State of Michigan · 2012 Edition of the LSC and NFPA 99 to ... System (FSES), NFPA 101A, 2001 Edition adopted in 2003, with the 2013 Edition of the FSES, NFPA 101A.

C U S T O M E R D R I V E N. B U S I N E S S M I N D E D.

State of Michigan Licensing and Regulatory Affairs

Bureau of Community and Health Systems

Life Safety Code 2012 Updatefor Long Term Care Facilities

October 27th 2016


Welcome to the Health Facilities Evaluation Section

Fire/Life Safety Inspectors, Engineers, and Support Staff


2012 NFPA Life Safety Code Requirements


On May 4, 2016, CMS adopted the 2012 LSC and the 2012 Health Care Facilities Code. The final rule published in the Federal Register (Vol. 81, No. 86), is entitled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities” and is effective July 5, 2016. The final rule also adopted 2012 LSC Tentative Interim Amendments (TIA) 12–1, 12–2, 12–3, and 12–4, and 2012 HCFC TIA 12–2, 12–3, 12–4, 12–5 and 12–6.

REGULATION


S&C: 16-29-LSC


The effective date, July 5, 2016, is important as it determines whether the facility is surveyed as “NEW” or “EXISTING.”

• Facilities with plan approval on or before the effective date, or constructed/renovated before the effective date, are considered to be an “EXISTING” facility, and are surveyed using the existing chapters of the LSC.

• Facilities with plan approval after the effective date, or constructed/renovated after the effective date, are considered to be a “NEW” facility, and are surveyed using the new chapters of the LSC.

Effective Date: JULY 5, 2016


What does this mean?

• IF the facility was built before July 5th 2016, it will be surveyed to “Existing” Chapter 19 of the LSC.


The implementation date, November 1st 2016, is the date the States and CMS will start using the 2012 Edition of the LSC and NFPA 99 to complete surveys of CMS certified facilities.

Implementation: NOVEMBER 1st 2016


• The K-tag series for the CMS-2786 forms have been revised as part of the 2012 LSC updates.

• New K-TAG series include three (3) digits representing the Code Section and Sub-section.

NEW K-TAG Series


• CMS is replacing the current Fire Safety Evaluation System (FSES), NFPA 101A, 2001 Edition adopted in 2003, with the 2013 Edition of the FSES, NFPA 101A.

• This will become effective on the implementation date of the regulation adopting the 2012 edition of the LSC.

Fire Safety Evaluation System


LSC and HCFC TIA adoption

• All Tentative Interim Amendments 1-4 issued prior to April 16, 2014, have been adopted with the 2012 Edition of the LSC

• All TIAs 2-6 issued prior to April 16, 2014, have been adopted with the 2012 Edition of the NFPA 99, except for the following chapters: 7, 8, 12, 13.

Tentative Interim Amendments


• Regulations for waivers has been updated based on the CMS adoption of the 2012 Editions of LSC and HCFC (NFPA 99).

• The Regulation includes and continues the ability to grant waivers.

• If application of the LSC would result in unreasonable hardship for the facility, CMS may waive specific provisions of the LSC, but only if the waiver does not adversely affect the health and safety of residents.

WAIVERS


• While CMS does not directly enforce the Americans with Disabilities Act (ADA), CMS does expect compliance with the requirements as additional Federal requirements that facilities are required to follow.

• Example: Corridor projections, LSC allows a non-continuous projection to be no more than 6 inches from the corridor wall.

• ADA Requirements: Projections be not more than 4 inches from the corridor wall.

• Facilities are required to meet this more stringent requirement.

ADA Requirements


The 2012 LSC includes three new sections regarding the use of FRTW in health care occupancies. These requirements apply equally to buildings classified as both “NEW” and “EXISTING.

18/19.1.6.3(2)

18/19.1.6.5

18/19.1.6.6

Fire Retardant-treated Wood (FRTW)



The 2012 LSC no longer requires “New” or “Existing” health care occupancy patient sleeping rooms to have an outside window or door. However CMS regulations still requires all patient sleeping rooms to have an outside window or door, with certain expectations.

• Windows in atrium walls shall be considered outside windows for the purposes of this requirement

• For New construction, the window sill must not exceed 36 inches above the floor:

Patient Sleeping Rooms


2012 NFPA 99, HCFC Code Requirements



• Recognizing the ever increasing demand for electronically powered devices in medical care areas, the Code has increased the number of receptacles required in certain patient care rooms.

• Patient bed locations in general care areas now require a minimum of eight receptacles (previously the building code required four).

* This will be discussed further regarding the use of Surge bars and Power strips.

Electrical Systems Distribution


From the Surveyor’s Perspective


NFPA 99 / NFPA 70Relocatable Power Taps

“ Surge Bars” “ Power Strips”

• In Patient Care Vicinity: Patient Care EquipmentUL 1363A / UL 60601-1

• Outside Patient Care: Non Care EquipmentUL 1363


In the 2000 LSC, 8 components were required for a Fire Safety Plan.

In the 2012 LSC, a 9th component was added as a requirement.

1. Use of alarms2. Transmission of alarms to fire department3. Emergency phone call to fire department ** NEW **4. Response to alarms5. Isolation to alarms 6. Evacuation of immediate area7. Evacuation of smoke compartment8. Preparation of floors and building for evacuation 9. Extinguishment of fire

LSC Section 18/19.7.2.2

Fire Safety Plan


Delayed Egress Locking Systems

• 18/19.2.2.2.4, 7.2.1.6.1

• LSC 101 – 2000: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

• LSC 101 – 2012: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.


Delayed Egress Locking Systems

• More then one delayed egress lock can be used in the path of egress.

• Example: Mag Lock delay egress at stairway exit door, additional Mag Lock delay egress at exit door at bottom of stairway to outside exit.


• Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:

• Wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 inches.

• Fire Safety plan and training address the relocation of equipment during an emergency

• Equipment limited to: • Equipment IN USE• Medical Emergency Equipment NOT IN USE• Patient Lift and Transport Equipment

18/19.2.3.4, Corridor Storage


• KEY POINT (8 criteria to be met)• Corridor Width is at least 8 feet wide• Fixed furniture is securely attached to the floor or the

wall• Furniture does not reduce unobstructed width to less

than 6 feet wide• Located only on one side of the corridor• Grouped such that each group does not exceed an area

of 50 square feet

18/19.2.3.4, Corridor Storage Furniture


• Requires all fire-rated door assemblies to be inspected annually• Is the door and frame free from holes and breaks in all surfaces?• Are all the glazing, vision light frames and glazing beads intact and securely fastened?• Are the doors, hinges, frame, hardware and threshold secure, aligned and in working

order with no visible signs of damage?• Are there any missing or broken parts?• Is the clearance from the door edge to the frame no more than 1/8 inch?• Is the door undercut no more than 3/4 inch?• Does the active door leaf completely close when operated from the full open position?• Does the inactive leaf close before the active leaf when a coordinator is used?• Does the latching hardware operate and secure the door in the closed position?• Is the door assembly free from any auxiliary hardware items which could interfere with

its operation?• Has the door been modified since it was originally installed?• If gasketing and edge seals are installed, have they been verified for integrity and

operation?

NFPA 80 (2010 ed.) Fire Rated Doors Inspection


• Soiled linen rooms containing no more than 64 gallons of soiled linen are not considered hazardous

• Trash collection rooms are now defined as ‘Rooms with collected trash’ and are not considered hazardous if they contain no more than 64 gallons of trash

*** These may be hard to regulate for size and are recommended to be maintained as hazardous room***

Hazard Rooms 18/19.3.2.1.5


• New requirements for decorations: • Combustible decorations may not exceed 30

percent of the wall and ceiling area in a sprinklered smoke compartment

18/19.7.5.6, Decorations


• If your monthly generator load test does not meet the 30% capacity of the nameplate rating, then an annual load test is required.

• The new 2010 edition of NFPA 110, referenced by the 2012 LSC only requires a 90-minute load test, rather than a 2-hour load test.

• The new annual test will begin at 50% load for 30 minutes, then move to 75% load for 60 minutes, for a total of 90-minutes of continuous test.

• Natural Gas Generators are tested monthly with the Available Load. ( > 30% not required)

Generator Testing NFPA 110 ( 2010 ed.)


• A Hydrometer is used to test the state of charge of a battery cell. This is performed by measuring the density of the electrolyte, which is accomplished by measuring the specific gravity of the electrolyte.

Battery Specific Gravity




• In the 2012 LSC, if the fire alarm system is out of service for more than 4 Hours in a 24-hour period, the authority having jurisdiction (AHJ) must be notified, and a building must be evacuated or a Fire Watch must be provided until the system has been returned to service (NFPA 101, 9.6.1.6).

• In the 2012 LSC, in the Sprinkler system is out of service for more than 10 Hours in a 24-hour period, the AHJ must be notified, and a building must be evacuated or a Fire Watch must be provided until the system has been returned to service (NFPA 25, 15.5.2)

Fire Watch


• Notify your Local Responding Agencies – Local Fire Department , Police , EMS , Insurance

• Call the Bureau of Community and Health Systems COMPLAINT HOTLINE 1-800-882-6006

• This Number is Staffed during normal business hours and is monitored nights and weekends (Leave a message if no answer)

• Start Documentation of your Fire Watch as soon as possible • Constant rounds by dedicated person(s)• REMEMBER TO FOLLOW UP WHEN YOU END

YOUR FIRE WATCH

What if I implement a FIRE WATCH ?


• CALL 911 • Start your Emergency Action Plan Immediately• Do not attempt to fight a fire above your ability (Let the

Firefighters do their job)• Any Fire is a FIRE, Report it• The Fire Department will determine if the fire is out and

your building is Fire Safe• Call the Bureau of Community and Health Systems

1-800-882-6006• Follow the same steps as you would for reporting a Fire

Watch

What if I have a FIRE ?


Gogebic

Ontonagon Baraga

IronMarquette

Dickinson

Alger

Delta

Schoolcraft

Luce

Chippewa

Mackinac

Antrim

Cheboygan

Charlevoix

Otsego

Presque Isle

Alpena

GrandTraverse

Manistee

Benzie

Wexford

Kalkaska

Missaukee

Crawford Oscoda Alcona

Iosco

Mason Lake Osceola Clare GladwinArenac

OceanaNewaygo

Mecosta Isabella Midland Bay

Muskegon

Kent

Montcalm Gratiot Saginaw

Tuscola

Huron

Sanilac

Ottawa Ionia ClintonGenesee Lapeer

St. Clair

Allegan Ingham LivingstonOakland

Van Buren

Barry Eaton

Kalamazoo Calhoun

Berrien Cass St.Joseph Branch Hillsdale Lenawee

Jackson Washtenaw

Monroe

Wayne

Shiawassee

RoscommonOgemaw

Macomb

MenomineeEmmet

Montmorency

Leelanau

JEFF WORTLEY

JOSEPH SHELTON

JOHN HANES

JEFF TODY

ED HALE

BRUCE JOHNSON

GERALD RODABAUGH

HEALTH FACILITIES EVALUATION SECTION2016/2017


From the Field

Frequently found deficiencies


Exterior gates

Chains with locks are not allowed

Magnetic Release can be acceptable


Circuit Breakers for Fire Alarm Systems must be labeled and locked out.

NFPA 72Section 10.6.5.4 requires that,“Where a circuit breaker is the disconnecting means, a listed circuitbreaker locking device shall be installed.”

10.6.5.2.1 The location of the branch circuit disconnecting means shall

be permanently identified at the control unit.10.6.5.2.2 System circuit disconnecting means shall be permanently

identified as to its purpose in accordance with the following:(1) “FIRE ALARM” for fire alarm systems

(2) “EMERGENCY COMMUNICATIONS” for emergencycommunications systems

(3) “FIRE ALARM/ECS” for combination fire alarm and emergencycommunications systems

10.6.5.2.3 For fire alarm and/or signaling systems, the circuitdisconnecting means shall have a red marking.

10.6.5.2.4 The red marking shall not damage the overcurrentprotective devices or obscure the manufacturer’s markings.


Blocked Exit Paths


Hallway Storage, What is and isn’t IN USE ?

* Hanging Decorations at eye level throughout the corridor


Extension Cords:Temporary /

Emergency use only


Proper Oxygen Storage ?


Penetrations in Rated Walls


The Enforcement Process

ePOC Temporary Waivers

“Offsite/Paper Review”Time Lines


Offsite/Paper Review

In lieu of an on-site revisit


• Fire Safety Inspector (FSI) reviews the ePOC and decides whether an offsite/paper review is appropriate for the citations issued.

• If appropriate, the FSI sends an email to the facility requesting appropriate documentation to prove compliance for each K-tag cited at the LSC survey.

Determination of Eligibility


• Set the time and date stamp on the camera• Name each picture with the appropriate

K-tag#

Photos and Videos as Evidence


• When using photos that require an item to be of a specific size or distance, use a measuring tape in the photo to identify the distance or size requirement

• Make the area identifiable (i.e. room number)

Examples of Evidence


• If a door is required to be positive latching, video an individual pulling the door closed to a positive latch and then putting force against the door showing it remains closed to a positive latch.

K29 – Hazardous Areas


• Provide documentation an invoice or receipt from the company servicing your equipment or system regarding maintenance, repair or modifications made to the fire alarm, sprinkler, kitchen hood suppression or generator.

Invoice/Receipt


• Sign-in sheets verifying attendance of staff at in-service training and an outline of the training provided.

Staff Training


• In an email response to the FSI and [email protected] send the appropriate evidence.

• Please note that inbound emails with attachments are limited to 25 MB, so multiple emails may be required to send all documentation to the SA.

Facility Response

mailto:[email protected]


• FSI Reviews the evidence and if appropriate clears the citations.

• If the FSI does not believe that the evidence is appropriate an on-site Revisit can be conducted.

• This procedure will be posted on our website.

State Agency


Temporary Waiver

• Requesting Temporary Waivers (TW) in ePOC

• No separate form


• A citation requiring more than 60 days from the survey exit date to correct.

• In which the correction is clearly beyond the control of the facility/provider.

• A TW will not be approved for a correction that can be made in a reasonable period of time (less than 60 days) or

• A correction that is clearly within the control of the facility/provider.

Requirements


K56 – Automatic Sprinkler SystemsNo TW can be issued for K56 (K351)


• Include the TW language in the POC text field for the appropriate K-tag.

• Enter the TW Expiration Date in the Completion X5 field.

ePOC


1. Justification that the unmet provision will not adversely affect the health and safety of facility occupants.

2. Include a timetable with milestone dates of major activities to correct the deficiency.

3. Document increased fire safety awareness during the Waiver period.

Waiver Criteria


• Request a reasonable period of time to complete all activities.– Planning and design– Plan review submittal and approval

Allow Sufficient Time


• 6/30/16: Obtain quote from company• 7/15/16: Request architectural drawings• 7/30/16: Submit architectural drawings for

plan review• 9/30/16: Receive approval from plan review• 10/10/16: Product shipped to facility• 10/26/16: Installation complete

Measureable Milestones


• Acknowledging results after your revisit

ePOC

C U S T O M E R D R I V E N. B U S I N E S S M I N D E D. 64


Deficiency Free Surveys


Deficiency Free Surveys


HEALTH FACILITIES EVALUATION SECTION

Main Line: 517-241-3408 Fax: 517-241-3423

James D. Scott Manager517-241-3420 (Office)517-643-5173 (Cell)

Kimberly Grafuis Secretary 517-241-3410

Marcia Whitmore Secretary 517-241-3410

Riyadh Almuktar Engineering Unit 517-285-5927 (Cell)

Duane Dimet Camps Unit 517-285-0128 (Cell)

Rob Gruesbeck Engineering Unit 517-331-5379 (Cell)

Ed Hale Fire Safety Unit 906-632-7936 (Cell)

John Hanes Fire Safety Unit 517-388-5610 (Cell)

Andrea Humphrey Engineering Unit 517-388-4498 (Cell)

Bruce Johnson Fire Safety Unit 517-243-1387 (Cell)

Kim Osborn Analyst 517-284-8948 (Office)

Gerald Rodabaugh Fire Safety Unit 517-243-5515 (Cell)

Joseph Shelton Fire Safety Unit 517-242-2387 (Cell)

Jeff Tody Fire Safety Unit 517-881-5759 (Cell)

Jeff Wortley Fire Safety Unit 517-243-9608 (Cell)

Pier-George Zanoni Engineering Unit 517-648-9508 (Cell)

Kasra Zarbinian Engineering Unit517-241-3422 (Office)517-897-1411 (Cell)


State of Michigan · 2012 Edition of the LSC and NFPA 99 to ... System (FSES), NFPA 101A, 2001 Edition adopted in 2003, with the 2013 Edition of the FSES, NFPA 101A.

Documents