Mar 02 2016

CMS Enforces Different Time-Description

Category: BlogBKeyes @ 12:00 am
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I received the following comment from a reader:

During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even though they’re we’re clearly within The Joint Commision’s plus or minus 20 day window for semi-annual testing. He said CMS goes by the NFPA code (not JC) and that, that window is not in the code so therefore the testing must be completed before the 6 month anniversary. However, he stated that the quarterly inspections and testing can be done in a calendar basis and not by the revised quarterly interval parameters that JC has implemented (every 3 months, plus or minus 10 days).

This is an example where the accreditation organization has developed a thoughtful and practical interpretation of the NFPA standards regarding frequency of inspections and tests. Then CMS comes along and denies the practicality of the interpretation because it is not permitted in the NFPA codes or standards. That’s one of the problems with the NFPA standards is they don’t define time, such as what “semi-annual” or “every 6 months” means.

I’ve heard some state agencies surveying on behalf of CMS actually require the annual inspection or testing activity to occur exactly on the same date as the previous activity, one year later. So if it was last tested on April 15, it had to be next tested on April 15 of the next year, regardless what day of the week that landed on. That was extreme and I hope responsible people came to their senses.

But part of the problem is the people who are interpreting these rules have never worked in a hospital. They seem to not understand that hospitals need a reasonable window of opportunity to schedule these inspections and tests. Facility departments have decreasing resources available to them and it would sure be helpful if the government would just give them a little help now and then by interpreting issues with a little kinder attitude.

Wouldn’t it be nice if all of the authorities having jurisdiction (i.e. CMS, accreditation organizations, state fire marshals, etc.) were on the same page for critical issues like this?

 

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Dec 18 2015

Multiple Delayed Egress Locks in the Path of Egress

Category: BlogBKeyes @ 12:00 am
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Q: I have heard you state that once the 2012 edition of the Life Safety Code is finally adopted hospitals will be allowed to have more than one delayed egress locks in the path of egress. I understand that the 2000 LSC only allows one delayed egress lock in the path of egress, but I cannot find it written in the 2012 edition that more than one delayed egress lock is permitted in the path of egress. Can you explain this to me?

A: You won’t find it written in the 2012 LSC that more than one delayed egress locks can be used in the path of egress because it is not written in the LSC anywhere. In the world of the Life Safety Code, unless it is otherwise stated, you are permitted to do something as long as the code does not prohibit it. This concept may be contrary to some people who look to the LSC for permission to do something. But, this method of interpreting the LSC will get you in trouble if you are not familiar with the entire content of the code, because the reference that prohibits something may be located in a different chapter or section than the one you are looking at.

But, getting back to delayed egress locks: Section 7.2.1.6.1 of the 2000 and the 2012 editions of the LSC discusses the requirements you must follow to utilize delayed egress locks. Nowhere in section 7.2.1.6.1 does it prohibit more than one delayed egress locks in the path of egress. But to fully understand the issue, we must look at section 18/19.2.2.2.4 of the 2000 LSC, which has Exception No. 2 which says: “Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.”

So, there is this exception in the healthcare occupancy chapters of the 2000 LSC that limits delayed egress locks to just one in the path of egress. As section 4.2.2.2 of the 2000 LSC states, where specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the requirements of the occupancy chapters shall govern. That is why multiple delayed egress locks are not permitted in the path of egress in a hospital.

The 2012 edition of the Life Safety Code changed all that, but not by writing something new into the code. They did it by deleting the substance of the exception that limited the number of delayed egress locks in the path of egress. Take a look at section 18/19.2.2.2.4 (2), which says: “Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.” The reference that limited delayed egress locks to just one in the path of egress in healthcare occupancies was deleted.      

So, that is why when the 2012 edition of the Life Safety Code is finally adopted, you will be able to have more than one delayed egress locks in the path of egress in hospitals, provided you meet all of the requirements.

If you want to start using the 2012 edition now on the issue of delayed egress locks, before the new code is adopted, CMS (and the accreditation organizations) will allow you to do so through the use of the categorical waiver, as outlined under the CMS S&C memo 13-58-LSC, issued August 30, 2013. For a full review of CMS S&C memo 13-58-LSC, click on this link:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

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Dec 02 2015

When Will CMS Adopt the 2012 Life Safety Code?

Category: BlogBKeyes @ 12:00 am
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Q: When will CMS adopt the new 2012 Life Safety Code? It seems they are taking a long time to do it.

A: I don’t know when CMS will finally adopt the 2012 Life Safety Code, if at all. They certainly have made formal statements that they are considering adopting the 2012 LSC; in December 2011 they announced that they are reviewing the 2012 edition for consideration of adoption, and in April 2014 they published a proposed rule of adopting the 2012 LSC and requested the public to send them comments, which they did. But since then, there has not been any official announcement concerning the adoption of the 2012 LSC. Some people think the adoption is a political event, tied to Congress and the President’s approval, which is not true. It may be political, but contrary to popular myth, Congress does not have to vote on approving CMS adopting a new edition of the LSC, and the President does not have to sign it into law. The last time I talked with an official representative from CMS’s home office in Baltimore, they said the decision when to adopt the 2012 LSC is now in the hands of their lawyers. Stay tuned…

 

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Jan 15 2015

More on the CMS S&C Memo Concerning Power Strips

Category: BlogBKeyes @ 6:00 am
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12-120-878-TS[1]I received a question from a reader that I was unable to immediately answer. The question dealt with the use of power strips in a business occupancy: Did the categorical waiver to allow the use of power strips described in the  S&C memo 14-46-LSC, issued September 26, 2014 apply to business occupancies? The reader explained that the physician office building where he worked did not have hospital grade receptacles so it did not make sense to him that using UL listed power strips was necessary.

My immediate thought was the CMS issued categorical waiver would only apply to healthcare occupancies because NFPA 99 (2012 edition) does not apply to business occupancies. NFPA 99 is referenced by the healthcare occupancy chapter in section 18.5.1.3 of the 2012 LSC, but it is not referenced by the business occupancy chapters in the same LSC.

But, since I was not sure, I asked the question of a reliable source at CMS and they said the 2012 NFPA 99 Section 3-3.2.1.2(d)2 pertains to the minimum number of receptacles in all Patient Care Rooms.  Patient Care Rooms is defined as any room of a health care facility wherein patients are intended to be examined or treated.  In addition, the 2012 NFPA 99 Section 10.2.3.6 pertains performance criteria and testing for patient-care-related electrical appliances and equipment.  Patient-care-related electrical equipment is defined as electrical equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity.

As these definitions do not make a differentiation based on occupancy,  it is CMS’s understanding that 2012 NFPA 99 power strip requirements would be applicable in all health care facilities in rooms where patients are intended to be examined or treated regardless of occupancy classification.

So, the answer to the question is the categorical waiver applies to all patient care rooms, regardless of the occupancy classification. This means if you want to use power strips in a physician exam room in a medical office building that is a business occupancy, you need to follow the guidelines in the S&C memo and only use UL listed power strips. However, for other areas of the business occupancy that are not considered patient care rooms, the NFPA 99 requirements concerning UL listed power strips do not apply. But it is wise to purchase only UL listed power strips since you cannot control where they may end up.

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Oct 01 2014

CMS Issues Categorical Waiver on Power Strips

Category: BlogBKeyes @ 3:00 pm
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12-120-878-TS[1]CMS issued a new S&C memo 14-46 in late September that made allowances for healthcare organizations to utilize power strips in patient care areas.

CMS has determined that the 2000 edition of the Life Safety Code contains provisions on the use of power strips in health care facilities that may result in unreasonable hardship for providers or suppliers. Further, CMS says an adequate alternative level of protection may be achieved by compliance with the 2012 edition of the Life Safety Code, which has extended allowances on the use of power strips in patient care areas.

CMS has determined that the 1999 edition of NFPA 99 Standard for Health Care Facilities, section 3-3.2.1.2 (d)(2) which requires a sufficient number of receptacles located so as to avoid the need for extension cords or multiple outlet adapters, is outmoded and unduly burdensome. NFPA 99 is referenced in part by the Life Safety Code. Power strips are also known as multiple outlet adapters, multiple-plug adapters, and relocatable power taps.

CMS says by contrast, the 2012 edition of NFPA 99 has extended allowances for use of power strips in ‘patient care rooms’, which replaces the term ‘patient care areas’.

The requirement in the 1999 edition of NFPA 99 for sufficient receptacles to be located in all patient care areas as to avoid the need for power strips has been removed in the 2012 edition. In place, the 2012 edition has increased the minimum number of receptacles in patient care rooms for new construction.

Effective immediately, CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas/rooms, if the provider/supplier complies with all applicable 2012 NFPA 99 power strip requirements and with all other 1999 NFPA 99 and 2000 Life Safety Code electrical system and equipment provisions. NOTE: This applies to patient care rooms in all occupancies; not just healthcare occupancy. So does apply to patient care rooms in business occupancies as well as ambulatory care occupancies.

A patient care room is defined as any room in a health care facility wherein patients are intended to be examined or treated. This definition appears to include operating rooms and procedure rooms as well and is not limited to just healthcare occupancies.

The CMS S&C memo 14-46 describes basic requirements that health care facilities must comply with in order to use the new categorical waiver.

  • Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section 6.3.2.2.6.2 of the 2012 NFPA 99.
  • Power strips may be used in a patient care vicinity to power rack-mounted, table-mounted, pedestal-mounted or cart-mounted patient care related electrical equipment assemblies, provided all of the conditions are met in section 10.2.3.6. They do not have to be an integral component of manufacturer tested equipment.
  • Power strips may not be used in a patient care vicinity to power non-patient care-related electrical equipment, such as personal electronics.
  • Power strips may be used outside of the patient care vicinity for both patient care-related equipment and non-patient care-related equipment.
  • Power strips providing power to patient care-related electrical equipment must be Special Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.
  • Power strips providing power to non-patient care-related electrical equipment must be Relocatable Power taps (RPT) listed as UL 1363.

The categorical waiver is available to all health care providers and suppliers and need only to document their decision to use the waiver, stating that they comply with all of the requirements to do so. This document must be provided to the surveyor team at the entrance conference. Organizations wishing to use the categorical waiver need not apply for them or wait until they are cited to use them.

To review the CMS S&C 14-46 memo, follow this link:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-46.pdf

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Jul 01 2014

Congratulations! CMS Approves The Joint Commission for Six More years

Category: BlogBKeyes @ 6:00 am
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I suspect most of you didn’t give this much thought, but ever since 2009, The Joint Commission has had to apply to CMS for their deeming authority to survey hospitals and other healthcare organizations on behalf of the federal agency for Medicare & Medicaid reimbursements. Joint Commission was approved by CMS in 2010 for 4 years, which would expire this year if they did not re-apply.

Re-apply they did and this time it appears CMS was waiting for them and gave them a huge list of things they needed to change about their standards and practices, or they would not receive CMS deeming approval. In all, CMS identified at least 52 specific items that Joint Commission needed to address before they would receive the deeming status that they needed to stay in business.

To their credit, The Joint Commission did the work necessary to comply with the CMS demands. The changes they made that would be most notably in the physical environment areas, include:

  • Open PFIs will be cited on the final survey report;
  • Agreeing that only CMS can approve equivalencies;
  • Issuing two new Elements of Performance (EPs) which address the requirements for the organization to conduct risk assessments when determining the best equipment maintenance strategy, under EC.02.04.03, EP 24, and EC.02.05.05, EP 6;
  • Issued new EC.02.02.01, EP 18 requiring radiation workers to be checked periodically;
  • Issued new EC.02.02.01, EP 19 requiring procedures for trash storage and disposal;
  • Changed EC.02.03.01, EP 10 to include the phrase “and report fire alarms”;
  • Changed EC.02.05.03 to add the rooms “intensive care, and emergency rooms”.

You might be surprised to learn how hard The Joint Commission has been working to re-write their standards to comply with CMS’s demands. It is easy to think of the largest accreditor as an agency that perpetuates itself year after year, but that is not the case anymore. They have a boss (CMS) that they have to report to, and follow their directives. One indication of the seriousness of this issue, is usually The Joint Commission announces changes to the standards six months before they become effective. The fact that most of the changes mentioned above are effective July 1 (or July 2), 2014, and were only announced to the public during June, says they deviated from their normal practice to satisfy CMS.

It must have worked, since CMS published a statement in the Federal Register on Friday, June 27, 2014 announcing their approval for The Joint Commission as a deeming authority, for another six years. I seriously mean this when I say Congratulations! to The Joint Commission for this achievement. I know it must have been difficult.

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Jun 06 2014

Changes With Equivalency Requests for The Joint Commission

Category: BlogBKeyes @ 11:00 pm
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imagesO752ZQ8RAs a result of the June 4, 2014 online announcement by The Joint Commission which identified major changes for the Statement of Condition Plan for Improvement (PFI) list, they also mentioned that beginning July 1, 2014 all equivalency requests submitted to them will be passed along to the appropriate CMS Regional Office for their approval.

What The Joint Commission did not say is CMS will not accept any equivalency requests unless it is submitted as part of the organization’s Plan of Correction. This means, hospitals will no longer be able to submit an equivalency request prior to a survey, but will only be able to submit equivalency requests after the Life Safety Code deficiency is cited in a survey report.

What affect will this have on hospital facility managers? I think both changes involving the PFI list and the equivalency requests has the potential for a huge impact on the overall safety of the physical environment, and it won’t be positive.

In just the two days since Joint Commission announced this change, I must have talked with or emailed with over 20 different facility managers and safety officers of Joint Commission accredited hospitals, discussing what options they have with these new changes. This has many of these individuals very concerned since two key tools are changing on how they manage their Life Safety Code deficiencies.

Allow me to summarize these changes:

1). Beginning July 1, 2014, Joint Commission says all items identified on the PFI list will be cited as deficiencies on the survey decision report. No longer will hospitals enjoy a pass from receiving a written deficiency in the survey report for anything identified on the PFI list. [I talked with one facility manager who has over 200 items on his PFI list and their organization is in the survey window for their triennial survey. He needs to clear those PFIs or risk having them identified on the survey report.]

2). Joint Commission says they will review equivalency requests and send them on to the CMS Regional Office for final action. Since CMS does not accept equivalency requests for LSC deficiencies that have not been cited on a survey report, no longer will facility managers be allowed to be proactive and seek an equivalency for a deficiency prior to a survey.

So, I see a very strong potential for facility managers to discontinue being proactive and identify their LSC deficiencies prior to a triennial survey, since there is no relief from the PFI list and there is no opportunity to seek an equivalency. They very likely will take the stand of wait-and-see if the surveyor finds the deficiency and then deal with it afterwards. I fear our industry may fall back into the “hide our skeletons” concept of over 20 years ago. No longer will some facility managers want to be transparent and self-identify their problems. By failing to self-identify their deficiencies, those deficiencies do not get resolved, and if the surveyors fail to identify them, then they likely will not get resolved at all. How safe is that for our patients?

Do not misunderstand me… I do not advocate facility managers to discontinue being proactive and identifying their LSC deficiencies prior to a survey. In fact, I encourage them to continue as though nothing has happened in regards to the PFI list, and still use it as a tool to manage their deficiencies. But, human nature being what it is, I suspect many hospitals will not be as safe as they once were because some facility managers will no longer be proactive and self-identify their LSC deficiencies.

And, you can forget about the cost effective and economical Traditional Equivalencies that Joint Commission used to accept. CMS will not accept those at all, and will only accept the more costly Fire Safety Evaluation System (FSES) as identified in NFPA 101A.

I think this is a very sad day for healthcare. While I was an advocate for fair play amongst all the accreditation organizations, I wanted CMS to approve the advantage that Joint Commission had with the PFI list and approving equivalencies prior to the deficiency being cited, for all accreditors, not just for Joint Commission. Instead, CMS did not clearly understand the potential actions their insistence will cause.

It looks like CMS will not stop until all the accreditation organizations are homogenized into one big quasi-government group whereby you won’t be able to tell them apart. What good is that?

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Jun 06 2014

Follow Up on Changes to the PFI LIst

Category: BlogBKeyes @ 6:00 am
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imagesFWHXWLWMSince yesterday, I have received a lot of emails and calls concerning the Joint Commission announcement on changes to their PFI list. On Wednesday, June 4, 2014, Joint Commission published an online article which announced major changes to their survey decision report process, which will become effective July 1, 2014.

Currently, an organization is encouraged to report any Life Safety Code deficiency that they cannot resolve within 45 days of discovery, onto the Statement of Conditions Plan for Improvement (PFI) list, and identify a projected completion date. For many years (20 years?) placing a LSC deficiency on the PFI list provided the organization relief from a surveyor finding in the event of a survey. In the accreditation organization’s announcement on Wednesday, items listed on the PFI list will no longer be free from a surveyor’s citation beginning July 1, 2014.

The reason is the Centers for Medicare & Medicaid Services (CMS) has insisted that the Joint Commission stop this practice, and cite every deficiency that the surveyor sees during the survey. To their credit, Joint Commission has agreed to comply with the federal agency’s directive.

But I have received many emails and telephone calls from facility managers asking “What should I do?” Now that the Joint Commission will cite any item identified on the PFI list, many facility managers are reluctant to self-identify their deficiencies that will likely lead to a surveyor finding.

Let’s remember what the Statement of Conditions PFI list is all about: It is a Joint Commission management tool designed for facility managers to self-report Life Safety Code deficiencies so they can manage the resolution of the deficiency.  The PFI list is there for you to use in order to track the LSC deficiencies to completion. It is not a device in which Joint Commission can say “Gotcha” and hit you over the head.

There is no Joint Commission standard that says you must enter all LSC deficiencies into the PFI list that cannot be resolved within 45 days. Joint Commission does have a Frequently Asked Question (FAQ) on the subject, and the answer they provided is as follows:

The Joint Commission allows resolution of a deficiency by either correcting it immediately (preferred), managing it using a corrective maintenance work order system (with tracking capabilities) with resolution within 45 days, or creating a Plan for Improvement (PFI) and managing it using the electronic Statement of Conditions (SOC).

This is not a standard requirement of the accreditation organization, but more like a recommendation. I see it as an option for the facility manager. He/she does not need to enter the LSC deficiencies in the PFI list if he/she does not want to, especially now that there is no incentive to do so.

But don’t let that short-sightedness be your downfall: It may be better to list all your LSC deficiencies that you cannot resolve within 45 days on the PFI list and risk being cited for them, in order to track and manage each deficiency to a successful conclusion. I guess each facility manager needs to consider all of the alternatives and make their own decision.

For those that missed the Joint Commission announcement, click on the following link:  http://www.jointcommission.org/issues/article.aspx?Article=3hzpYDrgAaZdWi6C%2b1xoxANtx2DFfvVdArnSt2rJ2Yc%3d&j=1752680&e=brad@keyeslifesafety.com&l=9552_HTML&u=28545686&mid=1064717&jb=0

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Jun 05 2014

Joint Commission Announces Changes to PFIs and Equivalencies

Category: BlogBKeyes @ 1:30 pm
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Yesterday, Joint Commission published an online notice of changes to their survey decision reports effective July 1, 2014, that effectively eliminates the strategic advantage of healthcare organizations self-reporting Life Safety Code deficiencies on the PFI list, and changes how equivalencies are approved. The reason for these changes is to align Joint Commission’s survey process with the requirements of the Centers for Medicare & Medicaid Services (CMS). Joint Commission is in the process of having their renewal application for deemed status from CMS approved, and this action appears to be a direct result of CMS insistence to follow their rules.

CMS has for many years prevented other accreditation organizations (HFAP and DNV) the ability to have documents similar to the PFI list that provides protection from surveyor findings during a survey, and eliminated those AO’s authority to approve equivalencies. It appears now that by this action, a level playing field with all the AOs has been achieved and any unfair advantage that Joint Commission had is eliminated.

Specifically, the changes that Joint Commission announced in their online publication stated:

  • While Joint Commission retains their Plan For Improvement (PFI) section of the Statement of Conditions, they eliminated the protection of a finding on a survey report. They now say they will list all open, unresolved PFIs on the survey decision report, which puts them on the same level with the other AOs.

 

  • Joint Commission will no longer approve equivalencies, but will submit them to the appropriate CMS Regional Office for their approval. This also puts Joint Commission on the same level as the other AOs. In addition, this appears to eliminate the Traditional Equivalencies that Joint Commission used to approve, as CMS will only accept equivalencies that are based on NFPA 101A, which uses the Fire Safety Evaluation System (FSES).

Joint Commission also announced that they have created a new section in the survey decision report called the “Opportunities For Improvement” (OFI), in addition to the still current “Requirement for Improvement” (RFI) section.  This is significant as currently single observations of Category C elements of perforamce are not posted on the survey decision report, which is contrary to CMS’s directive. CMS has stated for years that all deficiencies observed by a surveyor must be cited in the survey decision report.

Now, single observations of Category C elements of performance will be cited in the survey decision report under the OFI section, rather than the RFI section. The ability to clarify away surveyor findings after the survey on Category C standards in the OFI section is eliminated. However, the online notice did not say that Joint Commission is eliminating the ability for healthcare organizations to clarify Category C findings scored under the RFI section.

So, based on this online notice, it is apparent that CMS held their ground with Joint Commission and made them implement the changes to eliminate the uneven playing field. It appears that all AOs are on the same page, and Joint Commission no longer has an unfair advantage on PFIs or Equivalencies.

It appears that these changes only applies to Joint Commission programs that are under the authority of CMS.

To review the online notice on these significant changes, go to:   http://www.jointcommission.org/issues/article.aspx?Article=3hzpYDrgAaZdWi6C%2b1xoxANtx2DFfvVdArnSt2rJ2Yc%3d&j=1752680&e=brad@keyeslifesafety.com&l=9552_HTML&u=28545686&mid=1064717&jb=0

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Feb 20 2014

Problems with the CMS Categorical Waivers

Category: BlogBKeyes @ 6:00 am
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imagesGNA83O1G

I have been receiving some feedback from friends and readers of the Keyes Life Safety Compliance website concerning the CMS categorical waivers. One of the issues seems to focus around whether a building is fully sprinklered or not.

The whole concept of what constitutes a fully sprinklered building seems to be different among various AHJs. Some want every square inch to be protected with water-based fire protection systems, and others will permit the exceptions found in NFPA 13. Here is how I see the issue:

Sections 18/19.3.5.1 in the 2000 LSC says new healthcare construction needs to be protected with automatic sprinkler systems in accordance with section 9.7. The exception to 18/19.3.5.1 allows for areas of buildings where the AHJ will not permit sprinklers, to be protected by ‘alternative protection measures’ (whatever that means) without the building being classified as nonsprinklered. This exception was inserted to account for those areas of the country where the local AHJ would not permit sprinklers in electrical rooms or elevator equipment rooms. The phrase ‘alternative protection measures’ means whatever the AHJ wants it to mean; from installing clean agent suppression systems (Halon, FM-200, CO2, etc.) to perhaps just a smoke or heat detection system. Or, it can mean something else.

Section 9.7.1.1 says where automatic sprinklers are required by the occupancy chapter, they must be in accordance with NFPA 13 (1999 edition). NFPA 13 has some exceptions where a building does not have to have sprinklers installed in certain areas and it still would qualify as ‘being protected with automatic sprinklers in accordance with NFPA 13’. Therefore, with the exceptions allowed by NFPA 13, I see the Life Safety Code as saying these buildings are protected with automatic sprinklers in accordance with NFPA 13.

The CMS categorical waivers on unoccupied openings in exit enclosures references the new 2012 LSC, section 7.1.3.2.1 (9)(c), which says existing openings in an exit enclosure are permitted as long as it meets multiple conditions, one of which being the building is protected with automatic sprinklers in accordance with section 9.7. There we are… back to 9.7, which references NFPA 13, which has some exceptions in certain buildings to not have sprinklers, but the building still has an ‘automatic sprinkler system in accordance with NFPA 13’. If the hospital implements any of these NFPA 13 exceptions then I would say it qualifies for the CMS categorical waiver. But technically, the hospital is not “fully sprinklered”, but would be considered protected with automatic sprinklers in accordance with section 18/19.3.5 and 9.7 of the 2000 LSC. The CMS S&C memo 13-58-LSC does not require a fully sprinklered building in order to qualify for the categorical waiver on the unoccupied openings to an exit enclosure. It only requires automatic sprinklers in accordance with section 9.7, which references NFPA 13.

But it never matters what I say; only what the AHJs say. If you have an AHJ that will not allow the CMS categorical waivers due to an approved NFPA 13 exception, then use the above logic as an argument that it should be allowed.

I also have some reports that certain state department of public health (DOH) do not recognize the CMS categorical waivers and will not permit them in the hospitals under their jurisdiction. That’s okay, as the state AHJs do not have to follow what CMS says, if they are assessing compliance with their own regulations and standards. Even if the state DOH is the official designated state survey agency for CMS, the most restrictive codes and regulations apply, and in this case the state regulations would take precedence of the CMS categorical waivers.

I hope this information is helpful…

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