November 11, 2013 | | Comments 0
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What is a Life Safety Code® deficiency?

One of the time-honored pursuits, mostly as a function of what you can and cannot manage through the plan for improvement (PFI) process, is what exactly constitutes a Life Safety Code® (LSC) deficiency. Just so you know, I used the “exactly” descriptor for a reason—because the definition, while pretty clear (at least to my mind—feel free to disagree) is a fair distance from exact, but read on and maybe it will become a little more clear.

The “secret” to all of this can be found on pp. 24-25 of the 2000 edition of the LSC. Contained on these two pages are the “documents or portions thereof” that “are referenced within this (Life Safety) Code as mandatory requirements and shall be considered part of the requirements of this (Life Safety) Code.” Thus, these requirements include some of the items you’d probably expect to be there: NFPA 10 Standard for Portable Fire Extinguishers, NFPA 13 Standard for the Installation of Sprinkler Systems, NFPA 70 National Electrical Code, NFPA 99 Standard for Health Care Facilities; and maybe some that you wouldn’t necessarily include in the mix, but make sense when you think about it: NFPA 30 Flammable and Combustible Liquids Code, NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations. Not that I usually get into product endorsements, but I think even a casual glance at the list of required elements would point you towards having a subscription to all the NFPA codes—and that’s not getting into the other publications cited as required (ANSI, ASME, UL) because they all have a share in the mandated references. Oh yes, and the final “other” publication mentioned is Webster’s Third New International Dictionary of the English Language, Unabridged; you could probably get into a lot of trouble with that…

Therefore, an LSC deficiency is really any condition or practice that is not compliant with any of the referenced codes (is your head spinning yet?), so you can probably craft a PFI for just about any safety-related hazard. In this world of ever-shrinking operational budgets, the PFI process may become an everyday tool as opposed to the once in a blue moon process it has sometimes been in the past. Remember, if the deficiency can be resolved within 45 days, then you can use your work order system. But if you can’t resolve the deficiency within 45 days (and budget constraints are no doubt going to have a greater impact on that in the future), then the PFI could become your new BFF.

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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