This is Why
Healthcare systems are continually challenged to properly assess their compliance with the Life Safety Code® (NFPA 101), understand the interpretations and exceptions to the Code, and maintain compliance through cost-effective measures. Partnering with RPA makes these complex requirements achievable, while bringing positive, reliable outcomes in the event of an emergency.
Facilities need to be in a state of continual survey readiness. Any of the following situations could lead to Life Safety Code® compliance scrutiny:
- An incident recently occurred that prompted a CMS surveyor, Accreditation surveyor, State Health Department surveyor or Fire Marshal to target a problem.
- A specific surveyor is more thorough than others and is digging deeper into the organization than ever before.
- A surveyor is incorrectly interpreting the Life Safety Code® and therefore citing the facility for something that is not a true deficiency.
- A fire occurred at your facility and the fire protection features of the building failed to function as intended (smoke had unobstructed movement between smoke compartments, etc.).
- The local, state or federal Authorities Having Jurisdiction (AHJ) changed or refined their interpretation of a Code requirement.
This is How
The Life Safety Code® Assessment (LSCA – formerly the Statement of Conditions or SOC) is completed to ensure that the building and its inherent fire protection features will protect the lives of patients and staff during a fire. This program will be evaluated based on the updated life safety requirements of The Centers for Medicare & Medicaid Services (CMS) and the 2012 Edition of the Life Safety Code®. An RPA partnership will help you be prepared for life safety surveys by agencies working on behalf of CMS or accrediting agencies such as The Joint Commission, Det Norske Veritas (DNV), Healthcare Facilities Accreditation Program (HFAP) and The Accreditation Association for Ambulatory Health Care (AAAHC).
Through our representation on the NFPA 101® Technical Committee on Health Care Occupancies and NFPA Health Care Section Codes & Standards Committee, we are able to utilize our extensive knowledge of the Code, permitted exceptions, and interpretations to complete projects more accurately than anyone else in the industry.
- Review and update Basic Building Information.
- Provide a wall-to-wall, roof-to-basement Life Safety Code® survey to include the following:
- Field conditions of life safety features including, but not limited to, rated doors, exit signage, means of egress, and hazardous areas.
- Full survey of all required smoke and fire rated walls, vertical openings, corridor walls in areas that are not fully sprinklered, and travel distances.
- Support the organization in addressing alternative ways to review spaces (suites, etc.) to reduce overall costs while maintaining compliance and best practices.
- Report of Findings and Recommendations.
- Prepare all official correspondence on behalf of the facility related to life safety compliance issues including Time Limited Waivers (TLW) and Fire Safety Evaluation System (FSES).
- Fire & Smoke Door Assembly Inspection and inventory of doors (optional).
- Full AutoCAD services for all required Life Safety compliance drawings.
- Web-based life safety management tools.
- Annual Continuous Readiness Program (Spot Check / Update / Validate – SUV Service): Annual services that include Spot-check assessments (monitoring of existing deficiencies, survey of newly renovated areas), Updates to the compliance plan based on code changes and/or recent interpretations, and Validate that deficiencies have been appropriately remediated.
- Staff Education and Training.
- Changes with New Survey Process: Post-survey Counsel/Waiver support:
- Survey Findings: Assist in reviewing survey finding for accuracy and proper application of the Code.
- Waivers: Support in evaluating post-survey equivalency or waiver options (submittals are only permitted following a citation; as of August 1, 2016).
Downloadable Life Safety Services Brochures
Life Safety Assessment Brochure for Hospitals
Life Safety Assessment Brochure for Long Term Care Facilities
Life Safety Assessment Brochure for Ambulatory Surgery Facilities
Smoke & Fire Door Assemblies Inspection Services Brochure for Hospitals