We are EXPERTS in complex regulatory and code compliance
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.
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.
- Fire response plan, LIP, copy at operator or security (EC.02.03.01 EP-9)
- Stairwell signage (floor information) tactile (LS.02.01.20 EP-10)
- Kitchen hood extinguishing (FA/Energy/Fans) (EC.02.03.05 EP-13)
- Succession plan and delegation of authority (EM.02.01.01 EP-12)
- Generator EPO remote/not on exterior enclosures (EC.02.05.03 EP-11)
- Corridor/Suite Perimeter Doors (LC.02.01.30 EP-13)
- Triennial 4 hours generator run applies to all HAP/AHC (EC.02.05.07 EP’s 9&10)
- Written surgical fire risk assessment and plan (EC.02.03.01 EP-11)
- Exit sign testing with batteries (EC.02.05.07 EP-1)
- Elevator fire fighter operations monthly test (EC.02.03.05 EP-27)
- LIM’s (EC.02.05.05 EP-7)
- 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.
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)
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.
According to Section 188.8.131.52.2 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.
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.
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.
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.
- 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.
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.
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.
- When the facility is undergoing an addition or renovation, dust and contaminants from construction need to be managed.
- Hospital pharmacies need to make sure no contamination of sterile compounds takes place.
- Conscious patient areas need to have correct pressurization and ventilation.
- Utility and portable water systems need to be checked for Legionella growth.
- 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
- Safe: Making sure harm does not come to patients derived from the care that is meant to help them
- Effective: Administering services established from scientific knowledge to everyone who would benefit and ceasing services to people not likely to benefit
- 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
- Timely: Diminishing wait times and harmful setbacks for those who receive and give care
- Efficient: Ward off waste, including waste of supplies, equipment, energy and ideas
- 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.
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.
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.
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 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.
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.
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.
- Fire escape ladders
- Horizontal exits
- Smokeproof enclosures
- Exit passageways
- Areas of refuge
- Alternating tread devices
Notice that elevators are not mentioned on the list.
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.
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.
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.
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.
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 184.108.40.206.1 of the Life Safety Code. All fire-rated door decorating should be looked at as a no-go during festivities.