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The NFPA Life Safety Code is where the requirements for keeping corridors clear and unobstructed originates from.

According to Federal Law and Life Safety Code Requirements, new healthcare aisles, corridors and ramps used for exit access in a hospital or nursing home must be at least 8 feet clear and unobstructed.

During a Life Safety Code survey, do you know what healthcare facility leaders should be aware of during the Preconstruction Risk Assessment?

When planning for construction, demolition, renovation or general maintenance, the healthcare facility undergoes a Preconstruction Risk Assessment for air quality, infection control, utility requirements, vibration, noise and other hazards that affect care, services and treatment. A tip is to designate someone to lead the Preconstruction Risk Assessment by making a plan to show and document information.

In Healthcare Occupanices, what type of fire extinguishers are needed in kitchen grill areas and how far away should they be from appliances that produce grease?

Fire extinguishers placed in kitchen grill areas should be Class K extinguishers. Class K extinguishers are specifically used for putting out grease-based fires. These extinguishers must be within 35 feet of all grease-producing appliances.

What is the #1 finding failure in a Life Safety Code Survey during the Facility Orientation?

According to The Joint Commission, the answer is that facility team leaders do not know the location of their smoke compartments. It is advised that Facility Directors document where the facility's smoke compartments are and share this information with the rest of their team.

Are you aware of the different types of The Joint Commission surveys?

The follow list includes the five different types of The Joint Commission surveys.

  1. Full U (Full Unannounced/Triennial)
  2. Med Def (Medicare Deficiency) - This survey type has a 50% rate of returned visits
  3. SSU/OQPS (Special Survey Unit & Office of Quality and Patient Safety)
  4. ICM 2 or 3 (Intracycle Monitoring)
  5. Extension Survey (New Building/Services)

Is it considered compliant to have a door between a hospital and non-hospital space that will allow providers to go back and forth between the hospital and non-hospital space? This door would not be used by patients.

No. It is not compliant to have a door between a hospital and non-hospital space for providers to go back and forth. The only time this is acceptable is in the case of a fire escape door. This fire escape door would have to be locked at all times. When the fire alarm is activated, the fire escape door would unlock electronically.

A full floor to ceiling wall that meets all LSC requirements is the only acceptable option to separate space between a hospital and non-hospital.

According to the recent FGI Guidelines update, procedure and operating rooms were realigned based on the level of invasiveness of the procedure and perceived risk to the patient.

A new table was added to assist designers and facility owners to determine which procedures should be performed in each room type. It should be noted that you should not add procedures or services in existing rooms based upon the chart without first checking with DAAC.

Did you know that an MRI scanner uses magnets that are 140 times more powerful than the magnetic field of Earth?

This would be enough power to make a steel fire extinguisher come off the wall. Any room within a hospital that contains an MRI machine should only be using non-ferrous or non-magnetic extinguishers.

What are 11 survey requirements that every healthcare facility manager should know according to The Joint Commission? (Part 2: 6 through 11)
  1. Fire response plan, LIP, copy at operator or security (EC.02.03.01 EP-9)
  2. Stairwell signage (floor information) tactile (LS.02.01.20 EP-10)
  3. Kitchen hood extinguishing (FA/Energy/Fans) (EC.02.03.05 EP-13)
  4. Succession plan and delegation of authority (EM.02.01.01 EP-12)
  5. Generator EPO remote/not on exterior enclosures (EC.02.05.03 EP-11)
  6. Corridor/Suite Perimeter Doors (LC.02.01.30 EP-13)

What are 11 survey requirements that every healthcare facility manager should know according to The Joint Commission? (Part 1: 1 through 5)
  1. Triennial 4 hours generator run applies to all HAP/AHC (EC.02.05.07 EP’s 9&10)
  2. Written surgical fire risk assessment and plan (EC.02.03.01 EP-11)
  3. Exit sign testing with batteries (EC.02.05.07 EP-1)
  4. Elevator fire fighter operations monthly test (EC.02.03.05 EP-27)
  5. LIM’s (EC.02.05.05 EP-7)
Here are some tips for success on a Life Safety Code Survey from The Joint Commission during your Facility Orientation:
  • Make sure you know the location of the electrical panel with the designated breaker for the fire alarm.
  • Know the number and types of sprinklers so you can determine the number of spares needed.

The Facility Orientation is the first step of the Life Safety Code Survey and should take about an hour.

What is the #1 most cited standard for the Environment of Care (EC) and Life Safety (LS) chapters of 2017 according to The Joint Commission?

The Joint Commission ranks LS.02.01.35 (The Hospital provides equipment for extinguishing fires) as the #1 most cited standard of 2017.

  • 59% Non-Compliant: Manage systems for extinguishing fires including the integrity (nothing supported by sprinkler piping, missing escutcheons)
  • 41% Non-Compliant: Sprinkler heads are not damaged; They are free of corrosion, foreign materials, paint and have necessary escutcheon plates installed
  • 34% Non-Compliant: Other issues, including blocked access to fire extinguishers (wildcard)

What is included in Building Gross Square Feet (BGSF) Line Items?

All columns along the perimeter of the wall, any furr-outs along the columns and exterior wall material are all included in exterior wall thickness.

In a hospital, would bins that hold patient records waiting to be disposed of be required to have an FM fire rating?

According to Section of the Life Safety Code, the answer is yes. Bins used for patient records waiting to be disposed of should meet FM Approval Standard 6921 requirements. Other waste bins used for reasons besides recycling clean waste and/or patient records waiting to be disposed of do not have to meet FM Approval Standard 6921 requirements.

The 2018 FGI Guidelines are available and ready to use for the next four years.

This 2018 edition of the FGI Guidelines includes three separate versions specifically for hospitals; outpatient facilities; and residential health, care and support facilities.

Until October of 2018, the Department of Health is permitting the implementation of FGI Guidelines from the 2014 edition and 2018 edition for new projects. After that, only the 2018 edition will be valid.

2018 FGI Guidelines can be found by clicking here.

According to The Joint Commission, here are survey changes due to SAFER:

No more Direct and Indirect EP designations

  • Consolidate ESC into one 60-day time frame

No more A or C categories

  • No more Opportunities for Improvement (OFI's)
  • No more Measure of Success (MOS)

See it/Cite it Survey Methodology

*Note: This does not apply to Sentinel Events where a MOS is required. At this time, the submittal of a MOS for Sentinel Events is still required.

The 2012 edition of the Life Safety Code (LSC) does not require windows and/or doors exposing the outside environment in a patient sleeping room. Does that mean that patient sleeping rooms should be designed without windows?

Although, the requirement for access or direct visibility to the outside environment has been deleted since the LSC 2009 edition, the design of new hospital patient sleeping rooms should still be designed with visibility to the outside world. Many local building codes and state agencies overseeing hospital development require windows in patient sleeping rooms. Plus, there is a significant amount of evidence that human beings have a psychological need to see the outside and that aids in the healing process.

The following should be noted regarding Long-Term Care Facility requirements for the Physical Environment to resident bedrooms and bathrooms:
  • Bedroom – Each bedroom must accommodate no more than four residents each. Facilities that have been approved for construction or facilities certified after November 28, 2016 must accommodate no more than two residents per bedroom.
  • Bathroom – Each individual resident bedroom must be located near a toilet and bathing facilities or be equipped with such. Facilities that have been approved for construction or facilities certified after November 28, 2016 must equip each residential bedroom with a bathroom. The bathroom must include at least a sink and a toilet.

Would it be acceptable to remove the label on a fire protection rated door that is installed in a location where a fire protection rated door is not required?

The label may be removed and doing so is identical to rendering the door as other than a fire protection rated door. Although you may remove the label, covering the label is not allowed. One last thing to note is that the provisions of NFPA 80 do not apply here.

Fire drills in a health care occupancy assess staff productivity during an emergency fire plan but what is the protocol for patients that are bedridden?

Patients that are too weak to get out of bed are not required to be moved outside or to a safe area during a fire drill. Staff can simulate the relocation of bedridden patients using empty wheelchairs and replicated patients.

This is true according to the Life Safety Code which is referred to by Centers for Medicare & Medicaid Services (CMS).

There are four (4) critical areas for Healthcare Facility Managers and their team to focus on when it comes to Infection Control.
  1. When the facility is undergoing an addition or renovation, dust and contaminants from construction need to be managed.
  2. Hospital pharmacies need to make sure no contamination of sterile compounds takes place.
  3. Conscious patient areas need to have correct pressurization and ventilation.
  4. Utility and portable water systems need to be checked for Legionella growth.
What classifies in the Life Safety Code as rehabilitation work on existing buildings?
  • Addition: Increase in building area, aggregate floor area, building height or number of building stories
  • Change of Use or Occupancy Classification: Change in the occupancy classification of a building or portion of a building
  • Modification: Arrangement of any area; addition, relocation or eradication of any door or window; addition or eradication of a load bearing element, arrangement or extension of any system; or installation of any additional equipment
  • Reconstruction: Arrangement of a space that alters an exit corridor shared by more than one occupant space; or the arrangement of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems are not consistently managed
  • Renovation: Replacement or upgrading of materials, equipment or fixtures that doesn’t result in an arrangement of building spaces inside
  • Repair: Restoration, patching, or painting of materials, equipment or fixtures in good condition

Do you know what the six domains of Health Care Quality are?
  1. Safe: Making sure harm does not come to patients derived from the care that is meant to help them
  2. Effective: Administering services established from scientific knowledge to everyone who would benefit and ceasing services to people not likely to benefit
  3. Patient-Centered: Maintaining an atmosphere of care that is considerate to individual patient desires, needs and values and making sure patient values influence clinical decisions
  4. Timely: Diminishing wait times and harmful setbacks for those who receive and give care
  5. Efficient: Ward off waste, including waste of supplies, equipment, energy and ideas
  6. Equitable: Provide consistent quality care to all patient regardless of sex, geographical location, ethnicity and socioeconomic status

These six domains come from the Institute of Medicine's definition of quality care in a healthcare setting. Many other organizations use these domains as their general standard such as the Department of Health.

Healthcare occupancies, especially hospitals, have strict guidelines when it comes to the exact location of handrails in certain areas.

Out of all the areas including stairs, enclosures, ramps, corridors and exit passageways, which one does not have strict guidelines for the exact location of handrails? The answer is corridors. Even though there is no guidelines on handrails for corridors, there are other codes to consider including complying with ADA requirements.

Should hospital “out-buildings” and offsite doctor’s offices participate in fire drills?

Yes. Since these offsite locations are usually considered business occupancies, the requirement is once per shift per year, but this also depends on who your facility is accredited by and the entity that is enforcing the Life Safety Code.

If a hospital is undergoing a short-term project and needs some extra storage space during construction, would it be appropriate to store new equipment that is still in the packaging in unused patient rooms until the project is complete?

This all depends on who the authority is that has jurisdiction. If the storage equipment items qualify as construction, alterations, additions or repair, you may be able to store the items in the unused patient rooms. Of course, alternate life safety standards need to be followed and you should be following in accordance with your own policies as well.

When are playrooms and breast-feeding rooms included in a specific part of a healthcare facility's DGSF?

When a play area or breast-feeding room is located near a specific department, they are to be included in the department’s DGSF (Departmental Gross Square Feet). The exception is when play areas and breast-feeding rooms are positioned in a lobby or public space then they would be considered public spaces.

When is emergency lighting required for existing business occupancies?

If the public can access your building, then you are most likely going to need emergency egress lighting. However, based on the Code, the most general rule is emergency egress lighting is needed when you are required to have two or more paths of egress and/or have delayed egress locking on doors.

Need a tip on lead acid batteries for fire alarm systems in hospitals?

Lead acid type batteries used for fire alarm systems need to be replaced every five years after the date of manufacture according to NFPA. This can also be done more frequently if needed.

According to the Life Safety Code, the following departure components are approved means of egress:
  • Ramps
  • Stairs
  • Doors
  • Fire escape ladders
  • Horizontal exits
  • Smokeproof enclosures
  • Exit passageways
  • Areas of refuge
  • Alternating tread devices

Notice that elevators are not mentioned on the list.

What classification does a freestanding Emergency Department fall under out of Health Care Occupancy, Ambulatory Care Occupancy or Business Occupancy?

While Health Care and Ambulatory Care may be acceptable occupancy classifications, a freestanding Emergency Department would never be considered a Business Occupancy. This is because not all patients brought to an Emergency Department are able to walk or speak, so that takes Business Occupancy off the table.

Did you know that waivers and equivalencies are only valid until the next survey?

If CMS approved a waiver or equivalency, you should be going through the process repeatedly every three years. This statement is still true even if things have not changed.

Need some advice on how to assess the risk of patients' electronic devices?

A risk assessment is beneficial when deciding if patients should be allowed to bring personal laptops, hairdryers and other electronic equipment into the hospital. Healthcare facilities are expected to develop a course of action to recognize patients' personal equipment that would be included in the medical equipment management plan.

Hospital Submissions (Pennsylvania): DOH, DAAC, DLS or Local Code

Need a quick guide on whether to send your hospital submissions to DOH, DAAC, DLS or local code? Drawing submissions are required to go to DLS for I-2 and outpatient surgery centers. All hospital based departments, including business occupancies, must submit their narrative in correspondence to DAAC. All additions and alterations are going to be submitted to local code.

Door Decorating Limits Visibility

Different holidays and events throughout the year bring forth themed door decorating. It is important to remember that no decorations, accessories or other objects should limit visibly or access to doorways according to Section of the Life Safety Code. All fire-rated door decorating should be looked at as a no-go during festivities.

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