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January 16, 2014 Brad Keyes, CHSP

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

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January 16, 2014 Brad Keyes, CHSP

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

  2. 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

  3. 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 Managers Safety Officers Construction Managers Project Managers Consultants VP Facilities

  4. 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

  5. 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

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

  7. 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….]

  8. 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

  9. General Requirements 13.00.01 Life Safety Code Compliance 13.00.02 Alternative Life Safety Measures- Policy 13.00.03 Alternative Life Safety Measures- Implementation 13.00.04 Notification of Emergency Response Forces

  10. General Requirements 13.00.05 Facility Demographic Report (Replaces the old LSA) 13.00.06 Testing & Inspection- Definition of Time 13.00.07 Testing & Inspection- Documentation The above three standards will not be enforced until July 1, 2014

  11. Means of Egress 13.01.01 Corridor Door Latching 13.01.02 Door Locks 13.01.03 Corridor Width 13.01.04 Suites 13.01.05 Exit Signs 13.01.06 Exit Discharge 13.01.07 Corridor Projections 13.01.08 Path of Egress Obstruction

  12. Fire Detection Systems 13.02.01 Fire Alarm System- Installation 13.02.02 Fire Alarm System- Testing 13.02.03 Fire Alarm Systems- Transmitting Signal 13.02.04 Fire Alarm System- Technician Qualifications

  13. Fire Suppression Systems 13.03.01 Water-Based Fire Protection System- Installation 13.03.02 Water-Based Fire Protection System- Testing & Inspection 13.03.03 Water-Based Fire Protection System- Control Valves, Piping and Hangers 13.03.04 Fire Pumps- Weekly Test 13.03.05 Fire Pumps- Annual Test

  14. Fire Suppression Systems 13.03.06 Alternative Fire Suppression Systems- Installation & Testing 13.03.07 Water-Based Standpipes & Hoses- Inspection & Test 13.03.08 Water-Based Fire Department Connections- Inspection 13.03.09 Portable Fire Extinguishers- Installation, Inspection and Maintenance

  15. Fire Safety Systems 13.04.01 Fire Rated Barriers 13.04.02 Smoke Compartment Barriers 13.04.03 Fire & Smoke Damper- Testing 13.04.04 Overhead Rolling/Horizontal Sliding Fire Doors- Testing 13.04.05 Construction Type

  16. Fire Safety Systems 13.04.06 Separated Occupancies 13.04.07 Fire Rated Door Assemblies 13.04.08 Hazardous Areas 13.04.09 Ceilings 13.04.10 Corridor Walls

  17. Building Services 13.05.01 Fireplaces 13.05.02 Elevator Recall 13.05.03 Trash & Linen Chutes

  18. Operating Features 13.06.01 Decorations 13.06.02 Trash Receptacles 13.06.03 Portable Heaters 13.06.04 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.]

  19. Operating Features 13.06.05 Alcohol Based Hand Rub Dispensers 13.06.06 Definition of New Construction and Existing Conditions

  20. Waivers and Equivalent Systems 13.07.01 CMS Waiver of Life Safety Code 13.07.02 Fire Safety Evaluation System

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

  22. 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, 2014

  23. 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

  24. 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

  25. General Requirements 14.00.00 Life Safety From Fire [Note: CAH standards begin with ‘00’.] 14.00.01 Alternative Life Safety Measures- Policy 14.00.02 Alternative Life Safety Measures- Implementation 14.00.03 Notification of Emergency Response Forces

  26. General Requirements 14.00.04 Facility Demographic Information- FDI (Replaces the old LSA) 14.00.05 Testing & Inspection- Definition of Time 14.00.06 Testing & Inspection- Documentation The above three standards will not be enforced until July 1, 2014

  27. Means of Egress 14.01.00 Corridor Door Latching 14.01.01 Door Locks 14.01.02 Corridor Width 14.01.03 Suites 14.01.04 Exit Signs 14.01.05 Exit Discharge 14.01.06 Corridor Projections 14.01.07 Path of Egress Obstruction

  28. Fire Detection Systems 14.02.00 Fire Alarm System- Installation 14.02.00 Fire Alarm System- Testing 14.02.00 Fire Alarm Systems- Transmitting Signal 14.02.00 Fire Alarm System- Technician Qualifications

  29. Fire Suppression Systems 14.03.00 Water-Based Fire Protection System- Installation 14.03.01 Water-Based Fire Protection System- Testing & Inspection 14.03.02 Water-Based Fire Protection System- Control Valves, Piping and Hangers 14.03.03 Fire Pumps- Weekly Test 14.03.04 Fire Pumps- Annual Test

  30. Fire Suppression Systems 14.03.05 Alternative Fire Suppression Systems- Installation & Testing 14.03.06 Water-Based Standpipes & Hoses- Inspection & Test 14.03.07 Water-Based Fire Department Connections- Inspection 14.03.08 Portable Fire Extinguishers- Installation, Inspection and Maintenance

  31. Fire Safety Systems 14.04.00 Fire Rated Barriers 14.04.01 Smoke Compartment Barriers 14.04.02 Fire & Smoke Damper- Testing 14.04.03 Overhead Rolling/Horizontal Sliding Fire Doors- Testing 14.04.04 Separated Occupancies

  32. Fire Safety Systems 14.04.05 Fire Rated Door Assemblies 14.04.06 Hazardous Areas 14.04.07 Ceilings 14.04.08 Corridor Walls

  33. Building Services 14.05.00 Fireplaces 14.05.01 Elevator Recall 14.05.02 Trash & Linen Chutes

  34. Operating Features 14.06.00 Decorations 14.06.01 Trash Receptacles 14.06.02 Portable Heaters 14.06.03 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.] 14.06.04 Alcohol Based Hand Rub Dispensers

  35. Waivers and Equivalent Systems 14.07.00 CMS Waiver of Life Safety Code 14.07.01 Fire Safety Evaluation System

  36. 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

  37. 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

  38. Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety ComplianceQuestions?Brad Keyes, CHSPbkeyes@hfap.org(815) 629-2240 Office (815) 742-4367 Cell

  39. 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

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