December 28, 2017 | | Comments 0
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But I never wave bye-bye: Closing out 2017 with some LSC goodies…

As noted last week, this week’s foray looks into the changes to the Life Safety chapter that will be onboarding at the turn of the new year (the details can be found here). I think (for the most part), there is nothing particularly earth-shattering in the new requirements: really just a mix of updating the NFPA standards edition numbers, some increased granularity relative to fire alarm systems, and a couple of opportunities for some quick risk assessments/evaluations to ensure that what you had is not going to get you into survey difficulty. Also (and I guess only time will tell us how important this is going to be), it is important to continue to monitor the practical applications of Chapter 43, especially when one is in the throes of changing utilization to the point of a shift in occupancy classifications. My not-insubstantial gut tells me that this has great potential for consternation in the field, including the ongoing impact of inconsistent (bordering on draconian) interpretations. Certainly some of the granularity indicated below will lessen some of the over-interpretation woes (definitive reads on square footage should help), but those hard lines drawn in the sand can also represent some challenges as you are planning and executing renovation, etc., projects. In my experience, there aren’t too many projects that remain the same (in terms of scope) through the design and build phases, so you may find yourself paying more attention to expanding project footprints.

And so:

LS.02.01.10

  • Building undergoing change of use or occupancy must be in compliance with 101-2012:43.7 (certain exceptions, as always, apply); likewise, any additions must comply with the requirements for new.
  • Any of you with non-sprinklered smoke compartments undergoing major rehabilitation are putting sprinklers in (I hope); major rehabilitation involves more than 50% of the area of the smoke compartment or 4500 square feet—whichever comes first.
  • Multiple occupancies in a building must observe the most stringent occupancy requirements—so keep those occupancy separations well-defined and tight; also, outpatient surgical departments must be classified as ambulatory healthcare regardless of the number of patients served. Those of you at organizations considering going to provider-based models need to keep those surgical procedure locations under close watch.

 

LS.02.01.20

  • Make sure your horizontal sliding doors that are not automatic closing are limited to a single leaf and have a latch or other mechanism to prevent the door from rebounding; also, there are some specific requirements for horizontal doors serving an occupant load of 10 or fewer, including operability from either side without special knowledge or effort and a couple other things. 101-2012: 18/19.2.2.2.10.2 will help you with the details.
  • Make sure that every corridor provides access to at least two approved exits; no passing through any intervening rooms or spaces other than corridors or lobbies.
  • Have you included a look at door widths in your ongoing rated door program? Existing exit access doors have to be at least 32 inches in clear width, though you can hold on to your 28-inch doors if you’re not evacuating by bed, gurney, or wheelchair. New exit access doors have to be at least 41½ inches in clear width (psych hospitals have to be at least 32 inches wide). Doors not subject to patient use, exit stairway enclosures or serving newborn nurseries can hold the line at 32 inches. Door pairs with an inactive leaf must have the inactive leaf secured with automatic flush bolts. There are a few other pieces of this, so make sure you transfer/transmit the particulars to the folks inspecting the doors.
  • Existing exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair.
  • Travel distances to exits are measured in accordance with NFPA 101-2012: 7.6.

 

LS.02.01.30

  • Laboratories using quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are in accordance with NFPA 101-2012: 8.7 and NFPA 99 requirements. I’m thinking most of you are probably not in position of severe hazardousness, but if you’re thinking what I’m thinking, a little risk assessment should solidify any of the particulars.

 

LS.02.01.34

  • Make sure your fire alarm system is up to snuff relative to the applicable requirements of NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code—probably worth a conversation and some verification by your fire alarm inspection, testing, and maintenance folks. This includes a more than passing familiarity with placement and types of devices, ensuring an alternative power supply for alarm systems, etc. Make sure that manual and automatic initiation of the fire alarm system is in accordance with the noted requirements, including pull stations. Also, make sure your alarm zones are not larger than 22,500 square feet (for some reason, I think that this might provide some angst for folks…) and spaces open to corridors are provided with appropriate smoke detection.

 

LS.02.01.50

  • Make sure that any spots containing equipment using gas or gas piping are up to snuff with NFPA 54 National Fuel Gas Code and electrical complies with NFPA 70. You can maintain existing installations that are not fully compliant as long as there are no life-threatening hazards.
  • Make sure those pesky heating devices are in appropriate compliance—with both code and your organizational policy.
  • Equipment using gas or gas piping complies with NFPA 54-2012, National Fuel Gas Code; electrical wiring and equipment complies with NFPA 70-2012, National Electric Code. Existing installations can continue in service provided there are no life-threatening hazards.
  • If you have fireplaces in your facility, there are specific considerations, including carbon monoxide detection; 101-2012: 9.2.2 will give you the lowdown.
  • 101-2012 9.4 will get you the straight dope on escalators, dumbwaiters, and moving walks—and don’t forget to consult ASME/ANSI A17.1 for new and ASME/ANSI A17.3 for existing equipment.

 

LS.02.01.70

  • If you’re hanging draperies, curtains (including cubicle and shower curtains), and loosely hanging fabric in non-sprinklered compartments, then 101-2012: 10.3.1 is the compliance source. Of course, if you have sprinklers, there are exceptions…
  • No sprinkler protection? Upholstered furniture purchased on or after July 5, 2016 must meet Class 1 or char length and heat release criteria—101-2012: 10.3.2.1 and 10.3.3; mattresses purchased on or after 7/6/2016 must meet 101-2012 10.3.2.2 and 10.3.4
  • If you have a new engineered smoke control system, it must be tested in accordance with NFPA 92-2012, Standard for Smoke Control Systems. If you have an existing engineered smoke control system, it must be tested in accordance with established engineering principles.

 

Since I don’t want you to be completely comatose for your New Year’s celebrations, I will cover the ambulatory occupancy changes sometime in January (please feel free to prod me if you’d rather I do it sooner than later). And on that note, I wish each and every one of you safe celebrations and a most prosperously compliant New Year!

Entry Information

Filed Under: CMSEnvironment of careHospital safetyLife Safety CodeThe Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant based in Bridgewater, 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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