Achieving a State of Readiness: The Importance of Life Safety Code Compliance

  • January 25, 2017
  • Author: Joe Cassata

Joseph S. Cassata, AIAAsk any Centers for Medicare and Medicaid Services (CMS) Code Compliance firm and they will tell you the importance of life safety code compliance cannot be stressed enough. The proof is in the number of citations they bestow; life safety citations have been among the top cited issues for the past several years, with the two most common citations relating to sprinkler system maintenance and electrical wiring and equipment.

More often than not, the high rate of these deficiencies is directly linked to a misunderstanding of the Life Safety Code — a code that was updated in July 2016 when CMS released its Final Rule. This update adopts the National Fire Protection Association’s 2012 edition of the Life Safety Code (NFPA 101), as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code (NFPA 99). And although the update is filled with extremely important information, it can be a little daunting to sift through.

When it comes to life safety, regular code updates are necessary due to continual advancements in technology and safety protocols, as well as new scenarios that present themselves as healthcare delivery changes. Implementing the latest and greatest life safety measures is straightforward and standard in new construction, but things get a little more complicated in older facilities.

Related Content: Achieving a State of Readiness Infographic

Hospitals are built for permanence, meaning they’re built to stick around for a long time without significant depreciation; they typically have a lifespan of 100 years. Over the course of their lifespan, many of these older hospitals go through renovations, but they’re often phased and can span decades. The sporadic nature of these renovations can result in buildings that adhere to various versions of the NFPA Life Safety Code, and lack consistent documentation or life safety drawings.

In the Northeast, a 100-year-old healthcare institution recently faced this problem with facilities ranging from the 1890s through the early 1970s. During an unannounced CMS validation survey, inspectors encountered a number of violations, not the least of which was not having updated life safety drawings and documentation. CMS’ subsequent inspection report contained a number of condition-level deficiencies, which could lead to a terminated Medicare contract if not fixed within 90 days.

But life safety inspections aren’t doom and gloom. life safety codes exist to ensure healthcare institutions are able to provide the highest quality of care, which is a very good thing for patients and institutions. The key to looking at inspections in a positive light is understanding the codes and having the certainty that your facilities are compliant. That’s where CannonDesign and our REALIZE Life Safety Solutions Suite of Services comes in. With experience assessing more than 200 million SF of space, we created this service line to help healthcare organizations assess their current compliance with the newly adopted code standards without operational disruptions — and to give them certainty that their facilities are compliant.

We provided this exact service for the aforementioned 100-year-old hospital in the Northeast. To address their challenges, we conducted a current state assessment of more than 500,000 SF of space. We also provided an updated life safety plan, updated life safety drawings, and a corrective action plan that outlined our recommendations for improvement. Based on this detailed documentation, CMS granted the medical center an extension to remediate the deficiencies — and the institution is now making progress in becoming fully compliant.

More information on the 2012 NFPA Life Safety and Health Care Facility Codes and the importance of achieving a state of readiness can be viewed in this infographic.

Get the Achieving a State of Readiness Infographic >


Setting the Stage for Behavioral Health Transformation

  • June 25, 2015
  • Author: Joe Cassata

Last year, at around this time, the Facilities Optimization Solutions (FOS) team had a unique opportunity to work alongside our colleagues in Advisory Services and Architecture in a massive assessment of the State Psychiatric Hospitals and State Supported Living Centers in the State of Texas. Pairing our services with efforts to optimize operational, clinical, and design excellence and improve the statewide care model gave us the chance to demonstrate how facility conditions assessments can fit into a larger picture to improve services and care – in this case for the substantial behavioral health population across the state of Texas.
FIGURE 1: State Psychiatric Hospital and State Supported Living Center sites throughout the state of Texas. FIGURE 1: State Psychiatric Hospital and State Supported Living Center sites throughout the state of Texas.

A Tour of Texas

For our portion of the work, we deployed six FOS teams to travel to six different sites that were representative of conditions and facilities at sites across the state (Figure 1). At each of these sites we conducted comprehensive assessments at each facility that included condition, life cycle, and last date of replacement/repair for the all critical systems and infrastructure. Additionally, we analyzed historic facilities data from all other sites to give an educated estimate of the current state of those facilities. All of this information was further analyzed to provide a Facility Condition Index (FCI) value (Figure 2) to determine which buildings were considered distressed with low return on investment.

FIGURE 2: The FOS team utilized both current and historical data to calculate the Facility Condition Index of each campus. FIGURE 2: The FOS team utilized both current and historical data to calculate the Facility Condition Index of each campus.

Meanwhile, our colleagues in Advisory Services and Architecture were doing assessments and research of their own. They spent many hours visiting sites across the state – interviewing staff, leadership, and other stakeholders and documenting current practices. They researched best practice care models that are being implemented at other states and facilities. They analyzed data related to bed needs, workforce needs and staffing. They assessed the ability of existing facilities to support new care models and the viability of current real estate assets.

Multi-Faceted Facility Recommendations

In the case of the State Psychiatric Hospitals, all of this information was used to inform the creation of a comprehensive 10-year plan for the Department of State Health Services, which includes recommendations for transformative changes to care models, staffing, operations and facilities. The FCI values played a critical role, alongside the planning assessment and the bed need assessment in providing preliminary recommendations for what should be done with the facilities on each site (Figure 3), ultimately setting the stage for comprehensive care model transformation over time. 

The work we did with the State of Texas demonstrates the critical role FOS can play whenever a health system is considering an extensive overhaul to the services they provide. Understanding how facility conditions will impact the ability to support operational or clinical changes is critical to achieving any goals. The information brought forward in facility condition assessments can help leaders make educated, financially viable decisions about their next steps.

Our work also demonstrates the power of multi-disciplinary collaboration at CannonDesign, pairing our services with other disciplines across the firm has resulted in truly transformative solutions that will impact the lives of Texans for years to come.

State of Texas_revised table-02

Figure 3: Facility Condition Index was considered together with real estate viability and bed need to make facility recommendations at each site.