THE 2012 EDITION OF THE LIFE SAFETY CODE® NURSING …...Fire Safety Evaluation System (FSES) Time...

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THE 2012 EDITION OF THE LIFE SAFETY CODE®

NURSING HOME EDITION

SESSION #5

WELCOME

Moderator: Richard Schieferdecker

support.webinato.com

Audio

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QUESTIONS

How To Ask a Question:

POLLING

There will be occasional interactive poll questions.

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THE 2012 EDITION OF THE LIFE SAFETY CODE®

NURSING HOME EDITION

SESSION #5

AGENDA

Hot Topics – Common Findings

Life Safety Drawings

Waivers / Equivalencies

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SURVEY TOOLS AND TRAINING

http://surveyortraining.cms.hhs.gov/index.aspx



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CMS TOP FINDINGS….2016 2015 2014

1. K0056 – Automatic Sprinkler Systems

K0056 – Automatic Sprinkler Systems

K0062 – Sprinkler System Maintenance

2. K0062 – Sprinkler System Maintenance

K0029 – Hazardous AreaSeparation

K0056 – Automatic Sprinkler Systems

3. K0144 – Generators Inspection/Testing

K0062 – Sprinkler System Maintenance

K0050 – Fire Drills

4. K0038 – Exit Accessible at All Times

K033 – Exit Components K0029 – Hazardous AreaSeparation

5. K0029 – Hazardous AreaSeparation

K0144 – Generators Inspection/Testing

K0052 – Fire Alarm System Testing

6. K0025 – Smoke PartitionConstruction

K0038 – Exit Accessible at All Times

K0144 – Generators Inspection/Testing

7. K0050 – Fire Drills K0025 – Smoke Partition Construction

K0025 – Smoke Partition Construction

8. K0067 ‐ HVAC K020 – Vertical Shafts K0071 – Laundry Chutes

9. K0071 – Laundry Chutes K0050 – Fire Drills K0147‐ Electrical Wiring and Equipment

10. K0018 – Corridor Doors K0018 – Corridor Doors K069 – Cooking Equipment

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SPRINKLER SYSTEM INSTALLATION K56 → K351

SPRINKLER SYSTEM MAINTENANCE K62 → K353

NFPA 25, 2011 Edition

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EXIT DISCHARGE K38 → K271

Terminate at the public way

Hard‐packed, all weather travel surface

Free of snow or ice

Slope not exceeding 1 in 20

EXIT CORRIDORS K39 → K232

Corridor clutter / storage

30 minute rule

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HAZARDOUS AREAS K29 → K321

EXISTING1 hour enclosure

¾ hour door

Sprinkler protection

Smoke partition

Self‐closing door

50 SF or greater with storage

NEW1 hour enclosure

¾ hour door

Sprinkler protection

Self‐closing door

100 SF or greater with storage

SMOKE BARRIERS K25 → K372(wall), K379(doors)

Outside wall to outside wall

Floor to deck

All penetrations sealed

Doors smoke resisting

Doors self‐closing

HINT: INSPECT IN THELESS OBVIOUS

LOCATIONS...NOT JUSTABOVE THE CORRIDOR

DOORS

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CONSTRUCTION TYPE / PROTECTION K12 → K161

FIRE DRILLS K50 → K712

Varying times

Varying conditions

Each shift quarterly

Knowledge of procedures and competence of staff as observed in drills

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CORRIDOR DOORS K18 → K363

ELECTRICAL K147 → K511

NFPA 70 (NEC)

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WHY DRAWINGS

Rated fire / smoke barrier

walls

30 min corridor walls

Rated enclosures / shafts

Exits

Exterior

Stairs

Passageways

Horizontal

LIFE SAFETY FEATURES

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LIFE SAFETY FEATURES

Existing Hazardous Areas

Sprinklered

Non-sprinklered

New Hazardous Areas

Ambulatory & Business

HAZARDOUS AREAS

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HAZARDOUS AREAS

Suite Type

Sleeping suite

Non-sleeping suite

Non-patient care suite

Suite Size

SUITES

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Compartment Boundaries

Compartment Size

22,500sq.ft.

Sprinkler Protection

SMOKE COMPARTMENTS

SUITES & SMOKE COMPARTMENTS

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LOGO

COVER PAGE – GENERAL BLDG. INFO

ALTERNATE APPOACHES

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WAIVERS

Fire Safety Evaluation System (FSES)

Time Limited Waiver

Permanent Waiver

Categorical Waiver

NFPA 101A (guide)

Addresses Alternate Approaches to Life Safety

Accepted method by TJC and CMS

Calculations and process by occupancy type

Evaluates each smoke zone

Factors include

• Occupancy risk factors

• Safety parameters

FIRE SAFETY EVALUATION SYSTEM (FSES)

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OCCUPANCY RISK PARAMETERS ‐ HEALTHCARE

Construction

Interior Finish

Corridor Partitions

Corridor Doors

Zone Dimensions

Vertical Openings

Hazardous Areas

Smoke Control

Egress Routes

Fire Alarm

Detection

Sprinkler Protection

OCCUPANCY SAFETY PARAMETERS ‐ HEALTHCARE

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√

√

√

√

All Zones Must be Zero (0) or Greater

Construction issues

Travel distance issues

Deficient egress components

COMMON FSES APPLICATIONS

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A detailed written request outlining a time period in which the facility will become in prescriptive compliance with a Life Safety Code® provision.

• Deficiencies eliminated in future Code editions

• Temporary issues

• Issues identified in survey taking longer than 60 days to remediate.

TIME LIMITED WAIVERS

Executive Summary / Overview

Building Overview

• Construction info

• Building height

• Sprinkler protection

• Smoke detection

• Other pertinent info

Detailed Deficiency Description

Code / Standard References

• TJC Life Safety Chapter

• Life Safety Code® chapter and section

Intent of the Requirement

WAIVER SUBMISSION

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Hardship Assessment

• Cost (provide specifics when possible)

• Operational disruption

• Negative affect on patients

Waiver Justification

• What off‐sets the deficiency

• New or existing features above what is required

• Cost, source & commitment for alternative solution

Interim Life Safety Measures (ILSM)

• Clarify that ILSMs have been reviewed and applied

Patient Safety Assessment / Field Verification

• Clarify that the request will not negatively impact patient safety

• Statement clarifying an on‐site review & assessment

WAIVER DOCUMENTATION / SUBMISSION

Deficiency Alternative

Supporting documentation / descriptive drawings


Organization Name & Logo

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Supporting / descriptive photographs


Registered Architect

Licensed PE

CFPS

Local AHJ (fire marshal, building official, etc.)

WAIVER CERTIFICATION

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Why are Requests Commonly Returned or Rejected

• Substance Proposal does not constitute an equivalent or better situation

• Administrative Missing information in submission

Request form not provided or incomplete

No certifying letter

FSES not completed accurately

FSES drawings not included

COMMON PITFALLS

QUESTIONS

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Next Session

Referenced

Codes & Standards

THANK YOU

Dave Hood Nick GabrielePresident Vice President

THE 2012 EDITION OF THE LIFE SAFETY CODE® NURSING …...Fire Safety Evaluation System (FSES) Time...

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