Life Safety Code Survey Process for Hospitals

1
Life Safety Code SurveyProcess for Hospitals

• Henry Kowalenko
• Supervisor
• Design Standards Unit

2
Rules and Regulations

• The following rules and regulations are used when
  surveying a facility
• Illinois Hospital Licensing Requirements
• 77 IL Administrative Code 250
• Center for Medicare and Medicaid Services (CMS)
• CFR 485.623d Standard Life Safety from Fire
• NFPA 101 Life Safety Code (2000 Edition)
• Chapter 19, Existing Healthcare Occupancies
• National Fire Protection Association
• Illinois Plumbing Code
• 225 ILCS 320 February , 2004
• Illinois Accessibility Code
• 71 Illinois Administrative Code 400

3
Survey Process

• The IDPH inspector will be escorted on a tour of
  the facility. The following items should be
  available.
• Keys to all areas
• Ladder
• Flashlight
• Small floor plan
• Fire barriers and ratings
• Suite designations
• Exits

4
Survey Process

• The inspector will conduct a review of the
  following documentation
• Fire drill records
• Fire alarm inspection
• Emergency generator
• Fire extinguishers
• Kitchen hood suppression systems
• Fire and emergency policy procedures

5
Survey Process

• During the inspection, the fire alarm and
  sprinkler systems will be tested.
• Fire alarm testing will include
• Pull Stations the facility will need to have
  keys available to reset the fire alarm
• Smoke detectors - Functional test (no magnets),
  canned smoke needs to be available
• Sprinkler testing will include
• Water flows (if sprinklered)

6
Common Deficiencies

• Common deficiencies cited and the associated
  K-tag
• K-12 Construction Type
• Construction type must be at least Type ll (000)
  fully sprinklered
• If construction type is Type II (protected)
  steel or concrete lacks fireproofing.
• K-17 Corridors
• Unsealed penetrations
• Corridor wall does not extend to the deck
  (unsprinklered)
• K-23 Smoke Barriers
• Lack of smoke dampers at smoke barrier
  (unsprinklered)
• Solid cross corridor door do not meet the
  required 1 ¾ thickness
• ½ hour fire resistance rating must be maintained

7
Common Deficiencies

• Common deficiencies and associated K-tags
• K-29 Hazardous Areas
• Sprinklered areas lack smoke resistant enclosure
  self closing door
• Non-sprinklered areas do not have a 1 hour fire
  rated enclosure
• K-67 Air Conditioning
• Corridors used as air plenums are not allowed
• Ductwork is dirty
• Lacks proper filters filters are dirty
• Lack of humidification

8
Alternate Compliance

• Fire Safety Evaluation System (FSES) NFPA 101A
  (2001 Edition)
• FSES may be used when prescriptive compliance
  cannot be achieved
• The FSES is based on a point system

9
Plan of Correction - PoC

• Corrective Action for Each Deficiency
• What will be done
• When will it be complete
• Extended time frames provide milestone dates
• Who will be responsible
• Must correct deficiency
• Must have reasonable time frame
• Interim Life Safety Measures (ILSM)
• Use the forms provided

10
Design Standard Unit

• Supervisor
• Henry Kowalenko
• Administrative Assistant
• Jody Gudgel
• Staff Architects
• Lynn Manley Tom Busse
• William Bender Laura Cramer
• Project Designers
• Pam Hastings Theresa Jimenez

11
Design Standards Unit

• Staff Engineers
• Justin Dammerman Donald Hall
• Contact information
• Phone [phone]
• Fax [phone]
• Email (for general questions only)
• Design.standards_at_illinois.gov