Transcript No Slide Title

The Life Safety Specialist Surveyor
Preparing for the Life Safety
Specialist Documentation
Review and Facility Tour
Healthcare Engineering Consultants
The Life Safety Specialist (LSS)
 It is likely that the LSS will arrive with the team on the first or second day,
less likely later in the survey
 For 2011, the LSS will usually be scheduled for an additional day based on
the scheduled time of the previous survey
 The LSS will spend several hours on dedicated documentation review, but
much more time on the facility tour
 Other responsibilities assigned to the LSS will depend on the survey team
member preferences and responsibilities – they may conduct the “EC Interview”
and Emergency Management tracers
 The other survey team members will also observe life safety issues, but not
as detailed as the LSS – it is not likely that the nurse and physician will request a
ladder and flashlight!
 If the LSS observes deficiencies outside of their defined responsibility
(example: medical records privacy or medication security), they will report it to
the other team members
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The LSS Documentation Review
Life Safety Specialist (LSS) surveyor documentation
responsibilities include at a minimum:
LS.01.01.01: SOC and Life Safety Code
LS.01.02.01: Interim life safety measures
EC.02.03.05: Fire system tests
EC.02.05.07: Emergency power systems
EC.02.05.09: Medical gas and vacuum systems
Note: In 2011, the Life Safety Specialist may be assigned
additional responsibilities during the survey
Healthcare Engineering Consultants
The LSS Documentation Review
LS.01.01.01: SOC and Life Safety Code
 The SOC completion will be verified through the
Joint Commission Connect site (BBI’s and PFI’s)
 Have the SOC notebook available for review
 The PFI documents from the previous survey
may be reviewed to verify completion of
deficiencies (have them available, if requested)
 The compartmentation drawings will be
reviewed to assist in planning the facility tour
 Life Safety Code compliance will be verified
during the facility tour
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The Statement of Conditions
How Should the Statement of
Conditions (SOC) Document
be Completed?
Healthcare Engineering Consultants
The Statement of Conditions
What is the SOC?
The Statement of Conditions (SOC) is a document that is required to
be completed by every healthcare facility that applies for accreditation
by the Joint Commission. It references the *2000 edition of the Life
Safety Code and consists of the following sections:
 Basic Building Information (BBI) Form – electronic on Connect site
 Life Safety Assessment (LSA) Form – not electronic
 Plan for Improvement (PFI) Form – electronic on Connect site
BBI’s, LSA’s and PFI’s are
*Note: Other LSC editions may be selected, but the entire edition must
be followed
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The Statement of Conditions
SOC Notebook (Best Practice)
 A SOC notebook is strongly recommended to contain “hard
copies” of the SOC documents
 The notebook should include at least the following sections:
Section 1: The SOC policy and responsibility statement
Section 2: Current copies of the downloaded BBI forms
Section 3: Accurate, color-coded compartmentation prints
Section 4: The latest, completed LSA-type document
Section 5: Current and previous, downloaded PFI forms
Section 6: Any correspondence with the Joint Commission,
including equivalencies, letters and emails
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The Statement of Conditions
Why Should I have an SOC Policy? (Best Practice)
 The SOC policy describes how the Statement of Conditions
program is organized for the facility
What Should the SOC Policy Include?
 Who is responsible for completing and maintaining the SOC
 How often the SOC documents are reviewed
 Who reviews the SOC documents for timeliness
 PFI guidelines (when does a work order become a PFI?)
 Whether a BMP is implemented
 Whether an above-the-ceiling program is in place
 How the SOC documents are organized
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Statement of Conditions Document
The current Statement
of Conditions “hard
copy” document is dated
5/2004 and can still be
downloaded from
JointCommission.org for
the LSA form (do not
use the BBI or PFI “hard
copies” – they are
obsolete)
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Statement of Conditions Document
Notes About the e-BBI Form
 List on the e-BBI cover page every occupancy that will be
surveyed, even for business occupancies (make sure that the
BBI and survey list match!)
 The e-BBI questionnaires are only required for ambulatory,
hotel/ dormitory and healthcare occupancies
 Fill in the comments section regarding SOC preparer, location
of building drawings, mixed occupancies, equivalencies, special
building features or local AHJ requirements to the BBI
 If multiple occupancies are entered, the greatest percentage
defaults to the BBI form, so multiple BBI entries are required
 Be sure to download the electronic version of the BBI form
before it is saved so that a “back-up” is available, and place a
copy in the SOC Notebook
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Statement of Conditions Document
Compartmentation Requirements
Mixed Occupancies: (LSC: 19.1.2.1)
Sections of health care facilities shall be permitted to be
classified as other occupancies, provided that they meet the
following conditions:
1) They are not intended to serve health care occupants for
purposes of housing, treatment, or customary access by
patients incapable of self-preservation
2) They are separated from the health care occupancy by a fire
rating of at least 2 hours
3) Separation between ambulatory and business occupancies
only requires a 1 hour rating (LSC: 21.1.2.1)
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Statement of Conditions Document
e-BBI Form – Buildings
Be sure to complete for all
healthcare and ambulatory
facilities
Optional for business
occupancies, but strongly
suggested for the cover
page
Healthcare Engineering Consultants
Statement of Conditions Document
e-BBI Form - Healthcare
Refer to instructions related to
“stories” in the Life Safety Code
Note instructions related to
building construction type
(occupancy)
Building age is important due to
significant code changes
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Statement of Conditions Document
e-BBI Form – page 2
1991 date significant due to
sprinkler requirement
Emergency power fuel type
important due to “wet
stacking”
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Statement of Conditions Document
e-BBI Form – page 3
“Previous inspections” data
provides valuable information to the
survey team!
Be sure to list local or regional
requirements (example: limited
generator testing due to high
pollution days) in the “Comments”
section at the bottom of the form as
well as other requested information
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Statement of Conditions Document
LSA Form (is not electronic):
 Is a voluntary assessment tool,
although some assessment is required
at least annually
 Is not required for “Business
Occupancies”
 The Joint Commission surveyor
normally expects some type of form,
document or evaluation to be completed
 Dated 5/2004, so a cover sheet that is
signed annually is recommended
 Can still be downloaded from the Joint
Commission home page website
(search “Statement of Conditions”)
 Can use PPR form or similar for the
LSA document
 Comments in LSA must match PFI
deficiencies
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Statement of Conditions Document
Life Safety Building Compartmentation Drawings
Blue – smoke barrier
Green – 1 hour fire
wall (hazardous area)
Red – 2 hour fire wall
Note: Color-coded
drawing is “best
practice”
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Statement of Conditions Document
Notes About the PFI Forms
 The forms should not be used for “operational deficiencies”,
such as exit lights burned out, doors out of minor adjustment or
small penetrations that can be easily filled – these should be
completed using the routine work order system
 The normal “trigger time” from a work order to PFI is 45 days
 Document the “PFI’s” on a continuing basis – be sure that the
PFI log is up-to-date and ready to be reviewed by the surveyor
 Don’t forget to enter the projected start and completion dates
and the actual completion date
 Failure to meet the completion dates without a delay approval
results in Conditional Accreditation 6 months after the
projected completion date has passed!
 If applicable, keep any previously signed PFI copies available
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Statement of Conditions Document
The first page for the electronic
PFI forms is used to list the
deficiencies
Notice that a “No Deficiencies”
option is available
(and should be completed, if
applicable)
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Statement of Conditions Document
The second page for the
electronic PFI forms is used to
indicate the deficiency resolutions
Don’t forget to complete all of the
requested information, including
the proposed action, source of
funds and the projected start and
completion dates
The projected completion dates
can be altered until they are
“frozen” before or during the
actual survey!
Comments for each PFI should
include a note regarding the
implementation of ILSM’s!
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Statement of Conditions Document
The listing document simply
provides a summary of all of the
deficiencies that have been
recorded on the PFI form for
tracking purposes – keep a copy
of this in the SOC notebook for
reference purposes
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The Life Safety Specialist
Documentation Review
Should I Implement and
Document a Building Maintenance
Program (BMP)?
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The Building Maintenance Program (BMP)
 Is voluntary; no scoring benefit in 2011
 No longer requires a measure of effectiveness
 Measurement system can use random samples
 Results should be used to determine revisions to
inspection or test frequencies
 Information should be provided to the hospital
safety committee if changes are made to the
program
 Is basically a PM program for the buildings
 Is still considered a Best Practice
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Fire System Tests
Fire System Component Test Schedule
Standard Element of Performance
Points to Remember
Clearly define supervisory devices
(fire pump, low air pressure on dry
or pre-action systems and water
tank level indicators expected)

 Tamper and flow device test
intervals increase to quarterly on
7/1/11
 Inventory all doors on magnetic
releasing devices and document test
results
 Document tests results for each
individual heat and smoke detector,
pull box and audible and visual
device
EC.
02.03.05
1
Scoring
Category
Test
Interval
NFPA
Reference
Fire Component Tests
Supervisory switches
C
Q
NFPA 72
2
Tamper switches, flow devices
C
S/A
NFPA 72
3
Duct detectors, door releasing
devices
Smoke and heat detectors, pull
boxes
Audible and visual alarms
C
A
NFPA 72
C
A
NFPA 72
C
A
NFPA 72
A
Q
NFPA 72
6
Off-premises transmission
equipment
Fire pump churn test
C
W
NFPA 25
7
Water tank level alarms
C
S/A
NFPA 25
8
C
M
NFPA 25
C
A
NFPA 25
10
Water tank level alarms (cold
weather only)
Main drain tests on system
risers
Fire department connections
A
Q
NFPA 25
3
4
5
9
11
Fire pumps (flow test)
A
A
NFPA 25
12
Standpipe test
C
5 yr
NFPA 25
13
Kitchen extinguishing systems
A
S/A
NFPA 96
14
A
A
NFPA 2001
C
M
NFPA 10
C
A
NFPA 10
17
Carbon dioxide/ gaseous
extinguishing systems
Portable fire extinguishers
(visual check)
Portable fire extinguishers
(preventive maintenance)
Occupant hoses
C
NFPA 25, 1962
18
Smoke/ fire dampers
C
3 yr–hydro
5 yr–new
6 years
19
HVAC smoke detectors w/
shutdown
Horizontal/ vertical fire doors
A
A
NFPA 90A
C
A
NFPA 80
15
16
20
Healthcare Engineering Consultants
NFPA 80, 105
Fire System Tests
Fire System Component Test Schedule
Standard Element of Performance
Points to Remember
Document receipt time of fire alarm
signal to local fire department or
receiving station
EC.
02.03.05
1
NFPA
Reference
Supervisory switches
C
Q
NFPA 72
2
Tamper switches, flow devices
C
S/A
NFPA 72
3
Duct detectors, door releasing
devices
Smoke and heat detectors, pull
boxes
Audible and visual alarms
C
A
NFPA 72
C
A
NFPA 72
C
A
NFPA 72
A
Q
NFPA 72
6
Off-premises transmission
equipment
Fire pump churn test
C
W
NFPA 25
7
Water tank level alarms
C
S/A
NFPA 25
8
C
M
NFPA 25
C
A
NFPA 25
A
Q
NFPA 25
3
4
 Document static and residual
pressure readings for main drain
tests and time back to static
pressure (best practice)
 Visually inspect fire department
connections quarterly
10
Water tank level alarms (cold
weather only)
Main drain tests on system
risers
Fire department connections
 Indicate the day and month of
portable fire extinguisher checks
Test
Interval
Fire Component Tests
5
 The 5-year standpipe test was
added to the requirements in 2009
Scoring
Category
9
11
Fire pumps (flow test)
A
A
NFPA 25
12
Standpipe test
C
5 yr
NFPA 25
13
Kitchen extinguishing systems
A
S/A
NFPA 96
14
A
A
NFPA 2001
C
M
NFPA 10
C
A
NFPA 10
17
Carbon dioxide/ gaseous
extinguishing systems
Portable fire extinguishers
(visual check)
Portable fire extinguishers
(preventive maintenance)
Occupant hoses
C
NFPA 25, 1962
18
Smoke/ fire dampers
C
3 yr–hydro
5 yr–new
6 years
19
HVAC smoke detectors w/
shutdown
Horizontal/ vertical fire doors
A
A
NFPA 90A
C
A
NFPA 80
15
16
20
Healthcare Engineering Consultants
NFPA 80, 105
Fire System Tests
Points to Remember
Don’t forget to implement and
document “Interim Fire System
Measures” (IFSM), when required
Fire System Component Test Schedule
Standard Element of Performance
EC.
02.03.05
1
Scoring
Category
Test
Interval
NFPA
Reference
Fire Component Tests
Supervisory switches
C
Q
NFPA 72
2
Tamper switches, flow devices
C
S/A
NFPA 72
3
Duct detectors, door releasing
devices
Smoke and heat detectors, pull
boxes
Audible and visual alarms
C
A
NFPA 72
C
A
NFPA 72
C
A
NFPA 72
A
Q
NFPA 72
C
W
NFPA 25
 If the occupant hoses have been
removed, keep a copy of the
approval letter from the AHJ
3
6
Off-premises transmission
equipment
Fire pump churn test
 Place inaccessible smoke and fire
dampers on the PFI for a 6-year,
renewable period (for tracking
purposes only)
7
Water tank level alarms
C
S/A
NFPA 25
8
C
M
NFPA 25
C
A
NFPA 25
10
Water tank level alarms (cold
weather only)
Main drain tests on system
risers
Fire department connections
A
Q
NFPA 25
 Document that duct detectors trip
the air-handling units
4
5
9
11
Fire pumps (flow test)
A
A
NFPA 25
12
Standpipe test
C
5 yr
NFPA 25
13
Kitchen extinguishing systems
A
S/A
NFPA 96
14
A
A
NFPA 2001
C
M
NFPA 10
C
A
NFPA 10
17
Carbon dioxide/ gaseous
extinguishing systems
Portable fire extinguishers
(visual check)
Portable fire extinguishers
(preventive maintenance)
Occupant hoses
C
NFPA 25, 1962
18
Smoke/ fire dampers
C
3 yr–hydro
5 yr–new
6 years
19
HVAC smoke detectors w/
shutdown
Horizontal/ vertical fire doors
A
A
NFPA 90A
C
A
NFPA 80
15
 Only applies to vertical and
horizontal smoke and fire doors,
not security doors or curtains
16
20
Healthcare Engineering Consultants
NFPA 80, 105
Fire System Test Monitoring
Best Practice for Monitoring Compliance
Regulatory Compliance Dashboard for Fire System Tests
Description
JAN
Supervisory
Devices
Tamper
Switches
Water Flow
Devices
Duct Detectors
1/15
X
X
X
1/15
X
X
X
1/15
X
X
X
Door Releasing
Devices
Smoke
Detectors
Pull Boxes
FEB
MAR
APR
AUG
SEP
OCT
NOV
DEC
W
W
W
X
X
X
X
X
X
X
1/18
X
Visual Alarms
X
Kitchen
Systems
JUL
X
X
Fire Pump Flow
Test
Water Tank
Level Alarms
Main Drain
Riser Test
Fire Dept.
Connections
Standpipe Test
JUN
1/22
Audible Alarms
Signal Time to
FD
Fire Pump
Churn Test
MAY
1/6
4, 11
25
X
W
W
W
X
W
W
W
X
W
W
X
N/A
X
X
X
X
1/12
X
X
5 yr
X
X
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Comments
Fire System Test Monitoring
Regulatory Compliance Dashboard for Fire System Tests (continued)
Description
CO2/ Gaseous
Systems
Portable
Extinguishers
Portable
Extinguishers
Occupant
Hoses
JAN
APR
MAY JUN JUL AUG SEP OCT
NOV
DEC
X
X
Comments
X
1/23
X
X
X
X
X
X
X
X
X
X
X
3 yr
Smoke/ Fire
Dampers
HVAC
Shutdown
Horiz/ Vertical
Fire Doors
FEB MAR
X
6 yr
1/25
X
X
Key to dashboard symbols:
X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required
A/R – Indicates that action is required when applicable
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Healthcare Engineering Consultants
The LSS Documentation Review
EC.02.05.07: Emergency Generators
 Perform and document weekly generator visual checks (NFPA 110)
 Perform and document monthly generator tests between 20 and 40
days and with at least 30% of the rated load for 30 minutes
 Document that all automatic transfer switches are exercised monthly
 Conduct annual load bank tests if the 30% load is not achieved and
manifold temperatures are not sufficient (possible change from the 2 hour
to a 1.5 hour test in 2011 – not yet approved)
 Combining the annual and trienniel tests can be performed by starting
the load at 30% of nameplate for the first 30 minutes of the test
 Document the static or dynamic 4-hour trienniel test for all generators
 Test fuel oil quality annually, unless fuel is consumed from the entire
tank (NFPA 110)
 Utilize “Interim Emergency Power Measures” (IEPM) when necessary
Note: Refer to NFPA 99 and 110 for more information
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The LSS Documentation Review
EC.02.05.07: Emergency Battery Lights
 Required in all anesthetizing locations (NFPA 70: 517.63 ) Task Light!
“administration of nonflammable inhalation anesthetic agents
in the course of examination or treatment”
Note: Grandfathering usually permitted in existing OR’s
 Required in “Level 1 or Level 2 EPS equipment locations”
(NFPA 110: 7.3.1) Task Light!
 Required in business occupancies for egress lighting where emergency
power is not required or not available (NFPA 101: 7.9.1.1) Egress Light!
 Monthly push-to-test required for all battery installations
 Differentiate between “task lighting” and “egress” lighting
 Annual battery replacement in lieu of 90-minute discharge test
Note: 10% of lights must be tested for 90 minutes annually, even if the
batteries are changed.
Healthcare Engineering Consultants
The LSS Documentation Review
EC.02.05.07: Stored Emergency Power Supply
Systems (SEPSS)
 Standard applies to Level 1 systems (NFPA 111: 4.5.1)
Level 1: “failure of the equipment to perform could result in
loss of human life or serious injuries”
 Testing requires:
1. Quarterly functional test (5 minutes or class specification)
2. Annual full-load test for 60% of SEPSS class duration
Note 1: NFPA 111 requires a monthly inspection, quarterly functional test
and annual full load test for full class duration for Level 1 systems
Note 2: The Joint Commission references exit lighting, life support
ventilation, fire detection and alarm systems, and public communications
systems as Level 1 systems, but most are not SEPPS systems
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The LSS Documentation Review
EC.02.05.09: Medical Gas and Vacuum Systems

Medical gas and vacuum system preventive maintenance
program is required (facility must define PM) and must include:
- Bulk medical gas and vacuum system components and source valve
- Master signal panels and area alarms
- Automatic pressure switches and shutoff valves
- Flexible connectors and outlets
 Testing per NFPA 99 is required for new installation,
modification or repair (cross-connections, purity, pressure)
 Main supply valves and area shut-off valves must be
accessible and clearly labeled
 Utilize “Interim Medical Gas Measures” (IMGM) when necessary
Note: Significant changes to NFPA 99 are likely to occur when the next vote
occurs at the NFPA Annual Meeting
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The LSS Documentation Review
EC.02.05.09: Medical Gas and Vacuum Systems
 Certification of installers and verifiers per ASSE 6000 series is
required
 Medical air quality must meet NFPA 99 requirements below:
Parameter
Limit Value
Pressure dew point
39 degrees F
Carbon monoxide
10 ppm
Carbon dioxide
500 ppm
Gaseous hydrocarbons
25 ppm (as methane)
Halogenated hydrocarbons
2 ppm
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The LSS Documentation Review
Medical Gas and Vacuum System PM Recommendations
Component Description
Note: The recommendations
provided in the chart to the
right are from NFPA 99, the
2005 edition, Appendix C,
section 5.2. Tests that are
required due to new system
installations, renovations or
repair are listed in chapter 5
of NFPA 99
Recommended Test Frequency
Gas cylinder manifold pressure
Daily
Gas cylinder manifold changeover signal
Daily
Liquid cylinder manifold pressure
Daily
Liquid cylinder manifold changeover signal
Daily
Liquid cylinder reserve/ in-use signal
Annually
Bulk liquid system contents gauge
Daily
Bulk system pressure gauges
“Regularly” (weekly)
Bulk system master signal
“Periodically” (monthly)
Main line vacuum system gauge
Daily
Medical air intake location
Quarterly
Medical air pressure gauge
Annually
Medical air high level water sensor
Annually
Medical air receiver drain
Daily
Medical compressed air alarms
Annually
Medical air compressors/ vacuum pumps
Per manufacturer specifications
Dew point sensor/ CO monitor
Annually
Warning system components
Annually
Audible/ visual alarms
Monthly
Shut-off valve leak test
“Periodically” (annually)
Outlet leakage and flow
“Periodically” (annually)
Medical air purity
As determined by facility
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The LSS Documentation Review
Interim Utility System Measures (IFSM, IEPM, IMGM)
Interim Utility System Measures
Best Practice!
Project Number: _________________
Affected System: Fire System: _____
Date: ____________________
Emergency Power _____
Medical Gas: _____
Description of Project: ______________________________________________________
Strongly recommended to
document that interim
measures have been
implemented to compensate
for utility systems that are
taken out of service
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Interim Measures Required:
_____ Affected staff notified
Comments: ______________________________________
_____ Additional Equipment Required Specify: _________________________________
_____ Back-up Procedures in Place Specify: ___________________________________
_____ Emergency Procedures Reviewed Comments: ____________________________
_____ Other: ______________________________________________________________
_____ Other: ______________________________________________________________
_____ Other: ______________________________________________________________
Additional Comments: ______________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Date Project Completed: ___________________ Reviewed By: ____________________
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The LSS Facility Tour
Typical Tour Sequence
1. Start on the roof, penthouse, mechanical equipment rooms
2. Take the “most traveled stairwell” from the top to the bottom
3. Take the elevator back up to the top patient floor
4. Check smoke/ fire doors and compartmentation features
5. Inspect chutes, storage areas, utility chases, hazardous areas
6. Continue down to the lower and basement levels to specific
areas, such as the kitchen, loading dock, fire pump, emergency
generators, fire annunciator panel, compressed gas and
infectious waste storage
7. Complete checklist, or until problems are found!
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The LSS Facility Tour
Checklist for the Facility Building Tour
 Smoke and fire doors
Check: Closure, label rating, gaps, undercuts, warpage, kick plate
 Smoke and fire compartments
Check: Penetrations, proper sealant
 Roof and penthouse
Check: Contractor supplies, smoking, exhaust fans labeled
 Exit stairwells
Check: Door rating, closure, signage, exit discharge
 Linen/ trash chutes and receiving rooms
Check: Door rating, closure, fusible link, chute blockage
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The LSS Facility Tour
Checklist for the Hospital Building Tour (cont’d)
 Hazardous areas
Check: Storage of flammables, room rating, door closer
 Fire pump
Check: Controls turned “on”, valves open, tampers OK
 Fire annunciator panel
Check: Bypass, trouble, ground fault or supervisory
 Soiled linen rooms
Check: Proper storage, dirty separated from “clean”
Healthcare Engineering Consultants
The LSS Facility Tour
Checklist for the Hospital Building Tour (cont’d)
 Medical waste storage
Check: Locked area, secure, sharps not accessible
 Loading dock
Check: Smoking, improper storage, powered equipment
 Kitchen area
Check: Cleanliness, storage, CO2 tanks, refrigerator temps,
K-type portable extinguishers within 30’ of fat fryer
 PFI verification
Check: Previous PFI’s have been resolved as listed
Healthcare Engineering Consultants
The LSS Facility Tour
Checklist for the Hospital Building Tour (cont’d)
 ILSM verification
Check: Construction areas for ILSM implementation
 Mechanical equipment rooms
Check: Storage, unlabeled containers, cigarettes, labeling
 Emergency generators
Check: In “auto” mode, batteries/ charger, fuel leaks
 Medical gas systems
Check: Manifolds, medical air and vacuum pumps
Healthcare Engineering Consultants
The LSS Facility Tour
Checklist for the Hospital Building Tour (cont’d)
 Compressed gas storage rooms
Check: Full and Empty separation, chained or on racks
 Egress corridors
Check: Equipment “not in use”, containers > 32 gallons
 Eyewashes, showers and portable fire extinguishers
Check: Test dates on log or tag
 Chapel
Check: Candles, open flames
 Other?
Healthcare Engineering Consultants
The LSS Facility Tour
Multiple “Operational”
Deficiencies are Likely to
be Found During the
Facility Tour
Healthcare Engineering Consultants
Operational Deficiencies
Operating Features

A clear space >18 inches below sprinkler heads to the top of
storage must be maintained
Exception: Perimeter wall shelving, unless below the
sprinkler (refer to NFPA 13)

Portable space heating devices are only permitted in nonsleeping staff and employee areas, with heating elements that
do not exceed 212 degrees F (LSC, 2009 edition, 19.7.8)

Combustible decorations are prohibited, unless flame
retardant (19.7.5.4)

Soiled linen or trash collection receptacles shall not exceed
32 gallons in capacity (19.7.5.5)
Exception: Attended or in hazardous area
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Operational Deficiencies
Operating Features
 Holiday decoration policy and implementation
 Candles used in the chapel
 Furnishings, decorations or other objects may not
obstruct access, egress or block the visibility of
exits (7.1.10.2.1)
 Exit doors must be free of mirrors, draperies or
hangings that may conceal, obscure or confuse the
direction of exit (7.5.2.2), and;
 Hallway Clutter!
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The Life Safety Specialist Surveyor
Questions?
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