life safety code survey process (for hospitals) design standards unit rules and regulations
DESCRIPTION
Life Safety Code Survey Process for HospitalsHenry Kowalenko Supervisor Design Standards UnitRules and RegulationsThe following rules and regulations are used when surveying a facility Illinois Hospital Licensing Requirements77 IL Administrative Code 250Center for Medicare and Medicaid Services (CMS)CFR 485.623d Standard: Life Safety from Fire NFPA 101 Life Safety Code (2000 Edition) Chapter 19, Existing Healthcare Occupancies National Fire Protection AssociationIllinois Plumbing CodeTRANSCRIPT
Life Safety Code SurveyLife Safety Code SurveyProcess for HospitalsProcess for Hospitals
Henry KowalenkoHenry KowalenkoSupervisorSupervisor
Design Standards UnitDesign Standards Unit
Rules and RegulationsRules and RegulationsThe following rules and regulations are used when The following rules and regulations are used when surveying a facilitysurveying a facility
Illinois Hospital Licensing RequirementsIllinois Hospital Licensing Requirements77 IL Administrative Code 250 77 IL Administrative Code 250
Center for Medicare and Medicaid Services (CMS)Center for Medicare and Medicaid Services (CMS)CFR 485.623d Standard: Life Safety from FireCFR 485.623d Standard: Life Safety from Fire
NFPA 101 Life Safety Code (2000 Edition)NFPA 101 Life Safety Code (2000 Edition)Chapter 19, Existing Healthcare OccupanciesChapter 19, Existing Healthcare OccupanciesNational Fire Protection AssociationNational Fire Protection Association
Illinois Plumbing CodeIllinois Plumbing Code225 ILCS 320 February , 2004225 ILCS 320 February , 2004
Illinois Accessibility CodeIllinois Accessibility Code71 Illinois Administrative Code 40071 Illinois Administrative Code 400
Survey ProcessSurvey Process
CMS Survey CMS Survey Sample Validation Survey or Full Survey Due to Sample Validation Survey or Full Survey Due to ComplaintComplaint
UnannouncedUnannouncedClinical (nurses)Clinical (nurses)Life Safety Code (architects)Life Safety Code (architects)
Survey all healthcare occupanciesSurvey all healthcare occupanciesSurvey business occupanciesSurvey business occupancies
Billing under the hospitals provider numberBilling under the hospitals provider numberBuildings can be onsite or offsiteBuildings can be onsite or offsiteNFPA 101NFPA 101-- Chapter 39, Chapter 39, ““Existing Business OccupanciesExisting Business Occupancies””
Survey ProcessSurvey Process
The IDPH inspector will be escorted on a The IDPH inspector will be escorted on a tour of the facility. The following items tour of the facility. The following items should be available:should be available:
Keys to all areasKeys to all areasLadderLadderFlashlightFlashlightSmall floor planSmall floor plan
Fire barriers and ratingsFire barriers and ratingsSuite designationsSuite designationsExitsExits
Survey ProcessSurvey Process
The inspector will conduct a review of the The inspector will conduct a review of the following documentation:following documentation:
Fire drill recordsFire drill recordsFire alarm inspection Fire alarm inspection Emergency generator Emergency generator Fire extinguishersFire extinguishersKitchen hood suppression systemsKitchen hood suppression systemsFire and emergency policy proceduresFire and emergency policy procedures
Survey ProcessSurvey Process
During the inspection, the fire alarm and During the inspection, the fire alarm and sprinkler systems will be tested.sprinkler systems will be tested.
Fire alarm testing will includeFire alarm testing will includePull stations Pull stations –– the facility will need to have keys the facility will need to have keys available to reset the fire alarmavailable to reset the fire alarmSmoke detectors Smoke detectors -- functional test (no magnets), functional test (no magnets), canned smoke needs to be availablecanned smoke needs to be available
Sprinkler testing will includeSprinkler testing will includeWater flows (if sprinklered)Water flows (if sprinklered)
Plan of Correction Plan of Correction -- PoC PoC
Corrective action for each deficiencyCorrective action for each deficiencyClearly identify what will be doneClearly identify what will be done
DonDon’’t say t say ““completedcompleted””
When will it be complete When will it be complete –– month/day/yearmonth/day/yearIf the corrective action requires a number of steps, identify If the corrective action requires a number of steps, identify the steps and when the steps and when theythey will be complete. Example:will be complete. Example:
Hire consultantHire consultant……………………..month/day/year..month/day/yearReview solutionsReview solutions………………...month/day/year...month/day/yearBid workBid work……………………………………..month/day/year..month/day/yearStart workStart work……………………………………month/day/yearmonth/day/yearWork Work complete,,,,,,,,,,,,,,,,,monthcomplete,,,,,,,,,,,,,,,,,month/day/year/day/year
Plan of CorrectionPlan of Correction--PoCPoCWho will be responsibleWho will be responsible
DonDon’’t use proper namest use proper namesDirector of Facilities, etc,Director of Facilities, etc,
Must have reasonable time frameMust have reasonable time frameInterim Life Safety Measures (ILSM)Interim Life Safety Measures (ILSM)
Additional fire drillsAdditional fire drillsAdditional fire extinguishersAdditional fire extinguishersFire watchFire watch
Use the forms providedUse the forms providedEssentialEssential
Plan of CorrectionPlan of Correction--PoCPoC
LSC Monitoring SurveysLSC Monitoring SurveysOnsite inspections to verify complianceOnsite inspections to verify complianceBased on the PoCBased on the PoCUnannouncedUnannouncedSurveys continue until PoC is completeSurveys continue until PoC is complete
Alternate ComplianceAlternate Compliance
Fire Safety Evaluation System (FSES) Fire Safety Evaluation System (FSES) ––NFPA 101A (2001 Edition)NFPA 101A (2001 Edition)
FSES FSES may bemay be used when prescriptive used when prescriptive compliance cannot be achievedcompliance cannot be achievedThe FSES is based on a point systemThe FSES is based on a point systemNot typically accepted for new constructionNot typically accepted for new construction
Licensure SurveysLicensure Surveys
Plan review process completed Plan review process completed Receive a letter indicating reviews are done, submit Receive a letter indicating reviews are done, submit certificationscertifications
How do we know your done with construction?How do we know your done with construction?PrePre--occupancy Checklistoccupancy Checklist
www.idph.state.il.us/healthcarefacilities/DSU/Prewww.idph.state.il.us/healthcarefacilities/DSU/Pre--OccupancyChecklistComplete.pdfOccupancyChecklistComplete.pdf77--10 days review of certification10 days review of certificationCertifications deemed completeCertifications deemed completeOnOn--site survey scheduled site survey scheduled -- announcedannouncedFederally mandated surveys take precedenceFederally mandated surveys take precedence
Licensure SurveysLicensure Surveys
OnOn--site inspection process identical to site inspection process identical to CMS surveyCMS survey
The extent of survey will vary according to the The extent of survey will vary according to the scope of workscope of workIDPH will issue a letter of deficiencies citedIDPH will issue a letter of deficiencies citedProvider/architect to respondProvider/architect to respondReRe--visit may be necessaryvisit may be necessary
Licensure SurveyLicensure Survey
Occupancy letter Occupancy letter Date of occupancyDate of occupancyStipulations (if any)Stipulations (if any)
Emergency repairEmergency repairIDPH notificationIDPH notificationPlan/specification submittalPlan/specification submittalFull compliance with codeFull compliance with code
Licensure SurveyLicensure Survey
Phased projects Phased projects -- temporary occupancytemporary occupancy77--item request must be submitted and item request must be submitted and deemed acceptabledeemed acceptableOnOn--site inspection requiredsite inspection requiredSystems must be in compliance (HVAC, Systems must be in compliance (HVAC, sprinkler, electrical, etc)sprinkler, electrical, etc)Complete preComplete pre--occupancy checklist must be occupancy checklist must be submitted for the final phase of a projectsubmitted for the final phase of a projectOnOn--site inspectionsite inspection
Common DeficienciesCommon Deficiencies
K014
Common DeficienciesCommon Deficiencies
K017
Common DeficienciesCommon Deficiencies
K-018
Common DeficienciesCommon Deficiencies
K-038
Common DeficienciesCommon Deficiencies
K-038
Common DeficienciesCommon Deficiencies
K-039
Common DeficienciesCommon Deficiencies
K-044
Common DeficienciesCommon Deficiencies
K-051
Common DeficienciesCommon Deficiencies
K-051
Common DeficienciesCommon Deficiencies
K-056
Common DeficienciesCommon Deficiencies
K-0147
Common DeficienciesCommon Deficiencies
K-147
Design Standards UnitDesign Standards Unit
Staff EngineersStaff EngineersJustin DammermanJustin Dammerman Donald HallDonald Hall
Contact informationContact informationPhone Phone 217217--785785--42644264FaxFax 217217--782782--03820382Email (for general questions only)Email (for general questions only)
[email protected]@illinois.gov
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