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Life Safety Plan Requirements

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Safety drawings of people require a lot of information. However, if you overload the drawings with too much information, they can be difficult to read. Balance is key, and different situations may require different information. Drawings issued for a construction project may need to contain more information than documents used as a security document for living life. For example, some local or state building or fire officials may want to see all fire alarm devices, exit signs, or portable fire extinguishers on life safety plans. However, depending on the size and scale of the drawings, these elements may begin to obscure the necessary information. National Fire Protection Association (NFPA) – The NFPA publishes the codes and standards that CMS uses to determine compliance with fire safety requirements of our regulations. Potentially explosive atmospheres must be marked on lifetime safety drawings. These areas may include storage rooms of a certain size, dirty storage rooms, boiler rooms, bulk central laundry, or physical facility maintenance sheds (NFPA Table 18/19.3.2.1 lists specific areas classified as hazardous). In most cases, Chapter 18 hazardous areas are surrounded by one-hour fire barriers and sprinkler protection (sprinklers are required for all new health care facilities).

The same areas of Chapter 19 are usually protected by a 1-hour barrier or fire extinguisher and closed by a smoke separator/self-closing positive door. If the personal safety drawings show a storage room as a hazardous area with a 1-hour fire barrier, the surveyor expects a 45-minute compliant door and walls that lead to the properly sealed structure with all penetrations. If the drawings show a 2-hour fire wall, the surveyor expects a 90-minute compliant door and flap. In areas that are not designated as apartments, the land surveyor expects an 8-foot open hallway, with the exception of authorized cycling equipment. State Law Exception – The LSC or HCFC does not apply if CMS determines that a state is in effect that is imposed by state law and adequately protects patients in healthcare facilities. (See section 1863 of the Act.) The LSC is a set of fire safety requirements designed to provide an adequate level of fire safety. It includes construction, protection and operating functions that provide protection against fire, smoke and panic. The HCFC is a set of requirements to include minimum requirements for installation, inspection, testing, maintenance, performance and safety practices for facilities, materials, equipment and devices. The LSC and HCFC, which is regularly revised, is a publication of the NFPA, which was founded in 1896 to promote science and improve fire safety methods. Plans for a construction or renovation project must be submitted to the appropriate authority (AHJ) for review of the Building Code and the Life Safety Code, so they must contain the information for both codes as well as any additional information (for example, exit signs and fire alarm devices) required by the relevant JHA. This set of life safety documents is used to ensure ongoing compliance with the Life Safety Code, unlike plans submitted at the time of construction to comply with building codes. Since most evaluators review the facility`s compliance with the Life Safety Code, Life Safety Code terminology should be used for living persons safety drawings.

While not mandatory or generally shown, there are a few additional elements that can add value to living life security documents. For example, the type of construction of the building should be noted on the drawings. Since minimum building construction is a requirement of the Life Safety Code, it is important to document this information to demonstrate compliance. It will also help future projects if building extensions or major renovations are desired. It also documents cases where previously approved exemptions or special conditions have been granted that have been approved by the relevant JHAs. Since many hospitals today refer to certain parts of the facility as “ambulatory health facility”, “commercial occupation” or even “factory/industry occupation” (in the case of the central energy system), it is necessary to identify these occupations on the personal safety drawings and indicate the required fire separations. Again, a small key shot on the drawings, which shows the different assignments, can bring clarity.

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