January 04, 2021 | | Comments 0
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The roar of the ’20s continues: Optimism abounds!

I trust that you all were able to carve out some downtime over the holidays. While there was (seemingly) much less rushing around than normal, in many ways, the past month or so has been no less exhausting. At any rate, I hope this finds you well and ready for the climb up (out?).

As mentioned the last time we “gathered,” our friends in Chicago are in the process of modifying the survey of the physical environment as it extends to behavioral health organizations. As fate would have it, the changes revolve around ongoing efforts to align Joint Commission standards and performance elements with the requirements of NFPA 101-2012 Life Safety Code® (LSC) and NFPA 99-2012 Health Care Facilities Code, including clarification of fire drill requirements. A couple of items of particular note follow:

  • Behavioral healthcare facilities that use door locking to prohibit individuals from leaving the building or spaces in the building are considered healthcare occupancies. I don’t see this as an issue for inpatient units as this already the “mark,” but it may come into play in your outpatient clinic settings and perhaps any residential care settings. With all the changes in the survey process relating to care locations outside of the main hospital, I think proper identification of occupancy classifications is going to be under greater scrutiny than ever.
  • If you do have residential board and care facilities in your organization, they’ll be looking for at least six fire drills per year for each building and that means evacuation (unless otherwise permitted by the LSC; please check out NFPA 101-2012: 32/33.7.3 for details and exceptions), two of which need to be conducted at night when residents are sleeping. For some strange reason, the pre-publication standard indicates that “at least two annual drills” would be conducted during the night; I think this is probably one more word—that being “annual”—than it needs to be. I don’t know, it just seems less clear than saying, perhaps, at least two drills per year would be conducted at night or something like that. But that may just be me.
  • Depending on the capacity of the branches of your essential electrical system, you may have some flexibility relative to the number of required transfer switches; your system must still be divided into three branches (life safety, critical, equipment), but if your system is 150kVA or less, then you don’t need to have at least one automatic transfer switch for each branch. I suspect that most folks that have facilities that were constructed, had a change in occupancy type, or undergone a major electrical system upgrade since 1983 are probably all set with this, but I think we can anticipate the question being asked—better to know what you have going in, and probably a useful piece of information to include on your Statement of Conditions.

The LS chapter changes appear to be aimed at ensuring that the requirements for new and existing occupancies are appropriately noted; at this point, I don’t see anything particularly problematic, but, as they so often note in the fine print, actual results may vary. You can find the details here.

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

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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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