Health Care Occupancy Life Safety Code® Assessments: Purpose and Common Findings

Paul Dzurinda

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Sep 14, 2022

The “health care ecosystem,” as discussed in our first blog post, is comprised of the patient, staff, physical environment and organization’s patient care strategy. High Reliability Organizations (HROs) protect the health care ecosystem by designing, constructing, maintaining, and operating facilities in a manner that keeps them safe, secure, and resilient.

Since fire emergencies can largely impact the health care ecosystem, fire safety remains a prime focus amongst HROs. To provide the regulatory framework for protecting the healthcare ecosystem against the impacts of fire, the National Fire Protection Association’s 2012 edition of NFPA 101®, Life Safety Code®(LSC) is adopted and enforced by healthcare accrediting organizations, such as The Joint Commission, Det Norske Veritas and others. HROs help protect the healthcare ecosystem from fire-related hazards by proactively performing Life Safety Code® Assessments (LSCAs) continuously.

Understanding the Purpose of LSCAs

Simply stated, but extremely comprehensive, the purpose of the LSCA is to assess all areas of a health care facility to measure compliance with the Life Safety Code®. The LSCA is typically performed by starting at the highest story of the building, working downwards in a consistent, methodical fashion. All rooms/areas are assessed, including patient sleeping and treatment rooms, mechanical rooms, and electrical, storage and housekeeping closets. As LSC deficiencies are identified and documented, plans are developed to correct each item. To cover the period during which a LSC deficiency remains unresolved, alternative life safety measures are considered and implemented as necessary.

Selecting Qualified Individuals to Perform LSCAs

According to The Joint Commission standards, the health care organization “should establish the qualifications of individuals it selects to assess compliance with the LSC” and that “knowledge of the Life Safety Code® and its application in unique occupancies is important.” Some health care facilities perform the LSCA using in-house staff. More commonly, many HROs partner with Jensen Hughes and rely on our extensive knowledge and experience to help them manage LSC compliance.

Determining Frequency of LSCAs

Accrediting organizations do not dictate a prescribed frequency for conducting LSCAs. However, at minimum, many HROs partner with Jensen Hughes to perform the LSCA annually. Larger organizations with multiple buildings will often divide the campus/buildings into multiple sections and conduct the LSCA on a more frequent basis that ensures all areas are assessed at least annually (e.g., monthly, quarterly). This method is sometimes preferred for larger HROs, as it allows deficiencies found during the LSCA to be managed more efficiently.

Addressing Common LSCA Findings

To assist HROs in keeping all facets of the health care ecosystem aligned, we employ our software solution, ProtectAdvisrTM, to manage LSC compliance in our partnerships. Using the software’s data collection and reporting capabilities, we identified several common LSC deficiencies, which should be addressed in a proactive manner.

  1. Improperly Constructed Fire/Smoke Barriers: Maintaining rated barriers remains a challenge (e.g., fire and smoke barriers). Many of the deficient conditions we note during LSCAs go beyond the typical unsealed penetrations. For example, wall construction issues are often found, like improper head-of-wall joints that are unsealed, sealed only with mineral wool or sealed with drywall joint compound. In addition, improper drywall repairs using “scab patches” are often noted. Documents such as those published by the Gypsum Association should be used to properly repair drywall.
  2. Missing Fireproofing Materials: Different types of materials can be used to protect structural members from the effects of fire. Spray-applied fireproofing material (SFRM) is the most common type seen in health care organizations. Over the life of a building, it is not uncommon to find SFRM removed from sections of beams when items such as pipes, conduits and other utilities are installed/supported by the beams. It is important to note that even a small amount of missing SFRM can lead to the failure of structural elements during a fire situation. For this reason, if SFRM is found missing during an LSCA, it must be replaced using materials that are of the proper type, bond strength and compatibility (be sure to check SFRM manufacturer’s information).
  3. Door Latching: Deficiencies in opening protectives (e.g., doors) are commonly noted during LSCAs, including a lack of or improperly working latching hardware. Manual flush bolts on doors often present issues since they do not permit doors to automatically latch, thereby requiring staff to remember to re-engage the manual bolts before leaving the area. For this reason, many authorities having jurisdiction (AHJs) prohibit the use of manual flush bolts on doors that are required to latch, such as fire, corridor and hazardous area doors.

    Another common issue is the lack of latching hardware on suite boundary doors. For years, many facility managers relied on the “five-pounds-force rule” in lieu of providing latching hardware. By this rule, one was permitted to demonstrate that a door will remain closed when at least five pounds of force is applied. However, CMS and other accrediting organizations, including The Joint Commission, require latching hardware on doors, even if the door remains closed with a force of at least five pounds. The only exception is if the door is a powered door and the door manufacturer states that latching hardware is not an available option (this exception is difficult to apply).
  4. Sprinkler Head Coverage: Classifying a building as “fully sprinklered” brings about many beneficial leniencies in the LSC. However, to claim “fully sprinklered” status, sprinkler heads must be present in all spaces, unless specific exceptions are met. For example, the 2010 edition of NFPA 13 allows the omission of sprinklers from some electrical rooms if certain provisions are met. A common issue seen during LSCAs is the lack of sprinklers in elevator machine rooms and telecommunications rooms. Per NFPA 13, there are no exceptions to installing sprinklers in these rooms. However, it may be possible to consider installing gaseous suppression systems in lieu of sprinklers, in certain cases with AHJ approval.

    Learn more
    about how Jensen Hughes can support Life Safety Code® Assessments in your health care organization.
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About the author

Paul Dzurinda
Paul is the Health Care Life Safety Code Assessment (LSCA) Service Line Leader and a Senior Consultant, specializing in codes/standards compliance within the healthcare industry