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Understanding the New CMS Categorical Waivers on the 2012 Life Safety Code

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.

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Understanding the New CMS Categorical Waivers on the 2012 Life Safety Code

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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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

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