Staying on Top of Life Safety Code Compliance

Make it a continuous quality improvement process BY ROBERT KURTZ


n her nine years as an ASC administrator, Angie Jimenez has come to appreciate the importance of complying with the Life Safety Code (LSC). “While regulations require us to

comply, it is more important that we do so to help assure we can provide the safest and most secure environment to patients, employees and visitors,” says Jimenez, administrator of Vista Ophthal- mic Ambulatory Center in Guaynabo, Puerto Rico, and Caguas Ambula- tory Surgical Center in Caguas, Puerto Rico. “Patients can have their proce- dures in other facilities and employees can seek work at other locations. What can help distinguish an ASC from other organizations is and service.”

its quality in safety

The LSC, published by the National Fire Protection Association (NFPA),

Highlights of Recent Changes These requirements stayed the same for many years, when CMS required


is the fire and life safety guidelines adopted by the Centers for Medicare & Medicaid Services (CMS). ASCs that choose to participate in Medicare are required to meet all requirements of the 2012 edition of the NFPA 101: LSC, says Dale Lyman, a career firefighter and founder of Lyman Code Consult- ing, a provider of National Fire Protec- tion Association and LSC consulting services based in Greeley, Colorado. “The code includes requirements

for how ASCs must be constructed, types of fire protection systems, fire safety policies and procedures and the inspection, testing and mainte- nance of those required systems,” he says.

facilities to meet the 2000 edition of the LSC, says Lyman, author of the 2017 book Ambulatory Surgery Cen- ter Safety Guidebook: Managing Code Requirements for Fire and Life Safety. That changed in 2016, when CMS adopted the 2012 edition of the LSC— the version CMS still uses today. There are notable differences between the two versions of the code, Lyman says. “Some depend upon the date a facility was opened and began operations, while others apply only to facilities that obtained building per- mits after July 5, 2016. “Many ASCs now renewing their accreditation for deemed status are experiencing some of these changes during their LSC surveys,” he says. “Some examples of changes in the LSC that may apply to recently con- structed ASCs include requirements for the number of outlets connected to the emergency power supply and the requirement for the facility to complete a ‘risk assessment.’ For ASCs that fall

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