Changes to the HFAP Chapters on Life Safety, Physical Environment, and Emergency Management Brad Keyes, CHSP HFAP Engineering Advisor Jamie Crouch, BSBM, MHA Clinical Safety & Regulations Specialist, Spectrum Health

NOTE: The following changes are tentative, based on the changes to the 2017 HFAP manual submitted to CMS for approval. While CMS approval is expected, some minor changes may occur that are not accounted for in this presentation.

Objectives Upon completion of this program, the learner will: Understand what changes were made to the HFAP Acute Care and Critical Access Hospital manuals mainly due to CMS adopting the 2012 Life Safety Code Realize when these changes will become effective

Why the Changes…? On May 4, 2016, CMS published their Final Rule to adopt the 2012 Life Safety Code, which became effective on July 5, 2016. However, in S&C Memo 16-29 issued June 20, 2016, CMS says they will not survey with the 2012 LSC until November 1, 2016, which allows 4 months of leniency to allow AOs and healthcare providers the opportunity to make necessary changes and get ready.

Why the Changes…? HFAP has submitted all the necessary changes to the Physical Environment, Emergency Management, and Life Safety chapters to CMS, and will be ready to enforce the new requirements associated with the 2012 LSC on November 1, 2016. Until then, healthcare providers may take advantage of the changes that lessen their compliance (i.e. waterflow switch testing, fire pump testing) that began on July 5, 2016.

Introduction There is an new Introduction to the Life Safety chapter for multiple reasons: To explain the different occupancies used in typical hospitals Removed three (3) standards that were not scoreable and made them introductory items Waivers Equivalencies New vs. Existing Construction

Introduction Emphasized the standards on ‘Definition of Time’ and ‘Documentation’ to emphasize the importance Added a paragraph on the Facility Demographic Report, emphasizing the technical aspect of the document and the need for a technical person to complete it Added a Table of Contents

Note…. Changing to the 2012 Life Safety Code caused an avalanche of changes to other NFPA standards referenced by the 2012 LSC. This presentation will not attempt to identify those standards that were change solely due to a change in the edition of a code or standard.

Note…. The following presentation does not include every change caused by the adoption of the 2012 Life Safety Code, but rather those changes that are most likely to affect the majority of healthcare providers. Healthcare providers are expected to know and understand the changes with the 2012 Life Safety Code that applies to them.

Note…. This presentation applies to both HFAP hospital manuals; the Acute Care manual and the Critical Access Hospital manual. You will note that the standards are virtually the same between the manuals with just the chapter numbering system being different.

13.00.04 14.00.04 for CAH Notification of Emergency Response Forces Modified the amount of time to implement a fire watch for sprinkler impairments from ‘4 or more hours’ to ‘10 or more hours’. [NFPA 25-2011, 5.5.2(4)] This change only applies to sprinkler impairments… not fire alarm impairments Added language to reference the new standard (13.00.09) on Fire Watches

13.00.05 14.00.05 for CAH Facility Demographic Report (FDR) Added language that the FDR is an engineering analysis report and is technical in nature and needs to be completed by a technical person There have been situations were non-technical people attempt to complete the FDR which lead to misunderstandings of basic NFPA principals

13.00.06 14.00.06 for CAH Testing & Inspection – Definition of Time Changed language to make this standard only apply to the Life Safety chapter… it does not apply to other HFAP chapters Added phrase ‘calendar’ in weekly & monthly requirement Modified quarterly, semi-annually, annual, 3-Year and 5-Year requirements to conduct the testing/inspection activity during the last month of the period.

13.00.06 14.00.06 for CAH Testing & Inspection – Definition of Time Added definition for 6-Year requirement for testing/inspection Added language that the testing/inspection activity cannot exceed the allowable amount of time to conduct the activity Deleted the scoring section as this standard is not scored. Added comment to score non-compliance under the standard that requires the test/inspection

13.00.06 14.00.06 for CAH Testing & Inspection – Definition of Time Added language to emphasize that the completion of the activity (test or inspection) is required during the indicated time period.

13.00.07 14.00.07 for CAH Testing & Inspection – Documentation Added language regarding fire extinguisher documentation. The requirements of this standard do not apply to the annual inspection and maintenance tags located on portable fire extinguishers. Deleted the scoring section as this standard is not scored. Added comment to score non-compliance under the standard that requires the test/inspection

13.00.09 14.00.09 for CAH Fire Watch This is a brand new standard on Fire Watches, based on CMS’ directive found in their Final Rule to adopt the 2012 Life Safety Code. A Fire Watch now requires a dedicated individual who performs no other duties, to constantly circulate in the areas affected by the impairment, looking for fire, fire hazards, or hazardous conditions that may affect the fire safety of the facility. [NFPA 25-2011, A.15.5.2(4)(b)]

13.00.09 14.00.09 for CAH Fire Watch ‘Constantly circulates’ means this individual may not leave the impaired area unless he/she is relieved by another individual. The individual performing the Fire Watch must be trained on Fire Watch responsibilities. The training is documented. Fire Watches are documented.

13.01.01 14.01.01 for CAH Doors Removed language allowing a device that keeps the door closed with 5 lbs. of force on existing conditions that was installed prior to 1970. Added language that horizontal sliding doors do not have to be side-hinged or break-away if the door serves less than 10 people. [19.2.2.2.10.2]

13.01.02 14.01.02 for CAH Door Locks Removed language allowing only one delayed egress lock in the path of egress. Added language that described new elevator door locks. [19.2.2.2.4 and 7.2.1.6.3] Added language allowing two releasing operations (i.e. deadbolt locks) in existing conditions on doors serving no more than 3 persons. [19.2.2.2.4(5) and 7.2.1.5.10.6] Added language to allow special locking arrangements for patient security. [19.2.2.2.5.2]

13.01.02 14.01.02 for CAH Here are the specific requirements for elevator lobby locks (7.2.1.6.3): Doors separating elevator lobbies and exit access corridors may be electrically locked The building is protected throughout with sprinklers The elevator lobby is protected with smoke detectors Initiation of the building fire alarm system by other than manual pull stations unlocks the locks, until the fire alarm system is reset Loss of power to the locks unlocks the door

13.01.02 14.01.02 for CAH The elevator lobby could be considered two ways: 1) The lobby is a room; therefore the door between the lobby and the corridor must latch, or 2) The lobby is a continuation of the exit access corridor, and if it is a dead-end, it cannot extend more than 30 feet. A two-way communication system to a constantly staffed location is provided in the elevator lobby (The typical nurse station is not constantly staffed). The staff at the constantly staffed location are capable, trained and authorized to provide emergency service. Delayed egress locks and access control locks are not permitted

13.01.02 14.01.02 for CAH Where would you find elevator lobby locks in a healthcare setting…? Mainly where the elevator opens onto a lobby that is separated from the rest of the floor due to security (i.e. psychiatric, forensic, etc.) or for patient safety (i.e. nurseries, L&D, Mother/Baby, etc.)

13.01.02 14.01.02 for CAH Here are the specific requirements for locking arrangements where the patient special needs require specialized protective measures for their safety (i.e. nurseries, L&D, ICU, ER) elevator lobby locks (19.2.2.2.5.2): Staff can readily unlock doors at all times The building is protected throughout with sprinklers

13.01.02 14.01.02 for CAH The entire locked area is smoke detected (i.e. smoke detectors in all rooms and corridors), or the locked doors can be unlocked at a constantly attended location inside the locked area (NOTE: The typical nurse station is not constantly attended) The locks are electrical locks that fail safe (unlock) on loss of power The locks release upon activation of the fire alarm system and the sprinkler system

13.01.03 14.01.03 for CAH Corridor Clutter Added language to allow fixed furniture in corridors 8 feet wide, provided: There is 6 feet clear width The group of fixed furniture is on one side of the corridor and not more than 50 square feet The groups of fixed furniture are separated by 10 feet and do not obstruct access to building features The corridor is protected with smoke detectors or the fixed furniture is under direct supervision

13.01.03 14.01.03 for CAH Corridor Clutter Added language to allow certain wheeled equipment to be left unattended in corridors, provided 5 feet clear width remains; the fire safety plan and training program addresses the relocation of the wheeled equipment during a fire alarm; wheeled equipment is limited to: Carts in use Medical emergency equipment not in use Patient lift & transport equipment

13.01.03 14.01.03 for CAH Corridor Clutter Computers on Wheels are not considered medical emergency equipment and therefore are not permitted to be left in the corridor unattended for more than 30 minutes

13.01.04 14.01.04 for CAH Suites Modified the language to allow sleeping suites up to 7,500 square feet and 10,000 square feet, provided they meet the requirements of 19.2.5.7.2.3.(A) and (B) Added language that specifies suites must be separated from all other areas by barriers equal to corridor walls [19.2.5.7.1.2] Hazardous areas inside a non-sleeping suite do not have to be separated if the entire suite is considered a hazardous area (i.e. Lab) [19.2.5.7.1.3(C)]

13.01.04 14.01.04 for CAH Suites Spaces containing sterile surgical materials limited to one-day supply in ORs or similar spaces that are sprinklered are permitted to be open to the remainder of the suite without separation [19.2.5.7.1.3(D)] If the suite requires two means of egress, then one of the means of egress is permitted to another suite, provided the separation between the two suites complies with corridor requirements. [19.2.5.7.2.2(C)]

13.01.04 14.01.04 for CAH Suites Maximum travel distance from any point in a sleeping suite to an exit access door is 100 feet. [19.2.5.7.2.4(A)] Sleeping suites must be provided with constant staff supervision within the suite. [19.2.5.7.2.1(C)] Maximum travel distance from any point in a non-sleeping suite to an exit access door is 100 feet. [19.2.5.7.3.4(A)]

13.01.07 14.01.07 for CAH Corridor Due to a CMS decision, maximum corridor projections are limited to 4 inches rather than the 6 inches specified in the 2012 Life Safety Code Alcohol based hand-rub (ABHR) dispensers are required to be separated from each other by 48 inches [19.3.2.6(4)] ABHR dispensers must have 1 inch clearance side-to-side to ignition sources and cannot be mounted over them [19.3.2.6(8)]

13.01.08 14.01.08 for CAH Path of Egress Obstructions ‘Corridors’ was deleted from examples where this standard applies, since corridors has it’s own standard

13.01.10 14.01.10 for CAH Exit Enclosures Added language that allows existing unoccupied mechanical rooms to open onto an exit enclosure (i.e. stairwell) provided: No fuel-fired equipment in the mechanical room. The space does not contain any storage of combustibles (i.e. boxes of spare parts, filters, supplies) The building is protected throughout with automatic sprinklers. [7.1.3.2.1(9)(c)]

13.01.10 14.01.10 for CAH Exit Enclosures Added language that allows fire alarm circuits in conduit in existing exit enclosures [7.1.3.2.1(10(i)] Added language requiring stairwell interruption gates in stairwells that extend more than one-half story beyond the level of exit discharge [7.7.3.4]

13.02.02 14.02.02 for CAH Fire Alarm System – Testing Deleted requirement for quarterly waterflow switch testing.

13.02.03 14.02.03 for CAH Fire Alarm System – Transmitting Signal Changed the requirement for testing the off-premises fire alarm monitoring equipment from quarterly, to annually.

13.03.03 14.03.03 for CAH Water Based Fire Protection – Control Valves, Piping & Hangers Deleted reference to section 9.7 regarding tamper switches on control valves. The Life Safety Code technical committee moved this requirement to the Annex section, A.9.7.2.1, but it still will be enforced by HFAP. Added HVAC duct to list of items not permitted to be suspended from sprinkler pipe.

13.03.04 14.03.04 for CAH Fire Pumps – Monthly Test Changed title from ‘Weekly’ to ‘Monthly’ Added language to differentiate between ‘electric motor driven’ fire pumps, and ‘engine driven’ fire pumps Added language that no-flow tests are now required monthly for electric motor driven fire pumps, rather than weekly [NFPA 25-2011, 8.3.1.2]

13.03.05 14.03.05 for CAH Fire Pumps – Annual Test Deleted requirement for a 30-minute churn test during the annual flow test.

13.03.06 14.03.06 for CAH Alternative Fire Suppression Systems – Installation & Testing Deleted cooking hood fire suppression systems from list of alternative systems since there is a separate standard for cooking hood fire suppression systems

13.03.07 14.03.07 for CAH Water Based Standpipe & Hoses – Inspection & Test Modified existing language to apply to wet standpipes Added new language to allow dry standpipes to be hydrostatic tested. [NFPA 25-2011, 6.3.2.1] Added language to include fire department connections as dry standpipes needing hydrostatic testing (NEW) [NFPA 25-2011, 6.3.2.1]

13.03.08 14.03.08 for CAH Water Based Fire Department Connections Deleted comment regarding fire hose connections which was a poor attempt to differentiate them from fire department connections

13.03.09 14.03.09 for CAH Portable Fire Extinguishers Deleted comment that fire extinguisher cabinets are required to be marked. Added language that fire extinguishers that are visually obstructed must have means to indicate their locations. This includes extinguishers in cabinets that are flush with the wall or recessed into the wall. If extinguisher cabinets extend from the wall into the corridor (or room) then they are not required to be marked. [NFPA 10-2010, 6.1.3.3.2]

13.03.09 14.03.09 for CAH Portable Fire Extinguishers Added language that permits electrical monitoring of fire extinguishers through the fire alarm system. [NFPA 10-2010, 7.2.1.2]

13.03.10 14.03.10 for CAH Fire Hose Valves This is a new standard and a new obligation that requires quarterly inspections of all fire hose valves, and annual test on 2½ inch valves and 3-Year test on 1½ inch valves. The test requires the fire hose valve to be opened, but full flow of water is not required [NFPA 25-2011, 13.5.6]

13.03.11 14.03.11 for CAH Internal Inspection of Piping This is a new standard and a new obligation that requires the sprinkler piping to be internally inspected on a 5-Year basis, by removing a cap or opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line, looking for foreign material and slime. If slime is found, it must be tested for Microbiological Influenced Corrosion (MIC). [NFPA 25-2011, 14.2 ]

13.03.12 14.03.12 for CAH Cooking Hood Fire Suppression This is a new standard on an existing requirement to inspect cooking hood fire suppression systems. There are two inspection requirements: Monthly, conducted by the owner’s representatives Semi-annually, conducted by a certified contractor [NFPA 17A, 2009] The presence of a NFPA 96 compliant fire extinguishing system in the cooking hood allows the kitchen to not have to be classified as a hazardous area, due to the heat producing appliances. [19.3.2.5.5]

13.04.02 14.04.02 for CAH Smoke Barriers Changed title to ‘Smoke Barriers’ to be consistent with NFPA nomenclature [19.3.7.1] Modified the language to refer to them as ‘Smoke Barriers’ rather than Smoke Compartment Barriers [19.3.7.1]

13.04.03 14.04.03 for CAH Fire & Smoke Dampers Added language to require a ‘Pass’/’Fail’ decision in the damper test/inspection report [13.00.07] Changed language to require documents to be maintained for 6 years.

13.04.05 14.04.05 for CAH Construction Type Added language to require the use of NFPA 220-2012 nomenclature

13.04.06 14.04.06 for CAH Separated Occupancies Added language that a 2-hour fire rated floor assembly is permitted for an occupancy separation, but is not allowed for a building separation (i.e. separating construction types) Building separations must be vertical and not allowed to be horizontal.

13.04.07 14.04.07 for CAH Fire Rated Door Assemblies Added language that all fire rated doors assemblies (including side-hinged swinging doors) must be tested and inspected on an annual basis. [7.2.1.15.2] Added language that frames on 3-hour fire rated door assemblies must have an hourly rating on the label. Deleted phrase ‘undercuts’ and inserted ‘space between the door and the floor’ to be consistent with NFPA

13.05.01 14.05.01 for CAH Fireplaces Re-wrote the standard to allow direct-vent gas fireplaces to be located in smoke compartments containing patient sleeping rooms, as long as the fireplace is not located in a patient sleeping room. Other requirements: CO detector located in the room with the fireplace The smoke compartment must be protected with sprinklers The fireplace has a sealed glass front with a wire mesh panel or screen The controls for the fireplace are secured or locked [19.5.2.3]

13.05.04 14.05.04 for CAH Generator Inspection Added language to allow sealed lead-acid type batteries provided a conductive test is performed weekly [NFPA 110-2010, 8.3.7.1] Added language to require an annual fuel quality test. [NFPA 110-2010, 8.3.8] Added language to require a remote stop switch. [NFPA 110-2010, 5.6.5.6]

13.05.05 14.05.05 for CAH Generator Inspection Modified annual load test to run for 90 minutes instead of 2-hours [NFPA 110-2010, 8.4.2.3]

13.05.10 14.05.10 for CAH Medical Gas Systems & Equipment – Maintenance Modified language to require electrical devices in gas storage rooms or manifold rooms to be protected or mounted 60 inches above the floor. [NFPA 99-2012, 5.1.3.3.2 (10)] Deleted word ‘dedicated’ for mechanical ventilation systems. They may now be shared with other ventilation systems connected to spaces that do not contain combustible or flammable materials. [NFPA 99-2012, 9.3.7.5.3.5]

13.05.10 14.05.10 for CAH Medical Gas Systems & Equipment – Maintenance Added language on ventilation requirements for storage rooms and manifold rooms. One cfm per five cubic feet of compressed gas, designed to be stored in the space, but not less than 50 cfm and not more than 500 cfm. [NFPA 99-2012, 9.3.7.5.3.2] Note: This ventilation requirement only applies to new construction.

13.05.12 14.05.12 for CAH Health Care Facilities Code This is a new standard that identifies NFPA 99-2012 edition has been adopted with the exception of chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management) and 13 (Security). Tentative Interim Amendments TIA-12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6 were also adopted. . CMS is allowing waivers on unreasonable hardships in meeting certain provisions of NFPA 99, provided it does not pose a safety risk to the patients.

13.05.12 14.05.12 for CAH Health Care Facilities Code NFPA 99 is applicable to all healthcare facilities, except home care. Existing systems that are not in strict compliance with NFPA 99 are permitted to be continued in use, unless HFAP has determined such use constitutes a distinct hazard to life.

13.05.12 14.05.12 for CAH Health Care Facilities Code A Risk Assessment is required to be conducted by the healthcare organization on certain building services to determine the risk Category that the system must comply with The Risk Assessment must be reviewed and approved by the organization’s Safety Committee

13.06.01 14.06.01 for CAH Decorations Modified language to allow combustible decorations under the following conditions: Decorations cannot interfere with door operations Decorations do not exceed more than 20 percent of wall and ceiling area in a room, space, or smoke compartment that is unsprinklered Decorations do not exceed more than 30 percent of wall or ceiling area in a room, space, or smoke compartment that is sprinklered Decorations do not exceed more than 50 percent of wall or ceiling area in patient sleeping rooms having a capacity not exceeding four persons [19.7.5.6(4)]

13.06.01 14.06.01 for CAH Decorations Added language that doors cannot be covered or obscured.

13.06.02 14.06.02 for CAH Trash Receptacles Added language to allow containers for clean waste and containers for patient records awaiting destruction to not exceed 96 gallons capacity and not have to be stored in a designated hazardous room, provided the container is labeled and listed as meeting the requirements of FM Approval Standard 6921, or equal.

13.06.04 14.06.02 for CAH Life Safety Drawings Modified the language to accommodate the change in name from smoke compartment barriers to smoke barriers.

13.06.05 14.06.05 for CAH Alcohol Based Hand-Rub Dispenser Added language to allow ABHR dispensers in corridors of ambulatory healthcare occupancies Added language that one ABHR dispenser per room does not contribute to the aggregate total of dispensers per smoke compartment. Modified requirement regarding mounting ABHR dispensers close to electrical sources (now allowed to be 1 inch side-to-side) Modified maximum projection into corridors to be 4 inches. [19.3.2.6]

13.06.06 14.06.06 for CAH Definition of New Construction and Existing Conditions Deleted entire standard and moved content to the chapter Introduction.

13.07.01 14.07.01 for CAH CMS Waiver of the Life Safety Code Deleted entire standard and moved content to the chapter Introduction.

13.07.02 14.07.02 for CAH Fire Safety Evaluation System Deleted entire standard and moved content to the chapter Introduction.

Facility Demographic Report There have been a couple major changes to the FDR… Included the NFPA definitions of Healthcare occupancies, Ambulatory healthcare occupancies, and Business occupancies Modified Line 14 to limit which Construction Type can be selected

Facility Demographic Report Modified Line 21 to limit where smoke detectors are located Modified Line 24 to include special locks on doors for Elevator lobbies, and Specialized protective measures New Line 27 requires the organization to identify the Category designation for their building services Deleted the line inquiring about Categorical Waivers

Transition… Those are the changes to the 2016 HFAP Life Safety chapter in the Acute Care manual and the Critical Access manual… Now let’s focus our attention on the Emergency Management chapter and the Physical Environment chapter…

11.01.01 03.01.01 for CAH Periodic Monitoring for Safety Issues Changed language from ‘resolution’ to ‘action item’ regarding inspection reports. Inspections must be documented with date, initials or signatures of individuals participating in the inspection, and all deficiencies identified with the action item of said deficiencies.

11.01.03 03.01.03 for CAH Safety Committee Changed title from ‘Safety Team/Committee’ to ‘Safety Committee’ Added language to Safety Committee responsibilities: Meets periodically Review reports Analyze trends Discuss safety related issues in the physical environment Identify opportunities to resolve physical environment safety issues.

11.01.03 03.01.03 for CAH Safety Committee Added language that the Safety Committee reports appropriate results of monitoring and committee actions and recommendations to leadership, Quality Assessment Performance Improvement (QAPI), and department managers. Added language that HFAP does not specify the frequency of Safety Committee meetings, but meetings held less than once every two months require a risk assessment to indicate the effectiveness of less frequent meetings.

11.01.04 03.01.04 for CAH Safety Committee Changed title from ‘Safety Team/Committee Chairperson’ to ‘Safety Committee Chairperson’ Deleted ‘Team’ from reference to Safety Committee Deleted language regarding chairperson has sufficient administrative support (ambiguous).

11.01.05 03.01.05 for CAH Safety Officer Deleted requirement to reaffirm appointment annually. The appointment needs to be documented, but no longer is there a requirement to reaffirm it every year.

11.01.07 03.01.07 for CAH Safety Team/Committee Functions Combined the content of 11.01.07 with 11.01.03 and DELETED 11.01.07.

11.01.08 03.01.08 for CAH Review of Safety Policies/Procedures Deleted the term ‘Team’ from the reference to ‘Safety Team/Committee’. Deleted the requirement that a cover memo to leadership is required regarding policy review.

11.02.02 03.02.02 for CAH Security Management Added content from 11.02.03 to combine these standards into one.

11.02.03 03.02.03 for CAH Local Security Support Moved content from this standard to 11.02.02 and DELETED this standard.

11.03.01 03.03.01 for CAH Hazardous Materials & Waste Program Added language to define what Hazardous Materials actually are: A hazardous material is defined as any substance or material that could adversely affect the safety of the public, handlers or carriers during use, transportation, storage, or disposal. Added language to require the individual designated to be responsible for spills, to be in writing Added language to interview staff on spill training

11.03.02 03.03.02 for CAH Storage & Disposal of Trash Deleted language regarding the language on the CMS CoP reference on radioactive materials. Added language to have written procedures approved by the Safety Committee every 3 years.

11.03.03 03.03.03 for CAH Program Minimizes Exposure Deleted requirement to have policies on decontamination. This is covered in the Emergency Management chapter.

11.03.04 03.03.04 for CAH Labels, Inventory & SDS Changed time required to produce copies of SDS from 5 minutes to 10 minutes.

11.03.06 03.03.06 for CAH Hazardous Materials – Routine Monitoring Deleted examples in the Document Review section. It implied ethylene oxide and nitrous oxide were the only hazardous materials requiring monitoring.

11.04.01 03.04.01 for CAH Written Fire Control Plans Modified who the Fire Safety plan is made available to; instead of ‘supervisory staff’, changed to just read ‘staff’.

11.04.02 03.04.02 for CAH Fire Drills - Quarterly Added language that audible notification devices (i.e. chimes, horns) may be silenced between 9:00 pm and 6:00 am but the fire alarm system still has to be activated. Added language that staff participates in fire drills inasmuch as the policy requires them to. Deleted the definition of quarterly and annual frequencies. Drills are now allowed to be conducted anytime during the calendar quarter, and anytime during the calendar year.

11.04.04 03.04.04 for CAH Approved by State & Local Authorities Changed ‘plus or minus 30 days’ to read ‘once per calendar year.

11.04.06 03.04.06 for CAH Fire Response – Staff Training Deleted requirement to have fire response groups.

11.06.08 03.06.08 for CAH Potable Water Deleted the definition of the term ‘Annual’. Now the water is required to be tested anytime during the calendar year.

11.07.01 03.07.01 for CAH Adequate Facilities & Supplies Combined 11.07.02 with 11.07.01 and vacated 11.07.02. Added language regarding window sill height for new construction patient sleeping rooms.

11.07.02 03.07.02 for CAH Facilities Located for Safety of Patients Combined 11.07.02 with 11.07.01 and DELETED 11.07.02.

11.07.07 03.07.07 for CAH Monitoring the Physical Environment Added language that offsite patient care areas are inspected semi-annually.

Transition…. Now let’s take a look at the one change in the Emergency Management chapter….

09.02.01 17.02.01 for CAH Emergency Exercises Changed language that requires hospital to ‘conduct two exercises within the past 12 months’, to ‘conduct two exercises within the past calendar year’.

Other Changes… Where ever an ‘annual’ requirement is cited in the EM chapter, it now allows that activity to occur anytime during the calendar year. Where ever a ‘semi-annual’ requirement is cited in the EM chapter, it now allows that activity to occur anytime during the 6 month period.

In Conclusion… So… Be prepared to have all 2012 Life Safety Code requirements completed by November 1, 2016. That means you need to have all of the new requirements completed by November 1, including: Your first quarterly fire hose valve inspection Your first annual fire door test/inspection Your first annual fire hose valve test Your first 3-Year fire hose valve test Your first 5-Year sprinkler pipe internal inspection You cannot wait to perform your ‘first’ test/inspection after November 1.

Questions? Brad Keyes, CHSP bkeyes@hfap.org 815-629-2240

Changes to the HFAP Chapters on Life Safety, Physical Environment, and Certificate of Attendance ___________________________ Awarded 1.5 contact hours Changes to the HFAP Chapters on Life Safety, Physical Environment, and Emergency Management A 90 minute audio-conference October 4, 2016 _________________ Brad Keyes, Presenter