Feb 27 2014

Delayed Egress on Doors in Ambulatory Health Care Occupancies

Category: BlogBKeyes @ 6:00 am


A friend of mine was working on a project involving ambulatory health care occupancy, and they wanted to use a delayed egress lock on an interior door.  The 2000 Life Safety Code (LSC) limits special locking arrangements to exterior doors in ambulatory health care occupancy, but the 2012 LSC does not include that limitation.  They wanted to know what I would recommend.

Well, they are correct: The 2012 edition of the LSC did away with the limitations of the special locking arrangements found in section of the LSC. Section 20/ of the 2012 edition of the LSC now permits delayed egress locks on any door in the path of egress, where the 2000 edition of the LSC limited them to the exterior door.

I assumed that the individual who asked me the question was bound by the 2000 edition of the LSC, such as a Joint Commission accredited organization, or perhaps a CMS provider for Medicare. My initial thought is the organization would have to comply with the conditions of the 2000 edition of the LSC, and cannot take advantage of the more lenient 2012 edition until such time that edition is adopted by CMS and/or Joint Commission.

However, CMS did issue a categorical waiver to healthcare organizations to allow them to use many of the provisions of the 2012 edition of the LSC now, before the 2012 edition is actually adopted (which may be at least another 12 months away). I reviewed the CMS S&C memo 13-58 once again, and while CMS did state in one of their opening paragraphs that they have the authority to grant waivers for ambulatory surgical centers, they failed to do so in the body of their memo. They have a categorical waiver on doors to allow healthcare occupancies to use the more liberal 2012 LSC position on delayed egress locks, but that categorical waiver only applies to healthcare occupancies, and not ambulatory surgical centers, assuming the ambulatory health care occupancy my friend was referring to was an ambulatory surgical center.

Therefore, I concluded that the organization should (or must) comply with the 2000 edition of the LSC and only install special locking arrangements on exterior doors. Once the 2012 edition of the LSC is adopted, they can then install delayed egress locks on interior doors.

I also mentioned that if the facility in question is only accredited by The Joint Commission, and does not receive any funds from CMS as a Medicare or Medicaid provider, then they could contact the Standards Interpretation Group (SIG) at Joint Commission and ask them if they would accept a Traditional Equivalency to allow them to use special locking arrangements on interior doors of their ambulatory care occupancy. (The telephone number for SIG is:  630-792-5900, select option 6.) My guess is they will, provided the organization meets all the requirements for a traditional equivalency.

If the facility in question actually is part of a larger organization that does have a CMS control number (CCN), then I advised my friend that they have no choice by to comply with the conditions of the 2000 edition of the LSC.

My friend replied asking if they could request a standard CMS waiver to allow the organization to install the delayed egress lock on an interior door now, before the 2012 edition of the LSC is adopted.

My reply was yes, there is always the possibility for a waiver, but CMS will not accept a waiver request unless it is in response to a survey deficiency. In other words, the waiver process is not valid until someone representing CMS cites a deficiency.

As a safety professional, I would never recommend or advise a client to knowingly violate the current edition of the LSC, even though we know that issue will be viewed differently in a more recent edition. There is always the chance that CMS may not adopt the 2012 LSC, although I would be very surprised if they did not.

However, any organization may do what they want, and often times they disregard the advice of a safety professional, and violate the LSC, taking the risk that they will not get caught. In this case, it is understandable as the presumption is the 2012 edition will be effective within the next 12 months or so, and they may feel they will not have any surveys or inspections before then.

So… in summary: The waiver process is not available to them since they have not been cited for non-compliance with the LSC. And, as a safety professional I cannot advise them to violate the LSC. What they do after that is their own business, and risk.

I have some clients who ignore my advice, preferring to ask other safety experts until they find someone who agrees with the answer they want. Hey… it’s their hospital, not mine. I always advise clients to follow the current rules, regulations, codes and standards, but if they decide otherwise, then that’s on them.

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