Sep 22 2016

Oops! Brad Made a Mistake…

Category: BlogBKeyes @ 12:00 am
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I need to apologize to you, as I made an error in an earlier post where I stated the expected dates for the new testing/inspection requirements of the new 2012 Life Safety Code.

Previously, I said healthcare organizations needed to get their first quarterly, annual, 3-year, and 5-year test/inspection completed by November 1, 2016, which is the date CMS said the requirements of the new 2012 LSC will be enforced.

That wasn’t quite true… I received an email from a friend who also is a reader of my blog and said that is not what Joint Commission said at the annual ASHE conference. So, I contacted CMS directly in Baltimore, and communicated with the people who make these interpretations, and they told me this:

Although CMS will begin surveying to the new 2012 LSC on November 1, 2016, the regulation still requires the facility to be in compliance with the 2012 LSC and the 2012 NFPA 99 as of July 5, 2016.

Therefore, when CMS begins to survey on November 1, 2016, the healthcare facility should be able to verify compliance with any new daily, weekly, or quarterly requirements as it has been over 3 months since July 5th. But a facility would not yet be required to meet the new annual, 3-year, or 5-year requirements.

The email from CMS went on to explain that the first annual test/inspection activity that is a new requirement of the 2012 LSC is due July 5, 2017. Similarly, the first 3-year activity is due July 5, 2019, and the first 5-year is due July 5, 2021.

Just as a refresher, here is a list of the new testing/inspecting requirements of the 2012 LSC and the 2012 NFPA 99:

  • Quarterly main drain test on one system riser downstream of the backflow preventer where the sole water supply to the sprinkler system is through a backflow preventer;
  • Quarterly inspection of fire hose valves;
  • Annual test/inspection of all fire-rated door assemblies;
  • Annual test of the 2.5 inch fire hose valves;
  • 18-month test of non-stationary medical gas booms and articulating assemblies using flexible connectors for medical gas outlets;
  • 3-year test of the 1.5 inch fire hose valves;
  • 5-year internal inspection of sprinkler pipe.

So… according to the information provided by CMS, when they begin surveying to the 2012 LSC on November 1, 2016, you need to have your first quarterly main drain test conducted and your first quarterly inspection of fire hose valves. However, the annual, 18-month, 3-year, and 5-year new requirements are not due until their respective anniversary from the July 5, 2016 effective date.

I apologize for this miscommunication…. And I’m glad my friend took the time to point that out to me.

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Aug 04 2016

How the Changes to the SOC Process Will Affect Life Safety Compliance

Category: BlogBKeyes @ 12:00 am
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On July 13, 2016, The Joint Commission issued the following statement:

 “Effective Aug. 1, 2016, changes will become effective to the Statement of Conditions™ (SOC) process that will affect the survey of Life Safety (LS) chapter requirements. Following Aug. 1, 2016, the following changes to survey will occur:

  1. The open Plan for Improvement (PFI) items will no longer be reviewed by the survey team.
  2. The open PFI will no longer be imported into the Final Report.
  3. All Life Safety (LS) chapter deficiencies identified during survey will become Requirements for Improvement (RFI) with a 60-day Evidence of Standards Compliance (ESC). For those deficiencies that require more than 60 days, a Time-Limited Waiver process is available.
  4. Only equivalency requests related to survey events will be reviewed.

The Joint Commission has had the SOC as part of its accreditation program since 1995. The SOC was originally created to allow organizations a process to develop a plan for improvement to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures (ILSM) to ensure patient safety. Initially, these self-identified actions were not documented during survey because the SOC already documented the deficiency. The Joint Commission also created the ILSM process to mitigate risk while resolving the deficiencies. This allowed the SOC process to be the method for organizations to create and submit their Plan for Improvement (PFI), with an amount of time to make the correction that the organization could manage, while still providing a safe environment. Occasionally, an organization would need additional time to complete the corrective action, and The Joint Commission granted extension requests. Many of these extension requests occurred during the six-month automatic extension period.      

CMS has identified required changes to the SOC process, including:  

  • No longer allowing the SOC to document self-identified deficiencies, instead, taking the self-identified deficiencies and converting those to RFIs by the surveyor 
  • No longer allowing more than 60 days for corrective actions unless approved by the CMS regional office
  • The surveyor citing all deficiencies replacing the extension request component with a Time Limited Waiver process, using the Survey-related Plan For Improvement (SPFI) process that will be managed and tracked by the CMS regional office
  • Managing the survey-related equivalency process, as defined by CMS, using Salesforce and the SOC to manage and track the CMS regional office action  
  • Removing the six-month automatic extension
  • No longer granting requested extensions
  • Joint Commission leadership, after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process. Post survey, the CMS Time Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies. All questions should go to The Joint Commission Department of Engineering at 630-792-5900.”

 

This is another sad event for patient safety caused by a federal agency that cannot see the positive that the SOC / PFI process had for healthcare organizations. This action by CMS is not a knee-jerk reaction that was not carefully considered; rather this decision by CMS to not allow the hospitals and ambulatory surgical centers to have a process of self-identification of Life Safety Code deficiencies and an incentive to be proactive has been long-coming for years.

Back in 2008 when Det Norske Veritas (DNV) Healthcare received deeming authority from CMS, the new accreditor wanted a system similar to the Statement of Conditions PFI list, but was told by CMS that they could not. Similarly, in 2012 HFAP applied for a system similar to the PFI list but was also denied by the federal agency.

In 2014 when CMS issued their proposed rule to adopt the 2012 Life Safety Code, the public responded with many comments. Quite a few commenters mentioned that CMS should keep the SOC/PFI system and allow all of the accreditation organizations a chance to utilize it.

When CMS issued their final rule on May 4, 2016, they made it very clear that there will not be any Plan For Improvement list in the way that Joint Commission was operating. That was the writing on the wall and it became clear that the major hospital accreditor would have to discontinue its use.

This is a very sad event, because now it is feared that many hospitals will no longer be proactive and self-identify their own Life Safety Code deficiencies because any incentive to do so (i.e. not citing the deficiency on the survey report) has been removed. CMS has struck harder and put a stop to hospital self-identifying the projected completion date, and now makes all LSC deficiencies cited during a survey to be resolved within 60 days of the end of the survey.

Since major LSC deficiencies cannot be resolved that quickly, CMS is now requiring the healthcare organizations to request a time-limited waiver through the accreditor. This is another example of CMS tightening their grip on the accreditation process. In this case, it reduces the level of safety for the patients. Where is the logic in that?

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May 31 2016

Keyes Life Safety Boot Camp – Last Week to Register!

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 24 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 18 2016

The New NFPA 25 Standard

Category: BlogBKeyes @ 12:00 am
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Q: Just read your latest post on testing of PIVs and backflows in accordance with NFPA25.  You referenced the 1998 edition.  But aren’t we supposed to be following the newly adopted 2012LSC? I’m looking at it, and it now references the 2011 edition of NFPA25.

A: No… all CMS regulated hospitals are currently on the 1998 edition of NFPA 25. They will not move to the 2011 edition of NFPA 25 until the adoption of the 2012 LSC is effective, which will not happen until July 5, 2016, according to CMS’s final rule. At that point, CMS will expect compliance with the 2011 edition of NFPA 25. However, don’t expect your accreditation organization to be enforcing the new 2012 LSC (and referenced standards, like the NFPA 25) at that time. They have to submit changes to their manual to CMS for approval before they can enforce the 2012 LSC. That process may not be completed until September… or later.

 

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May 17 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 10 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 05 2016

Categorical Waivers and the New 2012 Life Safety Code

Category: Blog,Life Safety Code UpdateBKeyes @ 12:00 am
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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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May 03 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

Tags:


Apr 29 2016

The 2012 Life Safety Code is Nearly Adopted

Category: BlogBKeyes @ 10:33 am
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I received the following message from my friends at Russell Phillips and Associates, LLC:

For those of you that are awaiting the adoption of the 2012 Life Safety Code:  We recently learned that the CMS rule adopting the 2012 LSC passed out of the Office of Management and Budget (OMB) last week.  This final rule is now cleared to be published in the Federal Register and should be out soon. Many years in the making and it is finally very close to being here.  Now we need to see if it was approved in its entirety or if it was modified.

I was told by another source that May is the month that CMS likes to release final rules, and Friday is the day of the week that CMS likes to release notices in the Federal Register.

Keep your eyes posted….

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