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With the Joint Commission’s DireCtor of engineering: george mills

Plan B

Interim life safety measures offer fire protection during construction or deficiencies

Guest Columnist: Anne M. Guglielmo, CFPS, CHFM, CHSP, LEED A.P., engineer, The Joint Commission

An introduction from George Mills, MBA, FASHE, CEM, CHFM, CHSP,

director, Department of Engineering, The Joint Commission: This column clarifies standards expectations and provides strategies for challenging compliance issues, primarily in life safety and the environment of care, but also in the vital area of emer- gency management. You may wish to share the ideas and strategies in this column with your organization’s leadership. This month, I recruited Anne Guglielmo, engineer in the Department of Engineering with The Joint Commission, to take a closer look at aspects and issues related to this topic.

ife Safety (LS) Standard LS.01.02.01, helps the hospital focus on protecting patients,

visitors and staff during periods when the Life Safety Code®* is not met or during periods of construction, is an essential standard with several crucial elements

of performance (EPs) that can be cited by Joint Commission surveyors if the organization overlooks or implements the EPs incorrectly.

It’s no surprise that fire and smoke protection can be compromised in a frequently trafficked building used

24-hours-a-day. Doors break, walls get damaged, systems and components break down, and construction projects disrupt operations, all of which can lead to dangerous building deficiencies.

* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.

When these deficiencies occur and can’t be resolved immediately, it’s the orga- nization’s responsibility to protect the building’s occupants using other means, including interim life safety measures (ILSMs) designed to minimize fire risks to occupants while the deficiency is being fixed.

Creating a Plan for Improvement (PFI) to document the deficiency and the corrective actions to resolve the defi- ciency is crucial to successfully protect the patients, staff and visitors. The PFI must clearly define the deficiency so appropriate ILSMs can be chosen and implemented. The ILSM selection is guided by a complete and comprehen- sive policy, and is dependent on the PFI providing detailed information regarding the issues that may present a risk that the ILSM policy will address. ILSM actions are included in the final survey report associated with each open PFI.

Instead of tackling this standard’s

14 EPs in their original numbered order, I have grouped them in a different sequence to facilitate discussion and improve comprehension. The ILSM policy must be considered whenever construction or “Life Safety” Chapter deficiencies are discovered. For ease of reading this article, going forward I will refer to construction risk and “Life Safety” Chapter deficiencies as LSC deficiencies.

EP 3 The hospital has a written ILSM policy that covers situations when Life Safety Code deficiencies

cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.

This EP requires organizations to have a solid, well-designed policy that covers Life Safety Code deficiencies. One of the keys is defining what “immediately cor- rected” means to the organization within the written policy itself. Some define it as, for example, within the shift when the deficiency was found, others as within the completion of the next shift. Gen- erally, the definition should not exceed 24 hours for action. It’s also important

to remember that this policy requires you to evaluate the conditions identified. Many believe that, for example, because a fire door can’t close properly they

have to immediately implement ILSMs detailed in EPs 4 through 14 until a fix is in place. Instead, they need to first assess the big picture and the impact the deficiency has on the overall environ- ment. You can’t know whether an ILSM

is needed unless you assess the deficiency.

Compliance with this and any other EP in this standard will be checked during a survey. Th efore, it’s important that your ILSM policy achieves the following:

(1) addresses both construction-related and other deficiencies that are not imme- diately correctible; (2) contains criteria on which your organization can base

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Clarifications and Expectations:

Plan B

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decisions; and (3) lists expected imple- mentations (EPs 4-14). Th policy must clearly refer to the assessment process, and the associated documentation regarding

if an ILSM is needed. Also, the imple- mentation process to document actions/ inspections related to the ILSM neces- sary for the condition identifi It’s also important to conduct assessments of any active construction projects or deficiencies based on your policy to ensure that the policy is being implemented correctly.

Non-compliance with this EP can result in an adverse decision (under accredita- tion with follow-up survey decision rule AFS 10: “The organization has failed

to implement or make suffi prog- ress toward the plan for improvement described in a Statement of Conditions, which was previously accepted by Th Joint Commission; or has failed to develop and implement the ILSM policy and its criteria associated with evaluation and compensation for increased safety”); in other words, there is the potential for follow up survey activity.

Now that we’ve covered the ILSM policy, we can examine the ILSMs themselves that your hospital needs to follow (EPs 4-14, also summarized in the Sidebar), based on criteria in your policy, when Life Safety Code deficiencies are identifi that cannot be immediately cor- rected or during periods of construction.

EPs 10–11 The hospital provides additional training to those who work in the hospital on the use

of firefighting equipment and conducts one additional fire drill per shift per quarter.

During construction (or when a deficiency is identified), fire protection can become compromised in areas in which staff are still working. Before you can implement ILSMs like EPs 5, 6, and 7, workers in these affected spaces

need to be taught how to use firefighting

equipment they may not be familiar with. Also, although EC.02.03.03 stip- ulates that the organization should con- duct fire drills once per shift per quarter, twice per shift per quarter is required here if the assessment determines it is needed. Carefully document evidence.

EPs 5–7 The hospital provides temporary but equivalent fire alarm and detection systems

for use when a fire system is impaired; provides additional firefighting equipment; and uses temporary construction partitions that are smoke-tight, or made

of noncombustible or limited- combustible material that will not contribute to the development or spread of fire.

Your organization needs to be sure that static compensating equipment is in place in case a fi e system is impaired. Th tem- porary but equivalent equipment includes fi e alarm and detection systems, addi- tional extinguishers and other fi efi

tools that are adequately and safely stored in the affected area, and well-made con- struction barriers that will not contribute to the development or spread of fi e.

Be sure to inspect this equipment for appropriate installation, integrity and materials, and review your organization’s written assessment to ensure that what was called for is in the right place

and compliant.

EPs 4, 8–9 The hospital inspects exits in affected areas on a daily basis; increases

surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices; and enforces storage, housekeeping, and debris-removal

practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

First, note that your ILSM policy in EP 3 should identify the criteria

and expectations for the inspections, surveillance, and debris-removal actions involved in EPs 4, 8 and 9. Review that policy document carefully and check to see that the recommended ILSMs

listed for each corresponding deficiency were implemented effectively and that staff are properly trained to perform these additional duties. In addition, thoroughly review the documentation, including rounding forms and surveillance logs, and walk the space to ensure that house- keeping, storage and debris removing practices are being followed.

EP 12 The hospital inspects and tests temporary systems monthly and documents the testing completion dates.

This EP requires additional testing outside the scope of EC.02.03.05 (which calls for testing/inspecting detectors, alarms and other devices at varying regular frequencies). Just as it’s vital to examine primary fire safety equipment, temporary systems (including smoke detectors and extinguishers) need to be tested monthly, either by a contracted service or trained staff. Check to see

that testing records are in place and that results are accurate.

EPs 13–14 The hospital: conducts education to promote awareness of building deficiencies, construction hazards, and tempo- rary measures implemented to maintain fire safety; and trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features.

Whether it’s in-house employees or outside contractors, your personnel need to be made aware of the risks involved during construction or identified defi- ciencies. Personnel must be properly instructed to maintain a fire safe envi- ronment despite structural compromises.

You also need to make staff cognizant

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Clarifications and Expectations:

Plan B

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of what your expectations for them are during these circumstances.

EPs 1–2 The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out

needs to begin in the affected zone. For planned events like a system takedown for repair, fire department notification should to be done well before the project starts; for unknown outages, notifica- tion needs to occur as soon as possible. Also, appropriate signage indicating the location of an alternate exit(s) needs to be in place if, for example, construction activity blocks a normal exit point.

Be sure to properly document that

with the Life Safety Code by assigning an individual to assess compliance, completing and maintaining a current electronic Statement of Conditions, managing the resolution of deficiencies, meeting the time frames identified in a Plan for Improvement, and maintaining documentation of any inspections and

approvals made by state or local fire con- trol agencies. Those are the topics on the agenda for next month’s column. EC

of service more than four hours in a 24-hour period in an occupied building (notification and fire watch times are documented);

and posts signage identifying the location of alternative exits to everyone affected.

Now that we’ve examined the ILSMs in EPs 4-14, we can dovetail back to EPs 1 and 2, which are not subject to the ILSM assessment. If the fire alarm or automatic suppression system is com- promised for 4 out of a 24 hour period, a fire watch needs to be implanted. The fire watch includes notifying the fire department and a designated monitor

Clarification

The article, “HazMat-ter of Fact: Taking a closer look at EC.02.02.01 and the management of hazardous materials and waste,” in the December 2015 issue of this newsletter stated on page 8 that the US Occupational Safety and Health Administration (OSHA) classifies a material as corrosive if it has a pH level of less than 2.5 or greater than

11.0. This information is outdated. OSHA considers a substance corrosive if it has a pH level that is less than 2 or greater than 11.5.

your fire watch was conducted appro- priately, and regularly check construc-

tion/deficiency areas to ensure that any necessary signage is intact.

Next up: designing and maintaining the physical environment

By first addressing LS.01.02.01 and ILSM policies that cover situations when Life Safety Code deficiencies can- not be immediately resolved or during construction, we can better understand

LS.01.01.01. The latter is concerned with how hospitals need to design and man- age the physical environment to comply