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The Life Safety Specialist Surveyor


The Life Safety Specialist Surveyor Preparing for the Life Safety Specialist Documentation Review and Facility Tour Will limit Healthcare Engineering Consultants – PowerPoint PPT presentation

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Title: The Life Safety Specialist Surveyor

The Life Safety Specialist Surveyor
Preparing for the Life Safety Specialist
Documentation Review and Facility Tour
  • Will limit

Healthcare Engineering Consultants
The Life Safety Specialist (LSS)
  • It is likely that the LSS will arrive with the
    team on the first or second day, less likely
    later in the survey
  • For 2011, the LSS will usually be scheduled for
    an additional day based on the scheduled time of
    the previous survey
  • The LSS will spend several hours on dedicated
    documentation review, but much more time on the
    facility tour
  • Other responsibilities assigned to the LSS will
    depend on the survey team member preferences and
    responsibilities they may conduct the EC
    Interview and Emergency Management tracers
  • The other survey team members will also observe
    life safety issues, but not as detailed as the
    LSS it is not likely that the nurse and
    physician will request a ladder and flashlight!
  • If the LSS observes deficiencies outside of
    their defined responsibility (example medical
    records privacy or medication security), they
    will report it to the other team members

Healthcare Engineering Consultants
The LSS Documentation Review
Life Safety Specialist (LSS) surveyor
documentation responsibilities include at a
minimum LS.01.01.01 SOC and Life
Safety Code LS.01.02.01 Interim
life safety measures EC.02.03.05 Fire
system tests EC.02.05.07 Emergency
power systems EC.02.05.09 Medical gas
and vacuum systems Note In 2011, the Life Safety
Specialist may be assigned additional
responsibilities during the survey
Healthcare Engineering Consultants
The LSS Documentation Review
  • LS.01.01.01 SOC and Life Safety Code
  • The SOC completion will be verified through the
    Joint Commission Connect site (BBIs and PFIs)
  • Have the SOC notebook available for review
  • The PFI documents from the previous survey may
    be reviewed to verify completion of deficiencies
    (have them available, if requested)
  • The compartmentation drawings will be reviewed
    to assist in planning the facility tour
  • Life Safety Code compliance will be verified
    during the facility tour

Healthcare Engineering Consultants
The Statement of Conditions
How Should the Statement of Conditions (SOC)
Document be Completed?
Healthcare Engineering Consultants
The Statement of Conditions
  • What is the SOC?
  • The Statement of Conditions (SOC) is a document
    that is required to be completed by every
    healthcare facility that applies for
    accreditation by the Joint Commission. It
    references the 2000 edition of the Life Safety
    Code and consists of the following sections
  • Basic Building Information (BBI) Form
    electronic on Connect site
  • Life Safety Assessment (LSA) Form not
  • Plan for Improvement (PFI) Form electronic on
    Connect site
  • BBIs, LSAs and PFIs are
  • Note Other LSC editions may be selected, but
    the entire edition must be followed

Healthcare Engineering Consultants
The Statement of Conditions
  • SOC Notebook (Best Practice)
  • A SOC notebook is strongly recommended to
    contain hard copies of the SOC documents
  • The notebook should include at least the
    following sections
  • Section 1 The SOC policy and responsibility
  • Section 2 Current copies of the downloaded
    BBI forms
  • Section 3 Accurate, color-coded
    compartmentation prints
  • Section 4 The latest, completed LSA-type
  • Section 5 Current and previous, downloaded
    PFI forms
  • Section 6 Any correspondence with the
    Joint Commission, including equivalencies,
    letters and emails

Healthcare Engineering Consultants
The Statement of Conditions
  • Why Should I have an SOC Policy? (Best Practice)
  • The SOC policy describes how the Statement of
    Conditions program is organized for the facility
  • What Should the SOC Policy Include?
  • Who is responsible for completing and
    maintaining the SOC
  • How often the SOC documents are reviewed
  • Who reviews the SOC documents for timeliness
  • PFI guidelines (when does a work order become a
  • Whether a BMP is implemented
  • Whether an above-the-ceiling program is in
  • How the SOC documents are organized

Healthcare Engineering Consultants
Statement of Conditions Document

The current Statement of Conditions hard copy
document is dated 5/2004 and can still be
downloaded from for the LSA
form (do not use the BBI or PFI hard copies
they are obsolete)
Healthcare Engineering Consultants
Statement of Conditions Document
  • Notes About the e-BBI Form
  • List on the e-BBI cover page every occupancy
    that will be surveyed, even for business
    occupancies (make sure that the BBI and survey
    list match!)
  • The e-BBI questionnaires are only required for
    ambulatory, hotel/ dormitory and healthcare
  • Fill in the comments section regarding SOC
    preparer, location of building drawings, mixed
    occupancies, equivalencies, special building
    features or local AHJ requirements to the BBI
  • If multiple occupancies are entered, the
    greatest percentage defaults to the BBI form, so
    multiple BBI entries are required
  • Be sure to download the electronic version of
    the BBI form before it is saved so that a
    back-up is available, and place a copy in the
    SOC Notebook

Healthcare Engineering Consultants
Statement of Conditions Document
  • Compartmentation Requirements
  • Mixed Occupancies (LSC
  • Sections of health care facilities shall
    be permitted to be classified as other
    occupancies, provided that they meet the
    following conditions
  • They are not intended to serve health care
    occupants for purposes of housing, treatment, or
    customary access by patients incapable of
  • They are separated from the health care occupancy
    by a fire rating of at least 2 hours
  • Separation between ambulatory and business
    occupancies only requires a 1 hour rating (LSC

Healthcare Engineering Consultants
Statement of Conditions Document

e-BBI Form Buildings
Be sure to complete for all healthcare and
ambulatory facilities Optional for business
occupancies, but strongly suggested for the cover
Healthcare Engineering Consultants
Statement of Conditions Document

e-BBI Form - Healthcare
Refer to instructions related to stories in
the Life Safety Code Note instructions related
to building construction type (occupancy)
Building age is important due to significant
code changes
Healthcare Engineering Consultants
Statement of Conditions Document

e-BBI Form page 2 1991 date significant due to
sprinkler requirement Emergency power fuel
type important due to wet stacking
Healthcare Engineering Consultants
Statement of Conditions Document

e-BBI Form page 3 Previous inspections
data provides valuable information to the survey
team! Be sure to list local or regional
requirements (example limited generator testing
due to high pollution days) in the Comments
section at the bottom of the form as well as
other requested information
Healthcare Engineering Consultants
Statement of Conditions Document
  • LSA Form (is not electronic)
  • Is a voluntary assessment tool, although some
    assessment is required at least annually
  • Is not required for Business Occupancies
  • The Joint Commission surveyor normally expects
    some type of form, document or evaluation to be
  • Dated 5/2004, so a cover sheet that is signed
    annually is recommended
  • Can still be downloaded from the Joint
    Commission home page website (search Statement
    of Conditions)
  • Can use PPR form or similar for the LSA document
  • Comments in LSA must match PFI deficiencies

Healthcare Engineering Consultants
Statement of Conditions Document
Life Safety Building Compartmentation Drawings

Blue smoke barrier Green 1 hour fire wall
(hazardous area) Red 2 hour fire wall
Note Color-coded drawing is best practice
Healthcare Engineering Consultants
Statement of Conditions Document
  • Notes About the PFI Forms
  • The forms should not be used for operational
    deficiencies, such as exit lights burned out,
    doors out of minor adjustment or small
    penetrations that can be easily filled these
    should be completed using the routine work order
  • The normal trigger time from a work order to
    PFI is 45 days
  • Document the PFIs on a continuing basis be
    sure that the PFI log is up-to-date and ready to
    be reviewed by the surveyor
  • Dont forget to enter the projected start and
    completion dates and the actual completion date
  • Failure to meet the completion dates without a
    delay approval results in Conditional
    Accreditation 6 months after the projected
    completion date has passed!
  • If applicable, keep any previously signed PFI
    copies available

Healthcare Engineering Consultants
Statement of Conditions Document

The first page for the electronic PFI forms is
used to list the deficiencies Notice that a No
Deficiencies option is available (and should be
completed, if applicable)
Healthcare Engineering Consultants
Statement of Conditions Document

The second page for the electronic PFI forms is
used to indicate the deficiency resolutions Dont
forget to complete all of the requested
information, including the proposed action,
source of funds and the projected start and
completion dates The projected completion dates
can be altered until they are frozen before or
during the actual survey! Comments for each PFI
should include a note regarding the
implementation of ILSMs!
Healthcare Engineering Consultants
Statement of Conditions Document

The listing document simply provides a summary
of all of the deficiencies that have been
recorded on the PFI form for tracking purposes
keep a copy of this in the SOC notebook for
reference purposes
Healthcare Engineering Consultants
The Life Safety Specialist Documentation Review
Should I Implement and Document a Building
Maintenance Program (BMP)?
Healthcare Engineering Consultants

The Building Maintenance Program (BMP)
  • Is voluntary no scoring benefit in 2011
  • No longer requires a measure of effectiveness
  • Measurement system can use random samples
  • Results should be used to determine revisions to
    inspection or test frequencies
  • Information should be provided to the hospital
    safety committee if changes are made to the
  • Is basically a PM program for the buildings
  • Is still considered a Best Practice

Healthcare Engineering Consultants
Fire System Tests
  • Points to Remember
  • Clearly define supervisory devices (fire pump,
    low air pressure on dry or pre-action systems and
    water tank level indicators expected)
  • Tamper and flow device test intervals increase
    to quarterly on 7/1/11
  • Inventory all doors on magnetic releasing
    devices and document test results
  • Document tests results for each individual heat
    and smoke detector, pull box and audible and
    visual device

Healthcare Engineering Consultants
Fire System Tests
  • Points to Remember
  • Document receipt time of fire alarm signal to
    local fire department or receiving station
  • Document static and residual pressure readings
    for main drain tests and time back to static
    pressure (best practice)
  • Visually inspect fire department connections
  • The 5-year standpipe test was added to the
    requirements in 2009
  • Indicate the day and month of portable fire
    extinguisher checks

Healthcare Engineering Consultants
Fire System Tests

Points to Remember Dont forget to implement and
document Interim Fire System Measures (IFSM),
when required
  • If the occupant hoses have been removed, keep a
    copy of the approval letter from the AHJ
  • Place inaccessible smoke and fire dampers on the
    PFI for a 6-year, renewable period (for tracking
    purposes only)
  • Document that duct detectors trip the
    air-handling units
  • Only applies to vertical and horizontal smoke
    and fire doors, not security doors or curtains

Healthcare Engineering Consultants
Fire System Test Monitoring
Best Practice for Monitoring Compliance
Healthcare Engineering Consultants
Fire System Test Monitoring
Healthcare Engineering Consultants
The LSS Documentation Review
  • EC.02.05.07 Emergency Generators
  • Perform and document weekly generator visual
    checks (NFPA 110)
  • Perform and document monthly generator tests
    between 20 and 40 days and with at least 30 of
    the rated load for 30 minutes
  • Document that all automatic transfer switches
    are exercised monthly
  • Conduct annual load bank tests if the 30 load
    is not achieved and manifold temperatures are not
    sufficient (possible change from the 2 hour to a
    1.5 hour test in 2011 not yet approved)
  • Combining the annual and trienniel tests can be
    performed by starting the load at 30 of
    nameplate for the first 30 minutes of the test
  • Document the static or dynamic 4-hour trienniel
    test for all generators
  • Test fuel oil quality annually, unless fuel is
    consumed from the entire tank (NFPA 110)
  • Utilize Interim Emergency Power Measures
    (IEPM) when necessary
  • Note Refer to NFPA 99 and 110 for more

Healthcare Engineering Consultants
The LSS Documentation Review
  • EC.02.05.07 Emergency Battery Lights
  • Required in all anesthetizing locations (NFPA
    70 517.63 ) Task Light!
  • administration of nonflammable inhalation
    anesthetic agents
  • in the course of examination or treatment
  • Note Grandfathering usually permitted
    in existing ORs
  • Required in Level 1 or Level 2 EPS equipment
    locations (NFPA 110 7.3.1) Task
  • Required in business occupancies for egress
    lighting where emergency power is not required or
    not available (NFPA 101 Egress Light!
  • Monthly push-to-test required for all battery
  • Differentiate between task lighting and
    egress lighting
  • Annual battery replacement in lieu of 90-minute
    discharge test
  • Note 10 of lights must be tested for 90 minutes
    annually, even if the batteries are changed.

Healthcare Engineering Consultants
The LSS Documentation Review
  • EC.02.05.07 Stored Emergency Power Supply
    Systems (SEPSS)
  • Standard applies to Level 1 systems (NFPA 111
  • Level 1 failure of the equipment to
    perform could result in
  • loss of human life or serious injuries
  • Testing requires
  • 1. Quarterly functional test (5 minutes or
    class specification)
  • 2. Annual full-load test for 60 of SEPSS
    class duration
  • Note 1 NFPA 111 requires a monthly inspection,
    quarterly functional test and annual full load
    test for full class duration for Level 1 systems
  • Note 2 The Joint Commission references exit
    lighting, life support ventilation, fire
    detection and alarm systems, and public
    communications systems as Level 1 systems, but
    most are not SEPPS systems

Healthcare Engineering Consultants
The LSS Documentation Review
  • EC.02.05.09 Medical Gas and Vacuum Systems
  • Medical gas and vacuum system preventive
  • program is required (facility must define
    PM) and must include
  • - Bulk medical gas and vacuum system
    components and source valve
  • - Master signal panels and area alarms
  • - Automatic pressure switches and shutoff
  • - Flexible connectors and outlets
  • Testing per NFPA 99 is required for new
  • modification or repair (cross-connections,
    purity, pressure)
  • Main supply valves and area shut-off valves
    must be
  • accessible and clearly labeled
  • Utilize Interim Medical Gas Measures (IMGM)
    when necessary
  • Note Significant changes to NFPA 99 are likely
    to occur when the next vote occurs at the NFPA
    Annual Meeting

Healthcare Engineering Consultants
The LSS Documentation Review
  • EC.02.05.09 Medical Gas and Vacuum Systems
  • Certification of installers and verifiers per
    ASSE 6000 series is
  • required
  • Medical air quality must meet NFPA 99
    requirements below

Parameter Limit Value
Pressure dew point 39 degrees F
Carbon monoxide 10 ppm
Carbon dioxide 500 ppm
Gaseous hydrocarbons 25 ppm (as methane)
Halogenated hydrocarbons 2 ppm
Healthcare Engineering Consultants
The LSS Documentation Review
  • Medical Gas and Vacuum System PM Recommendations

Note The recommendations provided in the chart
to the right are from NFPA 99, the 2005 edition,
Appendix C, section 5.2. Tests that are required
due to new system installations, renovations or
repair are listed in chapter 5 of NFPA 99
Healthcare Engineering Consultants
The LSS Documentation Review
Interim Utility System Measures (IFSM, IEPM,
Best Practice! Strongly recommended to
document that interim measures have been
implemented to compensate for utility systems
that are taken out of service
Healthcare Engineering Consultants
The LSS Facility Tour
  • Typical Tour Sequence
  • Start on the roof, penthouse, mechanical
    equipment rooms
  • Take the most traveled stairwell from the top
    to the bottom
  • Take the elevator back up to the top patient
  • Check smoke/ fire doors and compartmentation
  • Inspect chutes, storage areas, utility chases,
    hazardous areas
  • Continue down to the lower and basement levels to
    specific areas, such as the kitchen, loading
    dock, fire pump, emergency generators, fire
    annunciator panel, compressed gas and infectious
    waste storage
  • Complete checklist, or until problems are found!

Healthcare Engineering Consultants
The LSS Facility Tour
  • Checklist for the Facility Building Tour
  • Smoke and fire doors
  • Check Closure, label rating, gaps,
    undercuts, warpage, kick plate
  • Smoke and fire compartments
  • Check Penetrations, proper sealant
  • Roof and penthouse
  • Check Contractor supplies, smoking,
    exhaust fans labeled
  • Exit stairwells
  • Check Door rating, closure, signage, exit
  • Linen/ trash chutes and receiving rooms
  • Check Door rating, closure, fusible link,
    chute blockage

Healthcare Engineering Consultants
The LSS Facility Tour
  • Checklist for the Hospital Building Tour (contd)
  • Hazardous areas
  • Check Storage of flammables, room rating,
    door closer
  • Fire pump
  • Check Controls turned on, valves open,
    tampers OK
  • Fire annunciator panel
  • Check Bypass, trouble, ground fault or
  • Soiled linen rooms
  • Check Proper storage, dirty separated from

Healthcare Engineering Consultants
The LSS Facility Tour
  • Checklist for the Hospital Building Tour (contd)
  • Medical waste storage
  • Check Locked area, secure, sharps not
  • Loading dock
  • Check Smoking, improper storage, powered
  • Kitchen area
  • Check Cleanliness, storage, CO2 tanks,
    refrigerator temps, K-type portable extinguishers
    within 30 of fat fryer
  • PFI verification
  • Check Previous PFIs have been resolved
    as listed

Healthcare Engineering Consultants
The LSS Facility Tour
  • Checklist for the Hospital Building Tour (contd)
  • ILSM verification
  • Check Construction areas for ILSM
  • Mechanical equipment rooms
  • Check Storage, unlabeled containers,
    cigarettes, labeling
  • Emergency generators
  • Check In auto mode, batteries/ charger,
    fuel leaks
  • Medical gas systems
  • Check Manifolds, medical air and vacuum

Healthcare Engineering Consultants
The LSS Facility Tour
  • Checklist for the Hospital Building Tour (contd)
  • Compressed gas storage rooms
  • Check Full and Empty separation, chained
    or on racks
  • Egress corridors
  • Check Equipment not in use, containers
    gt 32 gallons
  • Eyewashes, showers and portable fire
  • Check Test dates on log or tag
  • Chapel
  • Check Candles, open flames
  • Other?

Healthcare Engineering Consultants
The LSS Facility Tour
Multiple Operational Deficiencies are Likely to
be Found During the Facility Tour
Healthcare Engineering Consultants

Operational Deficiencies
  • Operating Features
  • A clear space gt18 inches below sprinkler heads to
    the top of storage must be maintained
  • Exception Perimeter wall shelving, unless
    below the sprinkler (refer to NFPA 13)
  • Portable space heating devices are only permitted
    in non-sleeping staff and employee areas, with
    heating elements that do not exceed 212 degrees F
    (LSC, 2009 edition, 19.7.8)
  • Combustible decorations are prohibited, unless
    flame retardant (
  • Soiled linen or trash collection receptacles
    shall not exceed 32 gallons in capacity
  • Exception Attended or in hazardous area

Healthcare Engineering Consultants

Operational Deficiencies
  • Operating Features
  • Holiday decoration policy and implementation
  • Candles used in the chapel
  • Furnishings, decorations or other objects may not
    obstruct access, egress or block the visibility
    of exits (
  • Exit doors must be free of mirrors, draperies or
    hangings that may conceal, obscure or confuse the
    direction of exit (, and
  • Hallway Clutter!

Healthcare Engineering Consultants
The Life Safety Specialist Surveyor
Healthcare Engineering Consultants
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