The Top Life Safety Code Findings
Cited by HFAP Surveyors
in 2012
Brad Keyes, CHSP
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,
on March 11, 2003
Healthcare Facilities Accreditation Program
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The New 2012 Life Safety Code
Accreditation organizations (such as HFAP) are
required to survey hospitals for compliance with
the 2000 edition, and cannot move to the more
recent edition until CMS adopts it
Last time, it took CMS, 3 years to
adopt the 2000 edition after they
said they were ‘reviewing’ it, so
look for this to become final in 2014 or 2015
Healthcare Facilities Accreditation Program
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The New 2012 Life Safety Code
There are significant changes in store for
hospitals and ASC when the 2012 edition is
finally adopted
HFAP will address those
changes in future webcasts
Healthcare Facilities Accreditation Program
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The Top Five LSC Findings
During 2012, HFAP surveyors identified the
following issues for opportunities for
improvement in regards to life safety
compliance:
1.
2.
3.
4.
5.
Corridor clutter
Rated wall penetrations
Fire alarm records
Doors
ALSM implementation
Healthcare Facilities Accreditation Program
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Corridor Clutter
Corridors must remain free of unattended items
for the required width of the corridor
Exception!
Crash carts and isolation supply carts are
excluded, as long as the carts are mounted on
wheels, and staff has been trained to relocate
the carts during a fire alarm
Healthcare Facilities Accreditation Program
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Corridor Clutter
Isolation supply carts are only permitted as long
as they are outside a patient’s room that is
currently on contact precautions
(Signs must be posted)
This does allow unattended items to be staged
in corridors for up to 30 minutes before it
becomes a deficiency
Healthcare Facilities Accreditation Program
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Corridor Clutter
Scenes like this will lead to surveyor findings
during a survey
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Corridor Clutter
‘Attended’ means an item is actively in use and
attended by a person, who must be located on
the unit
This may include housekeeping carts, foodservice
carts, maintenance carts, linen and trash carts,
computers on wheels…
Any item that has a person assigned to it and the
cart is accessed at least every 30 minutes
Healthcare Facilities Accreditation Program
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Corridor Clutter
However… Once the cart is no longer attended,
then it must be relocated to an appropriate
storage space
Healthcare Facilities Accreditation Program
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Corridor Clutter
The required width of the corridor is up to 8 feet
wide
New construction requires 8 foot wide corridors,
but existing may allow less
Nothing may be located in the corridor that
obstructs the required width (up to 8 feet)
Healthcare Facilities Accreditation Program
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Corridor Clutter
However, if the corridor is wider than 8 feet,
then you are permitted to store noncombustible items
as long as they do
not obstruct the
required width of
the corridor
(up to 8 feet)
Healthcare Facilities Accreditation Program
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Rated Wall Penetrations
The integrity of fire rated barriers and smoke
compartment barriers must remain intact in
order to prevent the transfer of smoke during a
fire
All wires, cables, pipes, conduits and ducts that
penetrate rated barriers must be properly sealed
Healthcare Facilities Accreditation Program
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Rated Wall Penetrations
Penetrations must be sealed by approved fire
rated materials (i.e. fire caulk) and methods to
ensure smoke-tight enclosures
Healthcare Facilities Accreditation Program
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Rated Wall Penetrations
Healthcare Facilities Accreditation Program
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Rated Wall Penetrations
Even repairs and
patching of holes
in rated walls
must be done
correctly, and in
accordance with
UL or FM Global
listings
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Fire alarm systems must be tested in accordance
with NFPA 72 (1999 edition)
Frequent deficiencies with
fire alarm test reports:
1. Test report does not list every device in the fire
alarm system, its location, and whether it passed
or failed its test
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Deficiencies with fire alarm test reports:
2. Not all devices are tested
•
•
•
•
•
•
Smoke, heat and duct detectors
Pull stations
Strobes, horns and bells
Control panels
Batteries
Interface devices
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Interface devices are relays and control modules
that connect the fire alarm system to other
devices, such as:
–
–
–
–
–
–
–
Magnetic locks
Magnetic hold-opens
Air handler shut-down
Smoke dampers
Fire pump
Elevator recall
Other fire suppression systems
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Deficiencies with fire alarm test reports:
3. Batteries in all control panels and NAC panels are
not tested properly:
•
•
•
Charger test
Discharge test
Load voltage test
(annually)
(annually)
(semi-annual)
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Deficiencies with fire alarm test reports:
4. Fire alarm technicians (whether they are your
employees or a
contractor’s) are not
properly certified,
licensed or work
for an approved
fire alarm contractor
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Deficiencies with sprinkler test reports:
1. Annual inspection is not conducted
2. Main drain tests are not conducted at system
risers
3. Annual control valve exercise is not performed
4. 5-year standpipe water-flow test not performed
5. Fire pump annual flow test is not performed
under emergency power
Healthcare Facilities Accreditation Program
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Life Safety Test Records
Deficiencies with emergency power generator
test reports:
1. Monthly load tests conducted outside of the 20
day / 40 day window
2. Not all Automatic Transfer Switches (ATS) are
tested each month
3. Annual load test not performed when a monthly
load test fails to meet 30% of the nameplate
capacity
Healthcare Facilities Accreditation Program
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Doors
Some doors are fire rated doors, while other
doors are non-rated, but they all must resist the
passage of smoke and close properly
Frequent deficiencies with doors:
1. Corridor doors (non-rated) do not close and latch
properly
Healthcare Facilities Accreditation Program
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Doors
Corridor doors cannot be propped open with
wedges or stops
Healthcare Facilities Accreditation Program
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Doors
Corridor doors cannot have roller latches
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Doors
Damaged fire rated doors must be replaced
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Doors
Labels on fire rated
doors are not legible
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Alternative Life Safety Measures
Alternative Life Safety Measures (ALSM) are also
known as Interim Life Safety Measures, must be
implemented to compensate for a life safety
deficiency
If part of the sprinkler system or fire alarm
system is impaired, then ALSM must be
implemented, such as a fire watch
Healthcare Facilities Accreditation Program
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Alternative Life Safety Measures
Other life safety impairments that would
requires ALSM:
– Partial or total obstruction of an exit access
corridor
– Closing an exit stairwell for maintenance
– Unsealed penetrations discovered in rated barriers
– Defective fire or smoke damper
– A fire alarm device that failed its test
Healthcare Facilities Accreditation Program
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Alternative Life Safety Measures
Other life safety impairments that would
requires ALSM:
– Non-functioning fire pump
– Sprinkler control valve that is not electronically
supervised
– Generator that failed its monthly load test
– Battery powered emergency lights with dead
batteries
Healthcare Facilities Accreditation Program
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Alternative Life Safety Measures
Possible measures to consider for
implementation:
– Staff education: Notify staff in area where
impairment is located of deficient life safety
– Staff education: Special training for staff affected
by impairment
– Daily inspections: Perform daily rounds of
impaired area
Healthcare Facilities Accreditation Program
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Alternative Life Safety Measures
Possible measures to consider for
implementation:
– Signage: Post signs identifying alternative exits
– Additional fire fighting equipment: Provide extra
fire extinguishers for area with impairment
– Temporary construction barriers: Provide
temporary non-combustible, smoke-tight fire
barriers in impaired area
Healthcare Facilities Accreditation Program
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Alternative Life Safety Measures
Possible measures to consider for
implementation:
– Debris removal: Enforce general housekeeping
practice by removing all debris daily from
impaired area
– Extra fire drill: Conduct an extra fire drill per shift
per quarter in the affected area
Healthcare Facilities Accreditation Program
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Alternative Life Safety Measures
All life safety deficiencies must be assessed for
ALSM if the deficiency cannot be resolved the
same day it is discovered
Once ALSM activity begins, it must continue
until the life safety deficiency is resolved
Healthcare Facilities Accreditation Program
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The Top Life Safety Code Findings Cited
by HFAP Surveyors in 2012
Questions?
Brad Keyes, CHSP
bkeyes@hfap.org
(815) 742-4367