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Archive Surgical Construction 2017

Navigate the New Life Safety Codes

Tips to ensure your project complies with CMS's detailed requirements.

Sandy Berreth, RN, MS, CASC


CMS surveyor CLOSE INSPECTION CMS surveyors will be inspecting facilities to ensure emergency preparedness protocols are current.

Medicare surveyors are cracking down on building safety. They've been enforcing the 2012 editions of the National Fire Protection Association's (NFPA) Health Care Facilities Code and Life Safety Code since last November. The codes are intended to ensure facilities have the systems and equipment in place to protect patients and staff in the event of a fire, power failure or other unforeseen emergency. CMS could withhold payments from out-of-code facilities and, in the most severe of cases, even threaten to shut down noncompliant centers. Financial penalties are concerning, but your main motivation should be the safety of your staff and patients. Here are 10 ways to ensure CMS surveyors see nothing worth noting during their visit to your facility.

1. New versus existing construction. If you remodel, you must follow the rules for new construction. You might have a 20-year-old building, but if you decide to renovate a procedure room, everything needs to be done according to the "new" rules.

2. Initial verification testing. Maintain records of your initial verification testing on fire alarms, sprinklers, generators and medical gases. Although a contractor might hold onto this documentation, file it away for safekeeping.

3. Blueprints. Likewise, always have a construction project's blueprints on file at your facility, including any changes to the plans that have been made along the way. Your contractor can provide you with a "clean" set once the work has been completed.

4. Fire doors. An expert must visually inspect and test fire doors for functionality annually. Although a fire marshal could perform the inspection, a fire alarm or sprinkler system vendor will be able to provide this service.

5. Doors to hazardous areas. You must install self-closing or automatic-closing doors at the entrance to any storage areas that house flammable, combustible or other materials that pose a greater than normal hazard. Check all doors that latch until you hear a click as part of a monthly Environment of Care checklist.

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