Brad Keyes, CHSP Senior Consultant for HFAP Understanding the New CMS Categorical Waivers on the 2012 Life Safety Code Brad Keyes, CHSP Senior Consultant for HFAP

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

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 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 late 2014 or early 2015 Healthcare Facilities Accreditation Program

The New 2012 Life Safety Code There are significant changes in store for hospitals when the 2012 edition is finally adopted In an unprecedented act of charity, CMS has decided to allow hospitals to use certain portions of the 2012 LSC now, rather than to wait until the full document is adopted Healthcare Facilities Accreditation Program

The New 2012 Life Safety Code This signifies that CMS still intends to adopt the 2012 edition of the LSC, and is on-track to do so. Some naysayers are saying that CMS is stalling the process of adopting the 2012 LSC, CMS must follow the Administrative Procedures Act of 1946 which requires a prolong procedure of conducting due diligence, posting proposed rules, soliciting public comments and developing responses Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Categorical Waivers On August 30, 2013, CMS issued the Survey & Certification memo S&C-13-58-LSC that permits healthcare facilities to use certain portions of the 2012 LSC This action is allowed under Federal regulations whereby CMS may waive specific provisions of the 2000 LSC which if rigidly applied would result in unreasonable hardship on a healthcare provider Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Categorical Waivers CMS did not explain why all of a sudden, after 10 years with the 2000 LSC they believe compliance with these specific sections is considered a hardship to hospitals… but we don’t look a gift horse in the mouth CMS refers to these waivers as ‘categorical’, meaning they are given outright without the hospital having to request them Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Categorical Waivers There are a few conditions hospitals must follow in order to utilize these categorical waivers: They are only offered and permitted in healthcare occupancy facilities (hospitals, nursing homes, and limited care facilities) The organization must formally elect to use one or more of the waivers and they must document this decision. There is no need to apply to CMS or HFAP for the use of these waivers. Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Categorical Waivers Conditions (cont’d): The organization must notify the survey team at the entrance conference of a survey that they have elected to use one or more categorical waivers, and present the documentation demonstrating their decision to do so (NOTE: It is not acceptable to first notify surveyors of waiver election after a LSC citation has been issued.) Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Categorical Waivers Conditions (cont’d): The survey team will review the documentation and assess the facility to confirm that all conditions of the waiver are met Deficiencies to the 2000 LSC that qualify for the CMS categorical waivers will not be cited as long as all of the other conditions are met for the categorical waivers Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Categorical Waivers HFAP has decided to endorse the CMS categorical waiver process for our accredited organizations, but only in healthcare occupancies NOTE: It is the responsibility of the healthcare organization to read, understand and fully comply with the conditions of the S&C 13-58-LSC memo Healthcare Facilities Accreditation Program

1. Medical Gas Master Alarm The 2000 LSC requires compliance with the 1999 edition of NFPA 99, which does not allow the use of a centralized computer as a substitute for medical gas alarm panel However, the 2012 LSC refers to the 2012 edition of NFPA 99, and section 5.1.9.4 does allow the use of a centralized computer in lieu of one of the master alarms Healthcare Facilities Accreditation Program

1. Medical Gas Master Alarm Therefore, a categorical waiver is permitted to allow a centralized computer system to substitute for one of the Category 1 medical gas alarm panels, but only if the organization is in compliance with all other NFPA 99-1999 provisions, as well as section 5.1.9.4 of the NFPA 99-2012 Healthcare Facilities Accreditation Program

2. Openings in Exit Enclosures The 2000 LSC limits openings in exit enclosures (stairwells, exit passageways) to the following: Doors for egress from the enclosure Doors from normally occupied spaces Doors from corridors Doors to interstitial spaces in Type I and Type II buildings, used solely for the distribution of pipes, ducts and conduits Healthcare Facilities Accreditation Program

2. Openings in Exit Enclosures Unfortunately, many hospitals were constructed with unoccupied mechanical rooms at the top of the facility with access to/from the exit stairwell Resolving this problem by construction of an alternative exit is impractical and burdensome Healthcare Facilities Accreditation Program

2. Openings in Exit Enclosures The 2012 LSC, section 7.1.3.2(9)(c) allows existing openings to unoccupied mechanical equipment spaces, provided the following is met: The door assembly is fire-rated The mechanical space does not contain fuel-fired equipment The mechanical space does not contain combustible storage The entire building is protected with sprinklers Healthcare Facilities Accreditation Program

2. Openings in Exit Enclosures Therefore, a categorical waiver is permitted to allow existing openings in exit enclosures, but only if the organization is in compliance with all other 2000 LSC provisions on exiting, as well as section 7.1.3.2.1(9)(c) 2012 LSC Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 3. Emergency Generators The 2000 LSC requires emergency power generators to comply with NFPA 110 (1999 edition). NFPA 110 (1999 edition) requires diesel-powered generators that do not meet the monthly load test to operate annually with various loads for 2 continuous hours. Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 3. Emergency Generators The 2012 LSC requires compliance with NFPA 110 (2010 edition) which allows for a 90-minute load test for generators that do not meet their monthly load test requirements. The shorter run time for the annual test will save generator run time and reduce negative environmental impacts. Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 3. Emergency Generators The 2010 NFPA 110 allows for a 90-minute annual load test when the monthly load test requirements are not met. The requirements are: Operate the generator at not less than 50% capacity for 30 minutes Operate the generator at not less than 75% capacity for 60 minutes Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 3. Emergency Generators Therefore, a categorical waiver is permitted to allow the annual load test on emergency power generators to operate at 90-minutes, but only if the organization is in compliance with all other 1999 NFPA 110 provisions on generator inspection and testing, as well as section 8.4.2.3 of NFPA 110, 2010 edition. Healthcare Facilities Accreditation Program

4. Door Locks: Security Measures The 2000 LSC permits doors to be locked in the path of egress for clinical needs patients, such as patients in behavioral health units and Alzheimer units. However, the definition of ‘clinical needs’ did not carry over for the security needs of the patients, such as ER patients, ICU patients and pediatric or nursery patients. Healthcare Facilities Accreditation Program

4. Door Locks: Security Measures The 2012 LSC allows for door locking arrangements for patients requiring security measures, such as ER, ICU, Nursery and Pediatric patients. However, the following conditions must be met: Healthcare Facilities Accreditation Program

4. Door Locks: Security Measures Staff can readily unlock doors at all times Smoke detectors provided throughout the locked space, or: Locked doors can be remotely unlocked at a constantly attended location within the locked space The building is protected throughout by an approved automatic sprinkler system The locks are electrical that fail safe to release the locks upon loss of power The locks release upon activation of the smoke detectors within the locked space The locks release upon activation of the sprinklers Healthcare Facilities Accreditation Program

4. Door Locks: Security Measures Therefore, a categorical waiver is permitted to allow door locking arrangements where patient pose a security risk, but only if the organization is in compliance with all other 2000 LSC provisions on door provisions, as well as sections 18/19.2.2.2.2 through 18/19.2.2.2.6 of the 2012 LSC Healthcare Facilities Accreditation Program

5. Door Locks: Delayed Egress The 2000 LSC only allowed one delayed egress lock in the path of egress It has been determined that more than one delayed egress lock may be required along the path of egress to accommodate clinical, security, and other special needs patients. Healthcare Facilities Accreditation Program

5. Door Locks: Delayed Egress The 2012 LSC allows more than one delayed egress lock in the path of egress, provided: The entire building is protected with automatic sprinklers , or; The entire building is protected with smoke detectors Other provisions as listed in 7.2.1.6.1 Healthcare Facilities Accreditation Program

5. Door Locks: Delayed Egress Therefore, a categorical waiver is permitted to allow more than one delayed egress lock in the path of egress, but only if the organization is in compliance with all other 2000 LSC provisions as well as section 18/19.2.2.2.4 of the 2012 LSC Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 6. Suites The 2000 LSC limits sleeping suites to 5,000 square feet in size, and when the sleeping suite exceeds 1,000 square feet, two exits are required from the suite to the exit access corridor Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 6. Suites Significant changes for suites have been developed over the past few editions of the LSC: One of the two required exits from a suite is permitted to be into and through an adjoining suite, provided the barriers between the suite comply with the requirement for corridor barriers. The travel distance requirements ‘re-sets’ once you have entered the adjoining suite. [This applies to sleeping suites as well as non-sleeping suites.] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 6. Suites Changes for suites (cont’d): One of the two required exits from a suite is permitted to be into an exit stairwell; an exit passageway; or an exit door to the exterior The total area of a sleeping suite may be increased to 7,500 square feet provided the smoke compartment is protected with standard response sprinklers and smoke detectors, or protected with quick response sprinklers Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 6. Suites Changes for suites (cont’d): The total area of a sleeping suite may be increased to 10,000 square feet provided the patient sleeping rooms are arranged to allow direct supervision from a normally attended location within the suite; and the suite is totally protected with smoke detectors and quick response sprinklers Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 6. Suites Changes for suites (cont’d): The total travel distance between any point in a suite (sleeping or non-sleeping) and an exit access door from that suite is limited to 100 feet [The 50 foot travel distance limitation through 2 intervening rooms in non-sleeping suites has been deleted] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 6. Suites Therefore, a categorical waiver is permitted to allow these changes to suites, but only if the organization is in compliance with all other 2000 LSC provisions on suites, as well as sections 18/19.2.5.7 of the 2012 LSC Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 7. Waterflow Alarms The 2000 LSC requires compliance with the 1998 edition of NFPA 25, which requires quarterly testing of vane-type and pressure switch type waterflow alarms. Ironically, NFPA 72 National Fire Alarm Code (1999 edition) did not require quarterly, but semi-annual testing of the same devices Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 7. Waterflow Alarms The 2011 edition of NFPA 25 (which is referenced by the 2012 LSC) allows for the semi-annual testing of vane-type and pressure type waterflow devices, and is now consistent with the NFPA 72 requirements Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 7. Waterflow Alarms Therefore, a categorical waiver is permitted to allow semi-annual testing of vane-type and pressure switch type waterflow devices, but only if the organization is in compliance with all other 1998 NFPA 25 provisions on waterflow switches, as well as section 5.3 of the 2011 NFPA 25 Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 8. Fire Pump Testing The 2000 LSC requires compliance with the 1998 edition of NFPA 25, which requires weekly testing of fire pumps at no-flow conditions It is not unusual that organizations have worn out their fire pumps just from testing them on such a frequent basis Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 8. Fire Pump Testing The 2011 edition of NFPA 25 (which is referenced by the 2012 LSC) allows for the monthly no-flow testing of electric motor-driven fire pumps but not for engine-driven fire pumps, which must continue at a weekly frequency Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 8. Fire Pump Testing Therefore, a categorical waiver is permitted to allow monthly testing of electric motor-driven fire pumps, but only if the organization is in compliance with all other 1998 NFPA 25 provisions on fire pump testing, as well as section 8.3 of the 2011 NFPA 25 Healthcare Facilities Accreditation Program

9. Clean Waste Recycling Containers The 2000 LSC limits the size of trash collection containers to 32 gallons when located outside of a hazardous storage area Recycling containers containing clean waste is presumed to pose a lower risk of fire Healthcare Facilities Accreditation Program

9. Clean Waste Recycling Containers The 2012 LSC allows for a larger size of container used for recycling which will presumably reduce the number of trash receptacles and hazardous storage areas This is believed to reduce undue cost burdens in resources to maintain the containers Healthcare Facilities Accreditation Program

9. Clean Waste Recycling Containers Therefore, a categorical waiver is permitted to increase the size of containers used solely for recycling clean waste or patient records awaiting destruction, outside of a hazardous storage area to be a maximum of 96 gallons, but only if the organization is in compliance with section 18/19.7.5.7.2 of the 2012 LSC Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos The CMS S&C-12-21-LSC memo issued March 9, 2012 also allowed organizations to request waivers for select sections of the 2012 LSC, but at that time it required each hospital to wait until they were cited for the 2000 LSC deficiency, then request the waiver Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos This has changed for the S&C 12-21-LSC memo, as now the categorical waiver concept applies to those conditions as well. This memo applied only to healthcare occupancies as well. The sections covered under the S&C 12-21-LSC memo are: Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Capacity of the Means of Egress: Certain wheeled equipment may now be permitted to be left unattended in the exit access corridor, provided: 5 feet clear width remains The fire safety control plan addresses the relocation of the equipment during an emergency The wheeled equipment is limited to equipment in use; medical emergency equipment not in use; patient lift and transport equipment Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Capacity of the Means of Egress: Fixed furniture is permitted in corridors that are at least 8 feet wide, provided: The furniture is secured to the wall or floor Clear width remains 6 feet Fixed furniture is located on one side of the corridor Groupings do not exceed 50 sq. ft. Groupings separated from each other by 10 feet Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Capacity of the Means of Egress: Fixed furniture (cont’d): Furniture does not obstruct access to building features Corridors are protected with smoke detectors, or the groupings allow for direct supervision The smoke compartment is protected with automatic sprinklers [18/19.2.3.4, 2012 LSC] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Cooking Facilities: Certain types of cooking appliances are permitted to be installed open to the corridor provided: Meals are prepared for no more than 30 persons Separated with a smoke compartment barrier from other areas of the facility A range hood is installed The range hood must be protected with a fire suppression system No solid-fuel cooking allowed Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Cooking Facilities: Open to the corridor (cont’d): No deep-fat frying allowed Portable fire extinguishers required A timer switch control the cooking equipment Smoke detectors required Smoke compartment must be protected with automatic sprinklers [18/19.3.2.5.2 through 18/19.3.2.5.5, 2012 LSC] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Direct-Vent Gas Fireplaces: Direct-vent gas fireplaces are permitted in the same smoke compartment with patient sleeping rooms, but not in a patient sleeping room Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Direct-Vent Gas Fireplaces: Requirements: Smoke compartment must be protected with QR sprinklers Must include a sealed glass front with a wire mesh panel or screen Controls must be locked or located in a restricted location CO detector must be located in the same room [18/19.5.2.3, 2012 LSC] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Solid Fuel Fireplaces: Solid-fuel fireplaces are permitted provided they are not in the same smoke compartment as patient sleeping rooms Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Solid Fuel Fireplaces: Requirements: Must be separated from patient sleeping areas by a 1-hour fire rated barrier Must be equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650°F and constructed of heat tempered glass or other approved materials CO detector must be located in the same room [18/19.5.2.3, 2012 LSC] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Combustible Decorations: Combustible decorations are permitted on walls and ceilings in corridors and patient rooms in healthcare occupancies only, with certain limitations Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Combustible Decorations: The decorations such as photographs, paintings, and other art are attached directly to the walls, ceiling or non-fire-rated doors, provided: Decorations do not interfere with the operation or required latching of the door Decorations do not exceed 20% of the wall, ceiling or door areas inside a smoke compartment that is not protected with sprinklers Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Combustible Decorations: Decorations do not exceed 30% of the wall, ceiling or door areas inside a smoke compartment that is protected with sprinklers Decorations do not exceed 50% of the wall, ceiling or door areas inside patient sleeping rooms having a capacity not exceeding four persons in a smoke compartment that is protected with sprinklers [18/19.7.5.6, 2012 LSC ] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Combustible Decorations: NOTE: The percentage of decorations should be measured against the area of any wall or ceiling; not the aggregate total area of all the walls and ceilings. For this situation, the door is considered part of the wall. Decorations must be located so they do not interfere with the operation of any door, sprinkler, smoke detector, or other life safety feature. Hanging art that is not attached directly to the wall or ceiling is not included in this waiver. Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program 10. Other CMS S&C Memos Relative Humidity: Ventilation systems supplying anesthetizing locations are permitted to operate with a minimum RH of > 20 percent instead of > 35 percent, and not exceed 60 percent From S&C memo 13-25-LSC, dated April 19, 2013 [NFPA 99 (2012), 9.3.1.1] Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Reminder… Don’t forget: These changes are optional, and HFAP standards will not reflect these modifications If you want to take advantage of these categorical waivers, you must formally declare it in writing, and inform the survey team at the opening conference Healthcare Facilities Accreditation Program

Healthcare Facilities Accreditation Program Download Download your own copies of the CMS S&C memos discussed today. Read and understand them- you are responsible for compliance with all of the requirements in the memos if you elect to take advantage of them. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html Healthcare Facilities Accreditation Program

Understanding the New CMS Categorical Waivers on the 2012 Life Safety Code Questions? Brad Keyes, CHSP bkeyes@hfap.org (815) 742-4367