Transcript The Top Life Safety Code Findings Cited by HFAP Surveyors

Understanding the New CMS
Categorical Waivers on the 2012
Life Safety Code
Brad Keyes, CHSP
Senior Consultant for HFAP
The New 2012 Life Safety Code
The Centers for Medicare &
Medicaid Services (CMS)
announced in late 2011 that they are reviewing the
2012 edition of the Life Safety Code for adoption
The last time they upgraded,
they went from the 1985
edition to the 2000 edition,
on March 11, 2003
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The New 2012 Life Safety Code
Accreditation organizations (such as HFAP) are
required to survey hospitals for compliance with
the 2000 edition, and cannot move to the more
recent edition until CMS adopts it
It took CMS 3 years to
adopt the 2000 edition after they
said they were ‘reviewing’ it, so
look for this to become final in late
2014 or early 2015
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The New 2012 Life Safety Code
There are significant changes in store for
hospitals when the 2012 edition is finally
adopted
In an unprecedented act of charity, CMS has
decided to allow hospitals to use certain
portions of the 2012 LSC now, rather than to
wait until the full document is adopted
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The New 2012 Life Safety Code
This signifies that CMS still intends to adopt the
2012 edition of the LSC, and is on-track to do so.
Some naysayers are saying that CMS is stalling the
process of adopting the 2012 LSC, CMS must follow
the Administrative Procedures Act of 1946 which
requires a prolong procedure of conducting due
diligence, posting proposed rules, soliciting public
comments and developing responses
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Categorical Waivers
On August 30, 2013, CMS issued the Survey &
Certification memo S&C-13-58-LSC that permits
healthcare facilities to use certain portions of the
2012 LSC
This action is allowed under Federal regulations
whereby CMS may waive specific provisions of the
2000 LSC which if rigidly applied would result in
unreasonable hardship on a healthcare provider
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Categorical Waivers
CMS did not explain why all of a sudden, after
10 years with the 2000 LSC they believe
compliance with these specific sections is
considered a hardship to hospitals… but we
don’t look a gift horse in the mouth
CMS refers to these waivers as ‘categorical’,
meaning they are given outright without the
hospital having to request them
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Categorical Waivers
There are a few conditions hospitals must follow
in order to utilize these categorical waivers:
– They are only offered and permitted in healthcare
occupancy facilities (hospitals, nursing homes, and
limited care facilities)
– The organization must formally elect to use one or
more of the waivers and they must document this
decision. There is no need to apply to CMS or
HFAP for the use of these waivers.
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Categorical Waivers
Conditions (cont’d):
– The organization must notify the survey team at
the entrance conference of a survey that they
have elected to use one or more categorical
waivers, and present the documentation
demonstrating their decision to do so
• (NOTE: It is not acceptable to first notify surveyors of
waiver election after a LSC citation has been issued.)
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Categorical Waivers
Conditions (cont’d):
– The survey team will review the documentation
and assess the facility to confirm that all
conditions of the waiver are met
– Deficiencies to the 2000 LSC that qualify for the
CMS categorical waivers will not be cited as long
as all of the other conditions are met for the
categorical waivers
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Categorical Waivers
HFAP has decided to endorse the CMS
categorical waiver process for our accredited
organizations, but only in healthcare
occupancies
NOTE: It is the responsibility of the healthcare
organization to read, understand and fully
comply with the conditions of the S&C 13-58LSC memo
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1. Medical Gas Master Alarm
The 2000 LSC requires compliance with the
1999 edition of NFPA 99, which does not allow
the use of a centralized computer as a
substitute for medical gas alarm panel
However, the 2012 LSC refers to the 2012
edition of NFPA 99, and section 5.1.9.4 does
allow the use of a centralized computer in lieu
of one of the master alarms
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1. Medical Gas Master Alarm
Therefore, a categorical waiver is permitted to
allow a centralized computer system to
substitute for one of the Category 1 medical gas
alarm panels, but only if the organization is in
compliance with all other NFPA 99-1999
provisions, as well as section 5.1.9.4 of the NFPA
99-2012
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2. Openings in Exit Enclosures
The 2000 LSC limits openings in exit enclosures
(stairwells, exit passageways) to the following:
–
–
–
–
Doors for egress from the enclosure
Doors from normally occupied spaces
Doors from corridors
Doors to interstitial spaces in Type I and Type II
buildings, used solely for the distribution of
pipes, ducts and conduits
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2. Openings in Exit Enclosures
Unfortunately, many hospitals were constructed
with unoccupied mechanical rooms at the top
of the facility with access to/from the exit
stairwell
Resolving this problem by construction of an
alternative exit is impractical and burdensome
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2. Openings in Exit Enclosures
The 2012 LSC, section 7.1.3.2(9)(c) allows
existing openings to unoccupied mechanical
equipment spaces, provided the following is
met:
– The door assembly is fire-rated
– The mechanical space does not contain fuel-fired
equipment
– The mechanical space does not contain
combustible storage
– The entire building is protected with sprinklers
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2. Openings in Exit Enclosures
Therefore, a categorical waiver is permitted to
allow existing openings in exit enclosures, but
only if the organization is in compliance with all
other 2000 LSC provisions on exiting, as well as
section 7.1.3.2.1(9)(c) 2012 LSC
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3. Emergency Generators
The 2000 LSC requires emergency power
generators to comply with NFPA 110 (1999
edition).
NFPA 110 (1999 edition) requires dieselpowered generators that do not meet the
monthly load test to operate annually with
various loads for 2 continuous hours.
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3. Emergency Generators
The 2012 LSC requires compliance with NFPA
110 (2010 edition) which allows for a 90-minute
load test for generators that do not meet their
monthly load test requirements.
The shorter run time for the annual test will
save generator run time and reduce negative
environmental impacts.
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3. Emergency Generators
The 2010 NFPA 110 allows for a 90-minute
annual load test when the monthly load test
requirements are not met. The requirements
are:
– Operate the generator at not less than 50%
capacity for 30 minutes
– Operate the generator at not less than 75%
capacity for 60 minutes
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3. Emergency Generators
Therefore, a categorical waiver is permitted to
allow the annual load test on emergency power
generators to operate at 90-minutes, but only if
the organization is in compliance with all other
1999 NFPA 110 provisions on generator
inspection and testing, as well as section 8.4.2.3
of NFPA 110, 2010 edition.
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4. Door Locks: Security Measures
The 2000 LSC permits doors to be locked in the
path of egress for clinical needs patients, such
as patients in behavioral health units and
Alzheimer units.
However, the definition of ‘clinical needs’ did
not carry over for the security needs of the
patients, such as ER patients, ICU patients and
pediatric or nursery patients.
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4. Door Locks: Security Measures
The 2012 LSC allows for door locking
arrangements for patients requiring security
measures, such as ER, ICU, Nursery and
Pediatric patients.
However, the following conditions must be met:
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4. Door Locks: Security Measures
•
•
•
•
•
•
•
Staff can readily unlock doors at all times
Smoke detectors provided throughout the locked space, or:
Locked doors can be remotely unlocked at a constantly
attended location within the locked space
The building is protected throughout by an approved
automatic sprinkler system
The locks are electrical that fail safe to release the locks
upon loss of power
The locks release upon activation of the smoke detectors
within the locked space
The locks release upon activation of the sprinklers
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4. Door Locks: Security Measures
Therefore, a categorical waiver is permitted to
allow door locking arrangements where patient
pose a security risk, but only if the organization
is in compliance with all other 2000 LSC
provisions on door provisions, as well as
sections 18/19.2.2.2.2 through 18/19.2.2.2.6 of
the 2012 LSC
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5. Door Locks: Delayed Egress
The 2000 LSC only allowed one delayed egress
lock in the path of egress
It has been determined that more than one
delayed egress lock may be required along the
path of egress to accommodate clinical,
security, and other special needs patients.
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5. Door Locks: Delayed Egress
The 2012 LSC allows more than one delayed
egress lock in the path of egress, provided:
– The entire building is protected with automatic
sprinklers , or;
– The entire building is protected with smoke
detectors
– Other provisions as listed in 7.2.1.6.1
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5. Door Locks: Delayed Egress
Therefore, a categorical waiver is permitted to
allow more than one delayed egress lock in the
path of egress, but only if the organization is in
compliance with all other 2000 LSC provisions
as well as section 18/19.2.2.2.4 of the 2012 LSC
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6. Suites
The 2000 LSC limits sleeping suites to 5,000
square feet in size, and when the sleeping suite
exceeds 1,000 square feet, two exits are
required from the suite to the exit access
corridor
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6. Suites
Significant changes for suites have been
developed over the past few editions of the LSC:
1. One of the two required exits from a suite is
permitted to be into and through an adjoining
suite, provided the barriers between the suite
comply with the requirement for corridor
barriers. The travel distance requirements ‘resets’ once you have entered the adjoining suite.
[This applies to sleeping suites as well as non-sleeping suites.]
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6. Suites
Changes for suites (cont’d):
2. One of the two required exits from a suite is
permitted to be into an exit stairwell; an exit
passageway; or an exit door to the exterior
3. The total area of a sleeping suite may be
increased to 7,500 square feet provided the
smoke compartment is protected with standard
response sprinklers and smoke detectors, or
protected with quick response sprinklers
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6. Suites
Changes for suites (cont’d):
4. The total area of a sleeping suite may be
increased to 10,000 square feet provided the
patient sleeping rooms are arranged to allow
direct supervision from a normally attended
location within the suite; and the suite is totally
protected with smoke detectors and quick
response sprinklers
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6. Suites
Changes for suites (cont’d):
5. The total travel distance between any point in a
suite (sleeping or non-sleeping) and an exit
access door from that suite is limited to 100 feet
[The 50 foot travel distance limitation through 2 intervening
rooms in non-sleeping suites has been deleted]
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6. Suites
Therefore, a categorical waiver is permitted to
allow these changes to suites, but only if the
organization is in compliance with all other
2000 LSC provisions on suites, as well as
sections 18/19.2.5.7 of the 2012 LSC
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7. Waterflow Alarms
The 2000 LSC requires compliance with the
1998 edition of NFPA 25, which requires
quarterly testing of vane-type and pressure
switch type waterflow alarms.
Ironically, NFPA 72 National Fire Alarm Code
(1999 edition) did not require quarterly, but
semi-annual testing of the same devices
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7. Waterflow Alarms
The 2011 edition of NFPA 25 (which is
referenced by the 2012 LSC) allows for the semiannual testing of vane-type and pressure type
waterflow devices, and is now consistent with
the NFPA 72 requirements
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7. Waterflow Alarms
Therefore, a categorical waiver is permitted to
allow semi-annual testing of vane-type and
pressure switch type waterflow devices, but
only if the organization is in compliance with all
other 1998 NFPA 25 provisions on waterflow
switches, as well as section 5.3 of the 2011
NFPA 25
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8. Fire Pump Testing
The 2000 LSC requires compliance with the
1998 edition of NFPA 25, which requires weekly
testing of fire pumps at no-flow conditions
It is not unusual that organizations have worn
out their fire pumps just from testing them on
such a frequent basis
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8. Fire Pump Testing
The 2011 edition of NFPA 25 (which is
referenced by the 2012 LSC) allows for the
monthly no-flow testing of electric motor-driven
fire pumps but not for engine-driven fire
pumps, which must continue at a weekly
frequency
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8. Fire Pump Testing
Therefore, a categorical waiver is permitted to
allow monthly testing of electric motor-driven
fire pumps, but only if the organization is in
compliance with all other 1998 NFPA 25
provisions on fire pump testing, as well as
section 8.3 of the 2011 NFPA 25
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9. Clean Waste Recycling Containers
The 2000 LSC limits the size of trash collection
containers to 32 gallons when located outside
of a hazardous storage area
Recycling containers containing clean waste is
presumed to pose a lower risk of fire
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9. Clean Waste Recycling Containers
The 2012 LSC allows for a larger size of
container used for recycling which will
presumably reduce the number of trash
receptacles and hazardous storage areas
This is believed to reduce undue cost burdens in
resources to maintain the containers
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9. Clean Waste Recycling Containers
Therefore, a categorical waiver is permitted to
increase the size of containers used solely for
recycling clean waste or patient records
awaiting destruction, outside of a hazardous
storage area to be a maximum of 96 gallons, but
only if the organization is in compliance with
section 18/19.7.5.7.2 of the 2012 LSC
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10. Other CMS S&C Memos
The CMS S&C-12-21-LSC memo issued March 9,
2012 also allowed organizations to request
waivers for select sections of the 2012 LSC, but
at that time it required each hospital to wait
until they were cited for the 2000 LSC
deficiency, then request the waiver
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10. Other CMS S&C Memos
This has changed for the S&C 12-21-LSC memo,
as now the categorical waiver concept applies
to those conditions as well. This memo applied
only to healthcare occupancies as well.
The sections covered under the S&C 12-21-LSC
memo are:
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10. Other CMS S&C Memos
Capacity of the Means of Egress:
Certain wheeled equipment may now be permitted
to be left unattended in the exit access corridor,
provided:
• 5 feet clear width remains
• The fire safety control plan addresses the relocation of
the equipment during an emergency
• The wheeled equipment is limited to equipment in use;
medical emergency equipment not in use; patient lift
and transport equipment
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10. Other CMS S&C Memos
Capacity of the Means of Egress:
Fixed furniture is permitted in corridors that are at
least 8 feet wide, provided:
•
•
•
•
•
The furniture is secured to the wall or floor
Clear width remains 6 feet
Fixed furniture is located on one side of the corridor
Groupings do not exceed 50 sq. ft.
Groupings separated from each other by 10 feet
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10. Other CMS S&C Memos
Capacity of the Means of Egress:
Fixed furniture (cont’d):
• Furniture does not obstruct access to building features
• Corridors are protected with smoke detectors, or the
groupings allow for direct supervision
• The smoke compartment is protected with automatic
sprinklers
[18/19.2.3.4, 2012 LSC]
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10. Other CMS S&C Memos
Cooking Facilities:
Certain types of cooking appliances are permitted to
be installed open to the corridor provided:
• Meals are prepared for no more than 30 persons
• Separated with a smoke compartment barrier from
other areas of the facility
• A range hood is installed
• The range hood must be protected with a fire
suppression system
• No solid-fuel cooking allowed
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10. Other CMS S&C Memos
Cooking Facilities:
Open to the corridor (cont’d):
•
•
•
•
•
No deep-fat frying allowed
Portable fire extinguishers required
A timer switch control the cooking equipment
Smoke detectors required
Smoke compartment must be protected with automatic
sprinklers
[18/19.3.2.5.2 through 18/19.3.2.5.5, 2012 LSC]
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10. Other CMS S&C Memos
Direct-Vent Gas Fireplaces:
Direct-vent gas fireplaces are permitted in the same
smoke compartment with patient sleeping rooms,
but not in a patient sleeping room
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10. Other CMS S&C Memos
Direct-Vent Gas Fireplaces:
Requirements:
• Smoke compartment must be protected with QR
sprinklers
• Must include a sealed glass front with a wire mesh
panel or screen
• Controls must be locked or located in a restricted
location
• CO detector must be located in the same room
[18/19.5.2.3, 2012 LSC]
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10. Other CMS S&C Memos
Solid Fuel Fireplaces:
Solid-fuel fireplaces are permitted provided they are
not in the same smoke compartment as patient
sleeping rooms
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10. Other CMS S&C Memos
Solid Fuel Fireplaces:
Requirements:
• Must be separated from patient sleeping areas by a 1hour fire rated barrier
• Must be equipped with a fireplace enclosure
guaranteed against breakage up to a temperature of
650°F and constructed of heat tempered glass or other
approved materials
• CO detector must be located in the same room
[18/19.5.2.3, 2012 LSC]
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10. Other CMS S&C Memos
Combustible Decorations:
Combustible decorations are permitted on walls and
ceilings in corridors and patient rooms in healthcare
occupancies only, with certain limitations
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10. Other CMS S&C Memos
Combustible Decorations:
The decorations such as photographs, paintings, and
other art are attached directly to the walls, ceiling or
non-fire-rated doors, provided:
• Decorations do not interfere with the operation or
required latching of the door
• Decorations do not exceed 20% of the wall, ceiling or
door areas inside a smoke compartment that is not
protected with sprinklers
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10. Other CMS S&C Memos
Combustible Decorations:
• Decorations do not exceed 30% of the wall, ceiling or
door areas inside a smoke compartment that is
protected with sprinklers
• Decorations do not exceed 50% of the wall, ceiling or
door areas inside patient sleeping rooms having a
capacity not exceeding four persons in a smoke
compartment that is protected with sprinklers
[18/19.7.5.6, 2012 LSC ]
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10. Other CMS S&C Memos
Combustible Decorations:
NOTE: The percentage of decorations should be
measured against the area of any wall or ceiling; not
the aggregate total area of all the walls and ceilings.
For this situation, the door is considered part of the
wall. Decorations must be located so they do not
interfere with the operation of any door, sprinkler,
smoke detector, or other life safety feature. Hanging
art that is not attached directly to the wall or ceiling
is not included in this waiver.
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10. Other CMS S&C Memos
Relative Humidity:
Ventilation systems supplying anesthetizing
locations are permitted to operate with a minimum
RH of > 20 percent instead of > 35 percent, and not
exceed 60 percent
From S&C memo 13-25-LSC, dated April 19, 2013
[NFPA 99 (2012), 9.3.1.1]
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Reminder…
Don’t forget:
These changes are optional, and HFAP standards
will not reflect these modifications
If you want to take advantage of these categorical
waivers, you must formally declare it in writing, and
inform the survey team at the opening conference
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Download
Download your own copies of the CMS S&C
memos discussed today. Read and understand
them- you are responsible for compliance with
all of the requirements in the memos if you
elect to take advantage of them.
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Policy-and-Memos-toStates-and-Regions.html
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Understanding the New CMS Categorical
Waivers on the 2012 Life Safety Code
Questions?
Brad Keyes, CHSP
[email protected]
(815) 742-4367