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Healthcare Life Safety Compliance: Combustible decorations, stairwell treads, and temporary construction barriers

Hospital Safety Insider, October 20, 2016

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Q: In regards to the new CMS requirements regarding corridor projections, will alcohol-based hand-rub (ABHR) dispensers have to comply? Currently, our ABHR dispensers exceed the 4-inch limit for items projecting into the corridor. Will there be any equivalency permitted for this requirement?

A: CMS said in its final rule to adopt the 2012 Life Safety Code(r) (LSC) (issued May 4, 2016) that it will enforce the 4-inch projection rule rather than the 6-inch rule that NFPA permits. CMS takes this more restrictive requirement from the ADA requirements but the problem is, ADA applies to new construction and is not retroactive to existing conditions. CMS did not clarify that its 4-inch corridor projection rule is only for new construction, so it appears to me that CMS intends to enforce it in all situations... new and existing. It remains unclear whether the accreditation organizations will enforce this. They should, because if they don't and the hospital has a validation survey and is cited by the state agency for violating the 4-inch projection rule, then that will eventually reflect poorly on the accreditation organization. But with surveyors being the humans that they are, it is unclear if they will enforce this or not. While I do not recommend it, you can take a "wait-and-see" approach to determine whether you get cited for it. You will eventually, because CMS will enforce it. So I suggest you take action to eliminate those dispensers and look for new ones that do not extend more than 4 inches. There is no equivalency for this issue. I would think a waiver would not be approved for such a minor issue either.

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