january 16, 2014 brad keyes, chsp
DESCRIPTION
Changes to the 2014 Acute Care & Critical Access Hospital Manuals on Life Safety Compliance. January 16, 2014 Brad Keyes, CHSP. The New LS Surveyors. Beginning in January, 2014, a new surveyor with expertise on the Life Safety Code (LSC) will be joining each hospital survey - PowerPoint PPT PresentationTRANSCRIPT
January 16, 2014Brad Keyes, CHSP
Changes to the 2014 Acute Care &
Critical Access Hospital Manuals
on Life Safety Compliance
The New LS Surveyors
Beginning in January, 2014, a new surveyor with expertise on the Life Safety Code (LSC) will be joining each hospital survey
These LS surveyors will be assessing your facility and life safety documentation for compliance with the LSC
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The New LS Surveyors
HFAP decided to add the new LS surveyors to improve the overall evaluation of the organization’s compliance with the Life Safety Code.
They have LS expertise in their daily careers:Facility Managers Safety OfficersConstruction Managers Project ManagersConsultants VP Facilities
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The New LS Surveyors
The LS surveyor will be on-survey according to the following formula:– One (1) day for hospitals that have less than 50
licensed beds and has less than 100,000 square feet of healthcare occupancy
– Two (2) days for hospitals with 50 or more licensed beds, or has 100,000 square feet or more of healthcare occupancy
– One (1) additional day for each off-campus location containing a healthcare occupancy
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The New Manuals
Why did we make changes to the old standards?– Corrected some errors– Wanted to make the standards more relevant and
meaningful and arranged in a fashion that makes sense
– Wanted to emphasize certain requirements of the Life Safety Code by creating a specific standard
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The New Manuals
For the new 2014 Acute Care manual, we separated out the standards from the old chapter 11:
– Chapter 9 Emergency Management– Chapter 11 Physical Environment– Chapter 13 Life Safety
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The Acute Care Manual
The previous Acute Care manual Chapter 11 had 15 written standards on LSC compliance
The new Acute Care Chapter 13 has 49 written standards on LSC compliance, but only four (4) of those standards are new requirements
[We will identify those new requirements for you later….]
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The Acute Care Manual
The LS chapter is broken down into 8 different sections:– General Requirements– Means of Egress– Fire Detection Systems– Fire Suppression Systems– Fire Safety Systems– Building Services– Operating Features– Waivers and Equivalent Systems
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General Requirements
13.00.01 Life Safety Code Compliance13.00.02 Alternative Life Safety Measures-
Policy13.00.03 Alternative Life Safety Measures-
Implementation13.00.04 Notification of Emergency
Response Forces
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General Requirements
13.00.05 Facility Demographic Report (Replaces the old LSA)
13.00.06 Testing & Inspection- Definition of Time
13.00.07 Testing & Inspection- Documentation
The above three standards will not be enforced until July 1, 2014
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Means of Egress
13.01.01 Corridor Door Latching13.01.02 Door Locks13.01.03 Corridor Width13.01.04 Suites13.01.05 Exit Signs13.01.06 Exit Discharge13.01.07 Corridor Projections13.01.08 Path of Egress Obstruction
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Fire Detection Systems
13.02.01 Fire Alarm System- Installation13.02.02 Fire Alarm System- Testing13.02.03 Fire Alarm Systems- Transmitting
Signal13.02.04 Fire Alarm System- Technician
Qualifications
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Fire Suppression Systems
13.03.01 Water-Based Fire Protection System- Installation
13.03.02 Water-Based Fire Protection System- Testing & Inspection
13.03.03 Water-Based Fire Protection System- Control Valves, Piping and Hangers
13.03.04 Fire Pumps- Weekly Test13.03.05 Fire Pumps- Annual Test
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Fire Suppression Systems
13.03.06 Alternative Fire Suppression Systems- Installation & Testing
13.03.07 Water-Based Standpipes & Hoses- Inspection & Test
13.03.08 Water-Based Fire Department Connections- Inspection
13.03.09 Portable Fire Extinguishers- Installation, Inspection and Maintenance
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Fire Safety Systems
13.04.01 Fire Rated Barriers13.04.02 Smoke Compartment Barriers13.04.03 Fire & Smoke Damper- Testing13.04.04 Overhead Rolling/Horizontal Sliding
Fire Doors- Testing13.04.05 Construction Type
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Fire Safety Systems
13.04.06 Separated Occupancies13.04.07 Fire Rated Door Assemblies13.04.08 Hazardous Areas13.04.09 Ceilings13.04.10 Corridor Walls
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Building Services
13.05.01 Fireplaces13.05.02 Elevator Recall13.05.03 Trash & Linen Chutes
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Operating Features
13.06.01 Decorations13.06.02 Trash Receptacles13.06.03 Portable Heaters13.06.04 Life Safety Drawings[Previously, you were required to have LS drawings,
but this standard has new requirements. You will be held responsible to have basic LS drawings, but will not have to meet the additional new requirements until July 1, 2014.]
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Operating Features
13.06.05 Alcohol Based Hand Rub Dispensers
13.06.06 Definition of New Construction and Existing Conditions
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Waivers and Equivalent Systems
13.07.01 CMS Waiver of Life Safety Code13.07.02 Fire Safety Evaluation System
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The Critical Access Hospital Manual
For the new 2014 Critical Access Hospital manual, we separated out the standards from the old chapter 11:
– Chapter 3 Physical Environment and Emergency
Management– Chapter 14 Life Safety
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The Critical Access Hospital Manual
Unlike the Acute Care manual, the Physical Environment and Emergency Management standards are combined into one chapter: 3
These new standards will not be enforced during surveys until March 1, 2014
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The Critical Access Hospital Manual
The previous Critical Access Hospital (CAH) manual had 15 written standards on LSC compliance
The new CAH manual Chapter 14 has 47 written standards on LSC compliance, but only four (4) of those standards are new requirements
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The Critical Access Hospital Manual
The chapter is broken down into 8 different sections:– General Requirements– Means of Egress– Fire Detection Systems– Fire Suppression Systems– Fire Safety Systems– Building Services– Operating Features– Waivers and Equivalent Systems
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General Requirements
14.00.00 Life Safety From Fire[Note: CAH standards begin with ‘00’.]
14.00.01 Alternative Life Safety Measures- Policy
14.00.02 Alternative Life Safety Measures- Implementation
14.00.03 Notification of Emergency Response Forces
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General Requirements
14.00.04 Facility Demographic Information- FDI (Replaces the old LSA)
14.00.05 Testing & Inspection- Definition of Time
14.00.06 Testing & Inspection- Documentation
The above three standards will not be enforced until July 1, 2014
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Means of Egress
14.01.00 Corridor Door Latching14.01.01 Door Locks14.01.02 Corridor Width14.01.03 Suites14.01.04 Exit Signs14.01.05 Exit Discharge14.01.06 Corridor Projections14.01.07 Path of Egress Obstruction
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Fire Detection Systems
14.02.00 Fire Alarm System- Installation14.02.00 Fire Alarm System- Testing14.02.00 Fire Alarm Systems- Transmitting
Signal14.02.00 Fire Alarm System- Technician
Qualifications
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Fire Suppression Systems
14.03.00 Water-Based Fire Protection System- Installation
14.03.01 Water-Based Fire Protection System- Testing & Inspection
14.03.02 Water-Based Fire Protection System- Control Valves, Piping and Hangers
14.03.03 Fire Pumps- Weekly Test14.03.04 Fire Pumps- Annual Test
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Fire Suppression Systems
14.03.05 Alternative Fire Suppression Systems- Installation & Testing
14.03.06 Water-Based Standpipes & Hoses- Inspection & Test
14.03.07 Water-Based Fire Department Connections- Inspection
14.03.08 Portable Fire Extinguishers- Installation, Inspection and Maintenance
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Fire Safety Systems
14.04.00 Fire Rated Barriers14.04.01 Smoke Compartment Barriers14.04.02 Fire & Smoke Damper- Testing14.04.03 Overhead Rolling/Horizontal Sliding
Fire Doors- Testing14.04.04 Separated Occupancies
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Fire Safety Systems
14.04.05 Fire Rated Door Assemblies14.04.06 Hazardous Areas14.04.07 Ceilings14.04.08 Corridor Walls
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Building Services
14.05.00 Fireplaces14.05.01 Elevator Recall14.05.02 Trash & Linen Chutes
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Operating Features
14.06.00 Decorations14.06.01 Trash Receptacles14.06.02 Portable Heaters14.06.03 Life Safety Drawings[Previously, you were required to have LS drawings, but this
standard has new requirements. You will be held responsible to have basic LS drawings, but will not have to meet the additional new requirements until July 1, 2014.]
14.06.04 Alcohol Based Hand Rub Dispensers
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Waivers and Equivalent Systems
14.07.00 CMS Waiver of Life Safety Code14.07.01 Fire Safety Evaluation System
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Summary of Changes
Most of the standards in the new Life Safety chapters are not new requirements… Hospitals have had to comply with these requirements for years by virtue of compliance with the Life Safety Code, even though they were not specific HFAP standards
We just wrote new standards on certain LSC issues that we wanted to emphasize
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Summary of Changes
The four standards that are new requirements will not be enforced until July 1, 2014 to allow you time for compliance:– Facility Demographic Report– Testing & Inspection- Definition of Time– Testing & Inspection- Documentation– Life Safety Drawings
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Changes to the 2014 Acute Care & Critical Access Hospital Manuals
on Life Safety ComplianceQuestions?
Brad Keyes, [email protected]
(815) 629-2240 Office(815) 742-4367 Cell
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Certificate of Attendance___________________________
Awarded 1.0 contact hours
“Changes to the 2014 Acute Care & Critical Access Hospital Manuals
on Life Safety Compliance
A 60 minute audio-conference
January 16, 2014_________________ _________________
Beverly Robins Brad Keyes, Presenter
Director of Accreditation and Certification Keyes Life Safety Compliance, LLC