Presenters - ANHA

2012LifeSafetyCodeUpdate June20,2016

AlabamaDepartment ofPublicHealth 1

REVISED CMS REGULATIONS AND THE

2012 NFPA CODES

FIRE SAFETY REQUIREMENTSFOR NURSING HOMES

Alabama Department of Public HealthTechnical Services Unit

Presenters

Victor HuntSally Kimbrough-McAuley

Tony Dunklin



Change from 2000 Codes to 2012 Codes

• The Centers for Medicare and Medicaid Services (CMS) published announcement on May 4, 2016

• Adoption of National Fire Protection Association (NFPA) codes and referenced standards

• Adoption of 2012 Life Safety Code includes Tentative Interim Amendments (TIA) 12-1 through 12-4.

• Adoption of 2012 NFPA 99 Health Care Facilities Code, excluding chapters 7, 8, 12, and 13. Includes TIAs 12-2 through 12-6.

www.nfpa.org, “Codes and Standards,” “List of Codes and Standards,” select code,

“Editions,” 2012

2000 Codes to 2012 Codes

2000 Codes to 2012 Codes

• Compliance required on July 5, 2016 • Chapter 18, New Healthcare Occupancies

– Plan approval by ADPH on or after July 5• Chapter 19, Existing Healthcare

Occupancies – All facilities constructed prior to July 5– Plan approval by ADPH prior to July 5



Building Rehabilitation

• 2000 LSC – Alterations, renovations, additions, and new equipment meet requirements for NEW (paragraph 4.6.7)

• 2012 LSC – Comply with Chapter 43, Building Rehabilitation

Building Rehabilitation

Chapter 43 Work Categories • Repair• Renovation • Modification• Reconstruction• Change of use or occupancy classification • Addition

Means of Egress

Comply with Chapter 7Applies to New and Existing Buildings, per

7.1.1

Construction ProjectsLSC 19.7.9.2 Not new Means of egress in construction areas shall

be inspected daily for availability for full instant use in case of an emergency.



Emergency Hardware

• Fire Exit Hardware only on fire-rated doors– Latch holding device never permitted

(dogging, or dogged down) • Panic Hardware only on doors not fire-

rated – Dogging, or dogged down, is permitted

Per LSC 7.2.1.7

Electric Hardware on Egress Doors

New, per LSC 7.2.1.5.6 Electric hardware permitted in means of egress: 1. Hardware mounted on door leaf 2. Obvious operation in direction of egress (panic)3. Operable with one hand in direction of egress4. Hardware operation interrupts power to electric

lock 5. Loss of power to hardware unlocks door 6. Hardware listed per ANSI/UL 294Key, key pad, or card reader not allowed on

egress side of door.

Stairway Identification

LSC 7.2.2.5.4 • Requirements for special stair signage

apply to -– Existing enclosed stairs serving 5 or more

stories – New enclosed stairs serving 3 or more stories

“Story” includes basement level.



Stairway Identification

See LSC 7.2.2.5.4. •13 Requirements •Additional contents•Lettering minimum heights•Illumination by emergency

lighting•Tactile designation (Braille) for floor level number

Means of Egress LightingLSC7.8.1.2and7.8.1.2.2• Illuminationmustbecontinuous duringperiodswhenneeded.

• Canbecontrolledbyautomaticmotionsensor-typeswitches.

• 5conditions arelisted(3conditionsin2000LifeSafetyCode)

Delayed-Egress Locks

LSC 19.2.2.2.4 • 2000 LSC – “not more than one . . . in any

egress path” Deleted in 2012 LSC. Comply with Section 7.2.1.6.1 • Emergency lighting on egress side of the

door (new requirement) • Accurately reflect delay time on the sign

(not new)



Door Locking for SecurityLSC 19.2.2.2.5.1 • Patients require specialized security

or pose a security threat. • LSC Handbook: “addresses the locking of

sleeping room doors” • Doors released manually by staff

– Remote control (kill switch), or – Keying locks to keys carried by staff

• No change from 2000 Life Safety Code

Staff and Locked Doors

LSC 19.7.3.2Requires “adequate staff qualified to

release locks and direct occupants from the immediate danger area”

Door Locking for Safety

LSC 19.2.2.2.5.2 • Patients require specialized protective

measures for their safety. • New provision, not in 2000 Life Safety

Code • Corresponds to ADPH “Exit Door Locking

Arrangements” article



Door Locking for SafetyLSC 19.2.2.2.5.2 1. Staff can readily unlock doors at all times. 2. Emergency release switch (kill switch).

ADPH requires sign at each switch, and restricted resetting of switch.

3. Complete sprinkler system required4. Fail-safe electrical locks. ADPH allows

10-second unlocking delay for power failure to fire alarm.

Door Locking for Safety

LSC 19.2.2.2.5.2 5. Locks release automatically upon:

1. Smoke detection system activation, or2. Sprinkler system water flow, or3. Disablement of fire alarm system (ADPH)

6. Release switch at each locked door (ADPH)

7. Written justification (ADPH)

Sliding Doors

LSC 19.2.2.2.10.2 • New section containing 5 requirements• Emergency break-away swing feature not

required when the door serves fewer than 10 occupants. (New)



Projections Into CorridorsLSC 19.2.3.4(2) Corridors 6 feet or more wide• New LSC provision for 6 inch projections

from wall above handrail height• ADA Accessibility Guidelines (ADAAG)

allows 4 inch projections into circulation path.

• ADAAG allows 4-1/2 inch handrail projections.

• CMS – Technical assistance regarding how to avoid noncompliance with ADA requirement.

Projections Into Corridors

2012 LSC 19.2.3.4(2) •Allowed in corridors at least 6 feet wide

2010 ADA •Paragraph 307.2•Handrails 4-1/2 inches

Wheeled Equipment in Corridors

LSC 19.2.3.4(4) •Clear width at wheeled items isat least 60 inches •Fire Safety Plan and Training Program for Emergency relocation•Limited to:

•Equipment and carts in use•Medical emergency equipment not in use (new)•Patient lift and transport equipment (new)



Permissible Wheeled Equipment

Food Service Carts (In Use)Housekeeping Carts (In Use)Medication Carts (In Use)Isolation CartsCrash CartsWheeled Emergency Medical Equipment (not stored)Portable Lift EquipmentTransport Equipment

Fixed Furniture in CorridorsLSC 19.2.3.4(5) Summary of requirements: •Securely attached to floor or wall•On one side of the corridor•Each grouping limited to 50 square feet•Groupings at least 10 feet apart•No obstruction of access to building and fire equip.

•Corridors have smoke detection, or furniture in view from nurse station•Sprinkler system in compartment

Hazardous Areas

LSC 19.3.2.1.5• Soiled linen rooms with a volume

exceeding 64 gallons• “Trash collection rooms” changed to

“Rooms with collected trash.” Hazardous if volume exceeds 64 gallons.



Residential Cooking Equipment

LSC 19.3.2.5.2• Food warming or limited cooking • No fire extinguishing system required

(new expanded wording) • Room not required to be protected as a

hazardous area (modified wording)

“Culture Change” Kitchen

LSC 19.3.2.5.3 to prepare meals for up to 30 residents (per Appendix)

• “Cooking facility” open to corridor• No separation required from other spaces

within the smoke compartment• 13 Conditions listed • Requires plan review through Technical

Services

“Culture Change” KitchenLSC 19.3.2.5.4 to prepare meals for up to 30

residents• “Cooking facility” not open to corridor• Separation required from corridor• Not a sleeping room• 11 Conditions apply• Requires plan review through Technical

Services



“Traditional” Kitchens

LSC 19.3.2.5.5• Cooking equipment protected by kitchen

fire extinguishing system• Not considered hazardous area • Not open to the corridor

Alcohol-Based Hand Rub Dispensers

LSC 19.3.2.6 “ABHR” K-211• Comply with this paragraph in lieu of NFPA 30 • Quantity within a smoke compartment clarified,

generally up to 10 gallons totaled is acceptable– One dispenser within a bedroom not included in this

limitation

• More than 5 gallons stored in a compartment to comply with NFPA 30

• Aerosol dispensers added

Alcohol-Based Hand Rub Dispensers Locations

LSC 19.3.2.6(8)• In corridors at least 6 feet

wide. • At least 48 inches apart• Mounted over carpet only

in sprinklered smoke compartments

• Mounting near an ignition source, including:

– Light switch– Electrical receptacle



Alcohol-Based Hand Rub Dispensers

“Inappropriate Access” statements by CMS in code adoption announcement, Page 63.

• Certain patients or residents may misuse ABHR solutions, which are toxic and flammable.

• Secure dispensers from inappropriate access– Not in corridors in or near dementia or psychiatric units– Only where units can be easily and frequently

monitored

Powered Corridor Doors

LSC 19.3.6.3.7 New provision to allow powered doors in

corridor wall. Doors may swing or slide. • Must have latching device to keep the door in a

closed position• Must comply with 7.2.1.9, “Powered Door Leaf

Operation”

Protective Door Plates

LSC 19.3.6.3.122012 wording removed the height restriction

on protective plates on corridor doors.

Plates may be factory-applied or field-applied.Fire rating of the plate is not required.



Corridor Wall Openings

LSC A19.3.6.5.1 New Annex note • Unprotected mail slots and pass-through

openings in walls, vision panels and doors• Not intended to be at hazardous areas

Bedroom Outside Window

LSC 19.3.8 • NFPA deleted code requirement for outside

window or door at each sleeping room. However –• CMS added the requirement to the revised

federal regulations for hospitals and long term care facilities. Required sill heights.

• ADPH licensure requirement

Indoor Gas FireplacesLSC 19.5.2.3 Expanded requirements• Direct-vent type, per NFPA 54• May be within smoke compartment with sleeping

rooms if sprinklered with quick-response or residential sprinklers

• Not within a sleeping room• Locked or restricted gas controls• Wire mesh screen and sealed glass front • Electrically supervised carbon monoxide

detection in the room



Indoor Solid Fuel Fireplaces

LSC 19.5.2.3 • Minimum 1-hour fire separation from patient

sleeping space• Fireplace enclosure such as tempered glass • Electrically supervised carbon monoxide

detection in the room• AHJ may require lock on enclosure, and other

safety precautions.• Raised hearth required in Chapter 18 New.

Smoking Areas

LSC 19.7.4No changes.

Portable Space HeatersLSC 19.7.8No changes.

19.7.5.1 Drapes vs. Cubicle Curtains

• Cubicle curtains still have to be flame resistant.



19.7.5.1 Drapes vs. Cubicle Curtains

• Draperies and curtains are not required to be flame resistant in patient rooms within a sprinklered smoke compartment.

• Draperies and curtains in other rooms or areas if the panels are not more than 48 sq ft, not exceeding 20% of wall area, and in sprinklered locations.

19.7.5.4 Mattresses and Upholstered

Furniture• No change for Alabama Nursing Homes.

• Since all existing nursing homes in Alabama have complete automatic sprinkler systems, the requirement for smoke detectors in the patient room does not apply.

19.7.5.6Decorations

• Flame-retardant or treated with approved coating

• Meet the NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films, using the 20 kW ignition source

• Heat release not exceeding 100kW, NFPA 289, Standard Methods of Fire Tests for Individual Fuel Packages



19.7.5.6(4) Decorations Attached to

Walls, Ceilings & Doors Inside any room or space of a smoke compartment:

• Without a sprinklered system in the smoke compartment, decorations shall not exceed 20% of the wall, ceiling, and door in the area.

• With a sprinklered system in the smoke compartment, decorations shall not exceed 30% of the wall, ceiling, and door area.

• For patient sleeping rooms in a smoke compartment with sprinkler coverage, 50% is the max of the wall, ceiling, and door area.

19.7.5.7 Trash & Linen Containers

No new requirements. Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity.

Exception: No limit in hazardous areas.

19.7.5.7 Trash & Linen Containers

• Average density of container capacity in a room or space shall not exceed 0.5 gallon per square foot.Exception: No limit in hazardous areas.



19.7.5.7 Linen Containers

• General guideline: Bedrooms may have one 30 gallon linen container per resident.

19.7.5.7Trash & Linen

Containers

“Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.”

19.7.5.7 (Handbook)Trash & Linen

Containers



Recycling ContainersLSC 19.5.7.2 – New provision for clean

paper

• Up to 96 gallon size

• If more than 96 gallons, shall be located in a room with self-closing door. Walls and ceiling resist the passage of smoke.

• The container used shall be labeled and listed as meeting FM approved Standard 6921, or equivalent.

Essential 2012 NFPA Codes

catalog.nfpa.org

$98

$73

catalog.nfpa.org

Essential 2012 NFPA CodesNFPA 99



$60

catalog.nfpa.org

Essential 2012 NFPA CodesNFPA 25

• Types of SuitesSleeping SuitePatient Care Non-Sleeping SuiteNon-Patient Care Suite

• 19.2.5.7.2.1 Sleeping Suite ArrangementStaff SupervisionSleeping Rooms within the Suite

2012 NFPA 101 Suites



• 19.2.5.7.2.2 Sleeping Suite Means of Egress

Exit Access DoorsExit into Other Suites

• 19.2.5.7.2.3 Sleeping Suite Maximum Size

Not to Exceed 5,000 square feet

Suites, continued

Sprinkler Requirements • 19.3.5.2 High-rise Buildings

Sprinkler System Throughout

Egress Lighting

• 7.8.1.3 New StairsIllumination Levels

• 7.9.2.2 New Power Systems for Emergency Lighting

Type 10, Class 1.5, Level 1



• 4.1 Building Systems CategoriesThe Code lists four categories: Category 1Category 2Category 3Category 4Risk AssessmentApplication

NFPA 99 Fundamentals

• 9.1 ApplicabilityNew constructionRenovated or Altered

Requirement for smoke venting in anesthetizing locations has been deleted from NFPA 99.

Heating, Ventilation, and Air Conditioning

• 10.2.3.6 Multiple Outlet Connection

Two or more power receptacles connected to a flexible cord to supply power to components of a movable equipment assembly that is rack, table, pedestal or cart mounted is permitted if you meet the four steps listed.

TIA 12-5.

NFPA 99 Electrical Equipment



• 15.1 ApplicabilityNew & Existing

NFPA 99 Features of Fire Protection

• CMS is working on a separate rule for “Emergency Preparedness” and is excluding this chapter from their regulations.

NFPA 99 Emergency Management

Remember! If It’s Not Documented, It Didn’t Happen!

– 7.9.3 Testing of emergency lighting monthly and annually

– 7.10.9 Visual inspection of Exit signs/30 days

– 9.4.6 Elevator Testing



Fire Alarm

It’s official! The fire alarm system doesn’t have to wake the dead in health care facilities, see 9.6.3.6.3.

You may use the private operating mode.

Sprinkler Systems• All nursing homes shall have a complete

automatic sprinkler system. 19.3.5.1

• Maintenance and testing per NFPA 25

• Documentation on the sprinkler system that you must maintain includes design and inspections for the life of the fire protection system.

Sprinkler Systems Impairment

• Reference NFPA 25

Ø Must have an “Impairment Coordinator”

Ø Sprinkler system must be tagged to show that the sprinkler system is impaired; a tag shall be posted at each fire department connection, system connection valves, and other locations as required by the AHJ to indicate all or which part is impaired.




• Planned Impairment Program

• Emergency Impairments


If the sprinkler system is out of service for more than 10 hours in a 24 hour period:

ØEvacuate the building or the portion of the building, or

ØImplement an approved fire watch, orØEstablish a temporary water supply, orØSet up an approved program to eliminate

potential ignition source and limit the amount of fuel for a fire.

SprinklerSystems

• Identifythelocationoftheshutoffvalveswithapermanentsign

• Testsprinklerheadsifinserviceformorethan50years,repeatat10years

• Ifsprinklersysteminstalledpriorto1929replace

• Sprinklersystemwithfast-responseelementsafter20yearsreplacedortested



Statement of Deficiencies (SOD)

Due out of the state office within 10 working days

Plan of Correction (POC)

Must be returned to state office within 10 calendar days

§ Each deficiency must have a POC (Plan of Correction) with a completion date not later than the date shown in the ADPH letter

§ 35 days after the health team has left your facility

§ Waivers for additional time may be granted



4 ELEMENTS TO A POC

1. Specific corrective action.2. Identify any other occurrences.3. Policies/procedures you have set in place to

insure the deficiency will not occur again.4. How will you monitor the policies and

procedures you have set in place? Who will collect the information? How often will it be collected? What will trigger additional action?

An Example of a Citation

K-25 Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.

Example of a citation (cont.)Based on observation of all smoke barriers on 5/11/2016, the facility failed to maintain smoke barriers with a system or material capable of restricting the transfer of smoke. Findings include:

Smoke barrier at Room 201 had holes in several locations where drywall mud had fallen out. In some locations, the holes had been sealed with an orange foam product. The facility personnel could not provide documentation for the orange foam to verify if the product could be used in a commercial building for rated walls.



Rejected Plan of Correction Provided

1) The unsealed penetration in the smoke barrier at Room 201 will be repaired by the Maintenance Director.

2) The unapproved orange foam substance used to seal penetrations in the smoke barrier will be removed and will be sealed per life safety code standards by the maintenance personnel.

Rejected Plan of Correction Provided

3) The administrator provided training to the maintenance personnel on how to seal the smoke barrier and educated them on the importance of maintaining the wall to resist the transfer of smoke.

4) The maintenance personnel will monitor the smoke barriers weekly to ensure barriers are sealed appropriately and per life safety code standards. Any concerns noted will be addressed and monitoring will continue. A copy of these checks will be kept in the administrator’s office.

Reasons POC Rejected • This was the exact wording for the POC from

the previous years.• The name of the product used to seal the

penetrations was not provided.• What training did the administrator have in

order to train the maintenance staff on how to maintain the wall to limit the transfer of smoke?

• This facility was cited for this same tag three years in a row.



Why are we looking so closely?

• CMS has asked that the State Agency work to reduce repeat deficiencies in facilities.

• How can this be accomplished?ØFacilities must provide a better Plan of

Correction. ØFacility staff must be properly trained and

must be more diligent in follow-through

SprinklerSystems

• Newprovision– dry-typesprinklerheadsthathavebeeninstalledfor10yearsshallbereplaced,orasamplingsentfortesting.Retestafternext10years.

• Sampleneededfortestingnotlessthanfoursprinklersor1%,whicheverisgreater



Evacuation and Relocation Plan19.7

• No change– Written copies of your plan available for

supervisors and at the security desk, phone operators location, or nurses station.

– Instruct all employees periodically.– During fire drills, alarm shall be transmitted off

site.– Drill quarterly on each shift (not less than

once in any 3-month period).– Written record of drills, including participants

(LSC 4.7.6)

Fire Safety Plan 19.7.2.2• Remove all occupants.

• Transmission of fire alarm signal.

• Isolate the fire by closing the door to the effected room.

• Relocate patients as described per facility fire safety plan.

Written Safety Plan1.Use of alarms2.Transmission of alarm to fire department3.Emergency phone call to fire department (2003)4.Response to alarms5.Isolation of fire6.Evacuation of immediate area7.Evacuation of smoke compartment8.Preparation of floors and building for evacuation9.Extinguishment of fire



HCFA Transmittal Notice 99-94

• Issued by federal agency, still in effect– Deals with items in the corridor must be in

use, staff is actually using the equipment not just moving the equipment around because of the LSC survey. The equipment must have a permanent storage location, off of the corridor.

Not referring to “emergency medical equipment” in new wheeled equipment section.

Top 10 Deficiencies1. K147 Electrical2. K25 Smoke Barriers3. K18 Corridor Doors4. K29 Hazardous Areas5. K69 Cooking Equipment6. K66 Smoking 7. K130 Miscellaneous8. K50 Fire Drills9. K38 Maintain Exits10. K62 Sprinkler

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