into the ‘existing’ facility category, there are changes such as what doors in the facility are required to have automatic closing devices.”

When CMS adopted the 2012 edi- tion of the LSC, it also mandated compliance with provisions of the 2012 edition of NFPA 99 health care facilities code, bringing about sev- eral other important changes, says William Phillips, owner of Riteway Building Services, a provider of life safety compliance services based in Winter Park, Florida. “In the past, wherever there was a conflict with other health care facil- ity standards for compliance, NFPA 99 served as a guideline,” he says. “NFPA 99 now supersedes all conflicts and is the standard of reference and compli- ance. Another change, and one that refers to the NFPA and LSC, is that compliance has moved from being a performance-based issue to a risk- based issue. There is now more flex- ibility afforded to the individual sur- gery center to determine the actual frequency of when items are com- pleted, what work is to be performed and to what extent record creation and documentation occurs.”

Phillips highlights another notewor-

thy change that concerns the require- ments for personnel performing inspec- tions and tests. “They must now be properly trained and certified and hold manufacturer training and education credentials. This is complicated and new to ASCs and vendors perform- ing the work. As time goes on, these requirements will likely be enforced more stringently.”

Areas of Difficulty

The biggest challenge Jimenez says she faces in working to ensure her ASCs comply with the LSC is know- ing what is required. “What I feel warrants the most attention is mak- ing sure you really understand the LSC. Trying to figure out when you

Life safety compliance requires a year-long, ongoing program. You cannot accomplish compliance in a few hours or days.”

—William Phillips, Riteway Building Services

are in compliance and when you are not is stressful.” Two areas of the LSC she has require

learned close attention are

means of egress and emergency plan- ning. “In theory, it should be easy to meet means of egress requirements. However, in practice, you notice invol- untary staff mistakes, such as placing equipment that blocks an emergency exit. As for the emergency plan, I know that cannot just be a well-writ- ten document that no one other than the administrator or the nurse direc- tor has reviewed. It must be a living document that everybody in the ASC knows and understands.” Lyman says one common area of LSC deficiency concerns required fire protection and emergency sys- tems. “Managers often do not realize that there are ongoing requirements for these systems after a facility has opened and met all the initial con-

struction requirements. The LSC contains requirements for inspection, testing and maintenance of these sys- tems at prescribed intervals and doc- umentation of the processes.” Phillips says it is not unusual

for facilities to struggle with the LSC’s

major requirements. “Life

safety compliance requires a year- long, ongoing program. You can- not accomplish compliance in a few hours or days. It is a series of repeti- tive exercises requiring continuous monitoring. Without an effective program, you can easily lose track of when you performed an inspection and when you need to perform the next one, especially if these respon- sibilities change hands.”

Keeping Compliance Front of Mind To help keep her ASCs in compli- ance, Jimenez says she approaches LSC as a team responsibility. “We


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