January 16, 2014 Brad Keyes, CHSP Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance

The New LS Surveyors Beginning in January, 2014, a new surveyor with expertise on the Life Safety Code (LSC) will be joining each hospital survey These LS surveyors will be assessing your facility and life safety documentation for compliance with the LSC 2

The New LS Surveyors HFAP decided to add the new LS surveyors to improve the overall evaluation of the organization’s compliance with the Life Safety Code. They have LS expertise in their daily careers: Facility ManagersSafety Officers Construction ManagersProject Managers ConsultantsVP Facilities 3

The New LS Surveyors The LS surveyor will be on-survey according to the following formula: – One (1) day for hospitals that have less than 50 licensed beds and has less than 100,000 square feet of healthcare occupancy – Two (2) days for hospitals with 50 or more licensed beds, or has 100,000 square feet or more of healthcare occupancy – One (1) additional day for each off-campus location containing a healthcare occupancy 4

The New Manuals Why did we make changes to the old standards? – Corrected some errors – Wanted to make the standards more relevant and meaningful and arranged in a fashion that makes sense – Wanted to emphasize certain requirements of the Life Safety Code by creating a specific standard 5

The New Manuals For the new 2014 Acute Care manual, we separated out the standards from the old chapter 11: – Chapter 9Emergency Management – Chapter 11Physical Environment – Chapter 13Life Safety 6

The Acute Care Manual The previous Acute Care manual Chapter 11 had 15 written standards on LSC compliance The new Acute Care Chapter 13 has 49 written standards on LSC compliance, but only four (4) of those standards are new requirements [We will identify those new requirements for you later….] 7

The Acute Care Manual The LS chapter is broken down into 8 different sections: – General Requirements – Means of Egress – Fire Detection Systems – Fire Suppression Systems – Fire Safety Systems – Building Services – Operating Features – Waivers and Equivalent Systems 8

General Requirements Life Safety Code Compliance Alternative Life Safety Measures- Policy Alternative Life Safety Measures- Implementation Notification of Emergency Response Forces 9

General Requirements Facility Demographic Report (Replaces the old LSA) Testing & Inspection- Definition of Time Testing & Inspection- Documentation The above three standards will not be enforced until July 1,

Means of Egress Corridor Door Latching Door Locks Corridor Width Suites Exit Signs Exit Discharge Corridor Projections Path of Egress Obstruction 11

Fire Detection Systems Fire Alarm System- Installation Fire Alarm System- Testing Fire Alarm Systems- Transmitting Signal Fire Alarm System- Technician Qualifications 12

Fire Suppression Systems Water-Based Fire Protection System- Installation Water-Based Fire Protection System- Testing & Inspection Water-Based Fire Protection System- Control Valves, Piping and Hangers Fire Pumps- Weekly Test Fire Pumps- Annual Test 13

Fire Suppression Systems Alternative Fire Suppression Systems- Installation & Testing Water-Based Standpipes & Hoses- Inspection & Test Water-Based Fire Department Connections- Inspection Portable Fire Extinguishers- Installation, Inspection and Maintenance 14

Fire Safety Systems Fire Rated Barriers Smoke Compartment Barriers Fire & Smoke Damper- Testing Overhead Rolling/Horizontal Sliding Fire Doors- Testing Construction Type 15

Fire Safety Systems Separated Occupancies Fire Rated Door Assemblies Hazardous Areas Ceilings Corridor Walls 16

Building Services Fireplaces Elevator Recall Trash & Linen Chutes 17

Operating Features Decorations Trash Receptacles Portable Heaters Life Safety Drawings [Previously, you were required to have LS drawings, but this standard has new requirements. You will be held responsible to have basic LS drawings, but will not have to meet the additional new requirements until July 1, 2014.] 18

Operating Features Alcohol Based Hand Rub Dispensers Definition of New Construction and Existing Conditions 19

Waivers and Equivalent Systems CMS Waiver of Life Safety Code Fire Safety Evaluation System 20

The Critical Access Hospital Manual For the new 2014 Critical Access Hospital manual, we separated out the standards from the old chapter 11: – Chapter 3Physical Environment and Emergency Management – Chapter 14Life Safety 21

The Critical Access Hospital Manual Unlike the Acute Care manual, the Physical Environment and Emergency Management standards are combined into one chapter: 3 These new standards will not be enforced during surveys until March 1,

The Critical Access Hospital Manual The previous Critical Access Hospital (CAH) manual had 15 written standards on LSC compliance The new CAH manual Chapter 14 has 47 written standards on LSC compliance, but only four (4) of those standards are new requirements 23

The Critical Access Hospital Manual The chapter is broken down into 8 different sections: – General Requirements – Means of Egress – Fire Detection Systems – Fire Suppression Systems – Fire Safety Systems – Building Services – Operating Features – Waivers and Equivalent Systems 24

General Requirements Life Safety From Fire [Note: CAH standards begin with ‘00’.] Alternative Life Safety Measures- Policy Alternative Life Safety Measures- Implementation Notification of Emergency Response Forces 25

General Requirements Facility Demographic Information- FDI (Replaces the old LSA) Testing & Inspection- Definition of Time Testing & Inspection- Documentation The above three standards will not be enforced until July 1,

Means of Egress Corridor Door Latching Door Locks Corridor Width Suites Exit Signs Exit Discharge Corridor Projections Path of Egress Obstruction 27

Fire Detection Systems Fire Alarm System- Installation Fire Alarm System- Testing Fire Alarm Systems- Transmitting Signal Fire Alarm System- Technician Qualifications 28

Fire Suppression Systems Water-Based Fire Protection System- Installation Water-Based Fire Protection System- Testing & Inspection Water-Based Fire Protection System- Control Valves, Piping and Hangers Fire Pumps- Weekly Test Fire Pumps- Annual Test 29

Fire Suppression Systems Alternative Fire Suppression Systems- Installation & Testing Water-Based Standpipes & Hoses- Inspection & Test Water-Based Fire Department Connections- Inspection Portable Fire Extinguishers- Installation, Inspection and Maintenance 30

Fire Safety Systems Fire Rated Barriers Smoke Compartment Barriers Fire & Smoke Damper- Testing Overhead Rolling/Horizontal Sliding Fire Doors- Testing Separated Occupancies 31

Fire Safety Systems Fire Rated Door Assemblies Hazardous Areas Ceilings Corridor Walls 32

Building Services Fireplaces Elevator Recall Trash & Linen Chutes 33

Operating Features Decorations Trash Receptacles Portable Heaters Life Safety Drawings [Previously, you were required to have LS drawings, but this standard has new requirements. You will be held responsible to have basic LS drawings, but will not have to meet the additional new requirements until July 1, 2014.] Alcohol Based Hand Rub Dispensers 34

Waivers and Equivalent Systems CMS Waiver of Life Safety Code Fire Safety Evaluation System 35

Summary of Changes Most of the standards in the new Life Safety chapters are not new requirements… Hospitals have had to comply with these requirements for years by virtue of compliance with the Life Safety Code, even though they were not specific HFAP standards We just wrote new standards on certain LSC issues that we wanted to emphasize 36

Summary of Changes The four standards that are new requirements will not be enforced until July 1, 2014 to allow you time for compliance: – Facility Demographic Report – Testing & Inspection- Definition of Time – Testing & Inspection- Documentation – Life Safety Drawings 37

Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance Questions? Brad Keyes, CHSP (815) Office (815) Cell 38

Certificate of Attendance ___________________________ Awarded 1.0 contact hours “Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance A 60 minute audio-conference January 16, 2014 _________________ Beverly Robins Brad Keyes, Presenter Director of Accreditation and Certification Keyes Life Safety Compliance, LLC