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Survey Hot Topics&

Preparing for the 2012 Life Safety Code®

May 2015

RPA Effectiveness

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Agenda

Most Common NYSDOH K-tags

Status of the 2012 Life Safety Code

Key 2012 Provisions

Categorical Waivers

Power Strips

Q&A

K56 & K62: Sprinkler Systems

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K29: Hazardous Areas

K50: Emergency Plans

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K38: Exit Access

K25: Smoke Barriers

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K20: Stairwells & Shaft Enclosures

K18: Corridor Doors

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K147: Electrical Issues

K144: Generator Testing & Inspection

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K69: Commercial Cooking Equipment

K12: Construction Type

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Fire Safety Evaluation System (FSES)

The 2012 Life Safety Code®

Change Can Be Good!

Improved readability

Incorporates 12 years (4 editions) worth of changes

Primarily beneficial changes to Health Care Occupancies

Reflects benefits of automatic sprinkler protection

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2012 LSC Code Adoption

April 2014 proposed rule in the Federal Register

Adopt 2012 editions of 101 and 99

Proposing various alterations / exceptions

Comment period until June 16, 2014

Much review…NFPA, ASHE, AHCA

Expect adoption sometime in 2015

Waivers3/9/2012, CMS released Survey & Certification

(S&C) letter 12-21-LSC allowing health care facilities

to use the “cultural change” provisions contained

within the 2012 LSC Wheeled equipment in corridors

Fixed furniture in corridors

Combustible decorations

Fireplaces

Cooking facilities

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Challenges to the Waiver Approach

Health care facilities must first be cited for

noncompliant conditions and then request a

waiver to use 2012 LSC provisions

Waiver approval process can take time

Negative connotation associated with citations

Categorical Waivers

On 8/30/13, CMS permits facilities to apply various

provisions of the 2012 LSC

Provisions are generally less restrictive than the

provisions of the 2000 Edition

Includes the “cultural change” provisions

Facilities do not have to be cited to apply these

waivers

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Categorical Waivers

Facilities must COMPLY!

Assess compliance with applicable 2012 LSC

sections – not as easy as you may think!

Waiver compliance is not “automatic” – MUST

MEET ALL 2012 LSC REQUIREMENTS

Categorical Waivers

Facilities must DOCUMENT!

As directed by CMS, NYSDOH or other AHJs

RPA has developed a Categorical Waiver Declaration Form –

this approach meets CMS requirements and is accepted by

the other agencies with deemed status

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Categorical Waiver Declaration Form

http://www.phillipsllc.com/resources/resource-library /

Categorical Waivers

Facilities must PRESENT!

As directed by CMS, NYSDOH or other AHJs

It is critical that facilities inform AHJs of the use of

Categorical Waivers at the onset of their

inspection

It is not acceptable to be cited and then elect to use a

categorical waiver

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Categorical Waivers

1. Openings in Exit Enclosures

2. Door Locking for Patient Special Needs

3. Doors with Delayed Egress

Categorical Waivers

4. Suite-to-Suite Exiting

5. Suite Exiting Utilizing Stairs, Passageway or Exterior

6. Suite Size

7. Clean Waste and Patient Record Recycling

Containers

Containers are labeled & listed as meeting FM Approval Standard 6921

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Categorical Waivers8. Corridor Projections for Wheeled Equipment

• Equip. does not reduce corridor width to less than 60 in

• Fire Safety Plan addresses relocation of wheeled equip.

• Wheeled equip. is limited to i. Equip. & carts in useii. Medical emergency equip. not in useiii. Patient lift & transport equip.

Categorical Waivers9. Corridor Projections for Fixed Furniture

• 8 foot corridor• Furniture is securely attached to the floor or wall• Furniture does not reduce corridor width below 6’• Furniture located on one side of corridor• Furniture groupings do not exceed 50 ft2• Furniture groupings separated by at least 10’

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Categorical Waivers10. Alternative Type Kitchen Cooking Arrangements

Categorical Waivers11. Direct-Vent Gas Fireplaces

12. Solid Fuel-Burning Fireplaces

13. Combustible Decorations

14. Medical Gas Master Alarms

(a) Decorations do not exceed 20% of wall, ceiling, & door areas inside any room or space of a smoke compartment that is not fully sprinklered

(b) Decorations do not exceed 30% of wall, ceiling, & door areas inside any room or space of a smoke compartment that is fully sprinklered

(c) Decorations do not exceed 50% of wall, ceiling, & door areas inside patient sleeping rooms having a capacity not exceeding 4 persons in a smoke compartment that is fully sprinklered

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Categorical Waivers

15. Emergency Generators and Standby Power Systems

16. Testing of Vane-Type and Pressure Switch-Type

Water Flow Alarms

17. Testing of Electric Fire Pumps

18. Relative Humidity Levels in Anesthetizing Locations

19. Fire / Smoke Damper Testingnote: this waiver option is applicable to hospitals only

Categorical Waivers

20. Power strips

Power Strip Use in Patient Care Areas: The facility is electing to apply the 

categorical wavier permitting the application of the power strip provisions 

in the 2012 edition of NFPA 99.  This also exempts resident rooms in long‐

term care facilities from the NFPA 99 power strip provisions when the 

facility does not utilize line‐operated electrical appliances in resident 

rooms for diagnostic, therapeutic, or monitoring purposes.  

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Power Strips

Underwriters Laboratories (UL) Listing Standard

Phrase / Term

UL 1363 Relocatable Power Tap (RPT)

UL 1363ASpecial Purpose Relocatable Power Taps (SPRPT)

UL 60601-1 Medical Electrical Equipment

UL 1449Surge Protective Device (SPD)Transient Voltage Surge Suppressor (TVSS)

UL 1778 Uninterruptible Power Supply (UPS)

Categorical Waivers

Facilities must COMPLY! Make sure you meet the 2012 LSC requirements

Facilities must DOCUMENT! Use the Categorical Waiver Declaration

Facilities must PRESENT! Inform the AHJ during survey opening meeting

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David Hooddhood@phillipsllc.com

Scott Aronsonsaronson@phillipsllc.com

Dave Hood, Presidentdhood@phillipsllc.com