FIRE SAFETY/LIFE SAFETY
UPDATE
2013
Presented by:
Thomas W. Jaeger, P.E., President
Jaeger & Associates, LLC
Program Guide
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Current Nursing Home Fire/Life Safety Data
10 Top Life Safety Deficiencies in Oklahoma
Life Safety Code Essentials & Current Issues
Life Safety Code Current Issues
Recent CMS Policies
Changes in the 2012 Life Safety Code for Nursing
Homes & Assisted Living Facilities
Changes in the newer Editions of the Building Codes
for Nursing Homes and Assisted Living Facilitiies
2012 Life Safety Code
Future Life Safety Issues
Jaeger & Associates, LLC
Resource Links
• CMS Guidance to State Survey Agency
Directors and CMS Regional Offices
– http://www.cms.hhs.gov/surveycertificationge
ninfo/pmsr/list.asp#topofpage
• You will hear me mention Survey & Certification
(S & C) Letters all day, this is the Website to
obtain S & C Letters
Life Safety Updates
– www.AHCA.org
– www.AAHSA.org (leadingage.org)
Jaeger & Associates, LLC
WARNING
If you receive a deficiency for a
condition in your facility that has
existed for many years and it cost
more than a few thousand dollars to
correct, you should challenge the
deficiency or at least seek assistance.
Jaeger & Associates, LLC
Warning
I will be discussing three separate scenarios today, these
being:
1. Requirements in the 2000 Life Safety Code
2. Requirements in the 2012 Life Safety Code that have
been waived by CMS and can be provided today under the
2000 LSC
3. Requirements in the 2012 Life Safety Code that have not
been waived and can not be used until the 2012 LSC has
been adopted by CMS
Jaeger & Associates, LLC
Current Nursing Home Fire
Safety Data
Jaeger & Associates, LLC
Nursing Home Multiple Death Fires
(1973-2012)
1973-1977
1978-1982
1983-1987
1988-1992
1993-1997
1998-2002
2003-2007
2008-2012
# of Fires
5
1
0
3
1
0
2
0
# of Deaths
63
3
0
19
3
0
31
0
Average # of Deaths
Per Year
5 Year Period
12.6
0.6
0.0
3.8
0.6
0.0
6.2
0.0
Average # of Deaths
Per Year
20 Year Period
4.3
1.7
60% Reduction in
last 20 years
Average # of single deaths per years = 3-5
Jaeger & Associates, LLC
NHC Nashville Healthcare Center
Nashville, TN
NHC Nashville Healthcare Center
Nashville, TN
September 25, 2003
15 Deaths
Greenwood Health Center Fire
Hartford, CT
February 26, 2003
16 Deaths
Board and Care Multiple Death Fires
(1972-2011)
(Assisted Living)
# of Fires
1972-1976
1977-1981
1982-1986
1987-1991
1992-1996
1997-2001
2002-2006
2007-2011
1
5
8
5
12
3
4
2
# of Deaths
10
63
73
29
57
21
22
9
Average # of Deaths
Per Year
5 Year Period
2.0
12.6
14.6
3.8
9.0
4.2
4.4
1.8
Average # of Deaths
Per Year
20 Year Period
8.75
5.45
30% reduction in last 20
years
70% reduction in
last 10 years
Jaeger & Associates, LLC
Common Factors in Nursing Home
Multiple Death Fires*
• Building is not sprinklered
• Fire originates in patient sleeping area –
primarily patient sleeping room
• Door to room of fire origin is not closed
or is reopened during the fire
• Patient known to be outside the danger
area during the fire found dead inside
the danger zone after the fire
*Probably applies to Assisted Living Facilities
Jaeger & Associates, LLC
Top Ten Cited Deficiencies
Ten Most Frequently Cited Life Safety Deficiencies in the Nation,
March 2013
Tag
1.
2.
3
4
5
6
7
8
9
10
K147
K062
K029
K018
K038
K025
K144
K050
K056
K067
Percent of
Facilities
29.3%
27.5%
25.9%
24.6%
20.4%
18.3%
14.6%
14.2%
12.6%
11.6%
Oklahoma
Electrical Wiring & Equipment
Sprinkler System Maintenance
Hazard Area Enclosure
Corridor Doors
Exit Accessible At All Times
Smoke Barrier Construction
Generator Inspection/Testing
Fire Drills
Sprinkler System Installation
Ventilation Equipment
25.2%
13.2%
41.9%
17.4%
26.1%
27.4%
3.9%
15.2%
6.5%
31.6%
Oklahoma has a Higher Percentage than the Nation for 6 out of the top
10 Deficiencies cited in the Nation
Jaeger & Associates, LLC
Top Ten Cited Deficiencies
Ten Most Frequently Cited Life Safety Deficiencies in Oklahoma
March 2012
Tag
1
2.
3
4
5
6
7
8
9
10
K029
K046
K067
K025
K038
K147
K017
K066
K018
K069
Percent of
Facilities
41.9%
35.5%
31.6%
27.4%
26.1%
25.2%
19.4%
19.0%
17.4%
16.5%
Hazardous Area Enclosure
Emergency Lighting
HVAC
Smoke Barrier Construction
Exit Accessibility at all Times
Electrical Wiring and Equipment
Corridor Walls ??
Smoking Regulations
Corridor Doors
Cooking Facilities ??
Jaeger & Associates, LLC
Inspection, Testing and Maintenance
and Record Keeping
8
Approximately
out of the top 10 deficiencies for
nursing homes cited in Oklahoma have to do with
inspection, testing, maintenance or operational
issues, with many involving just plain old record
keeping
–Record Keeping, Record Keeping, Record Keeping
–Most important is Record Keeping and Documentation of
everything you do and everything your contractor does.
–If cited for deficiency on Contractor’s testing or inspection
Report, Get it Fixed before Survey or the surveyor will thank
you for paying a third party to do his/her job.
Jaeger & Associates, LLC
% Of No Cited Deficiencies
% of Facilities with NO Deficiencies Cited
Nation-18.3%
Oklahoma-5.5% (11th Lowest % in the Nation)
Other States in Region VI
Arkansas-28.4%
Louisiana-13.9%
New Mexico-11.1%
Texas-7.9%
Oklahoma has lowest % in Region VI
Jaeger & Associates, LLC
Life Safety Code Essentials &
Current Life Safety Issues
Jaeger & Associates, LLC
Life Safety Code Essentials
Life Safety Code
Mandatory Requirements-Have
to be Complied with
Permissive Requirements-Can
be Done, but not Mandatory
Jaeger & Associates, LLC
Life Safety Code Essentials
Inspection, Testing &
Maintenance of Fire/Life
Safety Systems, Devices
and Features
Jaeger & Associates, LLC
Life Safety Code Essentials
Record
Keeping
Jaeger & Associates, LLC
Inspection, Testing and Maintenance
and Record Keeping
A minimum of 2 staff
members must know where
all Inspection, Testing and
Maintenance Records are
located and have access to
these records 24/7
Jaeger & Associates, LLC
Inspection, Testing and Maintenance
and Record Keeping
If an outside contractor is
responsible to provide you with
any of the required completed
Inspection, Testing and
Maintenance Forms/Records,
they should be provided to you
on completion of the work or
within 24 hours
Jaeger & Associates, LLC
Inspection, Testing and Maintenance
and Record Keeping
Recommend
1. State and long term industry develop
standard inspection, testing and
maintenance forms.
2. State and long term industry agree on what
facility staff can do and what has to be done
by contractor.
Jaeger & Associates, LLC
CMS Mandates Sprinklers
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Mandatory sprinklers in all existing nursing
homes
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CMS issued “Notice of Final Rule Making” on August
13, 2008 (effective date October 14, 2008)
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A 5 year phase in period (All nursing homes must be
sprinklered by August 13, 2013)
No waivers or use of the FSES
Buildings with existing waivers for sprinkler deficiencies
will not be approved after the 5 year phase in period
CMS Sunsets smoke detector requirements when new
sprinkler system is installed and approved
See S & C Letter 09-04
Jaeger & Associates, LLC
CMS & NFPA Definition of
a Fully Sprinklered
Building
Applies to both nursing homes & assisted
living facilities
Jaeger & Associates, LLC
Current Life Safety Code Issues
Exceptions for Sprinklers and still classify
the Building as Fully Sprinklered
Tom, let me take a look at this and see what is going
on. The regulation is specific to the 1999 edition of
NFPA 13 and the 1998 edition of NFPA 25 and the
language contained in those particular documents . The
regulation also does not contain any waiver provisions
or use of the FSES in it, it is pretty much you have to
comply with the documents cited, but if the documents
have exceptions the exceptions would apply and could
be used to show compliance.
Jim Merrill
CMS-Baltimore
Jaeger & Associates, LLC
Current Life Safety Code Issues
What constitutes a fully sprinklered building
The sprinkler system must comply with the
appropriate edition of NFPA 13. Where the
Life Safety Code and/or NFPA 13 allow for
exceptions for sprinklers in certain areas of
the building, you do not have to install
sprinklers in those areas and you will be
considered a fully sprinklered building
Jaeger & Associates, LLC
Current Life Safety Code Issues
Exceptions for Sprinklers and still classify the
Building as Fully Sprinklered
• This does not mean exceptions for sprinklers
using a waiver or FSES
• It means:
• Where there is an exception in the codes and
standards
• When an Authority Having Jurisdiction permits
sprinklers to be omitted or allows alternate
protection to sprinklers
•Existing approved sprinkler systems are not
impacted by the mandatory sprinkler regulation
Jaeger & Associates, LLC
Current Life Safety Code Issues
.
Exceptions for Sprinklers
and still classify
the Building as Fully Sprinklered
Extracted from the 2000 Life Safety Code
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9.7.3.1
In any occupancy where the character of the potential fuel for
fire is such that extinguishment or control of fire is effectively
accomplished by a type of automatic extinguishing system
other than an automatic sprinkler system, such as water mist,
carbon dioxide, dry chemical, foam,Halon1301, water spray, or
a standard extinguishing system of another type, that system
shall be permitted to be installed in lieu of an automatic
sprinkler system. Such systems shall be installed, inspected,
and maintained in accordance with appropriate NFPA
standards.
Jaeger & Associates, LLC
Current Life Safety Code Issues
Exceptions for Sprinklers and still classify the
Building as Fully Sprinklered
Extracted from the 1999 NFPA 13
. 1-2* Purpose.
The purpose of this standard is to provide a reasonable degree of
protection for life and property from fire through standardization of
design, installation, and testing requirements for sprinkler systems,
including private fire service mains, based on sound engineering
principles, test data, and field experience. This standard endeavors to
continue the excellent records that have been established by sprinkler
systems while meeting the needs of changing technology. Nothing in
this standard is intended to restrict new technologies or alternate
arrangements, provided the level of safety prescribed by this standard
is not lowered. Materials or devices not specifically designated by this
standard shall be utilized in complete accord with all conditions,
requirements, and limitations of their listings.
Jaeger & Associates, LLC
Current Life Safety Code Issues
Exceptions for Sprinklers and still classify the
Building as Fully Sprinklered
Extracted from the 1999 NFPA 13
5-13 Special Situations.
5-13.1 Concealed Spaces.
There are 12 Exceptions as to where sprinklers are not required in
concealed spaces
5-13.2.1
One sprinkler shall be installed at the top of shafts.
Exception No. 1: Noncombustible or limited-combustible,
nonaccessible vertical duct shafts.
Exception No. 2: Noncombustible or limited-combustible,
nonaccessible vertical electrical or mechanical shafts.
Jaeger & Associates, LLC
Current Life Safety Code Issues
Exceptions for Sprinklers and still classify the
Building as Fully Sprinklered
Extracted from the 1999 NFPA 13
5-13.6 Elevator Hoistways and Machine Rooms.
5-13.6.1*
Sidewall spray sprinklers shall be installed at the bottom of each elevator
hoistway not more than 2 ft (0.61 m) above
the floor of the pit.
.
Exception: For enclosed, noncombustible elevator shafts that do
not contain combustible hydraulic fluids, the sprinklers at the
bottom of the shaft are not required.
5-13.6.3*
Upright or pendent spray sprinklers shall be installed at the top of elevator
hoistways.
Exception: Sprinklers are not required at the tops of
noncombustible hoistways of passenger elevators with car
enclosure materials that meet the requirements of ASME A17.1,
Safety Code for Elevators and Escalators.
Jaeger & Associates, LLC
Current Life Safety Code Issues
Exceptions for Sprinklers and still classify the
Building as Fully Sprinklered
•Examples of Exceptions in the Codes and Standards
oWet chemical systems for kitchen hoods
oGases system for high value electronic installations
oElevator shafts of certain elevators
oExamples where AHJ may not permit sprinklers
oHigh voltage electrical rooms
oElevator shafts and elevator machine rooms
Jaeger & Associates, LLC
Current Life Safety Code Issues
What happens if you are not fully sprinklered
by August 13, 2013
• If you have deficiencies of the sprinkler system such as
corroded sprinkler heads, a few missing heads in closets,
etc. these will be treated as a deficiency and the building will
not be classified as not being sprinklered.
•If there are large areas of the building not protected with
sprinklers, i.e. a floor or smoke compartment, the building will
be classified as not being fully sprinklered and CMS will
handle this on a case by case bases, but you are likely to
receive a scope and severity of Immediate Jeopardy
Jaeger & Associates, LLC
Current Life Safety Code Issues
What happens if you are not fully sprinklered
by August 13, 2013
• On February 7, 2013 CMS published a Proposed Rule
Making which would allow a 1 to 2 year extension beyond
August 13, 2013 to install sprinklers.
• The substantiation to qualify for the up to 2 year extension is
very onerous and specific.
•Replacement financed, designed & under construction
• Major renovation financed, designed & under construction
• Alternate protection provided
•Carrying forward existing waivers or FSES equivalencies for 2
years will not qualify as adequate substantiation for an
extension.
Jaeger & Associates, LLC
Sprinkler Issues
Applies to both nursing homes & assisted
living facilities
Jaeger & Associates, LLC
Current Life Safety Code Issues
CMS has withdrawn it recent policy that
outbuildings on nursing home property have
to be sprinklered. Examples are:
•Free standing outside smoke shelters
•Free standing laundry buildings
•Free standing kitchens or kitchens that
service nursing home residents in a
residential building on the same property
CMS will cover this in an upcoming S & C Letter
Jaeger & Associates, LLC
Current Life Safety Code Issues
Antifreeze in new and existing Sprinkler Systems
• NFPA has issued 3 new Tentative Interim
Amendments (TIA’s) to the 2011 NFPA 13 and
NFPA 25 that calls for additional requirements for
the use of antifreeze in sprinkler systems.
•Most nursing homes in Iowa would not be able
to meet these new requirements and would have
to redesign the sprinkler system or heat the
unheated area that is being protected by the
antifreeze system. Both could be very
expensive.
Jaeger & Associates, LLC
Current Life Safety Code Issues
Antifreeze in new and existing Sprinkler Systems
• Fortunately CMS has decided not to adopt or
enforce the 3 TIA’s for a variety of reasons.
Therefore for CMS (Federal) purposes
compliance with the TIA’s is not required and
cannot be cited as a deficiency on a federal
survey as a K tag.
• If Iowa wants to enforce the new requirements
for antifreeze it has to be show as a state
deficiency and then it becomes an IHCH/ICAL
issue.
Jaeger & Associates, LLC
Life Safety Code Essentials
• All new buildings required to be sprinklered
using Quick Response Sprinklers (QRS)
• All additions to existing buildings are required to
be to install QRS
Life Safety Code Essentials
• Existing sprinklers are not required to
be quick response sprinklers
Jaeger & Associates, LLC
Life Safety Code Essentials
Extract from NFPA 13, 1999 edition, Standard for the Installation of Sprinkler
Systems
5-3.1.5 Thermal Sensitivity
5-3.1.5.1
Sprinklers in light hazard occupancies shall be of the quick-response type as
defined in 1-4.5.2
Exception No. 1 Residential sprinklers shall be permitted in accordance with 5-4.5.
Exception No. 2 For modifications or additions to existing system equipped
with standard response sprinklers, standard response sprinklers shall be
permitted to be used.
Exception No. 3 When individual standard response sprinklers are replaced
in existing systems, standard response sprinklers shall be permitted to be used.
5-3.1.5.2
When existing light hazard systems are converted to use quick-response or residential
sprinklers, all sprinklers in a compartmented space shall be changed.
1-4.2 General Definitions
Compartment. A space completely enclosed by walls and a ceiling. The compartment enclosure is
permitted to have openings to an adjoining space if the openings have a minimum lintel depth of
8 in. (203 mm) from the ceiling.
Jaeger & Associates, LLC
Common Misinterpretation
• Maintaining 18 inch clear space below
sprinkler deflectors
•
From 1999 Edition of NFPA 13 “Standard for
the Installation of Sprinkler Systems.”
A-5-6.6
The 18-in. (0.46-mm) dimension is not intended to limit the height of
shelving on a wall or shelving against a wall in accordance with 5-6.6.
Where shelving is installed on a wall and is not directly below
sprinklers, the shelves, including storage thereon, can extend above
the level of a plane located 18 in. (0.46 mm) below ceiling sprinkler
deflectors. Shelving, and any storage thereon, directly below the
sprinklers cannot extend above a plane located 18 in. (0.46 mm)
below the ceiling sprinkler deflectors.
Jaeger & Associates, LLC
Locking of Doors in the of
Means of Egress
Jaeger & Associates, LLC
Life Safety Code Issues
Locking of doors for clinical
needs and safety of patients
• CMS has now made the locking of
doors a resident rights issue
Jaeger & Associates, LLC
Life Safety Code
CMS June 23, 2007 Memo
on locking of doors in means of egress
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•
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CMS requires a comprehensive and individualized
assessment of each resident’s needs to determine if
the resident requires
K38 will be cited if egress doors on a floor are locked
and there is evidence that all cognitively aware
residents, staff and visitors do not have access to
the method of opening the doors
If staff can not unlock the doors, it will most likely be
considered an immediate jeopardy situation.
Jaeger & Associates, LLC
Life Safety Code
CMS has made locking of doors in means of
egress a resident rights issue
1. Delayed Egress Locks
• Nothing has to be done
2. All other locks
• Cognitively aware residents
• Give info on how to unlock door and document when
and who
• Visitor ( to include surveyors )
• If going into locked unit
• Sign in and give information on unlocking door
• All staff assigned to locked unit or required to report to
locked unit during an emergency must be given
information on unlocking doors
3. All of the above should be included in facilities emergency
plans and operational plans
Jaeger & Associates, LLC
Life Safety Code
• Doors can be manually unlocked if
clinical needs of residents require
(no limit on the number of locks in
means of egress)*
• Delayed egress locks permitted in
means of egress clinical needs of
residents not required (only one
permitted in a means of egress)
* State Regulations may be more restrictive
Jaeger & Associates, LLC
Life Safety Code
Extract from 2000 Life Safety Code
18&19.2.2.2.4
Doors within a required means of egress shall not be
equipped with a latch or lock that requires the use of a tool
or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed
egress shall be permitted in health care occupancies, or
portions of health care occupancies, where the clinical needs of
the patients require specialized security measures for their
safety, provided that staff can readily unlock such doors at all
times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1
shall be permitted, provided that not more than one such device
is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with
7.2.1.6.2 shall be permitted
Jaeger & Associates, LLC
Life Safety Code
•
Locking of doors in the means of egress (Nursing Homes)
•
•
•
Clinical needs of resident determined by the facility
Key locking of doors
• No limit on the number of locks in the means of egress or which
doors in the means of egress
• Can be manual or electric
• Can be key or cipher lock
• Staff must be present 24/7 when doors are locked
• Keypad combination need not be posted at keypad
• Not required to unlock by activation of Fire Alarm System
Delayed egress lock (Nursing Homes and ALF’s)
• Only one in the means of egress
• Can lock any door
• Clinical needs of resident not required
• Limited time for delay
• Sounds an alarm
• Staff is not required to be present
• Not required to unlock by manual activation of Fire Alarm System
Jaeger & Associates, LLC
Life Safety Code
• Gates in secured outside areas are
doors in the Means of Egress and can
be locked.
•
Staff that can unlock gates must be
present when area is occupied.
Jaeger & Associates, LLC
Life Safety Code Issues
Applies to both nursing homes & assisted
living facilities
Jaeger & Associates, LLC
Commonly Cited Deficiencies
•
Fire Alarm System Required to Shutdown
HVAC Systems.
•
Not true – Life Safety Code nor NFPA 90A
requires activation of the fire alarm system to
shutdown the HVAC System
Jaeger & Associates, LLC
Life Safety Code Essentials
Corridor Doors
Corridor Doors
•
•
Section 19.3.6.3.1 Doors protecting corridor openings in other than required
enclosures of vertical openings, exits, or hazardous areas shall be
substantial doors, such as those constructed of 1 ¾ in. (4.4 cm) thick, solidbonded core wood or of construction that resists fire for not less than 20
minutes and shall be constructed to resist the passage of smoke.
Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall
not be required. Clearance between the bottom of the door and the floor
covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
– Exception No. 2: In smoke compartments protected throughout by an
approved, supervised automatic sprinkler system in accordance with
19.3.5.2,the door requirements of 19.3.6.3.1 shall not be mandatory, but
the door shall be constructed to resist the passage of smoke.
Section A.19.3.6.3.1 Gasketing of doors should not be necessary to achieve
resistance to the passage of smoke if the door is relatively tight-fitting.
Jaeger & Associates, LLC
Life Safety Code Essentials
Tag K018 Corridor Doors
Jaeger & Associates, LLC
Life Safety Code Essentials
Corridor Doors
• If you can see light between the door and the
door stop, the gap is too large.
Not true – There is no such thing as
a “light test”.
• Gap between a corridor door and the door stop
can not exceed 1/8 inch.
Not true-There is no limitation of
1/8 inch in the Life Safety Code for
corridor doors.
Jaeger & Associates, LLC
Life Safety Code Essentials
CMS Memorandum S & C-07-18, Dated April 29, 2007
This memorandum applies to corridor doors other than
those in required enclosures of vertical openings, exits
and hazardous areas
Memorandum Summary
• In a smoke compartment that is not fully
sprinklered, a gap between the face of a corridor
door and the door stop should not exceed ¼-inch,
provided that the door latch mechanism is
functional.
• In a smoke compartment that is fully sprinklered, a
gap between the face of a corridor door and the
door stop should not exceed ½-inch, provided that
the door latch mechanism is functional.
Jaeger & Associates, LLC
Life Safety Code Essentials
Corridor Doors
The gap between the edge of a corridor door and
the door frame shall not be greater than the
depth of the door stop.
Jaeger & Associates, LLC
Life Safety Code Essentials
Tag K018 Corridor Doors
Jaeger & Associates, LLC
Life Safety Code Essentials
Door Clearances for Smoke Barriers Different
than for Corridor Doors
Smoke Barriers
• Section 8.3.4.1 Doors in smoke barriers shall close
the opening leaving only the minimum clearance
necessary for proper operation and shall be without
undercuts, louvers, or grilles.
• Section A.8.3.4.1 The clearance for proper operation
of smoke doors is defined as 1/8 in. (0.3 cm). For
additional information on the installation of smokecontrol door assemblies, see NFPA 105,
Recommended Practice for the Installation of SmokeControl Door Assemblies.
Jaeger & Associates, LLC
Life Safety Code Essentials
Safe use of Oxygen
S & C Letter -07-10 states:
oUp to 300 cu. ft. of oxygen may be accessible as
operational supply outside of storage, if properly
secured
oAn individual oxygen container may be located in
a residents room for “as needed” (PNR bases)and
need not be stored in an enclosure when not in
use.
Life Safety Code Essentials
Oxygen Conversion Table
Weight
1 lb
9.527 lb
Gas
12.076 cu. ft.
115.1 cu. ft.
Liquid
0.105 gal
1.0 gal
Life Safety Code Essentials
Safe use of Oxygen
•No clear direction on the use oxygen
concentrators, “i-fills or ”homefills” from CMS
•CMS has stated that Ifill bottles can be filled
outside the resident sleeping room in any
hazardous area room and need not be done in a
special room protected for oxygen transfilling or
storage
•Residents should not be allowed to fill bottles or
containers, should be done by staff
Common Misinterpretations
No Smoking Signs
Question: Are no smoking signs required to be posted
in all areas where oxygen is being used in a health care
facility that has a no smoking policy?
Answer: No, if no smoking signs are prominently
posted at all major entrances into the health care facility.
Please see the exceptions to Section 8-6.4.2 of NFPA 99
and Section 19.7.4 of NFPA 101. I am not aware that
CMS has amended the requirements of NFPA 99 or
NFPA 101 to require no smoking signs other than what is
currently required in these two documents.
Jaeger & Associates, LLC
Life Safety Code Essentials
Smoke Barrier Construction
• Smoke dampers ARE NOT required to close upon
operation of the fire alarm system
• Smoke dampers are required to close when the
smoke detector associated with the smoke damper
activates
• Smoke dampers are required to be tested
• Smoke dampers are not required in fully ducted
HVAC systems
• Smoke dampers are not required if both sides of
smoke barrier are protected with Quick Response
Sprinklers (QRS)
Jaeger & Associates, LLC
Life Safety Code
Corridors and Corridor walls in
sprinklered buildings
• No fire resistance is required for
corridor walls or doors in corridors
except to exit enclosures and some
hazardous areas. Corridor walls
only have to limit the passage of
smoke and extend to a ceiling that
will limit the passage of smoke
• Doors required to resist the
passage of smoke
Jaeger & Associates, LLC
Life Safety Code Essentials
Inspecting & Maintaining Fire Rated/Smoke
walls, barriers & partitions
•Inspect Quarterly ,especially above ceiling, if required to
extend above ceiling
•Maintain written records of inspections
•Inspect openings in wall, barrier, or partition
•Doors
•Door latches if required, only one not required is doors
in smoke barriers
•Door closure if required, only not required is door to
sleeping room
•Penetrations, fire rated or resist passage of smoke
Life Safety Code Essentials
Testing of Fire and Smoke Dampers
Extract from 1999 NFPA 90A Installation Standard for HVAC Systems
5-2 Fire Dampers, Smoke Dampers, and Ceiling Dampers.
All fire dampers, smoke dampers, and ceiling dampers shall be operated
prior to the occupancy of a building to determine that they function in
accordance with the requirements of this standard.
3-4.7 Maintenance.
At least every 4 years, fusible links (where applicable) shall be
removed; all dampers shall be operated to verify that they fully close;
the latch, if provided, shall be checked; and moving parts shall be
lubricated as necessary
Fire Dampers & Smoke Dampers must be tested every 4 years
and records of testing must be maintained for 8 years
Jaeger & Associates, LLC
a
Life Safety Code Essentials
Who can do the Inspection, Maintenance and
Testing of systems, equipment and fire
protection feature?
• Inspections-Most can be done by facility staff
• Testing-Generally by licensed contractors
• Maintenance- By licensed contractors/facility
staff, if qualified
Jaeger & Associates, LLC
Life Safety Code Essentials
Fire Drills
• Requirements are in Chapters 18 & 19 of 2000
Life Safety Code for nursing homes.
Emergency Procedures
• Requirements are in Chapter 11 of Standard
for Health Care Facilities (NFPA 99) for
Nursing Homes. This can be used as a guide
for ALFs.
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Life Safety Code Essentials
• Increase in the enforcement of fire drill
procedures and Written Documentation
•Record Keeping
•Vary Drills
•Staff Participation only in nursing homes
•Staff and Resident Participation in ALF’s
•12 Drills per Year/4 per Shift (nursing homes)
•6 Drills per Year/Bimonthly with 2 drills at
night during sleeping hours (ALF’s)
•When you do drill between 9:00 PM and 6:00 AM you
do not have to use audible alarm, but you do have to
transmit alarm to fire department within 24 hours of
drill
Jaeger & Associates, LLC
Life Safety Code Essentials
Fire Drills
• Random scheduling of Fire Drills is NOT
defined in the Life Safety Code
• CMS says that drills should be conducted
throughout the shift hours and at least 1
hour before or after the last drill time for
that shift
• CMS says that if you run a drill at shift
change, the drill can only be counted for 1
shift.
Jaeger & Associates, LLC
Life Safety Code Essentials
Fire Drills
It is not mandatory that all staff members
participate in 4 fire drills per year. Staff
may be absent due to vacation, sick leave,
outside training, etc. There is actually a
benefit if a staff member is absent, it
measures how staff present compensates
for the absence.
Jaeger & Associates, LLC
Commonly Cited Deficiencies
Outside Emergency Lighting
•
Section A7.9.1.1: “Emergency lighting provided
outside the building should be to either a public
way or a distance away from the building that is
considered safe, whichever is closest to the
building being evacuated.”
•
CMS has interpreted that 50 feet is a safe
distance away from the building in most cases
Jaeger & Associates, LLC
Common Misinterpretation
Smoking
•
Designated smoking areas outside the building
are regulated similar to inside smoking areas.
Jaeger & Associates, LLC
Current Life Safety Code Issues
Charging wheelchair batteries in patient sleeping rooms
Tom, what I have answered on an individual basis was that
you could not charge wheelchairs in corridors or confined
spaces although that was predicated on the use of batteries
that produced flammable gases when charged. Today’s
use of gel or sealed batteries would probably negate the
charging in a confined space issue since they do not
produce flammable gases when charged. It could be cited
as an F-tag or K-tag at depending on what the situation
was.
Jim Merrill
CMS-Baltimore
Jaeger & Associates, LLC
Current Life Safety Code Issues
S & C Letter 12-04-NH Dated Nov. 10, 2011
Smoking
•Electronic Cigarettes (e-cigarettes)-not considered
a smoking device and needs no special protection
•Every smoking resident has to be assessed as to
need for supervised smoking and documented
•Facility policies must describe methods used to
determine if a resident can smoke unsupervised
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2012 NFPA Life Safety Code
&
CMS Cultural Changes
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Warning
I will now be discussing two separate scenarios, these
being:
1. Requirements in the 2012 Life Safety Code that have
been waived by CMS and can be provided today under the
2000 LSC
3. Requirements in the 2012 Life Safety Code that have not
been waived and can not be used until the 2012 LSC has
been adopted by CMS
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CMS Waivers 4 Changes in
the 2012 Life Safety Code
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Current Life Safety Issues
CMS has fast tracked adoption
of Changes in the 2012 Life
Safety Code via
S & C Letter-12-21-LSC
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Current Life Safety Issues
There are 4 changes in the 2012 Life Safety Code
that CMS has waived.
•You must comply with ALL the requirements in the 2012 LSC for
each waiver you are requesting
• You do not have to comply with the entire 2012 Life Safety Code
• You must first intentionally create a deficiency before you can apply
for a waiver
•You do not have to document financial hardship
• You do not have to document alternative protection
•The waived requirements apply to both new and existing buildings
The 4 waived cultural changes are:
Jaeger & Associates, LLC
Current Life Safety Issues
1. Kitchens serving 30 or less residents can be open to the
corridor.(Section 18 & 19.3.2.5.3 {1} thru {12} of 2012
LSC)
• Nursing unit containing the open kitchen must be
separated from all other areas by a smoke barrier.
• Residential hood system can be used and must have:
o
o
o
o
•
•
minimum air flow of 500 cfm
Ul 300A cooktop fire extinguishing system
A manual shut off switch to all cooktops with access to staff only and an
automatic shut off not exceeding 120 minutes
Compliance with NFPA 96 for all inspection, testing and maintenance of the
range hood and duct system.
Deep fat fryers are prohibited
Smoke detectors in the kitchen located no closer than
20 ft. from the cooktop or range.
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Current Life Safety Issues
NFPA has issued a Tentative Interim
Amendment to the 2012 Life
Safety Code to clarify the
requirements for the smoke
detectors in the open kitchen
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Current Life Safety Issues
Credit “Lenhardt Rodgers”
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Current Life Safety Issues
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Current Life Safety Issues
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Current Life Safety Issues
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Current Life Safety Issues
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Current Life Safety Issues
credit “Hoffman LLC”
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Current Life Safety Issues
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Current Life Safety Issues
2. Corridors
•
Fixed seating in the corridors permitted where corridor is at least
8 ft. in width (Section 18 & 19.2.3.4[5})
o Fixed seating must be attached to wall of floor and on only
one side of the corridor
o Fixed furniture does not reduce the clear width of the
corridor to less than 6 ft.
o Furniture is limited to grouping that do not exceed 50 sq. ft.
and each grouping must be separating from each other by a
minimum of 10 ft.
o Furniture can not block access to building service and fire
protection equipment
o Corridors are protected by a smoke detection system or so
arranged and located to allow staff supervision from a
nurse’s station or similar space.
Jaeger & Associates, LLC
Current Life Safety Issues
2. Corridors (cont)
•
•
Noncontinuous projections not more than 6 in. from the corridor
wall, positioned not less than 38 in. above the floor are
permitted. (Section 18 & 19.2.3.4[2])
Projections into the required width of the corridor shall be
permitted for wheeled equipment provided: (Section 18.2.3.4[4])
o The wheeled equipment does not reduce the clear width of
the corridor below 60 in.. The wheeled equipment is limited
to:
1. Equipment and carts in use.
2. Medical emergency equipment not in use
3. Patient lifts and transport equipment
o The fire safety plan and staff training program addresses the
relocation of the wheeled equipment during an emergency.
Jaeger & Associates, LLC
Current Life Safety Code Issues
CMS Issues S & C Letter 10-18
Memorandum Summary
• Changes to Previous Instructions: This letter addresses
the Centers for Medicare & Medicaid Services (CMS) policy
regarding the use of corridor wall-mounted computer
touch screens.
• Installation of Corridor Wall Items: Corridor wall mounted
technologies and other items, if properly installed, shall not
be considered corridor obstructions
• Corridor Obstructions: Other items may be considered
corridor obstructions.
Jaeger & Associates, LLC
Current Life Safety Issues
3. Fireplaces (Section 18 & 19.5.2.3[2])
•
Direct vent gas fireplaces are permitted in smoke compartments
containing resident sleeping areas provided all of the following
criteria are met:
o No such device shall be located in a resident sleeping room
o The smoke compartment the fireplace is located must be
protected with quick response sprinklers
o The fireplace shall have a sealed glass front with wire mesh
panel or screen
o The controls for the fire place shall be accessible to staff
only
o A carbon monoxide detector shall be provided in the room
where the fireplace is located
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Current Life Safety Issues
Credit “ Vetter Health Services”
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Current Life Safety Issues
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Current Life Safety Issues
4. Combustible Decorations (Section 18/19.7.5.6[4[)
•
Decorations such as photographs, paintings and other art are
attached to the walls, ceilings and non required fire rated doors
in accordance with the following:
o
o
o
o
Decorations on doors do not interfere with the operation or any
required latching of the doors
Decorations do not exceed 20% of the wall, ceiling or door areas
inside any space or room in a smoke compartment that is not fully
sprinklered
Decorations do not exceed 30% of the wall, ceiling or door areas
inside any space or room in a smoke compartment that is fully
sprinklered
Decorations do not exceed 50% of the wall, ceiling or door areas
inside any resident sleeping room housing not more than 4
residents in a smoke compartment that is fully sprinklered
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Current Life Safety Issues
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Life Safety Code
Future Issues
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Future Life Safety Issues
S & C: 13-22-NH,
Issued April 5,2013
Life Safety Code Short Form for
Nursing Homes
• Reduce survey costs
•Based on all nursing homes being sprinklered
•Solely at the option of the States
Jaeger & Associates, LLC
Future Life Safety Issues
To be eligible for the short form process a facility must:
• Be fully sprinklered
• Have no significant waivers
• Not certified by the use of the Fire Safety Evaluation System (FSES)
• Have not been cited in the past 2 years for:
1. K062 Sprinkler Maintenance
2. K054 Smoke Detector Maintenance
3. K050 Fire Drills
4. K104 Smoke Barriers
5. K051 Fire Alarm
• Not have more than 2 survey cycles since last long form survey
*None of the above 5 Ktags are on Oklahoma’s Top 10 Deficiency List
Jaeger & Associates, LLC
Future Life Safety Issues
Procedure for the short form process is:
• Facility must have a superior LSC compliance track record that are
identified on the confidential list that CMS makes available to the State
Survey Agencies.
• Ktags to be surveyed for the short form are:
1. K038-Exit access
2. K039-Exit corridor width
3. K047-Exit sign operational
4. K50-Fire drills
5. K052-Fire alarm system properly maintained
6. K062-Sptinkler system properly maintained
7. K072-Means of egress unobstructed by furnishings & decorations
8. K144-Emergency generator properly maintained
9. K211 Alcohol based hand rubs properly used
Jaeger & Associates, LLC
Future Life Safety Issues
CMS has announced that they will
publish a Proposed Rule to adopt
the 2012 Life Safety Code in August
2013. Will probably be finalized
early 2014
Jaeger & Associates, LLC
Changes to 2012 Life Safety Code
Other Major Changes in the 2012 Life
Safety Code for Nursing Homes that
are not currently Waivered
• Major changes for locking of doors
• Requirements for Draperies
• Construction Types
Jaeger & Associates, LLC
Current Life Safety Issues
Changes in the 2012 Life Safety Code
Locking of Doors in the Means of Egress
•
•
•
•
2000 Life Safety Code only allows:
– Manual locking of doors for the clinical needs of the residents
– Delayed egress locks on any door, only one lock in means of
egress
2012 Edition of Life Safety Code allows the locking of doors for
the clinical needs, security or safety of residents
No limit on the number of delayed egress locks in a means of
egress
Validating what is currently being done and required in Health
Care Facilities
Jaeger & Associates, LLC
Current Life Safety Issues
Changes in the 2012 Life Safety Code
Draperies(does not include cubicle curtains)
•
•
Draperies in sprinklered sleeping rooms not
regulated
Draperies in other sprinklered rooms or areas
o
o
Individual drapery or curtain panel area does not
exceed 48 sq. ft.
Total area of drapery or curtain panels per room or
area does not exceed 20% of the aggregate area of
the wall they are located.
Jaeger & Associates, LLC
Current Life Safety Issues
Changes in the 2012 Life Safety Code
With a little good comes a little bad
There will be some more restrictive requirements
in the 2012 Life Safety Code
– The more restrictive requirements will be mainly in
the Inspection, testing and maintenance
requirements of fire protection and life safety
equipment and systems , a couple examples are:
•
•
•
Replacement of dry sprinkler heads every 10 years
Obstruction investigation of sprinkler pipe every 5 years
Increase in the requirements for fire doors
Jaeger & Associates, LLC
Life Safety Future
Issues
Jaeger & Associates, LLC
Future Life Safety Issues
Nursing Homes
Changes are being made to the
International Building Code and
International Fire Code to incorporate
all the changes made for nursing
homes in the 2012 Life Safety Code
Jaeger & Associates, LLC
Future Life Safety Issues
Assisted Living Facilities
Due to the increase in acuity rate
of residents in Assisted Living
Facilities there have been
changes in the requirements for
existing ALF’s in the 2012 Life
Safety Code
Jaeger & Associates, LLC
Future Life Safety Issues
Assisted Living Facilities
All older editions of the Life Safety
Codes gave only two options if
residents became incapable of self
preservation (age in place) in existing
ALF’s
1. Comply with existing health care
requirements
2. Transfer the residents who are incapable
of self preservation to another facility
– Existing Facilities whoseJaeger
residents
& Associates, LLC
Future Life Safety Issues
Major changes in the 2012 Life Safety Code
for Existing Assisted Living Facilities
Existing Facilities whose residents
become incapable of self preservation
will now have three options:
1. Comply with health care requirements for
existing Health Care Facilities
Jaeger & Associates, LLC
Future Life Safety Issues
Major changes in the 2012 Life Safety Code
for Existing Assisted Living Facilities
2.Transfer residents who are incapable of self
preservation to another facility
NEW • 2.Upgrade fire/life systems and
3.Upgradecontinue
fire/life systems
and
continue
to comply
with
the to
comply with
the requirements
for existing
requirements
for existing
Assisted
AssistedLiving
Living Facilities
Facilities
Jaeger & Associates, LLC
Future Life Safety Issues
Assisted Living Facilities
Changes have been made to the 2015
International Building Code (IBC) and
International Fire Code (IFC to allow
residents incapable of self
preservation to be housed in assisted
living facilities. Currently the IBC and
IFC does not allow residents who are
incapable of self preservation to be
housed in assisted living facilities.
Jaeger & Associates, LLC
Future Fire/Life Safety Issues
Bariatric Residents
• Door widths
• Room sizes
• Lifts
• Prisoner Residents
• Security
•Locks
•Staff
• Patient rights
Jaeger & Associates, LLC
Future Fire/Life Safety Issues
Increase in Enforcement of
Disaster Plans due to
Hurricanes in the Gulf
States , Tornadoes and
Floods in the Midwest and
Hurricanes and Floods in
the Northeast
Jaeger & Associates, LLC
Question & Answer
Presented by:
Thomas W. Jaeger, P.E., President
Jaeger & Associates, LLC
THANK YOU
Presented by:
Thomas W. Jaeger, P.E., President
Jaeger & Associates, LLC