june 30, 2015 brad keyes, chsp engineering advisor bkeyes@hfap.org hfap life safety code update:...
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June 30, 2015Brad Keyes, CHSP
Engineering Advisorbkeyes@hfap.org
HFAP Life Safety Code Update:
Changes and Hot TopicsWebinar
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HFAP Life Safety Code Boot Camp at the Crowne Plaza Chicago O'Hare Hotel!
– September 10-11, 2015– Registration is limited, act fast to guarantee your spot!– Cost: $750 for 1st Participant per facility, $695 for
additional participants from the same facility.– Please contact Pamela Holloway via email at
pholloway@hfap.org or via phone at 312-202-8061.
Today, we will be discussing the following issues:– It’s not business as usual anymore;– Changes and Updates to the HFAP standards.
Learning Objectives
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Facility managers typically are saddled with the responsibilities of many departments:
– Maintenance– Plant Operations– Projects– Paint Shops– Environmental Services– Security– Laundry– Life Safety
It’s Not Business as Usual
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Preparing for survey can be time-consuming, which may lead the facility manager to rely on the results of previous surveys as a guide on preparation for future surveys.
For example; if the last survey did not reveal any deficiencies with the fire alarm test report, then the facility manager may decide not to review the current reports for compliance.
It’s Not Business as Usual
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They may think they’re ready and have all of their documentation prepared, but that approach will likely lead to problems with the new HFAP survey process.
As of January 1, 2014, HFAP has been assigning Life Safety Code experts to each Acute Care and Critical Access hospital survey.
It’s Not Business as Usual
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Many Life Safety Code deficiencies have been identified that previously were undetected.
In some cases, these deficiencies have been in existence for many decades, but were a LSC deficiency when they were installed.
It’s Not Business as Usual
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This has also lead to many organizations being unprepared for the document review session to determine compliance with the standards.
The new LS surveyors are better qualified and educated on what the codes and standards require for compliance.
It’s Not Business as Usual
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To begin with, let’s take a look at the most common problems with documentation…
It’s Not Business as Usual
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First: Read the standards!
Take the time to actually read all of the standards that apply to you’re area of responsibility.
It’s Not Business as Usual
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If you are the facility manager of your hospital, then presumably you are responsible for the Physical Environment and Life Safety chapters of the HFAP standards.
Possibly, you may also be responsible for the Emergency Management chapter as well.
It’s Not Business as Usual
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The HFAP standards were re-written in 2014 and while there are very few new requirements, the re-written HFAP standards actually identify and explain better what’s expected for compliance.
It’s Not Business as Usual
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Second: Ask questions if you do not understand!
There is no shame in not knowing or understanding a requirement.
It’s Not Business as Usual
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It is not unusual that a typical facility manager may not fully understand what’s required on a particular standard.
But, it is the organization’s responsibility to comply with the standards. So, if you’re not 100% sure on how to comply, then it is your responsibility to ask questions.
It’s Not Business as Usual
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You can always ask questions via telephone or email, through these connections:
– info@hfap.org• 312-202-8258• 800-621-1773, ext. 8258
– bkeyes@hfap.org• 815-629-2240 (office)• 815-742-4367 (cell)
It’s Not Business as Usual
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Reading and understanding the standards is a good start, but to be complete, you must assess your own documents.
It’s Not Business as Usual
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Third: Confirm compliance by reviewing your documentation!
It’s Not Business as Usual
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There are many reasons that it is critically important for the facility manager to review the inspection and testing documentation on the hospital’s fire-safety equipment:
It’s Not Business as Usual
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1. You should never trust an outside contractor for advice on compliance with a standard or regulation. If you hire a service contractor to test your fire alarm system, it is your responsibility to make sure that contractor is not only performing the test correctly, but is actually testing everything that is required to be tested.
It’s Not Business as Usual
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2. Contractors frequently do not know what edition of a particular NFPA standard the hospital is required to comply with. For example, the latest edition of inspection and testing of sprinkler systems is the 2014 edition; however, the hospital is currently required to comply with the 1998 edition. They may mistakenly assume you are required to comply with the most recent edition. (There are a lot of differences between the 1998 edition and the 2014 edition.)
It’s Not Business as Usual
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3. Check the inspection reports / work-orders from your own staff. Make sure they understand the correct procedures to follow for that particular test or inspection. Even the most seasoned veterans may develop ‘work-arounds’ or short-cuts that you may not be aware of unless you review their work.
It’s Not Business as Usual
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4. Look for items that did not pass the test or inspection, or were not tested due to inaccessibility. There are no acceptable reasons not to perform a test or inspection on a device that has a requirement to do so. If a device failed, then it needs to be repaired or replaced, and then retested; and the documentation proving all of this needs to be accessible.
It’s Not Business as Usual
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Now let’s look at some recent LSC deficiencies that took many hospitals by surprise…
It’s Not Business as Usual
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Doors Locked in the Path of Egress…
There has been only three exceptions that allows doors in the path of egress to be locked in a hospital:
1. Clinical needs locks2. Delayed egress locks3. Access-control locks
It’s Not Business as Usual
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Clinical Needs Locks only applies to behavioral health units, such as psychiatric units and Alzheimer’s units.
Clinical needs locks are not permitted anywhere else, such as baby units, ICUs and ERs.
It’s Not Business as Usual
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Hospitals that use infant security systems that lock the doors when the baby tag gets too close are being cited for non-compliance with 13.01.02 Door Locks.
They are not permitted because they lock the door in the path of egress.
It’s Not Business as Usual
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Hospitals counter that the doors unlock on a fire alarm, and the locks are needed to prevent infant abduction (a very emotional subject).
They never were permitted, but some local or state authority allowed them and HFAP surveyors never saw the problem until we hired Life Safety experts.
It’s Not Business as Usual
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[SOLUTION: In the Plan of Correction, the hospital will make modifications (i.e. sprinklers and smoke detectors) to qualify for the 19.2.2.2.5.2 allowance for Safety Needs locks in the 2012 LSC; then they will invoke the CMS categorical waivers that allow this. If sprinkler installtion takes a long time, then a time-limiting waiver request will be necessary.]
It’s Not Business as Usual
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Another frequent problem HFAP surveyors are finding is hospitals are using delayed egress locks in buildings that are not fully sprinklered or fully smoke detected (see 7.2.1.6.1 of the 2000 LSC).
It’s Not Business as Usual
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HFAP will allow the continued use of delayed egress locks as long as the hospital commits to completing their sprinkler installation and submit a waiver request.
It’s Not Business as Usual
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Let’s transition now, and take a look at the changes and updates HFAP has made in the Acute Care manual…
Changes and Updates
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We have made changes to our Acute Care manual in the Emergency Management, Physical Environment and Life Safety chapters.
Most of the updates are editorial, but there were some changes that affects the compliance of the standard…
Changes and Updates
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09.00.01 Emergency Operations Plan– No longer require the EOP to be integrated with the
community emergency preparedness plan; just be shared.
09.00.02 Emergency Hazard Vulnerability Analysis– No longer require the HVA to be integrated with the
community emergency preparedness plan; just be shared. No longer require hospitals to prioritize their potential hazards with community agencies.
09.01.01 Emergency Safety & Security– No longer require hospitals to have MOUs with area law
enforcement agencies.
Changes and Updates
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09.01.04 Emergency Decontamination– Hospitals that do not receive emergency patients are
exempt from having decontamination facilities.
09.01.07 Emergency Communications – Real-time electronic tracking systems complies with the
requirement to provide semi-annual updates on staff roster call-back trees.
Changes and Updates
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09.01.09 Emergency Triage– Hospitals that do not receive emergency patients are
exempt from having to provide emergency triage. Also, added statement that the need for hospitals to have decontamination capabilities is not reduced where governmental agencies provide decontamination in the field.
09.01.10 Emergency Evacuation– Hospitals no longer need to have their Evacuation Plan
integrated with the community emergency response agency- just reviewed.
Changes and Updates
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09.01.11 Volunteer Management– Hospitals that do not receive emergency patients are
exempt from having to provide a volunteer management plan.
09.02.01 Emergency Exercises– Added language for all healthcare occupancies and
ambulatory healthcare occupancies that provide patient care requires emergency drills twice per year. Business occupancies only require emergency drills once per year.
Changes and Updates
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11.00.02 Required Plans & Performance Standards– Change now requires hospitals to designate the individual
responsible for each subchapter of the management plans, and document their qualifications.
11.01.01 Periodic Monitoring for Safety Issues– Changed language to reflect standard only requires
monitoring of the environment for safety, not maintenance.
Changes and Updates
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11.01.02 Building Safety– This standard is still confused with PM activities on medical
and utility equipment. Language was added to clarify that medical equipment is scored under 11.05.01 and utility equipment is scored under 11.06.09.
11.01.04 Safety Team/Committee Facilitator– Added language to require documentation of the
appointment of the person who is the facilitator (chairperson) of the safety committee. Added language to consider 1-year term limits, to prevent poor facilitators from dominating the meeting.
Changes and Updates
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11.01.06 Teams Appointed for Specific Safety Areas– This standard is deleted as there is no reason for HFAP to
require hospitals to create sub-committees for specific safety areas.
11.01.08 Review of Safety Policies/Procedures– Changed language from ‘triennial’ to ‘once every 36
months’ for the review of safety policies and procedures.
11.01.10 Eyewash Stations & Emergency Showers– This is a brand-new standard to clarify HFAP’s position on
eyewash stations. (Not a new requirement).
Changes and Updates
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11.03.03 Program Minimizes Exposure– Deleted requirement that the program to minimize expose
must address protection from specific groups.
11.03.04 Labels, Inventory & SDS– Changed title of standard to “Labels, Inventory & SDS” to
reflect requirement for Safety Data Sheets rather than MSDS. Also added language that copies of SDS may be maintained on CDs or flash drives provided a battery operated computer is available to display them.
Changes and Updates
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11.04.02 Fire Drills– Deleted some language and added other language to
clarify that healthcare and ambulatory healthcare occupancies require fire drills once per shift per quarter; and business occupancies require fire drills once per shift per year. This is a departure from the former requirement that all patient care facilities must have fire drills once per quarter per shift regardless of the occupancy designation. Also deleted requirement that fire drills must transmit alarm signals to the local fire department.
Changes and Updates
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11.04.03 Critique of Fire Drills– Added language in Scoring Procedure column to ensure
the Safety Committee is reviewing the fire drill reports.
11.04.04 Approval by State & Local Fire Authorities– Added language where the state or local fire authorities
refuses to provide inspections, the hospital must have written documentation from those authorities indicating their decision to not provide inspections.
Changes and Updates
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11.04.05 Minimize the Risk to Danger from Fire– Added language to clarify that the hospitals do not have to
install features of fire safety that they are not required by codes, standards or regulations to do so.
11.04.06 Fire Response – Staff Training– This standard on fire safety training is relocated from
11.08.01. (No new requirements).
Changes and Updates
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11.05.01 Medical Equipment & Systems – Maint. – Changed language to clarify that the organization may use
an alternate method of communication on medical equipment inspections in lieu of stickers identifying the next inspection due date. (However, stickers are considered to be ‘Best Practice’).
11.06.03 Generator Inspection– This standard on generators is relocated to 13.05.04. (No
new requirements.)
Changes and Updates
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11.06.04 Generator Monthly Load Test– This standard on generators is relocated to 13.05.05. (No
new requirements.)
11.06.05 Generator 3-Year Load Test– This standard on generators is relocated to 13.05.06. (No
new requirements.)
11.06.06 Automatic Transfer Switch Test– This standard on transfer switches is relocated to 13.05.07.
(No new requirements.)
Changes and Updates
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11.06.07 Potable Water– Changed language to clarify that potable water needs to
be tested annually; not periodically. Added language that states if potable water is tested by other entities, then the test results need to be available during survey.
11.06.08 Medical Gas Shutoff Valves– This standard on medical gas shutoff valves is relocated to
13.05.08. (No new requirements.)
11.06.11 Medical Gas Systems - Maintenance– This standard on medical gas maintenance is relocated to
13.05.10. (No new requirements.)
Changes and Updates
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13.00.01 Life Safety Code Compliance– Deleted requirement to identify deficiencies in the Life
Safety Code Deficiency Report (deleted the report).
13.00.02 Alternative Life Safety Measures - Policy– Added language that the ALSM policy must identify when a
particular compensating measure is required to be implemented, and to what extent.
13.00.03 Alternative LS Measures - Implementation– Deleted requirement that all items on Corrective Action
Plan list must be assessed for ALSM.
Changes and Updates
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13.00.05 Facility Demographic Report– Deleted requirement to identify deficiencies in the Life
Safety Code Deficiency Report (deleted the report). Added language to explain business occupancies do not have to have a FDR completed. Added language that individual healthcare occupancies or ambulatory healthcare occupancies require individual FDRs.
13.00.07 Testing & Inspection - Documentation– Added language that this standard on documentation does
not apply to annual maintenance tags on portable fire extinguishers.
Changes and Updates
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13.00.08 Interior Finish– This is an entirely new standard on interior finishes, but
not a new requirement.
13.01.01 Doors– Changed title of standard from “Corridor Door Latching” to
“Doors” to better reflect the overall requirement for corridor doors. Added language that corridors doors must resist the passage of smoke and be side-hinge or pivot-swing type.
Changes and Updates
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13.01.02 Door Locks– Added language to clarify dead-bolt locks are not
acceptable. Added language in Scoring Procedure column that addresses how to evaluate delayed egress locks and access-control locks.
13.01.03 Corridor Clutter– Changed title of standard from “Corridor Width” to
“Corridor Clutter” to better reflect the overall requirement of this standard.
Changes and Updates
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13.01.05 Signage– Changed title of standard from “Exit Signs” to “Signage” to
better reflect the overall requirement of this standard. Added language to better clarify the NO EXIT signage requirement.
13.01.06 Exit Discharge– Added language that the exit discharge must be
maintained free of ice and snow.
Changes and Updates
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13.01.07 Corridor Projections– Changed title of standard from “Corridor Projections” to
“Corridor” to better reflect the overall requirement of this standard. Added language that corridors need to have two exits without passing through intervening rooms, and added language on dead-end corridors.
13.01.08 Path of Egress Obstruction– This standard is on path of egress obstructions. Added
language that corridor clutter is scored under 13.01.03.
Changes and Updates
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13.01.09 Travel Distance to Exits– This is a new standard on travel distances to exits, but not
a new requirement.
13.01.10 Exit Enclosures– This is a new standard on exit enclosures, but not a new
requirement.
13.02.01 Fire Alarm System – Installation & Maint.– Added word ‘Maintenance’ to standard tile to better
reflect fire alarm systems need to be maintained. Added language to reflect that fire alarm systems need to be maintained.
Changes and Updates
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13.02.03 Fire Alarm System – Transmitting Signal– Added language that fire alarm transmitting systems are
not permitted to use manual systems. Also added language to ensure the local fire department receives a signal on at least a quarterly basis.
13.02.04 Fire Alarm System–Technician Qualification– Added language that documents identifying the fire alarm
technician qualifications must be maintained at the hospital, even if the service is contracted to a vendor.
Changes and Updates
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13.03.01 Water Based Fire Suppression System – Installation & Maintenance
– Added word ‘Maintenance’ in standard title and standard to better reflect the need to maintain sprinkler systems.
13.03.02 Water Based Fire Suppression System – Testing & Inspection
– Added language that sprinkler control valves are required to be visually inspected on a monthly basis.
Changes and Updates
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13.03.03 Water Based Fire Prot. – Control valves– Added word ‘electronic’ to standard to better reflect
control valves must be electronically supervised.
13.03.07 Water Based Standpipe & Hoses – I & T– Added language where occupant use fire hoses are
removed, the hospital must have permission from their state or local AHJ.
13.03.08 WB Fire Department Connections– Deleted word ‘Inspection’ from title of standard to allow
fire department connections to be properly maintained in the standard.
Changes and Updates
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13.04.03 Fire & Smoke Damper– Removed the word ‘Testing’ from the title to better reflect
installation and maintenance of dampers is included. Added language on how to document the installation of dampers. Added language to state there is no code or standard that allows inaccessible dampers to remain inaccessible and untested.
13.04.04 Overhead Rolling Fire Doors– Deleted word ‘Testing’ from title of standard to better
reflect the standard includes installation and maintenance of overhead rolling fire doors.
Changes and Updates
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13.04.05 Construction Type– Added language on fire-proofing material needing to meet
the requirements of the Construction Type, and must be installed and maintained in accordance with the UL listing. Added language that Construction Type must be listed in accordance with NFPA 220 format.
13.04.08 Hazardous Areas– Changed word in standard from ‘should’ to ‘must’ to better
reflect that hazardous areas must be identified on the Life Safety drawings.
Changes and Updates
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13.05.02 Elevator Recall– Added language that elevator recall is required to be
tested monthly, regardless what the ANSI Elevator Safety Code says.
13.05.04 Generator Inspection– Existing standard, relocated from 11.06.03. Added
language that generators located indoors must be separated from the rest of the facility with 2-hour fire rated barriers. (Not a new requirement).
Changes and Updates
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13.05.05 Generator Monthly Load Test– This is an existing standard on generators, relocated from
11.06.04. (Not a new requirement).
13.05.06 Generator 3-Year Load Test– This is an existing standard on generators, relocated from
11.06.05. (Not a new requirement).
13.05.07 Automatic Transfer Switch test– This is an existing standard on transfer switches, relocated
from 11.06.05. (Not a new requirement).
Changes and Updates
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13.05.08 Medical Gas Shutoff Valves– This is an existing standard on medical gas shutoff valves,
relocated from 11.06.08. Added language that valves must be located such that there is a wall between the valve and the outlets. (Not a new requirement).
13.05.09 Utility Systems– This is a new standard (but not a new requirement) on
plant equipment to allow surveyors to cite utility maintenance deficiencies.
Changes and Updates
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13.05.10 Medical Gas Systems - Maintenance– This is an existing standard on medical gas systems,
relocated from 11.06.11. Added language that medical gas system must be maintained to NFPA 99 requirements. Added language on compressed gas cylinder storage, gas pipe labels, and inspection and testing frequencies. (Not a new requirement).
13.05.11 Cooking Hoods Cleaning– This is a new standard (but not a new requirement) on
cooking hood cleaning.
Changes and Updates
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13.06.04 Life Safety Drawings– Added new requirement to include smoke partitions on Life
Safety drawings.
13.06.06 Definition of New vs. Existing Construction– Added language that deficiencies involving new construction
and existing construction are not scored under this standard.
13.07.01 CMS Waiver of Life Safety Code– Added language that deficiencies with waivers are not
scored under this standard.
Changes and Updates
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13.07.02 Fire Safety Evaluation Plan– Added language that deficiencies with equivalencies are
not scored under this standard. Added language that equivalencies are only valid until the next survey.
Changes and Updates
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At this time we will answer any questions that you may have…
Questions…?
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HFAP Life Safety Code Update:
Changes and Hot Topics
Brad Keyes, CHSPbkeyes@hfap.org
(815) 629-2240
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HFAP Life Safety Code Boot Camp at the Crowne Plaza Chicago O'Hare Hotel!
– September 10-11, 2015– Registration is limited, act fast to guarantee your spot!– Cost: $750 for 1st Participant per facility, $695 for
additional participants from the same facility.– Please contact Pamela Holloway via email at
pholloway@hfap.org or via phone at 312-202-8061.
Certificate of Attendance__________________________
Awarded 1.0 contact hours
HFAP Life Safety Code Update:
Changes and Hot Topics A 1-hour Webinar
June 30, 2015
_________________ Brad Keyes
Engineering Advisor to HFAP
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