Aug 31 2016

Enforcement Date for the 2012 LSC

Category: CMS,Joint Commission,Questions and AnswersBKeyes @ 12:00 am
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Q: Can you provide some clarification? The NFPA 101 2012 edition was adopted July 5th is that correct? Joint Commission and CMS will not be reviewing using this current edition until November 1, 2016 is this also correct? Wheeled equipment once being use for patient care can now remain in the corridor?

A: Yes… CMS adopted the 2012 Life Safety Code on May 4, 2016 with an effective date set for July 5, 2016. However, they soon issued a S&C memo on June 20, 2016, that said while the new 2012 LSC is still effective on July 5, 2016, they will not enforce the requirements of the new code until November 1, 2016. This extra 4 months is needed for the accreditation organizations (AO) to modify their standards to address the new 2012 LSC requirements, submit them to CMS for review and approval, and then train their surveyors and clients. So, a November 1, 2016 enforcement date seems appropriate. This additional 4 months also allows you the opportunity to become fully compliant with the new requirements of the 2012 LSC, so that is a break as well.

While the new 2012 LSC is effective July 5, you will not see the AOs or CMS enforcing any of the new requirements, such as quarterly fire hose valve inspections, annual fire doors inspections, and 5-year internal inspections of the sprinkler pipe until November 1. But during this 4 month period of leniency, healthcare organizations may take advantage of the breaks the new 2012 LSC offers, such as monthly fire pump testing rather than weekly, and semi-annual water-flow switch testing rather than quarterly.

Section 19.2.3.4 (4) of the 2012 LSC does allow certain wheeled equipment to be left unattended in the corridor, provided it meets the following criteria:

  • The wheeled equipment does not reduce the clear width of the corridor to less than 5 feet
  • There must be a fire safety plan and training program to relocate the wheeled equipment during a fire or similar emergency
  • The wheeled equipment is limited to equipment in use; carts in use; medical emergency equipment not in use; patient lift equipment; and patient transport equipment.

In case you’re wondering, computers on wheels are not considered to be medical emergency equipment, so they do not qualify to be left unattended in the corridors for more than 30 minutes.