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Enforcement Date for the 2012 LSC

BKeyes : August 31, 2016 12:00 am : CMS, Joint Commission, Liquid Oxygen, Questions and Answers

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 (see attached) 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 (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.

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Say Goodbye to Joint Commission’s PFI List

BKeyes : July 23, 2016 12:00 am : Joint Commission, Questions and Answers

Q: Hello Brad, I hear the SOC as of 8/4/2016 will no longer be used. If time is needed to do a repair for a life safety item we need to apply for a waiver from CMS and if granted, will be for 60 days. how true is this rumor? Please say it ain’t so!

A: Well… it ain’t so as you describe it, but here is the truth:

CMS has told Joint Commission that they can no longer allow hospitals more than 60 days from the end of the survey to resolve a LSC deficiency, unless the hospital has applied for a time-limited waiver, which acts as an extension. This effectively eliminates any positive action the Plan For Improvement (PFI) section of the Statement of Conditions. However, contrary to what you’ve heard, the SOC remains in the format of the Basic Building Information (BBI) section. Joint Commission has said their surveyors will no longer look at the PFI section, and Joint Commission will eliminate the special section at the end of the survey deficiency report that contained the PFIs. Now, all LSC deficiencies will cited in the main portion of the survey deficiency report and will not receive any special dispensation, such as the PFIs used to.

Back in 2014, CMS told Joint Commission that they can no longer not cite a LSC deficiency even if it was listed in the PFI section. So, since July 2014 all LSC deficiencies listed in the hospital’s PFI section were cited in the end of the survey deficiency report and did not require a Plan of Correction (PoC) since it already had one in the PFI list. Fast forward two years, and CMS told Joint Commission again that they did not like the fact there was no PoC for the LSC deficiencies listed in the PFI section, and they did not like the hospital taking more than 60 days to resolve the LSC deficiency without CMS permission.

So… beginning August 1, 2016, the PFI list is effectively defunct, and all LSC deficiencies cited during a survey will need to be resolved within 60 days of the end of the survey. If it cannot be resolved within 60 days of the end of the survey then the hospital must submit a time-limited waiver request to Joint Commission who will then forward it to the proper CMS regional office for their review and approval. Once approved, the time-limited waiver request is good until the next survey cycle where it will become invalid and if the deficiency remains it will be cited again.

Hospitals may still submit regular waiver and FSES equivalencies for LSC deficiencies that are an unreasonable hardship to resolve. That is an entirely different process and they are submitted to the accreditation organization and then it is forwarded to CMS regional office for review and approval.

Joint Commission says the PFI list will still be part of the SOC and hospitals may use it as a tool to manage their LSC deficiencies. But I advise my clients to no longer write PFIs in the SOC and manage their LSC deficiencies with the Computerized Maintenance Management System (work order system). That way, there is no chance of a unscrupulous surveyor looking at the PFI list and then writing those deficiencies into the survey deficiency report.

It’s a whole new world out there and CMS is bound and determined to have everything their way.

Brad Keyes, CHSP

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New Fire Extinguisher Inspection Frequency

BKeyes : July 4, 2016 12:00 am : Questions and Answers

Q: I could’ve sworn I read somewhere that a monthly fire extinguisher inspection shall be done within 30 days AND that there is to be a 10 day grace period… For example, If the date of a tag showed Jan.31, the next inspection date permitted would be Feb.9th?   You can write down Jan. 31 and then Feb. 1st for the next inspection. Also, If a date is written May 13th, the next date needs to be done BY June 23rd? 10 day grace period from the previous monthly inspected date. Am I wrong or confused on this, I can’t seem to find the language in NFPA 10.


A: Not every AHJ agrees on the Fire Extinguisher monthly inspection issue. Joint Commission will allow the FE to be inspected anytime during the calendar month, which means if it was inspected on January 1 the next inspection could be anytime in February including February 28. However, that also means the FE could be inspected on January 31 and then next on February 1. That is not desirable and will likely receive the attention of a surveyor.

I know CMS does not like the formula used by Joint Commission, and they will follow what the standard requires. NFPA 10-2010, section says extinguishers are required to be inspected manually or by electronic monitoring at a minimum of 30-day intervals. The Annex section for continues to say inspections are performed on extinguishers 12 times per year, once a month.

So, I can see your state agency who surveys on behalf of CMS to require a minimum of 30 days between the monthly inspections, but each extinguisher needs to be inspected monthly. So, this may be a problem for February… If the extinguisher was last inspected on January 31, then 30 days from January 31 is March 2 (or March 1 if it is a leap year). You can’t inspect it less than 30 days but you have to inspect it every month. That’s a Catch-22. Be careful you don’t get caught in that unique trap.

There is no 10-day grace period in NFPA 10.







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Fire Pump ATS

BKeyes : June 27, 2016 12:00 am : Automatic Transfer Switch, Fire Pump, Questions and Answers

Q: A state surveyor cited us for not doing a monthly fire pump automatic transfer switch (ATS) test. We are doing a weekly churn test and an annual fire pump flow test that includes switching over the ATS. I was not aware that this had to be done monthly.

A: Yes… NFPA 110-1999, section 6-4.5 requires all transfer switches in Level I and Level II systems (hospitals typically have Level I systems) to be tested monthly. The state surveyor is correct. I find that it is not uncommon for some hospitals to overlook the ATS serving the fire pump. I guess they don’t always see that it is part of the Level I emergency power supply system. Out-of-site is out-of-mind!

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Mixed Fire Caulks

BKeyes : June 20, 2016 12:00 am : Fire Caulk, Questions and Answers

Q: In the past our hospital has used different brands of fire caulk on the same fire wall assembly. The fire caulk is two different brands and different colors and surveyors have stated that we cannot have “mixed” caulk. Where in the Life Safety Code does this say we cannot mix fire caulks?

A: There is no specific Life Safety Code reference that speaks to this, but the surveyors are correct. It has more to do with the UL listing of the fire-stop assembly where the mixed fire caulks are used. A proper fire-stop system is an assembly and must comply with the UL listing that it was tested to. For example; to seal a penetration in a fire-rated wall, the UL listing will identify what type of fire caulk to use, what material it is permitted to be used on (i.e. gypsum board or cement block), and how to apply it. The UL listing is typically specific to the brand of fire caulk material used. This is because the manufacturers pay to have Underwriter’s Laboratory test the assembly and the resulting UL listing is specific to their brand of fire caulk. There is no UL listing for when you mix the different brands of fire caulk on the same assembly. Will it work? Most likely it will, but it does not meet the UL listing of that particular assembly. This is why there is a movement in the industry to have the installers who install fire-stop materials be certified to do so. Education is needed so the installers fully understand how to properly apply the products.

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Surgery Suites

BKeyes : June 13, 2016 12:00 am : Questions and Answers, Suites

Q: Are surgery rooms considered to be patient sleeping rooms or non-sleeping rooms? In reference to allowable suite sizes, what is the maximum area of the suite?

A: Surgery rooms are definitely considered non-sleeping rooms. A sleeping room is a room designed and constructed for patient sleeping. Surgery rooms are not designed and constructed for patient sleeping. And by the way, (you didn’t ask, but….) neither are sleep labs. A sleep lab sleeping room is not a patient sleeping room, but is an exam room, and can qualify to be classified as business occupancies. Since it is a non-sleeping area, a surgery suite is permitted to be 10,000 square feet in size. However, if you had a patient sleeping suite, the 2000 Life Safety Code limits the size to 5,000 square feet. The 2012 Life Safety Code does permit patient sleeping suites to extend to 10,000 square feet but specific additional requirements have to be met. There are CMS categorical waivers that would allow a hospital to utilize the 2012 edition pertaining to patient sleeping suites.

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Fire Barriers in Ambulatory Healthcare Occupancies -Part 2

BKeyes : June 6, 2016 12:00 am : Ambulatory Care Occupancy, Fire Barrier, Questions and Answers

 Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to install a fire barrier after the unit is constructed and if there are any other options. Your comments would be appreciated.

A: Well…. From a code standpoint, you may be obligated to have two different barriers:

  1. A 1-hour fire rated barrier to separate the ambulatory healthcare occupancy from other units that are not ambulatory healthcare occupancies (i.e. physician’s offices that would be classified as business occupancies). See sections and of the 2000 Life Safety Code.
  2. A 1-hour rated smoke compartment barrier to subdivide your ambulatory healthcare occupancy into two compartments. Exceptions to this requirement apply if your unit is less than 5,000 square feet and the unit is fully protected with smoke detectors, or if the unit is less than 10,000 square feet if the unit is fully protected with automatic sprinklers. See section of the 2000 Life Safety code.

If you receive Medicare & Medicaid reimbursement funds then you are obligated to comply with these codes. However, CMS does allow you to apply for a waiver if compliance with the Life Safety Code is a hardship for the organization. You cannot apply for a waiver until you are first cited for a Life Safety Code deficiency by an accreditation organization or a state agency surveying on behalf of CMS. But there are no guarantees that CMS would grant approval of a waiver request for this deficiency. Even if they did, the waiver is only valid for 3 years then you have to be cited again and then you have to submit a waiver request again. At best, it is a temporary process… not a permanent solution. My suggestion is to make plans to resolve the deficiency as soon as possible and if you get cited in the meantime, you can always submit a waiver request as part of your Plan of Correction.

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Fire Barriers in Ambulatory Healthcare Occupancies – Part 1

BKeyes : May 30, 2016 12:00 am : Ambulatory Care Occupancy, Fire Barrier, Questions and Answers

Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?

A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.

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ASC Fire Alarm Testing

BKeyes : May 23, 2016 12:00 am : Ambulatory Care Occupancy, Fire Alarm, Questions and Answers, Testing

Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.

A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section of the 2000 edition of the LSC requires compliance with section 9.6. Section requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.

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Dead-bolt Locks on Bathroom Doors

BKeyes : May 16, 2016 12:00 am : Door Locks, Questions and Answers

Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors. Is this permitted?

A: Actually, dead-bolt locks with a thumb-turn on the inside would be permitted on restroom doors, provided the doors to the restrooms are not positive latching. Restroom doors are not required to latch, therefore the larger restrooms rarely have positive latching hardware. Section of the 2000 Life Safety Code© says doors in the means of egress are not permitted to have more than one action to operate the door. If the door had a latch-set and a dead-bolt lock then that would not be permitted since it takes two actions to operate the door (unlock the dead-bolt and turn the latch-set). But since the bathroom door does not require a latch-set, then a dead-bolt lock that can be unlocked from the egress side would be permitted.

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