Compliance News: CMS Will Consider 2012 Life Safety Code in Notice-and Comment Rulemaking Process

By David L. Stymiest, PE, CHFM, FASHE





Last year CMS requested public comments about whether it should adopt the 2012 Life Safety Code® instead of the currently required 2000 edition. In its recently-issued final rule regarding revisions to the Conditions of Participation, CMS also addressed those public comments.

In response to the public comments that it received, CMS stated “We appreciate commenters’ suggestions regarding the LSC regulations set out under our ‘Physical environment’ CoP at §482.41. Suggestions received were outside the scope of this final rule and will be considered through separate notice-and-comment rulemaking in a LSC omnibus rule, targeted for publication in the near future.”

The discussion and response are on pages 113-114 of Final Rule CMS-3244-F, RIN 0938-AQ89, entitled “Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation.” This document is available from CMS at http://www.ofr.gov/OFRUpload/OFRData/2012-11548_PI.pdf.

Compliance News: Discharge from Exits

By Robert Trotter, CBO, CFM - Koffel Associates





The Life Safety Code® mandates that exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with a safe access to a public way. However, this requirement does not apply to rooftop exit discharge where approved by the authority having jurisdiction. Exits are permitted to discharge to roofs or other sections of the building or an adjoining building where the following criteria are met:

(1) The roof construction has a fire resistance rating not less than that required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof.

Compliance News: Hazardous Areas - Laundry Rooms

By Robert Trotter, CBO, CFM - Koffel Associates





According to the Life Safety Code® central/bulk laundries larger than 100-SF in health care occupancies are considered hazardous areas. There are two principle considerations when determining the required level of protection. First, you have to determine if the hazardous area is located in a new or existing health care occupancy. Secondly, you should know the applicable requirements at the time of construction. In other words, if a hazardous area required one-hour fire resistance rated separation at the time of construction, the fire barrier is not permitted to be downgraded to less than what was required for new construction.


Laundries in new health care occupancies must be protected by sprinklers and safeguarded by a fire barrier having a one-hour fire resistance rating. Laundries in existing health care occupancies must be safeguarded by a fire barrier having a one-hour fire resistance rating or it must be provided with an automatic extinguishing system. Existing isolated hazardous areas may have sprinkler piping serving not more than six sprinklers connected directly to a domestic water supply system under certain conditions. Where the sprinkler option is used, the hazardous area must be separated from other spaces by smoke-resisting partitions and doors. Regardless of the new or existing provisions doors must be self-closing or automatic-closing. Doors in fire barriers must be provided with positive latching hardware.

Compliance News: OSHA Revises Hazard Communication Standard

By David L. Stymiest, PE, CHFM, FASHE




In its March 20, 2012 press release and conference call, OSHA announced revisions to its Hazard Communication Standard to align it with the United Nations’ global chemical labeling system, known as the Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. OSHA stated that this change is intended to improve understanding and “will improve the quality, consistency and clarity of hazard information that workers receive, making it safer for workers to do their jobs and easier for employers to stay competitive in the global marketplace.”

According to OSHA, the standard will classify chemicals according to their health and physical hazards, and establish consistent labels and safety data sheets for all chemicals both made in the USA and imported from abroad.


Employers have until December 2013 to train employees to the new requirements. The new standard, informally known as HazCom 2012, will be fully implemented by 2016. OSHA noted that during the transition period to the effective completion dates noted in the standard, chemical manufacturers, importers, distributors and employers may comply with either 29 Code of Federal Regulations 1910.1200 (the final standard), the current standard or both.

How to obtain more information:

OSHA’s press release is available at:
http://www.dol.gov/opa/media/press/osha/OSHA20120280.htm

The voluminous final rule revising the standard is available at: http://s.dol.gov/P1
(That URL also contains links to an MP3 (audio) file of the conference call as well as further related information.)

The GHS is available from OSHA at: http://www.osha.gov/dsg/hazcom/ghs.html

A list of OSHA’s FAQ’s and responses is available at: http://www.osha.gov/dsg/hazcom/hazcom-faq.html

NFPA 110 and 111 Versions

What version of NFPA 110 and 111 should we be using as a regulatory reference? 

Choosing an Emergency Power Test Time

Many hospitals conduct their emergency power supply system (EPSS) tests at the start of the day, such as just before the first shift commences.  This is when most of the operating rooms are not yet occupied for the day.

Another option is in the afternoon, either immediately after lunch or later that afternoon.  Testing at the end of the lunch period, however, may conflict with the hospital's patient focus.  This early afternoon test may be problematic due to the hospital's concern about avoiding elevator recalls when there is a high visitor population riding the elevators. 

Some hospitals schedule EPSS testing for the third shift, or nighttime.  This approach can minimize the impact of the testing on daytime hospital operations, but may become problematic when equipment failures occur during the test and the full daytime shift complement of operations and maintenance personnel are not yet on duty to deal with the failure expeditiously.

For additional discussion, including a detailed discussion of the common effects of monthly EPSS testing in hospitals, refer to my 2009 ASHE Management Monograph “Managing Hospital Emergency Power Systems – Testing, Operation, Maintenance and Power Failure Planning” that can be obtained directly from ASHE at http://www.ashe.org/resources/management_monographs/mg2009stymiest.html.  

IMPORTANT NFPA DISCLAIMER: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at http://www.nfpa.org/.

Compliance News: CMS Eases Hospital Corridor Clutter Waiver Process

By David Stymiest, PE, CHFM, FASHE


CMS issued new Survey and Clarification Memo # S&C-12-21-LSC, which applies to both hospitals and nursing homes, on March 9, 2012. CMS is easing its process for obtaining waivers in order to take advantage of four provisions in the NFPA 101 Life Safety Code© 2012 edition. CMS will now “allow providers to implement these four changes by considering waivers of the current LSC requirements found in the 2000 edition of the LSC without showing ‘unreasonable hardship’.” The four 2012 Life Safety Code© portions referenced by CMS are 18/19.2.3.4 under Capacity of Means of Egress; 18/19.3.2.5.2, 18/19.3.2.5.3, 18/19.3.2.5.4 and sections 18/19.3.2.5.5 under Cooking Facilities; 18/19.5.2.3(2), (3) and (4) under Heating, Ventilating, and Air Conditioning; and 18/19.7.5.6 under Furnishings, Mattresses, and Decorations. CMS stated “Due to the complex nature of some of the requirements, each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.”

ASHE members should have already received both an ASHE Advocacy Alert and Issue Brief regarding this topic. Since CMS waivers are issued after adverse findings during validation surveys, our recommendation is that organizations stay tuned and follow the development of this issue. As of this writing The Joint Commission has not commented publically.

Compliance News: The NFPA 110 Installation Acceptance Test

By David Stymiest, PE, CHFM, FASHE





Many hospitals are installing new or replacement emergency power systems. NFPA 110 requires a special testing sequence before the system may be used. 

Although the NFPA 110-2005 edition is referenced by the 2010 FGI Guidelines for Design and Construction of Healthcare Facilities, readers should review the updated and considerably improved Installation Acceptance Test in Section 7.13 of NFPA 110-2010 (www.nfpa.org/110). The 2010 update was rewritten to clarify the intent of the testing. If a project team is considering deviating from verbatim NFPA 110 requirements because of facility-specific differences, all necessary authority having jurisdiction (AHJ) approvals should be obtained.

Some of the major requirements of the NFPA 110-2010 Installation Acceptance Test include:

Transfer Switch Location Battery Lighting

QUESTION:  Where is the requirement for battery lights at transfer switch locations?  When did that requirement first appear?

Maintenance Repair Shop

Why do Maintenance repair shops need sprinkler systems?

Cooking Appliances

Do we need approval or an inspection to move our cooking appliances?

Penetrations in 2-HR Fire Barriers

What does a penetration in a 2-hour fire barrier have to be sealed with in order to maintain fire resistance?

Mural Painted Exit Access Doors

Life Safety Tip from Bob Trotter, CBO, CFM, MCP

Mural Painted Exit Access Doors

Be careful about where painted murals are located.  Exit access and exit doors with painted murals for decorative effect are not acceptable, as casual occupants might not be aware of such means of egress even though it is visible. The 2000 edition of NFPA 101^®, Life Safety Code^® 7.5.2.2 states “Exit access and exit doors shall be designed and arranged to be clearly recognizable”.

Improper Exit Arrangement

Life Safety Tip from Bob Trotter, CBO, CFM, MCP

Improper Exit Arrangement

If a temporary partition is installed to separate an area undergoing construction, repair, or improvement operations, alternate EXITS need to be identified. According to LS.01.02.01 Element of Performance 2 of the 2012 Hospital Accreditation Standards “The hospital posts signage identifying the location of alternate exits to everyone affected”. The appropriate action for this scenario would be to cover or remove the EXIT sign and post the (floor plan) signage indicating the location(s) of alternate EXITS.

Separation of E-Cylinders

Is there a standard that notes that full e-cylinders need to be separated from empty cylinders?