Ask 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.
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.