Transcript Document

Life Safety and You
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Life Safety is comprised of:
Codes
Standards
Regulations
Documentation
LIFE-SAFETY-Refers to the joint consideration of
both the life and physical well-being of individuals.
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The publication Life Safety Code, known as NFPA
101, is a consensus standard widely adopted in the
United States. It is administered, trademarked,
copyrighted, and published by the National Fire
Protection Association and, like many NFPA
documents, is systematically revised on a three year
cycle.
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The Life Safety Code was originated in 1913 by the
Committee on Safety to Life.
The Committee on Safety to Life was restructured in
1963 and the first publication in 1966 was a
complete revision. The title was changed from
Building Exits Code to Code for Safety to Life from
Fire in Buildings and Structures. The final revision to
all "code language" was made and it was decided
that the Code would be revised and republished on
a three-year schedule.
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Life Safety Code and NFPA code are some of the
most critical building blocks for the protection of
your patients, visitors and staff.
You cannot compromise or take short cuts with
anyone’s life.
Your time and dedication are critical to the success
of having complete Life Safety documents and good
surveys.
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Good set of Life Safety Drawings
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Have an updated EBBI and e-SOC
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Make sure the EBBI reflects your LS drawings
Update the e-SOC on TJC website
Have good testing records
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Understand what needs to be included and what
should be taken off
Know what is expected by TJC and CMS
All Life Safety documents organized
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Be able to produce your records quickly
Business Occupancy (BO)
 Lab, pharmacy, central sterile supply, central
storeroom, receiving, kitchen, cafeteria,
administration, gift shop, etc.
 Radiology, CT scan, etc. (usually)
 Clinics, dialysis (usually)
 Most areas where there’s no anesthesia
Requires 2-hour separation from HCO
Emergency Department
 Radiology/CT scan (rarely)
 Endoscopy (sometimes)
 Outpatient Surgery
Requires 2-hour separation from HCO, 1-hour
separation from BO
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Areas with patient sleeping accommodations
for four or more patients
Areas intended to provide services
simultaneously to four or more inpatients on
gurneys (e.g., Inpatient ORs)
Standard LS.01.02.01, EP 3: The hospital has a
written interim life safety measure (ILSM)
policy that covers situations when Life Safety
Code deficiencies cannot be immediately
corrected or during periods of construction.
(Situational Decision Rules, Category “A”)
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Policy should list the 11 measures (EP 4-14)
Make sure you have the current measures-somewhat
changed
Policy should state that ILSM applies to all LSC
deficiencies, not just construction (specifically all ePFI items)
Standard LS.01.02.01, EP 3: The policy includes
criteria for evaluating when and to what extent
the hospital follows special measures to
compensate for increased life safety risk.
(Category “A”)
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Criteria must be written
Most common method is matrix showing which
measure are implemented for which deficiencies
TJC has published a matrix for this in EC News a
number of times.
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Failure to implement ILSM is one of two
deficiencies in the Environment of Care that
can lead to Contingent Accreditation under
Accreditation Decision Rules.
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Standard EC.02.03.05
The hospital maintains fire life safety
equipment and fire safety building features
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EP-1 Supervisory Devices
EP-2 Tamper Switches / Water-flow Devices
EP-3 Duct/Heat/Smoke/Pulls
EP-4 Visual/Audio Devices
EP-5 Off Premises Transmission
EP-6 Weekly Fire Pump Churn Test(changing)
EP-7 Water Tank Level Alarms
EP-8 Water Tank Cool Weather Tests
EP-9 Sprinkler Main Drain Test
EP-10Fire Department Connections
EP-11 Fire Pump Test (Full Flow)
EP-12 Stand Pipe Test (5 year)
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EP-13 Kitchen Extinguishing System
EP-14 CO2 / Other Gaseous Systems
EP-15 Extinguisher Checks – Monthly
EP-16 Portable Extinguishers – Annual
EP-17 Occupant Hoses
EP-18 Smoke/Fire Dampers
EP-19 Air Handler Shutdown
EP-20 Vertical / Horizontal Doors
And there are many more………………..
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LSC Specialist Surveyors are often not LSC
experts.
What LSC surveyor tells you on site is not final,
and may not be correct.
Don’t hesitate to (respectfully) request
clarification: “To make sure we get the
correction right, can you show us where this is
in LSC?”.
If you’re still not satisfied, challenge finding
after completion of the survey.
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Documented rounding
Having zone responsibilities
Having a game plan ready
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Show maps for rounding
Show how a specific documented route can
show surveyors what you do
Any employee will follow the same process