Life Safety Code Updates

Life Safety Code

When the new 2012 edition of the Life Safety Code is finally adopted by the Centers for Medicare Medicaid Services (CMS), there will be many changes that all healthcare organizations will need to know. The following entries provide an explanation of most of these changes.


Fire Rated Door Frames

BKeyes : January 13, 2017 12:00 am : Fire Doors, Life Safety Code Update

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.

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Liquid Oxygen Transfilling Operation

BKeyes : January 6, 2017 12:00 am : Life Safety Code Update, Liquid Oxygen

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.

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Categorical Waivers and the New 2012 Life Safety Code

BKeyes : May 5, 2016 12:00 am : Blog, Life Safety Code Update

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.

 

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

BKeyes : June 6, 2014 6:00 am : Blog, Life Safety Code Update

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.

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

BKeyes : June 4, 2014 6:00 am : Blog, Life Safety Code Update

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.

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

BKeyes : June 3, 2014 6:00 am : Blog, Life Safety Code Update

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.

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

BKeyes : May 30, 2014 6:00 am : Blog, Life Safety Code Update

 

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.

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

BKeyes : May 28, 2014 6:00 am : Blog, Life Safety Code Update

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.

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

BKeyes : May 27, 2014 6:00 am : Blog, Life Safety Code Update

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.

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

BKeyes : April 14, 2014 4:15 pm : Blog, Life Safety Code Update

 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.

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The New 2012 Life Safety Code

BKeyes : January 6, 2014 6:00 am : Life Safety Code, Life Safety Code Update, LSC, Questions and Answers

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?

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Changes with Construction Barriers When the New 2012 LSC is Adopted

BKeyes : October 3, 2013 5:00 am : Blog, Life Safety Code Update

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.

Plastic Barrier Web 2Construction and renovation in healthcare facilities is a necessary force that needs to be reckoned with. It is going to happen, and the facility is not going to be shut down in order to accommodate it. A complete renovation of a unit will require the removal of the patients and staff, while the area is under construction. To protect the rest of the occupants of the building from the construction activities, sections 18/19.7.9.2 of the 2012 edition of the LSC has referenced compliance with NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Activities, 2009 edition. In previous editions of NFPA 241, non-flammable smoke-tight partitions were all that was required between the area under renovation, and the occupants of the building, which is typically what the accreditation organizations have been enforcing. The 2009 edition of NFPA 241 will now have these new requirements:

  • Temporary construction barriers must be erected to separate occupied areas of the building from those areas undergoing alterations, construction or demolition, when such operations are considered as having a higher level of hazard than the occupied portion of the building

One may think the issue of ‘higher level of hazard’ may be open for interpretation, but NFPA has defined a hazardous area as one that poses a degree of hazard greater than that normal to the general occupancy of the building. Most construction areas would qualify as hazardous areas, under this definition. Other requirements involving the temporary construction barriers:

  • The walls must have a 1-hour fire resistive rating, and the door assemblies (if provided) must have a ¾ hour fire rating.
  • Non-rated walls and opening protectives are permitted when an automatic sprinkler system is installed (construction tarps are not considered appropriate barriers or opening protectives)
  • Where sprinkler protection is to be provided, the installation must be placed in service as soon as practicable

In a construction area that does not have automatic sprinklers installed and placed in service, the temporary barriers must be 1-hour rated, which means non-flammable plastic sheeting will no longer be permitted. Walls meeting 1-hour fire resistive rating usually are constructed with steel studs, and ¾ inch gypsum board on both sides, taped and mudded, and sealed to resist the transfer of smoke. All openings in the walls must be ¾ hour fire rated self-closing, positive latching doors, mounted on fire-rated frames. The clearance between the bottom of the door and the floor covering cannot exceed ¾ inch. It is interesting that NFPA 241 says construction tarps are not permitted where the barriers are not required to be fire-rated. This would lead one to believe that the non-flammable plastic sheeting will no longer be permitted in healthcare occupancies for temporary construction barriers.

The standard says non-rated walls and doors are permitted where sprinklers are installed and operating. Since all new construction in healthcare occupancies has to include the installation of sprinklers, NFPA 241 now requires the sprinklers to be installed as soon as practicable. This usually means temporary upright sprinklers are installed and tested and placed into service, as soon as demolition is completed. Occupancy of the renovated area is not permitted until the fire-safety features are properly tested and inspected.

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Changes with Sprinkler Testing When the New 2012 LSC is Adopted

BKeyes : September 5, 2013 5:00 am : Blog, Life Safety Code Update

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.

Sprinkler_-_Quick_Response_Type_Sprinkler[1]According to the Life Safety Code, automatic sprinkler systems are required to be installed in agreement with NFPA 13 Standard for the Installation of Sprinklers. But NFPA 13 does not address how the sprinkler systems should be inspected, tested or maintained- just installed. Prior to 1992, NFPA attempted to identify the proper requirements for the inspection, testing and maintenance of the automatic sprinkler system in various publications, but at that time a decision was made to combine all the different NFPA standards on sprinkler inspection, testing and maintenance into one.  Thusly, NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems was born, which set standards for all sprinkler systems in all types of occupancies. NFPA 25 applies to hospitals, nursing homes, ambulatory care occupancies, business occupancies and all other types of facilities, regardless whether patients are treated in the building or not. Now, there may be a question whether or not NFPA 25 is enforced by authorities at all locations, but the standard does apply to all.

The 2012 edition of the LSC references the 2011 edition of NFPA 25. The changes with NFPA 25 since the 1998 edition (which was referenced by the 2000 edition of the LSC) that are considered significant are:

  • All deficiencies or impairments discovered during the inspection, testing or maintenance process must be corrected or repaired, and performed by qualified individuals
  • The location of shut-off valves must be identified
  • An informational sign must be placed at the system control riser supplying an anti-freeze loop, dry system, preaction system, or auxiliary system control valve. Each sign must indicate the following minimal information:
    • Location of the area served by the system
    • Location of auxiliary drains and low-point drains for dry pipe and preaction systems
    • The presence or location of anti-freeze or other auxiliary systems
    • The presence and location of heat tape
  • Components and systems are permitted to be inspected, tested and maintained under a performance-based program as an alternative means of compliance, subject to the approval of the AHJ
  • Vane and pressure type waterflow switches are permitted to be tested semi-annually, rather than quarterly. Other mechanical type waterflow switches must be tested quarterly
  • A main drain test must be performed quarterly downstream of a backflow preventer in systems were the sole water supply is through a backflow preventer or pressure reducing valve. This is in addition to the annual main drain tests required at each riser.
  • Dry sprinklers that have been in service for 10 years must be replaced, or a representative sample tested
  • All sprinklers that have been in service for 75 years must be replaced, or a representative sample tested
  • Standpipe hose valves (not Fire Department Connections) are required to be inspected quarterly for the following:
    • Ensure hose caps are in place and not damaged
    • Inspect hose threads for damage
    • Ensure valve handle is present and not damaged
    • Inspect gaskets for damage and deterioration
    • Ensure hose valve is not leaking
    • Ensure access to hose valves is not obstructed
  • Standpipe systems with 2½ inch hose valves must have their valves tested annually by opening and closing the valve
  • Standpipe systems with 1½ inch hose valves must have their valves tested every 3 years by opening and closing the valve
  • Standpipe water-flow tests every 5 years are for wet standpipes. Dry standpipes are required to have a hydrostatic pressure test every 5 years
  • Electric motor driven fire pumps are permitted to be tested monthly at no-flow conditions for 10 minutes. Engine driven fire pumps must continue to be tested weekly at no-flow conditions for 30 minutes.

The new requirement to identify the location of all shut-off valves in your sprinkler system may be accomplished many different ways: Plot them on your CAD drawings; Mark the suspended ceiling grids where the valves are located; List them on charts which are posted in conspicuous areas of the facilities department; Or do all three. Since the standard does not define how the valves are to be identified, you get to make that distinction until such time an AHJ interprets it for you.

If you are not already performing these inspections and tests, the new requirement for a quarterly main drain test downstream from the backflow preventer; and the quarterly inspections of the fire hose valves; and the annual (or 3-year) test of the fire hose valves may catch you by surprise. Make sure you begin a routine on these new inspections and tests, as the surveyors and inspectors will be fully aware of the requirements and won’t be bashful asking you for documentation.

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Changes with Portable Fire Extinguishers When the New 2012 LSC is Adopted

BKeyes : August 8, 2013 5:00 am : Blog, Life Safety Code Update

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.

fire-extinguisher-sm[1]Portable fire extinguishers may be the most over-looked and taken-for-granted component of fire safety in a healthcare facility today. Perhaps it is because for the most part, they are out-of-sight, out-of-mind? No, they are never really out-of-sight, but there are so many of them in a healthcare facility that individuals may tend to over-look them in the same manner as one may overlook the trees in a forest. Other than the security officer or the maintenance technician who is assigned to inspect fire extinguishers on a monthly basis, most people do not give them a second thought, until they are needed.

The 2000 edition of the Life Safety Code (LSC) referenced the 1998 edition of NFPA 10 Standard for Portable Fire Extinguishers, which is one of the oldest referenced standards that healthcare organizations have to comply with. There have been 3 revisions to this standard since then, and the 2012 edition of the LSC references the 2010 edition of NFPA 10.

Once the 2012 edition of the LSC is finally adopted, NFPA 10 will have changes that every facility manager will need to know. While some of the following items may appear to be requirements that organizations must already comply with, they do represent a change in the standard:

  • Other than wheeled extinguishers, portable fire extinguishers must be securely installed on the bracket or hanger provided by the manufacturer, or on a listed bracket for that purpose; or placed in a cabinet; or placed in a wall recess. (Placing the extinguisher on the floor, table, desk or other such item will no longer be permitted.)
  • Extinguishers installed under conditions where they may be subject to physical damage or dislodgement, must be installed in manufacturer’s strap-type bracket designed specifically for protection
  • The extinguisher must be mounted in such a way that the manufacturer’s operating instructions must be located on the front and clearly visible
  • Electronic monitoring of extinguishers is permitted
  • Non-rechargeable fire extinguishers must be removed from service no more than 12 years from the date of manufacture
  • Halogenated agent fire extinguishers (Halon) must be limited to applications where clean agent is necessary to extinguisher a fire without damaging equipment
  • Persons performing maintenance and recharging of fire extinguishers must be certified by one of the following criteria:
    • Factory training and certified
    • Certified by an organization acceptable to the AHJ
    • Licensed, certified or registered by a local or state AHJ

(Persons performing the monthly inspection are not required to be certified.)

  • Discharge hoses on wheeled units must be coiled in such a manner to prevent kinks and allow rapid deployment
  • Hoses on wheeled-type extinguishers must be completely un-coiled and examined for damage during the annual maintenance procedure

Electronic monitoring of fire extinguishers is permitted in lieu of physical monthly inspections. Procedures for monthly inspections have been changed for non-wheeled, rechargeable extinguishers to accommodate electronic monitoring systems, and now only requires:

  • Extinguisher is located in its designated place
  • Access to and visibility of extinguisher is not obstructed
  • Pressure gauge reading is in the proper range
  • Fullness determined by weighing

Dropped from the monthly inspection list is the following:

  • Confirming that the operating instructions are facing outward
  • Ensuring the safety seals and tampers indicators are not broken or missing
  • Examination for obvious physical damage, corrosion, leakage or clogged nozzles.

imagesCAIP9B6BProbably the largest impact of change in fire extinguishers to the average facility is the electronic monitoring that will be permitted once the 2012 edition of the LSC is finally adopted. Manufacturers of these specialized monitoring cabinets have sensors to ensure nothing is parked in front of the cabinets; special listed mounted brackets to determine the weight and presence of the extinguisher; and pressure sensors integrated with the extinguisher to monitor pressure ranges. These specialized monitoring cabinets communicate back to a central monitoring area, and have proven to be very useful in high-theft areas.

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Changes With Suites of Rooms – Part 2: Non-Sleeping Suites

BKeyes : March 2, 2012 6:00 am : Life Safety Code Update

Previously, we discussed the changes that are in store for the patient sleeping suites, which are considerable. Now we are going to look at the few changes the 2012 edition of the Life Safety Code will bring for non-sleeping suites when it is finally adopted.

Like the sleeping suites, non-sleeping suites that require 2 or more exit access doors, one of those doors is permitted to be to: 1). A direct exit (outdoors); 2). An exit enclosure (stairwell); or 3). To a horizontal exit. The authorities having jurisdiction (AHJ) pretty much allowed this arrangement with the 2000 edition of the LSC, but now it is clearly written into the code.

Also, one of the exits from a non-sleeping suite may be into and through an adjoining suite. The wall separation between the two suites must be equal to that which is required for the corridor walls. This means the wall must be 30-minute fire rated and extend from the floor to the deck above if the smoke compartment where the suites are located is not protected with automatic sprinklers. Otherwise, if the smoke compartment is protected with automatic sprinklers, then the walls would have to resist the passage of smoke and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke. The doors between the two suites would have to close and latch. Travel distance requirements automatically reset once you have entered into the adjoining suite.

Speaking of travel distances, the 50 foot travel distance limitations when exiting through two intervening rooms which is found in the 2000 edition of the LSC is gone in the 2012 edition. The maximum travel distance from any point in the non-sleeping suite to an exit access door is 100 feet, regardless of the number of intervening rooms. The drawing above represents the 50 foot travel distance rule for a suite with 2 intervening rooms, which is found int he 2000 edition of the LSC. That situation will no longer apply once the 2012 edition is adopted.  Maximum travel distance from any point in the suite to an exit must not exceed 150 feet for buildings that are not fully protected with automatic sprinklers, and is 200 feet for buildings that are fully protected with automatic sprinklers.

Those are the only changes to non-sleeping suites that I can see.

(Drawing courtesy of HCPro Inc.)

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Changes With Suites of Rooms- Part 1: Sleeping Suites

BKeyes : February 29, 2012 6:00 am : Life Safety Code Update

Lots of changes are in store for suites of rooms when the 2012 edition of the Life Safety Code is finally adopted, and the changes are all for the better. This posting discusses those changes that apply to patient sleeping suites and the changes are found in section 19.2.5.7.2 of the 2012 edition.

1). Suites larger than 1,000 square feet are required to have two exit access doors. The 2012 edition now allows one of these to be either a direct exit to the outdoors, an exit enclosure (stairwell), or a horizontal exit, in addition with the actual exit access door.

2). Constant supervision by staff is required in patient sleeping suites. Direct supervision of the patients is required, and may be through glass walls, although cubicle curtains are permitted. Any patient room that does not have direct supervision must be protected with smoke detection.

3). If the patient sleeping suite is arranged in such a way where direct supervision of each patient sleeping room is not possible by staff, then the entire suite needs to be protected with smoke detection. (Yeah, I know this seems to contradict number 2 above, but I don’t make this stuff up…)

4). Where two means of egress are required from a suite, one of the means of egress may be through an adjoining suite, provided the separation between the two suites meets the requirements for corridor separation. This means the walls separating the suites would have to be 30-minute fire rated and extend from the floor to the deck above, if the suites are not sprinklered. If the suites are protected with sprinklers, then the walls would have to resist the passage of smoke and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke. In both cases, the door separating the suites would have to close and positively latch. Also, travel distance requirements automatically reset once you enter the adjoining suite.

5). Suites are limited to 5,000 square feet. However the suite may expand to 7,500 square feet if the smoke compartment where the suite is located is totally protected by an automatic sprinkler system with quick response sprinklers, or if the smoke compartment is protected by an automatic sprinkler system with standard response sprinklers and a smoke detection system. Also, the suite may expand to 10,000 square feet provided there is direct visual supervision of all patient sleeping rooms by the staff, and the suite is protected with automatic sprinklers and a smoke detection system.

6). Travel distances between any point in the suite and an exit access door (or an exit door) cannot exceed 100 feet. The travel distance from any point in a sleeping suite and an actual exit cannot exceed 150 feet if the building is not protected throughout by automatic sprinklers, or 200 feet if the building is protected by automatic sprinklers.

These changes for suites are an improvement over the limitations found in the 2000 edition. The biggest impact on hospitals will be the area limitations, as the sleeping suites will have the potential to be as large as 10,000 square feet. There are many hospital ICUs constructed in the past two decades where the designer did not have a good understanding on the concept of a suite, and they were built larger than 5,o000 square feet. The hospital had to go back and redefine the boundaries of the suite or ask the AHJ for an equivalency or waiver. With the new 2012 edition, this should solve this problem for many organizations.

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New Corridor Width Requirements

BKeyes : February 26, 2012 6:00 am : Life Safety Code Update

Here is a change in the Life Safety Code that I believe will do more harm than good: Changing what can be left unattended in hospital corridors. Currently, the 2000 edition of the LSC only permits attended items in the corridor, such as housekeeping carts, linen carts, foodservice carts, provided they are being attended by an individual. The exceptions to this rule have allowed crash carts and patient isolation supply carts (provided the cart is serving a patient on contact precaution isolation) to be left unattended.

The constant struggle that facility managers had with nurses and technicians was staff leaving items in the corridor, as the picture to the left indicates. The items left in the corridor were done so for various reasons: 1). Staff felt certain medical equipment such as blood pressure cuff machines and IV pumps were necessary to be placed in the corridor for quick and effective patient care; 2). Staff believed there simply was no other place to store the equipment; 3). Some room items such as chairs, tables and even beds were ‘temporarily’ stored in the corridor that ended up being hours and days, and 4). It simply was not convenient for staff to return equipment to their designated storage room. Whatever the reason, leaving unattended equipment in the corridor was not permitted by the 2000 edition of the LSC, and hospitals would be cited by surveyors if they discovered it.

Well, some of that could be changing when the new 2012 edition of the LSC is finally adopted. If CMS adopts the 2012 edition in its entirety, meaning they will not exclude any sections, then I believe facility managers will have new problems concerning items stored in corridors. Here is the reason why I believe that: Section 19.2.3.4 of the 2012 edition will now permit certain wheeled equipment to project into the required width of the corridor, provided the clear width of the corridor is not reduced to less than 5 feet, and there is a written fire safety plan and training program that addresses the relocation of the wheeled equipment during a fire. The permissible wheeled equipment is limited to 1). Equipment and carts in use; 2). Medical equipment not in use; and 3). Patient lift and transport equipment.

Number 1 above is the same as what the 2000 edition currently allows. But number 2 (Medical equipment not in use) sounds to me to be medical equipment that is in storage. The Annex section makes note that equipment ‘not in use’ is not the same as equipment ‘in storage’, but does not offer an explanation on how to tell the difference. And number 3… Patient lift and transport equipment can now be stored in corridors? How can that be safe for the swift and immediate evacuation of patients during a fire emergency?

Here are the potential problems as I see it:

  1. Give the staff an inch and they will take a mile. If you educate and train the staff that they can now store some equipment in the corridor as long as you have 5 feet clear width, they will certainly take more than that. They don’t carry tape measures with them and the possibility of something projecting into the 5 foot clear width requirement is likely.
  2. Where is staff going to relocate the wheeled equipment to, during a fire alarm? If the equipment does not have a designated storage room, then it will have to be stuffed into any empty room that staff can find. What happens when there are no empty rooms available?
  3. The new 2012 edition requires only wheeled equipment to be left in the corridor. Staff will soon either forget this stipulation or try to sneak in chairs, tables, and other non-medical equipment that does not qualify.
  4. How are you going to differentiate between medical equipment not in use, and medical equipment in storage? Unless there is a layer of dust on the stored equipment, it will all look the same. A surveyor may not believe the equipment is not stored.
  5. The ever-present Computers on Wheels (COWs) were not addressed in this new section. Are they considered medical equipment? That is yet to be decided.
  6. The new section says ‘transport’ equipment is allowed to be left unattended in corridors. That means you can expect a bunch of wheelchairs and gurneys lined up in the corridor. But not beds, or at least that seems to be what the code implies. You can guess that once staff sees gurneys and wheelchairs allowed to be stored in the corridor, they will try to add beds as well.
  7. During a fire emergency where patients are being evacuated from their rooms, most of them will be evacuated in their beds. Those beds never roll in a straight line, but take up more corridor room than the width of the bed. And there usually is a monitor, IV pump, or other medical equipment that trails along. All told, evacuating a patient in their bed requires at least 5 feet of corridor to do so quickly and safely. If medical equipment is still in the corridor, how do other staff individuals and fire-fighters get access into the unit when patients are being evacuated out of the unit?

At the minimum, this will require education, training, and then frequent surveillance to make sure this new section is followed correctly. More visits on the floors to make sure everything is within code. And then there is the section that allows fixed furniture that is screwed to the floor or wall, to project into an 8 foot wide corridor as long as the clear width remains 6 feet. There are other restrictions on the fixed furniture issue, but I don’t see fixed furniture in hospitals very often, if ever. I have been told that this section was created with nursing homes in mind, where patients are a bit more mobile and the fixed furniture allows for rest stations in strategic areas in the corridors.

That’s what I think about this new requirement. I would appreciate hearing from you what you think…

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Door Locks for Safety Needs

BKeyes : February 24, 2012 6:00 am : Life Safety Code Update

As we discussed in the previous posting, the healthcare chapters of the Life Safety Code allows for three (3) special locking arrangements:

  1. Clincal needs
  2. Delayed egress
  3. Access control

The phrase ‘Clinical needs’ was always poorly defined (or not defined at all) in the 2000 edition of the LSC, and was left to the authority having jurisdiction (AHJ) to decide for themselves what doors in a hospital qualify for locking arrangement as allowed by ‘clinical needs’. Many AHJs were liberal and allowed ‘clinical needs’ locks not only for psychiatric or Alzheimer’s patients, but also for infant security as well. However, there are some state AHJs who represent CMS that did not permit the use of ‘clinical needs’ locks for infant security. That alone caused quite a bit of problems for hospital facility managers.

Well, the 2012 edition includes explanatory information (which is not in the 2000 edition) in the annex section that identifies psychiatric, Alzheimer’s and dementia patients as examples where ‘clinical needs’ locks would be allowed. It specifically did not include infant security protection. However, section 19.2.2.2.5.2 of the 2012 edition says:

“Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:

  • Staff can readily unlock doors at all times
  • A total (complete) smoke detection system is provided throughout the locked space or locked doors can be remotely unlocked at an approved, constantly attended lcoation within the locked space
  • The building is protected throughout by an approved, supervised automatic sprinkler system
  • The locaks are electrical locks that fail safely so as to release upon loss of power to the device
  • The locks release by independent activation of a smoke detection system or waterflow in the automatic sprinkler system”

The Annex section of 19.2.2.2.5.2 does state pediatric units, maternity units and emergency departments as examples that qualify foir ‘safety needs’ locks. Now, the Annex section is not part of the enforcable code, but it does offer guidance and direction for AHJs to follow on their over-all interpretation of the the LSC. This new section in the 2012 edition should solve the debate if a nursery or pediatric unit can be locked.

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Changes With Electrically Locked Doors

BKeyes : February 22, 2012 6:00 am : Life Safety Code Update

Electrically locked doors. The 2000 edition of the LSC does not discuss them, directly. However, it does talk about the three types of locks that are permitted in hospitals: 1). Clinical needs; 2). Delayed egress, and 3). Access control.

Access control locks are the most misunderstood locks in hospitals today, and I would say nearly all the hospitals that I visit, have some sort of deficiency with access control locks. Let’s review quickly what is required for access control locks: A motion sensor on the egress side; A wall-mounted ‘Push to Exit’ button within 5 feet of the door; When the ‘Push to Exit’ button is depressed, it interrupts power to the lock for a minimum of 30 seconds; A loss of power to the control system renders the lock disabled; And activation of the building’s fire alarm or sprinkler system automatically unlocks the door. Nearly all of the access control locks that I have seen in my career utilize magnetic door locks, or mag-locks for short. These access control locks end up being a problem for facility managers because they get installed by well-intentioned, but poorly informed individuals who do not consult with the person who is knowledgeable on the Life Safety Code.

Now, when the 2012 edition of the LSC is adopted, there will be a new version of door locks, that will solve a lot of these problems. The three locks permitted in hospitals (clinical needs, delayed egress, and access control) will remain, but Chapter 7 will now permit doors that are ‘electrically locked’ to be considered the same as any other normal lock on the door. Section 7.2.1.5.6 says:

“Door assemblies in  the means of egress shall be permitted to be electrically locked if equipped with approved, listed hardware, provided that all of the following conditions are met:

  • The hardware for the occupant release of the lock is affixed to the door leaf
  • The operation has an obvious method of operation that is readily operated in the direction of egress
  • The hardware is capable of being operated with one hand in the direction of egress
  • Operation of the hardware interrupts the power supply directly to the electric lock and unlocks the door assembly in the direction of egress
  • Loss of power to the listed releasing hardware automatically unlocks the door assembly in the direction of egress
  • Hardware for new installation is listed in accordance with ANSI/UL 294.”

Now it is important to note that this section is under the heading of 7.2.1.5 “Locks, Latches and Alarm Devices” (2012 edition) and is not under the the heading 7.2.1.5.6 “Special Locking Arrangements”. That implies this new ‘electrically locked door’ section is not considered a special locking arrangement, but places it squarely on the same level as regular door locks. This is significant, as the healthcare chapter (18 and 19) specifically permits this new ‘electrically locked door’ under section 18/19.2.2.2.1, which says “Doors complying with 7.2.1 shall be permitted.” Well, that alone permits 7.2.1.5 and does not require it to qualify as a ‘Special Locking Arrangement’ in 7.2.1.5.6, which includes the access control requirements.

So, the mag-lock in the picture below is the typical ‘electrically controlled lock’ used in hospitals, and when the 2012 edition is finally adopted, this lock will be allowed (in accordance with the provisions of 7.2.1.5.6) in lieu of access control locks. However, be careful with the application and selection of equipment. The electronic ‘touch-sensitive’ crash bar in the picture above, probably would not be permitted, as a person wearing a glove would not be able to make the completion of the electrical circuit that bare skin requires. Also, those applications where a card-swipe reader or a proximity reader is used in conjunction with a mag-lock will not qualify for the 7.2.1.5.6 ‘electrically controlled locks’, as those locks require the use of a special tool. Section 19.2.2.2.4 (2012 edition) still does not allow the use of a special key or tool to operate the lock.

 

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Changes to Unoccupied Rooms Open to Stairwells

BKeyes : February 20, 2012 6:00 am : Life Safety Code Update

The current edition of the Life Safety Code (2000 edition) does not allow an unoccupied room (such as a mechanical room, janitor’s closet, storage room) to have an opening (doorway) from an exit enclosure (stairwell). There have been many hospitals designed and constructed since WWII that have at least one stairwell that extends up to the mechanical room penthouse, without the proper fire rated separation. I would venture to say that nearly half of the hospitals I consulted in over the past 5 years, has this problem. I can only surmise that the Building Code that the hospitals were originally designed and constructed to, did not share this requirement.

The picture to the left was taken from the landing between the top occupied floor, and the mechanical room above it. As you can see, the top of the stairwell has a door directly into the mechanical room, which is a violation of 7.1.3.2.1 (d) of the 2000 edition. You will also note there is a rope suspended down from the roof, in the picture. Having once worked in the construction trades, I knew what it was for, but the facility director saw me looking at it and offered his take on it: “That rope is for our Suicide Assistance Program.” (Everyone is a comedian….). I asked him to remove it.

Now, when CMS finally adopts the new 2012 edition of the Life Safety Code, there will be a change that should help those facility directors that still have this problem. Section 7.1.3.2.1 (9)(c) of the 2012 edition has an exception to openings on exit enclosures (stairwells) that says:

“Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria is met:

  • The space is used soley for non-fuel fired mechanical equipment
  • The space contains no stoarge of combustible materials
  • The building is protected through-out by an approved automatic sprinkler system.”

So, what does this mean? Well, if you have yet to resolve an existing mechanical room that opens onto an exit enclosure, and your building qualifies for this exception, then it appears to me that you will not have to resolve this problem when the new 2012 LSC is finally adopted. In the mean-time, I suggest you identify this deficiency as a PFI on your Statement of Conditions (if you are Joint Commission accredited) with an 18-month completion date. In the section of the PFI where you describe how you will resolve the problem, just say the issue will be resolved with the adoption of the new 2012 edition of the LSC.

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Stairwell Signage

BKeyes : February 3, 2012 6:00 am : Life Safety Code Update

Remember the rush we all made in the last 10 years or so to install stairwell identification signs inside our stairwells? Well, with the adoption of the new 2012 Life Safety Code, many hospitals may have to take down the signs that they put up and replace them with new signs.

The sign to the left is an example of a stairwell identification sign that we had to install in stairwells serving 5 or more stories. It identified all the correct parameters:

1). The name of the stairwell

2). The floor level

3). The top and bottom terminus

4). The direction to the exit

5). The level of the exit

 

This sign will no longer meet the requirements of 7.2.2.5.4.1 when the 2012 edition of the Life Safety Code is adopted.

 

With the adoption of the new 2012 edition of the Life Safety Code, hospitals will have to replace all of those signs with new ones similar to the second picture below, and in addition to the requirements above, the new signs must have the have the following additional parameters:

1). The sign needs to be illuminated by a reliable light source (the stairwell illumination light should be sufficient for this requirement)

2). The floor level designation needs to be tactile in accordance with ADA requirements

3). The sign may be painted or stenciled on the wall, or if a separate sign, it needs to be fastened to the wall

4). The stairwell identification lettering is required to be at the top of the sign, in minimum 1 inch tall letters

5). Stairwells that do not provide roof access must have the words ‘NO ROOF ACCESS’ and must be located underneath the stairwell identification lettering in minimum 1 inch tall lettering

6). The floor level number must be in the middle of the sign, and be a minimum 5 inches tall. Mezzanine levels must have the letter ‘M’ (or other appropriate identification letter) preceding the floor number, and basements must have the the letter ‘B’ (or other appropriate identification letter) preceding the floor level number

7). Identification of the lower and upper terminus of the stairwell must be located at the bottom of the sign and in minimum 1 inch tall letters and/or numbers.

There is no indication yet from any of the Accreditation Organizations (Joint Commission, HFAP and DNV) or the CMS that the old stairwell signs will be exempt from having to be replaced.

Also, when the new 2012 edition of the Life Safety Code is adopted, all new stairwells serving 3 or more stories are required to have stairwell identification signs.

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Fire and Smoke Doors

BKeyes : January 13, 2012 8:29 pm : Life Safety Code Update

When the 2012 edition of the LSC is finally adopted (sometime in 2013, presumably) one of the more striking changes that facility managers will have to adjust to, is the annual fire and smoke door inspection requirement. Section 19.2.2.2.1 of the 2012 edition of the LSC requires compliance with section 7.2.1. Section 7.2.1.15.2 requires compliance with NFPA 80 Standard for Fire Doors and Other Opening Protectives (2010 edition), and NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives (2010 edition). Also, just as a ‘good measure’, this testing and inspection requirement is repeated in section 8.3.3.1 in the 2012 edition of the LSC for fire doors.

Fire Doors- General

Section 5.2 of NFPA 80 provides the following basic requirements for the annual inspection and testing, which are summarized here:

  1. Fire door assemblies are required to be inspected and tested annually, with the written record of the inspection and test to be signed and dated.
  2. A written performance based inspection and testing program is permitted as an alternative means of compliance, but such programs need to be approved by all of your authorities having jurisdiction (AHJ).
  3. The functional test of the fire door must be performed by an individual with knowledge and understanding of the operating components of the door being tested. Since the standard does not specify what makes an individual “knowledgeable” or “understanding”, then the organization gets to make that determination. Be prepared to justify how you arrived at that determination, and have it documented.
  4. Before testing, a visual inspection must be performed on both sides of the door to identify any damage or missing parts that could create a hazard during the test.
  5. Inspections must include an operational test to verify that the assembly will close under fire conditions, and the door assembly must be rest after a successful test.
  6.  Hardware must be examined and any inoperative hardware, parts, or other defects must be replaced without delay.
  7. Tin-clad and kalamein doors must be inspected for dry rot of the wood core.
  8. Chains and cables employed must be inspected for excessive wear and stretching.
  9. A written record that is signed and dated by the knowledgeable individual performing the inspection must be maintained and made available to the AHJ.

Swinging Fire Doors

On swinging doors, the following must be verified:

  1. No open holes or breaks exist in the surfaces of either the door or the frame
  2. Glazing, vision light frames, and glazing beads are intact and securely fastened in place
  3. The door, frame, hinges, hardware and noncombustible threshold are secured, aligned and in working order with no visible signs of damage
  4. No parts are missing or broken
  5. Clearances under the bottom of the door cannot exceed ¾ inch, and if the door is mounted more than 38 inches above the floor, then the clearance cannot exceed 3/8 inch. Clearances between the top and vertical edges of the door and the frame cannot exceed 1/8 inch for wood doors, and must be 1/8 inch (+ 1/16 inch) for steel doors, as measured on the pull side of the door.
  6. The self-closing device is operational and the active door must fully close when operated from the full open position
  7. If a coordinator is installed, the inactive leaf must close before the active leaf
  8. Positive latching hardware operates and secures the door when it is in the closed position
  9. Ensure that auxiliary hardware items that interfere with the proper operation of the door are not installed on the door or frame
  10. No field modifications have been made to the door or frame that would void the rated label
  11. Where gasketing and edge seals are required, inspect to verify their presence and integrity

Sliding and Overhead Fire Doors

Section 5.2 of NFPA 105 requires horizontal sliding, vertical sliding or overhead rolling fire doors, the following must be verified:

  1. No open holes or breaks exist in the surfaces of the door or frame
  2. Slats, endlocks, bottom bar, guide assembly, curtain entry hood, and flame baffle are correctly installed and intact
  3. Glazing, vision light frames, and glazing beads are intact and securely fastened
  4. Curtain, barrel, and guides are aligned, level, plumb and true
  5. Expansion clearance is maintained in accordance with the manufacturer’s listing
  6. Drop release arms and weights are not blocked or wedged
  7. Mounting and assembly bolts are intact and secured
  8. Attachments to jambs are with bolts, expansion anchors, or as otherwise required by the listing
  9. Smoke detectors, if equipped, are installed and operational
  10. No parts are missing or broken
  11. Fusible links, if equipped, are in the location; chain/cable, s-hooks, eyes, and so forth are in good condition, meaning they are not kinked, pinched, twisted or inflexible
  12. Auxiliary hardware items that  interfere with the proper operation are not installed on the door or frame
  13. No field modifications to the door assembly have been performed that would void the door label

Smoke Door Assemblies

On smoke compartment door assemblies, the following actions and functions must be verified:

  1. Smoke door assemblies must be inspected annually.
  2. Doors must be operated to confirm full closure.
  3. Hardware and gaskets shall be inspected annually, and if any parts found to be damaged or inoperative must be replaced.
  4. Tin-clad and kalamein doors shall be inspected for dry rot of the wood core.
  5. A written record that is signed and dated by the knowledgeable individual performing the inspection must be maintained and made available to the AHJ.
  6. Records must be maintained for at least 3 years.
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