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1 1 Copyright Information Copyright 2013 HCPro, Inc. The Adopting the 2012 Life Safety Code : Prepare for Fire Safety Equipment Testing and Inspection Changes materials package is published by HCPro, Inc. For more information, please contact us at: 75 Sylvan Street, Suite A-101, Danvers, MA Attendance at the webcast is restricted to employees, consultants, and members of the medical staff of the Licensee. The webcast materials are intended solely for use in conjunction with the associated HCPro webcast. The Licensee may make copies of these materials for internal use by attendees of the webcast only. All such copies must bear the following legend: Dissemination of any information in these materials or the webcast to any party other than the Licensee or its employees is strictly prohibited. In our materials, we strive to provide our audience with useful and timely information. The live webcast will follow the enclosed agenda. Occasionally, our speakers will refer to the enclosed materials. We have noticed that non-hcpro webcast materials often follow the speakers presentations bullet-by-bullet and page-bypage. However, because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker s entire presentation. The enclosed materials contain helpful resources, forms, crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future. Although every precaution has been taken in the preparation of these materials, the publisher and speaker assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro, Inc. is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks; the Accreditation Council for Graduate Medical Education, which owns the ACGME trademark; or the Accreditation Association for Ambulatory Health Care (AAAHC). 2

2 If you are not hearing music or you are experiencing any technical difficulties, please contact our help desk at 888/ We will begin shortly! 3 4

3 Presented by: Brad Keyes, CHSP Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs. Keyes analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization s preparedness for survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 5 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, effective March 11, 2003 which took 3-years! 6

4 The New 2012 Life Safety Code CMS is required by law, to follow the federal rule-making procedure when they want to update to a newer edition of the Life Safety Code It requires CMS to conduct a due-diligence investigation, identifying the costs involved in making the change 7 The New 2012 Life Safety Code It also requires them to publish a notice of a proposed rule outlining their intent to adopt the 2012 edition, and allow 60 days for the public to respond CMS then is required to respond to all of the comments made by the public and make appropriate changes in their proposed rule 8

5 The New 2012 Life Safety Code Look for CMS to publish a proposed rule on adopting the 2012 edition of the LSC later this fall. The public will have 60 days to make comments on the proposed rule It will take up to 12 months for CMS to review all of the public comments before they issue their final rule 9 The New 2012 Life Safety Code Then CMS will publish their final rule on adopting the 2012 edition of the LSC in the Federal Register and it will become effective within 60 days after that Look for the 2012 edition of the LSC to be adopted and become effective in late 2014 or early

6 The New 2012 Life Safety Code The myth surrounding this rule-making procedure is that Congress must vote on the change to adopt the 2012 edition of the LSC That is not true! Congress has 60 days to review and comment on the final rule once it is published in the Federal Register But they do not vote on it 11 The New 2012 Life Safety Code It is no wonder it takes 3 years to move to a newer edition of the Life Safety Code CMS is held to this rule-making process and they do not have the authority to adopt a newer edition of the Life Safety Code without following the process 12

7 The New 2012 Life Safety Code This rule-making process is required by all Federal Government agencies, and is a result of the Administrative Procedure Act of 1946 The APA is designed to prevent a dictatorial agency of the government making changes in their rules without the public knowledge and opportunity to comment 13 The New 2012 Life Safety Code While this is a cumbersome and slow process to adopting a newer edition of the codes, the process is designed to protect the interests of the public It may not be a perfect system but what part of government is? 14

8 The New 2012 Life Safety Code All accreditation organizations must enforce the edition of the LSC that CMS has adopted, unless the hospital or nursing home does not seek Medicare & Medicaid reimbursement There are four (4) hospital accreditation programs who have received deeming authority from CMS: Healthcare Facilities Accreditation Program (HFAP- 1945) Det Norske Veritas Healthcare, Inc. (DNV- 2008) The Joint Commission (TJC- 2009) Center for Improvement in Healthcare Quality (CIHQ- 2013) 15 The New 2012 Life Safety Code All hospital accreditation organizations are required to survey for compliance with the 2000 edition, and cannot move to the more recent edition until CMS adopts it There are many advantages (and some disadvantages) to the facility manager of adopting the 2012 edition of the LSC 16

9 The New 2012 Life Safety Code There are significant changes in store for hospitals and nursing homes when the 2012 edition is finally adopted In a previous webinar, we covered the changes involving the new 2012 Life Safety Code itself 17 The New 2012 Life Safety Code Today we will cover some of the more significant changes involving testing and inspection of fire safety features Most of these testing and inspection requirements are found in standards referenced by the LSC, such as NFPA 10, NFPA 17A, NFPA 25, NFPA 72, NFPA 80, NFPA 96, NFPA 110, NFPA 241 [Code references are to the 2012 edition of the Life Safety Code otherwise stated] 18

10 Polling Question At this time, how prepared is your organization for the new 2012 edition of the Life Safety Code? A) 100% All ready and prepared B) 75% Ready C) 50% Some-what ready D) 25% Not very ready E) 0% Haven t even begun to think about it We will review the results of this polling question later in the program 19 Fire Door Testing and Inspection Sections and require all fire doors to be inspected and tested (per NFPA 80) The new NFPA 80 requires the individual conducting the inspection to have knowledge and understanding of the operating components of the door being inspected 20

11 Fire Door Testing and Inspection So, what qualifies the individual to have knowledge or understanding? NFPA 80 does not specify, so that means you get to decide who is qualified 21 Fire Door Testing and Inspection Unless they develop their own criteria, the authorities having jurisdiction (AHJs) will want to see how you determined that the designated individual is knowledgeable and understanding on door operations 22

12 Fire Door Testing and Inspection So, make sure you have some sort of evaluation documented that objectively addresses the qualifications of the individual It may be based on: Experience Training Education 23 Fire Door Testing and Inspection Some of the requirements for each fire door inspection and testing: Must be conducted annually with written records that are dated and signed Visually inspect doors for any damage or missing parts Operate the door fully to ensure door will close and function properly Inspect door hardware and replace all defective items Tin-clad doors must be inspected for dry rot of the wood core 24

13 Fire Door Testing and Inspection Additional requirements for each fire door inspection and testing: No holes or breaks exist in the surfaces of the door or frame Glazing and glazing beads are intact and secure Clearance between the bottom of the door and the threshold cannot exceed ¾ inch, unless the bottom of the door is mounted more than 38 inches above the floor, then the clearance is limited to 3/8 inch Check to make sure the coordinator is operating correctly 25 Fire Door Testing and Inspection Additional requirements for each fire door inspection and testing: Make sure positive latching hardware secures the door in the closed position Confirm that no field modifications have been made to the door or frame that would void the fire rating Check door and rating label to ensure it is legible, and it is the proper rating for the barrier 26

14 Fire Door Testing and Inspection A sample Fire Door Inspection form is included in your package Annual Inspection of Swinging Fire Door Assemblies Name of Property: Fire Door Assembly Location: Special Locking Arrangement?: Number of Leafs: Fire Rating of Each Leaf: Fire Rating of Frame: Rating of Barrier: Purpose of Rated Barrier: Automatic or Manual Operator?: Hold-open Device?: Inspected By: Date: Inspection Activity: Yes No N/A Comments 1. Is the door and frame free from holes and breaks in all surfaces? 2. Are all the glazing, vision light frames and glazing beads intact and securely fastened? 3. Are the doors, hinges, frame, hardware and threshold secure, aligned and in working order with no visible signs of damage? 4. Are there any missing or broken parts? 5. Is the clearance from the door edge to the frame no more than 1/8 inch? 6. Is the door undercut no more than ¾ inch? 7. Does the active door leaf completely closes when operated from the full open position? 8. Does the inactive leaf close before the active leaf when a coordinator is used? 9. Does the latching hardware operate and secure the door in the closed position? 10. Is the door assembly free from are auxiliary hardware items which could interfere with its operation? 11. Has the door been modified since it was originally installed? 12. If gasketing and edge seals are installed, have they been verified for integrity and operation? All No answers must be fully explained. Source: NFPA 80, 2010 edition Supervisor s Initial: Date: Work Order #: 27 Fire Extinguishers Fire extinguishers are often over-looked in a healthcare setting until they are needed Items can not be left unattended in front of fire extinguisher cabinets, obstructing access to them 28

15 Fire Extinguishers The new NFPA 10 will permit electronic monitoring of portable fire extinguishers, provided the system monitors these points: Extinguisher is located in its proper place Access to and visibility of extinguisher is not obstructed Pressure gauge reading is in the proper range Fullness determined by weighing Electronic monitoring eliminates monthly inspections. 29 Fire Extinguishers This is achieved by sensors in the cabinet which detects objects left unattended for more than a specified amount of time The sensor then sends a signal to the monitoring system which alerts someone to act on it The advantage to facility managers is electronic monitoring eliminates monthly inspections which means less labor cost. 30

16 Fire Extinguishers Other new requirements found in NFPA 10, include: All extinguishers must be mounted on a bracket or placed in a cabinet Where extinguishers are subject to physical damage, they must be installed with the manufacturer s strap-type bracket Extinguisher must be mounted so the operating instructions are located on the front Non-rechargeable extinguishers must be removed from service no, more than 12 years after date of manufacture 31 Fire Extinguishers Other new requirements found in NFPA 10, include: Halon type extinguishers must be limited to applications where clean agent is necessary Persons performing the annual maintenance and recharging must be certified by one of the following: Factory trained and certified Certified by an organization acceptable to the AHJ Licensed or certified by a local or state AHJ Electronic monitoring is permitted in lieu of physical monthly inspections 32

17 Fire Extinguishers Other new requirements found in NFPA 10, include: Discharge hoses on wheeled units must be coiled in such a manner to prevent kinks and allow rapid deployment Hose on wheeled type extinguishers must be completely un-coiled and examined for damage during the annual maintenance procedure 33 Fire Extinguishers Other new requirements found in NFPA 10, include: Monthly inspection procedures have changed for non-wheeled extinguishers in healthcare facilities to only require: Extinguisher is located in its designated place Access to and visibility of extinguisher is not obstructed Pressure gauge reading is in its proper place Fullness determined by weighing or hefting 34

18 Fire Extinguishers Other new requirements found in NFPA 10, include: No longer required for the monthly inspection: Confirming that the operating instructions are facing out Ensuring that the safety seals and tamper indicators are not broken or missing Examination for obvious physical damage, corrosion, leakage or clogged nozzles 35 Kitchen Hood Fire Extinguishing System Changes with NFPA 96 include: All abandoned pipe and conduits from a previous installation must be removed and holes sealed Addition of baffles plates, shelves, or any modification which obstructs the spray pattern of the nozzles are not permitted A Class K extinguisher is now required in the kitchen, within 30 feet of grease producing appliances 36

19 Kitchen Hood Fire Extinguishing System Changes with NFPA 17A include: During the owner s monthly inspection of the system, the pressure gauge of the container may be electronically monitored rather than physically monitored Service technicians must be certified Fire extinguishing systems need to be tagged noncompliant when an impairment is discovered All records must be retained for 1 year All fusible links must be replaced semiannually 37 Sprinkler System Significant changes are in store for testing and inspection of the water-based fire protection system according to the new NFPA 25 Administrative responsibilities now include: All deficiencies discovered during testing and inspection must be repaired by qualified individuals The location of shutoff valves must be identified 38

20 Sprinkler System Since NFPA 25 does not specify, you get to decide how to document the location of the sprinkler valves Can be done by marking the ceiling grid Can be done by posting signs on walls below the ceiling where the valve is located Can be done by marking their location on AutoCAD drawings and post a completed line drawing showing pipe and valve locations in your maintenance department 39 Sprinkler System And an informational sign needs to be installed on all control risers to an anti-freeze loop; dry system; pre-action system; or auxiliary control valves. Each sign must indicate: Location of area served by system Location of auxiliary drains and low-point drains for dry and pre-action systems The presence or location of anti-freeze systems The presence or location of heat tape 40

21 Sprinkler System Actual changes in the testing and inspection procedures, include: Vane and pressure type waterflow switches are permitted to be tested semi-annually (Used to be quarterly) One additional main drain test must be conducted each quarter downstream of the backflow preventer Dry sprinklers in service for 10 or more years must be replaced or a sample taken for testing 41 Sprinkler System Standpipe hose valves (not FDC) are required to be inspected quarterly for the following: Ensure hose caps are in place and not damaged Inspect hose threads for damage Ensure valve handle is present and not damaged Inspect gaskets for damage and deterioration Ensure hose valve is not leaking Ensure access to hose valve is not obstructed 42

22 Sprinkler System Standpipe systems with 2½ inch hose valves must have their valves tested annually by opening and closing the valve Standpipe systems with 1½ inch hose valves must have their valves tested every 3-years by opening and closing the valve Standpipe waterflow tests every 5 years are now only for wet standpipes. Dry standpipes are required to have hydrostatic test every 5 years 43 Fire Hose Valve Testing and Inspection A sample Fire Hose Valve Test & Inspection form is included in your package 44

23 Sprinkler System Electric motor driven fire pumps are to be tested monthly at no-flow conditions, while engine driven fire pumps are still required to be tested weekly at no-flow conditions 45 Fire Alarm Test Reports One of the most often cited findings in hospital surveys involves the fire alarm test report Not everything that was required to be tested was actually being tested, and until recently, surveyors and inspectors were not always asking to see documentation that everything was properly tested That has now changed, and AHJs are now holding organizations accountable for all testing requirements 46

24 Fire Alarm Test Reports The required information on the fire alarm test report has changed. NFPA 72 has a new name: National Fire Alarm and Signaling Code. This is to reflect the emphasis on the emergency communication system during an emergency. Changes on the test report include: A description of the property being tested The occupancy type classification of the property Name, address and contact information of the property representative Qualifications of the testing technician 47 Fire Alarm Test Reports Confirmation that there is a contract for testing and inspection of the fire alarm system Identification of the type of system or service that the alarm system provides Identification of the type of Mass Notification System used Identification of the Uninterruptible Power System (UPS) used Identification if the building is equipped with an In- Building Fire Emergency Voice Alarm Communication System Identification if building is provided with Notification Appliance Circuit (NAC) extender panels 48

25 Fire Alarm Test Reports Documentation that notification of key stakeholders was made prior to the beginning of the service Test results of devices tested (Visual Inspection / Functional Test) A separate Device Test Results sheet, identifying the following for every device tested: Device type System address Location Test results (Pass / Fail) 49 Fire Alarm Test Reports Make sure you review these changes with your fire alarm testing contractor Because the LSC surveyors will be asking to review them as soon as the 2012 edition of the Life Safety Code is finally adopted NFPA 72 has sample forms that your contractor can use The new test form is 11 pages long The current NFPA 72 test form is 4 pages long 50

26 Generator Testing NFPA 99 and NFPA 110 are the standards healthcare organizations must follow for the proper testing and inspection of the emergency power generators Changes with NFPA 110 include: The percentages listed are now considered not-less-than rather than absolute After each maintenance or repair service on the generator, an operational test must be initiated at an ATS and each ATS connected to the generator must be switched for a minimum of 30 minutes 51 Generator Testing Changes with NFPA 110 include: Paralleling gear must be subject to a testing, inspection and maintenance program that includes: Checking all electrical connections Inspection or testing for evidence of overheating and excessive contact erosion Removal of dust and dirt Replacement of contacts when required 52

27 Generator Testing Changes with NFPA 110 include: The testing, inspection and maintenance frequency for the paralleling gear is not specified in NFPA 110, but at the minimum should follow manufacturer s recommendation 53 Generator Testing Changes with NFPA 110 include: Automatic Transfer Switches (ATS) must be subject to an inspection and maintenance program that includes: Checking all electrical connections Inspection or testing for evidence of overheating and excessive contact erosion Removal of dust and dirt Replacement of contacts when required 54

28 Generator Testing Changes with NFPA 110 include: The inspection and maintenance frequency for the ATS is not specified in standard section of NFPA 110, but the Annex section recommends annual maintenance and quarterly inspections 55 Generator Testing Changes with NFPA 110 include: Battery inspections are now permitted weekly rather than at intervals of no more than 7 days Must include recording the voltage Maintenance of lead-acid batteries must include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing is permitted in lieu of the testing of specific gravity when warranted 56

29 Generator Testing Changes with NFPA 110 include: Quarterly load tests on batteries are recommended in the Annex section of NFPA 110 Load tests for nameplate capacity are calculated in kw, not amps [Use kw = 3 X PF X Amps X Volts / 1000 for conversion] An annual fuel quality test must be performed in accordance with ASTM standards 57 Generator Testing Changes with NFPA 110 include: Diesel powered generators that do not meet the requirements of the monthly load test, must continue to be tested monthly and be exercised annually with supplemental loads at not less than 50 percent of the nameplate capacity (in kw) for 30 minutes, and not less than 75 percent of the nameplate capacity (in kw) for 60 minutes, for a total duration of 90 continuous minutes (used to be 2-hours) 58

30 Generator Testing Changes with NFPA 110 include: Spark ignition generators must be exercised at least once a month with the available emergency load for 30 minutes or until the water temperature and oil pressure have stabilized Generator test must be initiated by simulating a power outage using the test switches on the ATS or by opening a normal breaker (not required) 59 Generator Testing Changes with NFPA 110 include: Generators must be tested once every 36 months with a load of not less than 30 percent of the nameplate rating (in kw) for 4 continuous hours Test must be initiated by operating one ATS switch, then operate the remaining ATS test switches Supplemental load is permitted to be used in order to reach the 30 percent level [While some Accreditation Organizations already require the 3-year 4-hour load test, it is not required by CMS until the 2012 LSC is adopted] 60

31 Generator Testing Changes with NFPA 110 include: Inspection, testing and maintenance records are required to be maintained for the life of the building Electronic records are permitted The monthly load test now requires the generator to be warmed up to normal operating temperatures before the load test begins Minimum temperature of the room containing the generator (including outside gen-sets) is now 40 F 61 Results of the Polling Question Let s look at the results of the polling question: At this time, how prepared is your organization for the new 2012 edition of the Life Safety Code? 62

32 Temporary Construction Barriers The new Life Safety Code references NFPA 241 Standard for Safeguarding Construction, Alterations, and Demolition Activities, 2009 edition and this standard has made changes involving temporary construction barriers Temporary construction barriers must be erected to separate occupied egress areas of the building from those areas undergoing alterations, construction, or demolition, when such operations are considered as having a higher level of hazard than the occupied portion of the building 63 Temporary Construction Barriers The rules for temporary barriers apply in areas open to the means of egress (corridor) Temporary walls must be 1-hour fire-rated with ¾ hour fire-rated doors, if provided Non-fire-rated walls are permitted when automatic sprinkler systems are installed and operating in the construction area Non-fire-rated walls are not permitted to be constructed with tarps according to the Annex section of NFPA

33 Temporary Construction Barriers It appears that non-combustible plastic sheeting is no longer permitted for temporary construction barriers 65 Temporary Construction Barriers 1-hour fire-rated barriers will definitely be required for construction areas that are not protected with sprinklers 1-hour barriers are typically made using 3½ steel studs, and attaching 5/8 gypsum wall board to both sides of the studs, and tape and mud all joints Not an easy proposition where pipes, duct and conduit are located 66

34 Temporary Construction Barriers Where sprinklers are installed and operating in construction areas, the temporary barrier is permitted to be non-fire-rated Time will tell if non-combustible plastic sheeting will be permitted for sprinklered construction areas since tarps are not permitted CMS and the AOs will have to issue an interpretation on this issue 67 Questions & Answers Submit a question: Brad Keyes, CHSP Owner Keyes Life Safety Compliance Rockton, IL 1. Go to the Q & A box located on your screen. 2. Type in your question. 3. Click the Icon to send. 68

35 Thank you for attending! For more information on programs HCPro offers please visit Be sure to register for HCPro s next live program: Value-Based Purchasing and Documentation Improvement: Strategies for Medical Record Accuracy October 8, 2013 at 1:00pm Eastern 69 This concludes today s program. Please do not close your browser. When the presentation ends you will be automatically redirected to the post-event survey. 70

36 Elizabeth Petersen Vice President HCPro, Inc. a 90-minute webcast on September 23, 2013 Adopting the 2012 Life Safety Code : Prepare for Fire Safety Equipment Testing and Inspection Changes attended Certificate of Attendance