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THE IMPACT OF THE 2012 CODES
OSHFM 2017 ANNUAL CONFERENCEOCTOBER 20, 2017
Chris J. Ricchiuto CHFM, CFPS
Life Safety Code Surveyor
The Joint Commission
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ONCE AGAIN, A CLEAN SLATE
. . .
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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)
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REFERENCED PUBLICATIONS CON’T
NFPA 110 – Generators
NFPA 70 - NEC
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CHANGES TO NFPA 101 & NFPA 99
NFPA 101 2012
Had 64 referenced publication changes
NFPA 99 2012
Had 30 referenced publication changes
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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
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OMG!
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RELAX!IT’S NOT ALL THAT BAD. IN FACT, ITS NOT BAD
AT ALL.
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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
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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
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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
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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)
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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)
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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)
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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.
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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)
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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.
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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.
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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)
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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.
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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
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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
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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
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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
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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
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DOORS
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THE REASON…
Fire Doors are a Critical Component of our Fire Protection Systems
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FOCUS ON DOORS
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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
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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.
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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
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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.
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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
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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
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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
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ADDITIONAL RESOURCES
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ADDITIONAL RESOURCES CON’T
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So Why Do We Do This?
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QUESTIONS?
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Thank You!
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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
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