Maintaining Life Safety Compliance During COVID

Shaine Grogan, PE, CFPS

Life safety codes ensure healthcare facilities provide the highest quality of care — critical for patients and institutions.

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Healthcare facilities are potential hotspots where COVID-19 can quickly spread. To limit the spread of the infection, the Centers for Medicare & Medicaid Services (CMS) issued blanket waivers for certain fire protection and life safety inspection, testing and maintenance (ITM) requirements at healthcare facilities. Despite any waivers in place, proper planning for fire protection and life safety ITM is a priority for healthcare facilities.

While COVID-19 has changed many aspects in healthcare facilities, properly functioning fire and life safety systems remain critical components of overall safety within a hospital. Where facilities are overdue or have taken advantage of ITM waivers, it is essential for facilities to proactively review their ITM plan to eliminate potential threats to life safety compliance.

What is the Life Safety Code & Health Care Facilities Code?

In the United States, Medicare and/or Medicaid provider compliance incorporates the requirements within the 2012 editions of the National Fire Protection Association (NFPA) 101 Life Safety Code LSC) and select chapters of NFPA 99 Health Care Facilities Code (HCFC). These codes require or reference other codes and standards for various fire protection and life safety ITM requirements, such as water-based fire protection systems, fire alarm systems, fire and smoke doors and opening protectives and smoke control systems.

How Can Remote Inspections Help?

Remote inspections are an efficient and powerful tool to help conduct fire and building inspections during COVID-19 and beyond. Throughout the pandemic, healthcare facilities have mostly been able to move forward with critical inspection, testing and maintenance efforts, supported by remote inspection tools that enable them to happen virtually. Just like traditional on-site or in person inspections, a remote inspection typically occurs as part of a jurisdiction’s permitting process, project, or contract schedule and needs to be approved by the Authority Having Jurisdiction (AHJ) for that area.

Meanwhile, a technical committee has been formed for a proposed new standard, NFPA 915, Standard on Remote Inspections. They have begun the work to create a first draft and it will be available for public comment later this year.

Looking ahead

Life safety codes exist to ensure health care facilities provide the highest quality of care, which is critical for patients and institutions. Facilities can ensure they are in compliance by working with an experienced partner and conducting a life safety assessment. This top-to-bottom review will ensure that the building and its inherent fire protection features will effectively protect people during a fire. While achieving and maintaining life safety compliance in a healthcare facility can be a daunting task during COVID, facilities need to be prepared to reduce risk, liability and unnecessary expenditures. As COVID-19 protocols are lifted, facilities with overdue ITM will need to have a plan in place to be in compliance. They should work with experts who have experience evaluating and designing holistic fire protection and life safety ITM plans.


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