California Society for Healthcare Engineering SOUTHERN CALIFORNIA SEMINAR LIFE SAFETY COMPLIANCE: ADAPTING TO THE 2012 LIFE SAFETY CODE 1
PROGRAM AGENDA Adoption of 2012 LSC CMS Final Rule / Amendments & Clarifications LSC Chapter 43 (Building Rehab) Some Benefits of the 2012 LSC Some New Requirements of the 2012 LSC Referenced Standards 2
HISTORY Jan. 2003 CMS Adopted 2000 LSC April 2014 CMS Proposes Adopting 2012 LSC May 2016 CMS Adopts 2012 LSC (Effective Date 7/5/2016) 3
CMS FINAL RULE PROVISIONS What about The Joint Commission, HFAP, DNV, AAAHC, etc.? Any Accrediting Organizations (AO) requesting Deemed Status must mirror CMS Final Rule provisions, as a minimum 4
CMS FINAL RULE PROVISIONS Adopts the 2012 edition of the Life Safety Code (NFPA 101) Adopts the 2012 edition of the Health Care Facilities Code (NFPA 99), except: Chapter 7 IT & Communications Chapter 8 Plumbing Chapter 12 Emergency Management Chapter 13 Security Updates various referenced codes and standards Identifies CMS amendments & clarifications 5
CMS FINAL RULE CLARIFICATIONS Fire Watch Agrees with the LSC / NFPA 25 Fire Watch provisions Loss of Fire Sprinkler System for more than 10 hours in a 24 hour period Previously kicked in after more than 4 hours / 24 hr. period Loss of Fire Alarm System remains at 4 hours / 24 hr. period 6
CMS FINAL RULE CLARIFICATIONS Requirements for Fire Watch Must be performed by dedicated staff Can have no other duties other than Fire Watch Must constantly circulate throughout facility, or portion affected by system outage Most observe for fire, fire hazards, or hazardous conditions Documentation of rounds not required 7
CMS FINAL RULE CLARIFICATIONS Sprinkler Protection in High Rise Buildings classified as Healthcare occupancy Required by 2012 LSC Includes a 12 year phase in period from time of Code adoption Compliance required by July 5, 2028 8
CMS FINAL RULE CLARIFICATIONS Alcohol Hand Based Rubs (ABHR) Proposal addressed taking all appropriate precautions to secure the ABHR dispensers from inappropriate access Final Rule clarified limiting access to those who may try to harm themselves or others Examples: Dementia & Psychiatric populations 9
CMS FINAL RULE CLARIFICATIONS Corridor Projections 2012 LSC permits max. 6 projections ADA permits max. 4 projections CMS clarifies they will cite >4 if organization is under an ADA Action 10
CMS FINAL RULE CLARIFICATIONS Occupancy Definitions Healthcare = 4 or more inpatients (overnight sleeping) Ambulatory = 4 or more incapable of self preservation (no overnight sleeping) CMS requires ASC to meet Ambulatory HC Chapter (1 or more) CMS recently agreed that Emergency Departments could be classified as Ambulatory if freestanding or properly separated from Healthcare portions of building 11
CMS FINAL RULE CLARIFICATIONS Occupancy Definitions Business Used for transaction of business other than mercantile Dentist / Doctor Offices Office areas of Hospital (if properly separated) Outpatient Clinics (3 or less incapacitated) 12
CMS INTERPRETIVE GUIDELINES Emergency Preparedness S&C 17 29 ALL (June 2, 2017) Life Safety Not Yet 13
2012 LSC CHAPTER 43 Building Rehabilitation Repair Renovation Modification Reconstruction Change of use or occupancy classification Addition 14
2012 LSC CHAPTER 43 Repair Renovation Replace in Kind 15
2012 LSC CHAPTER 43 Modification Addition or Relocation of Door Reconfiguration or Extension of Space Installation of Additional Equipment 16
2012 LSC CHAPTER 43 Reconstruction Reconfiguration of Space, Plus: Affects Exit or Corridor Used by More Than One Space, OR Work Area Not Permitted to be Occupied Due to Impairments OR Work Area Exceeds 50% of Building 17
2012 LSC CHAPTER 43 Change of Occupancy To a Building or a Portion of a Building 18
2012 LSC CHAPTER 43 Addition An Increase in Floor Area, Building Height, or Number of Stories 19
2012 LSC CHAPTER 43 Change of Use Change in Purpose (without changing the occupancy) That Affects Code Requirements Example Change in use of Room From Non Hazardous to Hazardous (Storage) Requires Sprinklers & 1 Hour Fire Rated Enclosure 20
2012 LSC CHAPTER 43 Change of Use Relaxation for Existing Healthcare If Room Does Not Exceed 250 sq. ft. and BUILDING is Sprinklered, 1 Hour Enclosure Not Required Put a self closer on door and call it good! 21
SIGNIFICANT BENEFITS OF 2012 LSC Sleeping Suite Size Increase Max. 5000 sf Direct visual supervision from area such as Nurses Station OR smoke detection within sleeping rooms 5001 sf 7,500 sf Quick Response sprinklers, OR Standard Response sprinklers and complete smoke detection throughout smoke compartment 7501 sf 10,000 sf Quick Response sprinklers AND complete smoke detection throughout smoke compartment, as well as direct visual supervision from area such as Nurses Station 22
SIGNIFICANT BENEFITS OF 2012 LSC Suite Exiting Arrangements Clarifies one (1) exit to the exit access corridor Permits additional exits to adjacent suites, the exterior, exit passageways or exit stairwells Modifies restrictions relating to intervening rooms 23
SIGNIFICANT BENEFITS OF 2012 LSC Clean Waste and Records Recycling Containers Increase the size of containers to a maximum 96 gallon located outside of Hazardous area Must meet FM 6921 (Containers for Combustible Waste) Does NOT apply to trash, soiled linen, etc. 24
SIGNIFICANT BENEFITS OF 2012 LSC Corridor Projections for Wheeled Equipment Equip. does not reduce corridor width to less than 60 in Fire Safety Plan addresses relocation of wheeled equip. Wheeled equip. is limited to: Equipment & carts in use Medical emergency equipment not in use Patient lift & transport equipment Gurneys, wheelchairs, lifts YES Beds NO 25
SIGNIFICANT BENEFITS OF 2012 LSC Security Cameras / Card Readers in Stairwells LSC 7.1.3.2.1(10)(b) indicates electrical conduits permitted to penetrate stair enclosure if serving the enclosure TJC Contended Cameras and Card Readers Were Not Necessary to be in a Stairwell, and therefore penetrations for these were not permitted Wireless Cameras? LSC 7.1.3.2.3 Stair Enclosure Not to be Used For Any Purpose That Has Potential To Interfere With Use as an Exit 26
SIGNIFICANT BENEFITS OF 2012 LSC Security Cameras / Card Readers in Stairwells 2012 LSC 7.1.3.2.1(10)(b) Annex Note: Penetrations for electrical wiring are permitted where the wiring serves equipment permitted by the Authority Having Jurisdiction to be located within the exit enclosure, such as security systems, public address systems, and fire department emergency communications devices. TJC has now indicated acceptance of cameras and card readers in stairwells, provided penetrations are properly protected Evac Equipment? 27
SIGNIFICANT BENEFITS OF 2012 LSC PERMITTED DOOR LOCKING CONCEPTS Clinical Needs Safety and Security Delayed Egress Access Control
DOOR LOCKING Clinical Needs of Patient (No Change) 19.2.2.2.6 Can be unlocked by one of the following: Remote control of locks Keying of all locks to keys carried by staff at all times Other such reliable means available to staff at all times.
DOOR LOCKING Safety & Security (New Allowance in 2012) Door locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety Pediatric Units NICU Maternity Units Emergency Departments Etc.
DOOR LOCKING Safety & Security, con t. All staff can unlock doors at any time Complete smoke detection system OR remote unlocking capability from constantly attended location within the space Locks release upon power loss (fail safe) Locks release upon smoke detection in the space or water flow from the space Entire building is fully sprinklered 31
DOOR LOCKING Delayed Egress (Requirement Relaxed) No specific justification required Removed the requirement that permitted only one delayed egress device per egress path. Building must be fully sprinklered or fully detected Be aware some building codes allow a maximum of 2 in the path of travel
DOOR LOCKING Access Controlled (No Change) No specific justification required Must unlock upon: Motion Sensor to Detect Approach of Person Manual Release Button (Push to Exit) Loss of Power (fail safe) Activation of Fire Alarm System Activation of Sprinkler System (if provided)
SIGNIFICANT BENEFITS OF 2012 LSC DOORS WITH TWO RELEASING OPERATIONS complying with 7.2.1.5.10.6 (New Text): 2000 Edition 2012 Edition Area served has occupant load of 3 or less Door release does not require simultaneous operation Existing hardware only
SIGNIFICANT BENEFITS OF 2012 LSC SLIDING DOORS (without breakaway) WITHIN MEANS OF EGRESS complying with 18/19.2.2.2.10.2 (New Text): 2000 Edition 2012 Edition Area served has occupant load of 10 or less Not Hazardous area Door operable from both sides without special knowledge or effort Self closing if fire rated Positive latching if opening to exit access corridor
NEW REQUIREMENTS OF 2012 LSC Stairwell Signage Applies to New stairwells serving three (3) or more stories Applies to Existing stairwells serving five (5) or more stories Specific text heights Specific text positions 36
NEW REQUIREMENTS OF 2012 LSC Door Inspection Program Requires annual inspection and testing of certain doors Allowance provided for a performance based program Must be performed by individuals who can demonstrate knowledge and understanding of doors and operating components No definition provided No specific certification required Applicable to ALL occupancies 38
ANNUAL DOOR INSPECTIONS What Doors Does This Apply To? All fire rated doors? Patient room doors that happen to be fire rated but not required to be? Traffic control / Function separation doors that happen to be fire rated? Only doors that are required to be fire rated? Doors within a smoke barrier? More confusion than anyone ever imagined! 39
ANNUAL DOOR INSPECTIONS What Doors Does This Apply To? 40
ANNUAL DOOR INSPECTIONS What Doors Does This Apply To? 7.2.1.15 Inspection of Door Openings 7.2.1.15.1 Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8: (1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7 (2) Door assemblies in exit enclosures (3) Electrically controlled egress doors (4) Door assemblies with special locking arrangements subject to 7.2.1.6 Compliance with 7.2.1.15.1 NOT required for Healthcare, Ambulatory Healthcare or Business Occupancies! 41
ANNUAL DOOR INSPECTIONS What Doors Does This Apply To? 7.2.1.15 Inspection of Door Openings 7.2.1.15.2 Fire rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. Compliance with 7.2.1.15.2 NOT required for Smoke Door Assemblies since for Healthcare does not require these doors to be smoke leakage rated! 42
ANNUAL DOOR INSPECTIONS What Doors Does This Apply To? Indicated in S&C Fire door assemblies to be inspected / held to NFPA 80 requirements Not specifically called out in S&C, but don t forget rated access panels and Linen / Trash Chute door assemblies Does not specifically address fire rated doors in locations where a fire rated door is not required Both CMS & TJC have previously indicated that if a door has a label it must be held to the label, even if labeled door is not required Option Remove label if not required? Non rated doors, inc. corridor doors to patient care rooms and smoke barrier doors not required to be inspected, but should be maintained Completion date for first annual inspection extended from 7/5/2017 to 1/1/2018 43
ANNUAL DOOR INSPECTIONS Excessive Gaps on Fire Doors Gasketing materials to address excessive gaps on fire doors must be specifically Listed for such use Material may have a label indicating Suitable for Installation on a 90 Minute Fire Rated Door, or similar wording 44
ANNUAL DOOR INSPECTIONS Excessive Gaps on Fire Doors Gasketing materials to address excessive gaps on fire doors must be specifically Listed for such use Simply indicates that the material can be installed on a COMPLIANT fire door without affecting the door s rating Does not mean that the material will bring a door with excessive gaps into compliance 45
ANNUAL DOOR INSPECTIONS Excessive Gaps on Fire Doors Gasketing materials to address excessive gaps on fire doors must be specifically Listed for such use Must be Listed to UL R27658 as MISCELLANEOUS FIRE DOOR ACCESSORY FOR EXCESSIVE CLEARANCES OR GAPS Very few products on the market carry this Listing 46
INSPECTION / TESTING / MAINTENANCE OF SYSTEMS Communicate with Vendors Ensure they are Meeting the ITM Documentation Requirements for Proper Referenced Standards NFPA 25 (Water Based Fire Protection Systems) 2011 edition NFPA 72 (National Fire Alarm Code) 2010 edition 47
INSPECTION / TESTING / MAINTENANCE OF SYSTEMS, con t. NFPA 10 (Portable Fire Extinguishers) 2010 Edition NFPA 96 (Commercial Cooking Operations) 2011 edition NFPA 14 (Standpipe and Hose Systems) 2010 edition NFPA 13 (Sprinkler System) 2010 edition 48
QUESTIONS A. Richard Fasano Manager, Western Region Office 916 686 1333 rfasano@phillipsllc.com www.phillipsllc.com 49