next survey is the triennial survey by your accreditation organization, or a validation survey by your state agency. At that time, the waiver or equivalency is no longer valid, and the surveyor will inspect the area to determine if the deficiency still exists, and if it does, the deficiency will be cited again. Then the hospital has the choice to either resolve the deficiency or submit a waiver (or equivalency) request again.

According to a statement from CMS, this process of having waivers and equivalencies valid until the next survey is a checks-and-balance system to ensure that the conditions in the hospital that allowed the waiver to be approved in the first place have not changed in the time since the waiver (or equivalency) was granted. It makes sense, in that CMS is ensuring that the conditions are still acceptable for a waiver or an equivalency.

However, the expense of submitting waivers or equivalencies every 3 years may be a real burden to some organizations, and there is no guarantee that CMS will approve a waiver (or equivalency) request for the same deficiency a second time. It is a very subjective process. That is why hospitals need to seriously consider resolving the deficiency instead.