THE 2012 EDITION OF THE LIFE SAFETY CODE HOSPITAL EDITION SESSION #6 WELCOME Moderator: Richard Schieferdecker support.webinato.com Audio 1
QUESTIONS How To Ask a Question: POLLING There will be occasional interactive poll questions. 2
THE 2012 EDITION OF THE LIFE SAFETY CODE HOSPITAL EDITION SESSION #6 JOINT COMMISSION TOP FINDINGS 3
CMS TOP FINDINGS. 1. K0056 Automatic Sprinkler Systems 2. K0062 Sprinkler System Maintenance 3. K0144 Generators Inspection/Testing 4. K0038 Exit Accessible at All Times 5. K0029 Hazardous Area Separation 6. K0025 Smoke Partition Construction 2016 2015 2014 K0056 Automatic Sprinkler Systems K0029 Hazardous Area Separation K0062 Sprinkler System Maintenance K033 Exit Components K0144 Generators Inspection/Testing K0038 Exit Accessible at All Times 7. K0050 Fire Drills K0025 Smoke Partition Construction K0062 Sprinkler System Maintenance K0056 Automatic Sprinkler Systems K0050 Fire Drills K0029 Hazardous Area Separation K0052 Fire Alarm System Testing K0144 Generators Inspection/Testing K0025 Smoke Partition Construction 8. K0067 HVAC K020 Vertical Shafts K0071 Laundry Chutes 9. K0071 Laundry Chutes K0050 Fire Drills K0147 Electrical Wiring and Equipment 10. K0018 Corridor Doors K0018 Corridor Doors K069 Cooking Equipment SPRINKLER SYSTEM INSTALLATION K56 K351 4
SPRINKLER SYSTEM MAINTENANCE K62 K353 NFPA 25, 2011 Edition EXIT CORRIDORS K39 K232 Corridor clutter / storage 30 minute rule 5
HAZARDOUS AREAS K29 K321 EXISTING 1 hour enclosure ¾ hour door Sprinkler protection Smoke partition Self closing door 50 SF or greater with storage NEW 1 hour enclosure ¾ hour door Sprinkler protection Self closing door 100 SF or greater with storage SMOKE BARRIERS K25 K372(wall), K379(doors) Outside wall to outside wall Floor to deck All penetrations sealed Doors smoke resisting Doors self closing HINT: INSPECT IN THE LESS OBVIOUS LOCATIONS...NOT JUST ABOVE THE CORRIDOR DOORS 6
CONSTRUCTION TYPE / PROTECTION K12 K161 FIRE DRILLS K50 K712 Varying times Varying conditions Each shift quarterly Knowledge of procedures and competence of staff as observed in drills 7
ELECTRICAL K50 K511 NFPA 70 (NEC) LIFE SAFETY FEATURES Rated fire / smoke barrier walls 30 min corridor walls Rated enclosures / shafts Exits Exterior Stairs Passageways Horizontal 8
WHY DRAWINGS CLARIFICATIONS 9
WHY DRAWINGS LIFE SAFETY FEATURES 10
HAZARDOUS AREAS Existing Hazardous Areas Sprinklered Non-sprinklered New Hazardous Areas Ambulatory & Business HAZARDOUS AREAS 11
SUITES Suite Type Sleeping suite Non-sleeping suite Non-patient care suite Suite Size SMOKE COMPARTMENTS Compartment Boundaries Compartment Size 22,500sq.ft. Sprinkler Protection 12
SUITES & SMOKE COMPARTMENTS COVER PAGE GENERAL BLDG. INFO LOGO 13
ALTERNATE APPOACHES WAIVERS Fire Safety Evaluation System (FSES) Time Limited Waiver Permanent Waiver Categorical Waiver 14
FIRE SAFETY EVALUATION SYSTEM (FSES) NFPA 101A (guide) Addresses Alternate Approaches to Life Safety Accepted method by TJC and CMS Calculations and process by occupancy type Evaluates each smoke zone Factors include Occupancy risk factors Safety parameters OCCUPANCY RISK PARAMETERS HEALTHCARE 15
OCCUPANCY SAFETY PARAMETERS HEALTHCARE Construction Interior Finish Corridor Partitions Corridor Doors Zone Dimensions Vertical Openings Hazardous Areas Smoke Control Egress Routes Fire Alarm Detection Sprinkler Protection OCCUPANCY SAFETY PARAMETERS HEALTHCARE 16
OCCUPANCY SAFETY PARAMETERS HEALTHCARE OCCUPANCY SAFETY PARAMETERS HEALTHCARE All Zones Must be Zero (0) or Greater 17
FSES CERTIFICATION Registered Architect Licensed PE CFPS Local AHJ (fire marshal, building official, etc.) COMMON FSES APPLICATIONS Construction issues Travel distance issues Deficient egress components 18
TIME LIMITED WAIVERS A detailed written request outlining a time period in which the facility will become in prescriptive compliance with a Life Safety Code provision. Deficiencies eliminated in future Code editions Temporary issues Issues identified in survey taking longer than 60 days to remediate. WAIVER SUBMISSION Executive Summary / Overview Building Overview Construction info Building height Sprinkler protection Smoke detection Other pertinent info Detailed Deficiency Description Code / Standard References TJC Life Safety Chapter Life Safety Code chapter and section Intent of the Requirement 19
WAIVER DOCUMENTATION / SUBMISSION Hardship Assessment Cost (provide specifics when possible) Operational disruption Negative affect on patients Waiver Justification Deficiency What off sets the deficiency New or existing features above what is required Cost, source & commitment for alternative solution Interim Life Safety Measures (ILSM) Clarify that ILSMs have been reviewed and applied Patient Safety Assessment / Field Verification Alternative Clarify that the request will not negatively impact patient safety Statement clarifying an on site review & assessment WAIVER DOCUMENTATION / SUBMISSION Supporting documentation / descriptive drawings Organization Name & Logo 20
WAIVER DOCUMENTATION / SUBMISSION Supporting / descriptive photographs COMMON PITFALLS Why are Requests Commonly Returned or Rejected Substance Proposal does not constitute an equivalent or better situation Administrative Missing information in submission Request form not provided or incomplete No certifying letter FSES not completed accurately FSES drawings not included 21
QUESTIONS Next Session Referenced Codes & Standards 22
THANK YOU Dave Hood President Nick Gabriele Vice President 23