1. January 16, 2014 Brad Keyes, CHSP Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance

2. The New LS Surveyors Beginning in January, 2014, a new surveyor with expertise on the Life Safety Code (LSC) will be joining each hospital survey These LS surveyors will be assessing your facility and life safety documentation for compliance with the LSC 2

3. The New LS Surveyors HFAP decided to add the new LS surveyors to improve the overall evaluation of the organization’s compliance with the Life Safety Code. They have LS expertise in their daily careers: Facility ManagersSafety Officers Construction ManagersProject Managers ConsultantsVP Facilities 3

4. The New LS Surveyors The LS surveyor will be on-survey according to the following formula: – One (1) day for hospitals that have less than 50 licensed beds and has less than 100,000 square feet of healthcare occupancy – Two (2) days for hospitals with 50 or more licensed beds, or has 100,000 square feet or more of healthcare occupancy – One (1) additional day for each off-campus location containing a healthcare occupancy 4

5. The New Manuals Why did we make changes to the old standards? – Corrected some errors – Wanted to make the standards more relevant and meaningful and arranged in a fashion that makes sense – Wanted to emphasize certain requirements of the Life Safety Code by creating a specific standard 5

6. The New Manuals For the new 2014 Acute Care manual, we separated out the standards from the old chapter 11: – Chapter 9Emergency Management – Chapter 11Physical Environment – Chapter 13Life Safety 6

7. The Acute Care Manual The previous Acute Care manual Chapter 11 had 15 written standards on LSC compliance The new Acute Care Chapter 13 has 49 written standards on LSC compliance, but only four (4) of those standards are new requirements [We will identify those new requirements for you later….] 7

8. The Acute Care Manual The LS chapter is broken down into 8 different sections: – General Requirements – Means of Egress – Fire Detection Systems – Fire Suppression Systems – Fire Safety Systems – Building Services – Operating Features – Waivers and Equivalent Systems 8

9. General Requirements 13.00.01 Life Safety Code Compliance 13.00.02Alternative Life Safety Measures- Policy 13.00.03Alternative Life Safety Measures- Implementation 13.00.04Notification of Emergency Response Forces 9

10. General Requirements 13.00.05Facility Demographic Report (Replaces the old LSA) 13.00.06Testing & Inspection- Definition of Time 13.00.07Testing & Inspection- Documentation The above three standards will not be enforced until July 1, 2014 10

11. Means of Egress 13.01.01Corridor Door Latching 13.01.02Door Locks 13.01.03Corridor Width 13.01.04Suites 13.01.05Exit Signs 13.01.06Exit Discharge 13.01.07Corridor Projections 13.01.08Path of Egress Obstruction 11

12. Fire Detection Systems 13.02.01Fire Alarm System- Installation 13.02.02Fire Alarm System- Testing 13.02.03Fire Alarm Systems- Transmitting Signal 13.02.04Fire Alarm System- Technician Qualifications 12

13. Fire Suppression Systems 13.03.01Water-Based Fire Protection System- Installation 13.03.02Water-Based Fire Protection System- Testing & Inspection 13.03.03Water-Based Fire Protection System- Control Valves, Piping and Hangers 13.03.04Fire Pumps- Weekly Test 13.03.05Fire Pumps- Annual Test 13

14. Fire Suppression Systems 13.03.06Alternative Fire Suppression Systems- Installation & Testing 13.03.07Water-Based Standpipes & Hoses- Inspection & Test 13.03.08Water-Based Fire Department Connections- Inspection 13.03.09Portable Fire Extinguishers- Installation, Inspection and Maintenance 14

15. Fire Safety Systems 13.04.01Fire Rated Barriers 13.04.02Smoke Compartment Barriers 13.04.03Fire & Smoke Damper- Testing 13.04.04Overhead Rolling/Horizontal Sliding Fire Doors- Testing 13.04.05Construction Type 15

16. Fire Safety Systems 13.04.06Separated Occupancies 13.04.07Fire Rated Door Assemblies 13.04.08Hazardous Areas 13.04.09Ceilings 13.04.10Corridor Walls 16

17. Building Services 13.05.01Fireplaces 13.05.02Elevator Recall 13.05.03Trash & Linen Chutes 17

18. Operating Features 13.06.01Decorations 13.06.02Trash Receptacles 13.06.03Portable Heaters 13.06.04Life Safety Drawings [Previously, you were required to have LS drawings, but this standard has new requirements. You will be held responsible to have basic LS drawings, but will not have to meet the additional new requirements until July 1, 2014.] 18

19. Operating Features 13.06.05Alcohol Based Hand Rub Dispensers 13.06.06Definition of New Construction and Existing Conditions 19

20. Waivers and Equivalent Systems 13.07.01CMS Waiver of Life Safety Code 13.07.02Fire Safety Evaluation System 20

21. The Critical Access Hospital Manual For the new 2014 Critical Access Hospital manual, we separated out the standards from the old chapter 11: – Chapter 3Physical Environment and Emergency Management – Chapter 14Life Safety 21

22. The Critical Access Hospital Manual Unlike the Acute Care manual, the Physical Environment and Emergency Management standards are combined into one chapter: 3 These new standards will not be enforced during surveys until March 1, 2014 22

23. The Critical Access Hospital Manual The previous Critical Access Hospital (CAH) manual had 15 written standards on LSC compliance The new CAH manual Chapter 14 has 47 written standards on LSC compliance, but only four (4) of those standards are new requirements 23

24. The Critical Access Hospital Manual The chapter is broken down into 8 different sections: – General Requirements – Means of Egress – Fire Detection Systems – Fire Suppression Systems – Fire Safety Systems – Building Services – Operating Features – Waivers and Equivalent Systems 24

25. General Requirements 14.00.00 Life Safety From Fire [Note: CAH standards begin with ‘00’.] 14.00.01Alternative Life Safety Measures- Policy 14.00.02Alternative Life Safety Measures- Implementation 14.00.03Notification of Emergency Response Forces 25

26. General Requirements 14.00.04Facility Demographic Information- FDI (Replaces the old LSA) 14.00.05Testing & Inspection- Definition of Time 14.00.06Testing & Inspection- Documentation The above three standards will not be enforced until July 1, 2014 26

27. Means of Egress 14.01.00Corridor Door Latching 14.01.01Door Locks 14.01.02Corridor Width 14.01.03Suites 14.01.04Exit Signs 14.01.05Exit Discharge 14.01.06Corridor Projections 14.01.07Path of Egress Obstruction 27

28. Fire Detection Systems 14.02.00Fire Alarm System- Installation 14.02.00Fire Alarm System- Testing 14.02.00Fire Alarm Systems- Transmitting Signal 14.02.00Fire Alarm System- Technician Qualifications 28

29. Fire Suppression Systems 14.03.00Water-Based Fire Protection System- Installation 14.03.01Water-Based Fire Protection System- Testing & Inspection 14.03.02Water-Based Fire Protection System- Control Valves, Piping and Hangers 14.03.03Fire Pumps- Weekly Test 14.03.04Fire Pumps- Annual Test 29

30. Fire Suppression Systems 14.03.05Alternative Fire Suppression Systems- Installation & Testing 14.03.06Water-Based Standpipes & Hoses- Inspection & Test 14.03.07Water-Based Fire Department Connections- Inspection 14.03.08Portable Fire Extinguishers- Installation, Inspection and Maintenance 30

31. Fire Safety Systems 14.04.00Fire Rated Barriers 14.04.01Smoke Compartment Barriers 14.04.02Fire & Smoke Damper- Testing 14.04.03Overhead Rolling/Horizontal Sliding Fire Doors- Testing 14.04.04Separated Occupancies 31

32. Fire Safety Systems 14.04.05Fire Rated Door Assemblies 14.04.06Hazardous Areas 14.04.07Ceilings 14.04.08Corridor Walls 32

33. Building Services 14.05.00Fireplaces 14.05.01Elevator Recall 14.05.02Trash & Linen Chutes 33

34. Operating Features 14.06.00Decorations 14.06.01Trash Receptacles 14.06.02Portable Heaters 14.06.03Life Safety Drawings [Previously, you were required to have LS drawings, but this standard has new requirements. You will be held responsible to have basic LS drawings, but will not have to meet the additional new requirements until July 1, 2014.] 14.06.04Alcohol Based Hand Rub Dispensers 34

35. Waivers and Equivalent Systems 14.07.00CMS Waiver of Life Safety Code 14.07.01Fire Safety Evaluation System 35

36. Summary of Changes Most of the standards in the new Life Safety chapters are not new requirements… Hospitals have had to comply with these requirements for years by virtue of compliance with the Life Safety Code, even though they were not specific HFAP standards We just wrote new standards on certain LSC issues that we wanted to emphasize 36

37. Summary of Changes The four standards that are new requirements will not be enforced until July 1, 2014 to allow you time for compliance: – Facility Demographic Report – Testing & Inspection- Definition of Time – Testing & Inspection- Documentation – Life Safety Drawings 37

38. Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance Questions? Brad Keyes, CHSP bkeyes@hfap.org (815) 629-2240 Office bkeyes@hfap.org (815) 742-4367 Cell 38

39. Certificate of Attendance ___________________________ Awarded 1.0 contact hours “Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance A 60 minute audio-conference January 16, 2014 _________________ Beverly Robins Brad Keyes, Presenter Director of Accreditation and Certification Keyes Life Safety Compliance, LLC