Fire Safety Compliance The changes that ASCs can expect with the implementation of the 2012 Life Safety Code BY ROBERT KURTZ


illiam E. Lindeman is the president of WEL Designs

PLC of Tucson, Arizona, a consulting firm for health care facility development and regulatory compliance. As a licensed architect working with health care providers since 1983, he has helped plan and design millions of square feet of ASCs, medical practice suites and other facilities.

The 2012 edition of the National Fire Protection Association’s (NFPA) document 101—the Life Safety Code (LSC)—took effect for all Medicare-certified facilities on July 5. What is the significance of this development for ASCs? LINDEMAN: There are currently about 300 different NFPA codes and standards. Each is traditionally updated every three years. Per NFPA 101, the editions of other applicable NFPA codes and standards current upon the publication of a new LSC are consequently adopted as “man- datory references” to it. For ASCs, this means the Centers for Medicare & Medicaid Services’ (CMS) adop- tion of the 2012 edition of NFPA 101 includes three additional NFPA codes and numerous NFPA stan- dards. Together, they define what is required to build new ASCs and/or comply as an existing ASC.

How will this development affect an ASC’s efforts to ensure fire safety compliance? LINDEMAN: For ASCs starting construction after July 4, there are many physical environment require- ments that will be affected by the new codes.


For ASCs, this means the Centers for Medicare & Medicaid Services’ (CMS) adoption of the 2012 edition of NFPA 101 includes three additional NFPA codes and numerous NFPA standards.”

—William E. Lindeman, WEL Designs PLC All ASCs that started construction

before July 5 will also be affected through retroactive upgrades and additional requirements for inspection, testing, maintenance and documentation of their fire alarm system, electrical systems, piped medical gas systems, fire-rated door hardware and more. The process of identifying the changes and their potential impact on ASCs is fairly complicated due to the volume of material to review and technical nature of the writing. CMS also does not always agree with NFPA and changes the meaning of some requirements.

What are some of the most significant changes worth noting? LINDEMAN: The majority of changes for most new facility construction

tive to temperature, humidity, pressure relationships and air quality through- out the facility. NFPA 101 has altered some impor- definitions and

tant fundamental

requirements that will affect existing and new ASCs. For instance: ■

The definition of “basement,” and therefore, how many stories are in a building. An existing ASC with a basement as previously defined may now find itself out of compliance with fire protection requirements.

■ stem from the 2012

edition of NFPA 99, which defines the requirements for electrical systems, piped medical gas systems, portable medical gas use, patient care electrical receptacles and more. That document appears to direct the most significant expansion in prescriptive physical environment requirements I have ever seen. For example, the minimum

number of electrical

receptacles required in patient care areas has grown tremendously. NFPA 99 also greatly expands the requirements for new facilities rela-

The definition of “hazardous areas” now includes any room where flam- mable or combustible materials are stored, with the exception of office supply closets. That, paired with a new requirement for automatic clos- ers on all doors to hazardous areas, will result in required door hardware upgrades in a majority of ASCs.

What should ASCs do to learn more about the revisions? LINDEMAN: The best resource at the onset may be Medicare deemed status-surveying organizations since they are charged with distilling the changes to physical environment requirements and training life safety surveyors in a timely manner. Organizations should also famil- iarize themselves with offerings from those same organizations as they become available.

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