Items to check off for LSC compliance
There are many detailed requirements of Life Safety Code (LSC) compliance, and many outpatient surgery managers are not aware of them.
For example, all gas cylinders, including those not in use, must be stored in an enclosure of noncombustible construction in an ambulatory surgery center (ASC), says William Lindeman, founder and president of Tucson, AZ-based WEL Designs, which is a health care facility planning firm. Lindeman spoke on the LSC at the recent annual meeting of the Ambulatory Surgery Center Association.
"The walls, floors, ceilings, doors — hear me, doors — interior finished shelf racks, have to be noncombustible," he says.
About one-third of ASCs have wood doors on their gas closets and are out of compliance, warns Lindeman. "For some reason this has been missed by professionals for a very long time," he says. "It's a very common thing to find."
Architects will tell you that you are in compliance because you have a one-hour rated door, Lindeman says. However, "if it's a large system, more than 3,000 cubic feet, has to be rated and noncombustible," he says. It is possible to obtain limited combustible wood doors that meet the standard, but the least expensive way involves a metal door, he says.
Hospitals are allowed to have up to 300 cubic feet of oxygen, equal to 12 E cylinders. George Mills, MBA, FASHE, CEM, CHSP, senior engineer in the department of standards interpretation, The Joint Commission, says. "Any more than that needs to be in a room we call 'limited construction,' which includes a door with a closure and positive latching," he says.
Consider these other suggestions:
• Conduct regular mechanical and electrical testing.
"Basically, it is safe to assume you will need to test and document anything that is mechanical or electrical in your facility, and anything in any way related to safe reliable exiting of the building," Lindeman says. To maintain the exits in a multi-tenant building, "it is your job to walk down those stair towers regularly to make sure the doors on it are latching securely and they can be used as a safe, reliable exit," he says.
Your engineer should photocopy the parts of the NFPA documents that address operational features, "because it's only you who can make it happen," Lindeman says.
"There are requirements for flame and smoke readings and furnishings and curtains and things inside your facility you have to respect." There's even a limit on the size and number of trash cans, he says. The largest single trash can is 32 gallons. The largest storage of trash in any given room is half a gallon per square foot maximum, unless the area is protected as a hazardous space, says Lindeman.
"There's two ways to protect a room as a hazardous space: fully [fire] sprinklering it, or fire rating it," he says. "So, if you're in a fire sprinklered building, you don't have to worry about the size of your trash containers any more."
Also, check for portable space heaters, which are forbidden in patient care areas, Lindeman says.
Fire extinguishers must be inspected every 30 days, he says. Ensure the fire extinguishers are located where they are supposed to be, make sure the instructions are facing out, and lift them to ensure they don't feel empty. "You need to examine for obvious damage and make sure the pressure gauge reading is in an acceptable range," Lindeman says. "This is a monthly test I'm sure you all already are doing but remarkably, are seldom documenting." You should have a written procedure so you can document that you did it correctly, sources point out.
• Conduct quarterly fire drills, one per shift in hospitals.
Your written fire emergency plan must list steps, including the use and response of fire alarms and code phrase training, pull of the alarm to dispatching authority, isolation of the fire, evacuation of the immediate area, evacuation of the smoke compartment, maintenance of the overall building for evacuation, and ensuring the fire is extinguished, Lindeman says.
"When you find a fire, you need to set off the alarm immediately," he says. "If you can't set off the alarm, you need to use a code phrase the staff is trained to recognize." It could be code red that means "I found a fire, someone pull the alarm, because I can't right now."
"It's little, but it's missing from a lot of emergency plans you see out there," Lindeman says.
The lowest priority? The fire itself, Lindeman says. "That's the last thing you worry about when there's a fire, is actually putting it out," he says.
There are many detailed requirements of Life Safety Code (LSC) compliance, and many outpatient surgery managers are not aware of them.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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