Making Healthcare Facilities Safer
August 31, 2016

On May 4, 2016 Centers for Medicare & Medicaid Services (CMS) published the final rule implementing the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code and the 2012 Edition of NFPA 99 Health Care Facilities Code. The new guidelines apply to hospitals, long term care facilities, critical access hospitals, inpatient hospice facilities, and ambulatory surgery centers among others. The final rule requires facilities comply with the new rules within 60 days from when the rule is published, or July 5, 2016. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Health Facilities Accreditation Program (HFAP) have both indicated that they will survey to the new standards as of July 5, 2016.

Now is the time to verify compliance and update your compliance documents, manuals and plans, before your next survey.

A highlight of some of the many changes between the previous 2000 Edition and the 2012 Edition of the LSC are as follows:

Referenced Codes
Several codes that are in effect by reference are updated as well, those include:
• 2010 NFPA 10 – Portable Fire Extinguishers
• 2010 NFPA 13 – Installation Sprinkler Systems
• 2011 NFPA 25 – Sprinkler System Maintenance
• 2010 NFPA 72 – National Fire Alarm and Signaling
• 2010 NFPA 80 – Fire Doors
• 2011 NFPA 96 ‐ Kitchen Hood Systems
• 2012 NFPA 99 – Health Care Facilities
• 2010 NFPA 110 – Emergency Power
• 2009 NFPA 241 – Safeguards During Construction

All categorical waivers go away – they are now part of the 2012 LSC.

Projections into the 8’ and 6’ corridor widths in hospitals are allowed in certain conditions such as:
• Non-continuous projections not more than 6 inches (150 mm) from the corridor wall, positioned not less than 38 inches (965 mm) above the floor, shall be permitted.
• Projections into the required width shall be permitted for wheeled equipment, provided that some additional requirements are met.

The Suites section is completely reorganized and better explained.

Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that several additional requirements are met. This allowance is geared towards Long Term Care Facilities.

Alcohol Based Hand Rub Dispensers (ABHRD)
Very specific requirements now address the location, capacity, type, separation, quantity, placement and operation of dispensers and storage of the ABHRD sanitizing liquid.

Nonrated factory ‐ or field ‐applied protective plates, unlimited in height, are now permitted on Corridor and Smoke Barrier Doors.

Fire Safety Plan
A written health care occupancy fire safety plan shall provide for several factors in the event of a fire.

Draperies and Curtains
New, specific requirements are put in place for draperies and curtains including area and coverage.

Recycling Containers
Specific requirements and exemptions are in place for clean waste recycling containers including size, volume and placement.

Combustible Decorations
Requirements are established for the amount, type, quantity and location of combustible decorations, including artwork.