© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

THE IMPACT OF THE 2012 CODES

OSHFM 2017 ANNUAL CONFERENCEOCTOBER 20, 2017

Chris J. Ricchiuto CHFM, CFPS

Life Safety Code Surveyor

The Joint Commission

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

ONCE AGAIN, A CLEAN SLATE

. . .

Department of Engineering 2017 - 3

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

NFPA 101 LIFE SAFETY CODE 2012 EDITION

Chapter 2 Referenced Publications (64 total)

NFPA 10 – Fire Extinguishers (2010)

NFPA 13 – Sprinklers (2010)

NFPA 25 – ITM Suppression Systems (2011)

NFPA 72 – Fire Alarms

NFPA 80 – Doors (2010)

NFPA 99 – Healthcare Facilities (2010)

NFPA 105 – Smoke Control Doors (2010)

Department of Engineering 2017 - 4

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

REFERENCED PUBLICATIONS CON’T

NFPA 110 – Generators

NFPA 70 - NEC

Department of Engineering 2017 - 5

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

CHANGES TO NFPA 101 & NFPA 99

NFPA 101 2012

Had 64 referenced publication changes

NFPA 99 2012

Had 30 referenced publication changes

Department of Engineering 2017 - 6

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

JOINT COMMISSION CHANGES TO THE STANDARDSAND EP’S AS RELATED TO NFPA 101 2012

54 have been retained

241 have been revised

37 are new

27 have been consolidated

21 have been deleted

Changes to the EC & LS Standards Only

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

OMG!

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

RELAX!IT’S NOT ALL THAT BAD. IN FACT, ITS NOT BAD

AT ALL.

Department of Engineering 2017 - 9

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

HERE’S WHY

The standards and EP’s are more prescriptive

Have greater alignment with CMS expectations

Only reflect changes made to the embedded codes

All of the changes have been positive

Categorical Waivers are no longer necessary

Inclusion of most CMS S&C Waivers into NFPA 101

Except 20% humidity waiver

Department of Engineering 2017 - 10

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

NFPA 101 ADOPTION (A BRIEF HISTORY)

Chapters 18 & 19 for new and existing Healthcare Occupancies

Existing Occupancies are any facilities built prior to July 5th 2016

New Occupancies are facilities built after July 5th

2016

If stamped plans were approved prior to July 5th

2016, occupancy is classified as existing

Implemented on November 1st 2016

Department of Engineering 2017 - 11

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

NFPA 101 ADOPTION (TIA’S)

TIA 12-1

Updated table listing the protection requirements of elevator hoistways, shafts, barriers, horizontal exits, etc.

TIA-2

Deals with cooking equipment located within a smoke compartment

TIA-4

Deals with special locking arrangements

Department of Engineering 2017 - 12

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

SO WHAT’S ACTUALLY CHANGED?

Some EOC Examples:

NFPA 25 – Suppression Testing

Semi-annual flow tests vs quarterly

NFPA 72 – Fire Alarms

Annual communication test vs quarterly (EP 5)

▪ 2016 is still quarterly (prior to Nov 1st)

Department of Engineering 2017 - 13

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

EXAMPLES CON’T

NFPA 110 – Generators

Maintenance Free starting batteries are allowed

▪ Eliminating the monthly specific gravity testing and associated hazards

▪ Remote stop location

▪ Annual fuel testing per ASTM (new EP)

Department of Engineering 2017 - 14

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

NFPA 99 HEALTH FACILITIES CODE

Chapter 4

4.2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.

TIA 12-2

HVAC requirements

TIA 12-3

Life Safety Branch (alternate supply)

Department of Engineering 2017 - 15

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

EC.02.05.01 EP 2 (K901)

Building systems are designed to meet Categories 1 – 4 requirements.

These are established by formal and documented risk assessment procedure by qualified personnel.

See NFPA 99-2012 Chapter 4 for description of the four categories related to gas, vacuum, electrical and electrical equipment.

Department of Engineering 2017 - 16

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

EC.02.05.01 EP 23 (K913)

Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body.

Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters.

A written record of the risk assessment is maintained and available for inspection. (For full text refer to NFPA 99-2012: 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2)

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 17

EC.02.03.01 EP 11 (K932) WILDCARD

The organization meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15.

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 18

EC.02.04.03 EP 8 (K931) (K919)

All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99-2012, Chapter 14.

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 19

EC.02.04.03 EP 14

The hospital meets all other HealthCare Facilities Code requirements; facilities code for electrical equipment in the patient care vicinity as related to NFPA 99-2012: Chapter 10. (Wildard)

Note: For hospitals that use Joint Commission accreditation for deemed status purposes: the hospital meets the applicable provisions of the Life Safety Code Tentative Interim Amendment (TIA) 12-5. (RPT’s)

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 20

EC.02.05.01 EP 2 (K901)

Building systems are designed to meet Categories 1 – 4 requirements.

These are established by formal and documented risk assessment procedure by qualified personnel.

See NFPA 99-2012 Chapter 4 for description of the four categories related to gas, vacuum, electrical and electrical equipment.

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 21

EC.02.05.03

EP 1: Type 1 or Type 3 essential electrical systems comply with NFPA 99-2012 if upgraded since 1983

Essential electrical system must be divided into three branches

Life safety branch

Critical branch

Equipment branch

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 22

EC.02.05.01 EP 23 (K913)

Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body.

Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters.

A written record of the risk assessment is maintained and available for inspection. (For full text refer to NFPA 99-2012: 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2)

Department of Engineering 2017 - 23

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

INTERIM LIFE SAFETYMEASURESAND

FIRE AND LIFE SAFETY RISKASSESSMENTS

Are Required Anytime a Deficiency is Discovered

Using established internal process

Requires a multi-disciplinary approach

Must be hard wired into our teams

Required during any construction/renovation

Using a Decision Matrix similar to an ICRA

NFPA 101 Chapter 43 has specific requirements for renovation activities

Department of Engineering 2017 - 24

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

RISK ASSESSMENT SCENARIOS

Emergent

Loss of a Fire Pump

Loss of Water

Scheduled

Planned Impairments due to construction

▪ ILSM Policy driven

Alarm or Trouble Condition

Department of Engineering 2017 - 25

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

RISK ASSESSMENT SCENARIOS CON’T

Routine Maintenance Activity

Stairwell renovations: e.g., painting

Exit and Egress Door Maintenance

Observed during rounds:

Damaged fire alarm devices

Damaged doors, etc.

All deficiencies are ultimately owned by the Facility Director/Manager when discovered during survey/inspections

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 26

Department of Engineering 2017 - 27

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

DOORS

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 28

THE REASON…

Fire Doors are a Critical Component of our Fire Protection Systems

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 29

FOCUS ON DOORS

Department of Engineering 2017 - 30

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

EC 02.03.05 EP25

Referenced Codes

NFPA 80 (2010)

NFPA 80 (2010)

Went into effect July 5th 2016 with a November 1st

2017 deadline

NFPA, TJC and CMS presented at the NFPA Annual Conference in June of 2017

Extended the deadline to Jan 1st 2018

July 28, 2017 S&C letter

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 31

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 32

EC.02.03.05 EP 25

The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening.

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 33

CLASSIFICATION OF DOORS

1. Fire Doors

Inventory driven from LS Drawings

2. Smoke Barrier Doors

3. Hazardous Area Doors

4. Corridor Doors

Should have a process in place to manage other 3 door categories

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 34

EC.02.03.05 EP 25 (CONTINUED)

Note 1: Non-rated doors, including corridor doors to patient care rooms and smoke barrier doors, are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105. However, non-rated doors should be routinely inspected and maintained in proper working order.

Note 2: For additional guidance on testing of door assemblies, see NFPA 101-2012: 7.2.1.5.10.1; 7.2.1.5.11; NFPA 80-2010: 4.8.4; 5.2.1; 5.2.3; 5.2.4; 5.2.6; 5.2.7; 6.3.1.7; NFPA 105-2010: 5.2.1.

Department of Engineering 2017 - 35

© C

opyr

ight, T

he J

oin

t C

om

mis

sio

n

FIRE DOOR INSPECTIONS CON’T

Performed by “Trained and Qualified” Individuals

Competencies should be set and measured annually

Training resources/programs are available

Many organizations are self-performing

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 36

NEW S&C’S AND SURVEY EXPECTATIONS

17-29-ALL SUBJECT: Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures - E tags

Ref: S&C 17-30-Hospitals/CAHs/NHs REVISED 06.09.2017 SUBJECT: Requirement to Reduce

Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of

Legionnaires’ Disease (LD)

17-38-LSC SUBJECT: Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies

5lbs of force…corridor doors

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 37

CMS SURVEY PROCESS

Validate 5% of all AO surveys

K-tag wildcards reference NFPA codes

State Operations Manual (SOM) mandate that every room in the facility is inspected

Have significantly more time to survey the physical environment

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 38

ADDITIONAL RESOURCES

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 39

ADDITIONAL RESOURCES CON’T

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 40

So Why Do We Do This?

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 41

QUESTIONS?

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 42

Thank You!

© C

opyrig

ht,

Th

e J

oin

t C

om

mis

sio

n

Department of Engineering 2017 - 43

JOINT COMMISSION LSC FIELD DIRECTORS

Jim Kendig, MS, CHSP, CHCM, HEM, LHRM

Field Director, LSCS

Email: jkendig@jointcommission.org

Office: 630-792-5819

Tim Markijohn, MBA/MHA, CHFM, CHE

Field Director, LSCS

Email: tmarkijohn@jointcommission.org

Office : 630-792-5148