Apr 30 2015

Fire Drills in an ASC

Category: BlogBKeyes @ 1:00 am

images0XCM788RI spoke at an Infection Control conference last week in St Louis, sponsored by the Excellentia Advisory Group. There were 13 different presentations made but mine was the only one that was not traditionally an IC subject matter. I was asked to make a presentation on how the Life Safety Code relates to Infection Prevention in the Ambulatory Surgical Centers. At first, I was reluctant to accept this speaking engagement because I was not sure how I was going to draw the connection between compliance with the Life Safety Code and how it actually impacts the Infection Prevention program in an ASC. But, I did accept the invitation and I researched the LSC and came up with a what I think was an interesting presentation.

Keep in mind, my audience was a room full of RNs who typically do not have any Life Safety Code compliance experience. So, I decided to take the approach that compliance with the LSC is just basic patient safety compliance, and identified many of the requirements that surveyors would be looking for.

At the end of my presentation I had time to take a few questions. One lady asked if they had to activate the building fire alarm system when they conducted a fire drill. I replied that yes, technically they would, since section of the 2012 LSC requires it. They said that is a problem since the ASC shares the building with other tenants who are not part of their healthcare network.

I replied that they had a few of options: 1) They could coordinate with all of the other tenants prior to the fire drill alerting them of the pending alarm. The other tenants could conduct their own drill at that time if they chose; or 2) They could investigate to see if the fire alarm control panel can bypass the occupant notification appliances in the other tenants during their drill; or 3) They could conduct a risk assessment that identifies the hardship involved in sounding the building fire alarm system and conduct the drill without activating the alarm. This would have to be reviewed and approved by the ASC safety committee, and possibly a surveyor would accept that.

I asked if they thought they could use one of those scenarios, and they thought #3 would be the only possible solution. I asked why, and they said there was a massage parlor directly above their ASC and they didn’t believe they could get the cooperation from them and all the other tenants so they could activate the fire alarm system when they conducted a fire drill each quarter. I replied that I thought they had a pretty good case for a risk assessment since nobody wanted to see clients from the massage parlor escaping down the stairs during a fire alarm.

Uhm… the strange things I see (or don’t see) in this business.

All-in-all, I thoroughly enjoyed my day at the conference and I got to meet many interesting people.

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Apr 02 2015

New vs. Existing Construction for Ambulatory Healthcare Occupancies

Category: BlogBKeyes @ 1:00 am

A reader asked me recently what the Life Safety Code differences were between a new construction ambulatory healthcare occupancy, and an existing construction ambulatory healthcare occupancy. I did not immediately know, so I took the time to research this and I was surprised to learn what the differences (or non-differences) were.

The differences between new construction and existing construction of ambulatory healthcare occupancies are not monumental, but rather subtle. According to the 2000 Life Safety Code, here are some comparisons:

Description Chapter 20 New Construction Chapter 21 Existing Construction
Construction Type No restrictions for 1 story facilities; Building of two or more stories limited to Type 1 (443), Type I (332), Type II (222), Type III (211), Type IV (2HH), Type V (111). Type II (000), Type III (200), and Type V (000) are permitted if the entire building is protected with sprinklers.  Same
Occupant Load 100 square feet/person Same
Special Locking Arrangements Only permitted on exterior doors Same
Clear Width of Corridor 44 inches Same
Travel Distance between room and exit 100 feet Same
Travel distance between any point in a room and exit 150 feet Same
Travel distance increased for sprinklered buildings 50 feet Same
Emergency Power from Generators as per NFPA 99 Required when general anesthesia or life-support equipment is used. Same
Hazardous Areas Must meet the requirements of 8.4 and be protected with sprinklers, or protected with 1-hour construction Same
Anesthetizing Locations Must be protected in accordance with NFPA 99 Same
Fire alarm systems Manually initiation required Same
Portable fire extinguishers Required Same
Sprinkler System Not Required Same
Corridors Openings in corridor walls such as mail slots and pass-through windows permitted in windows and doors provided the opening is not more than 20 square inches. The opening may increase to 80 square inches if the room is protected with sprinklers. No Restrictions/No Requirements
Subdivision of Building Space Ambulatory healthcare occupancies must be separated from other occupancies with 1-hour fire rated barriers with ¾ hour fire rated doors Same
Smoke Compartmentation The ambulatory healthcare occupancy must be divided in to not less than two smoke compartments. Facilities less than 5,000 square feet that are protected by a smoke detection system are exempt. Facilities less than 10,000 square feet and protected by sprinklers are exempt. Same
Smoke Compartment Size Not less than 15 square feet area (net) must be provided for every occupant in the ambulatory healthcare facility on either side of the smoke compartment barrier. Smoke compartments are limited to 22,500 square feet in size. Travel distance to reach a smoke compartment barrier doors must not exceed 200 feet. No Restrictions
Fire Drills Required quarterly on all shifts Same
Combustible decorations Prohibited, unless they are flame retardant Same
Portable Space Heating Devices Prohibited, unless the heating elements do not exceed 212°F and only used in non-sleeping staff and employee areas. Same



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Feb 27 2014

Delayed Egress on Doors in Ambulatory Health Care Occupancies

Category: BlogBKeyes @ 6:00 am


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

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

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

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

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

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

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

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

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

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

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

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

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

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