The Clarifications and Expectations column in the April 2017 issue of The Joint Commission Perspectives continues this month with additional insights into changes to the life safety code as a result of conversion to the 2012 LSC. Everyone appears to be having difficulty getting their arms around all these changes, including TJC trying to maintain alignment with CMS, ourselves as consultants trying to understand what is a current requirement and what is soon to become a current requirement, and of course hospitals which we continue to see slammed by all these changes. Some of the changes described in this article apply differently to existing facilities or planned new construction or remodeling. However other sections of the article describe requirements that we must maintain all the time. You will want to share this article with your facilities leadership and ask them to evaluate your level of compliance. To aide in this evaluation we will pose some of the issues discussed in this article as questions to be answered.
- 02.01.10, EP 7: Do all of your fire doors operate and latch as they did when they were first installed or has any part of the latching mechanism been modified and potentially void your fire door warranty?
- 02.01.10, EP 7: Do any of your fire doors have a protective kick plate greater than 16 inches from the bottom edge of the door?
- 02.01.10, EP 7: Do you have any fire doors with signs that are screwed into the fire door, damaging its integrity?
- 02.01.10, EP 8: Do you have any fire doors with signs that are affixed with adhesive, but the sign is larger than 5% of the door face?
- 02.01.10, EP 8: Do you have any areas of the hospital where staff have placed paper or cardboard signs, notices or art work on the fire door?
- 02.01.10, EP 9: Are the fire dampers located in a 3-hour fire barrier also rated for 3 hours as required by NFPA 90A-2012?
- 02.01.10, EP 9: Are the fire dampers located in a wall that is rated less than 3 hours, rated for a minimum of 1.5 hours?
- 02.01.10, EP 10: Are the spaces around pipes, conduits, bus ducts, cables, wires or pneumatic tubes penetrating the wall or floors protected with an approved fire rated material?
- 02.01.10, EP 10: When you look at your sealed penetrations, is one color fire stop used, or do you see multiple colors? Do you have the manufacturers specifications for each of these materials used at different times to prove their effectiveness?
- 02.01.10, EP 11: This is the new catch all EP. Have you evaluated, and are you compliant with all the new CMS K tags relative to compliance with the life safety code?
Perspectives also has a link to the draft future EC/LS standards which will take effect on July 1, 2017. These standards can be found at: https://www.jointcommission.org/assets/1/6/HAP_LSC_July2017_Prepub.pdf
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