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Briefing on Hospital Safety: Making sense of the new Life Safety Code

Hospital Safety Insider, November 10, 2016

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Our expert answers your questions about CMS' newly adopted rule and what you need to know

Editor's note: This Q&A was taken from the June 2016 webinar, "The Approved 2012 Life Safety Code®: What You Need to Know." Healthcare safety and life safety consultant expert Brad Keyes, CHSP, owner and senior consultant for Keyes Life Safety Compliance, gave his professional insight into how the newly adopted Life Safety Code will affect your facility. To listen to the full program on demand, check out the HCPro Marketplace at www.hcmarketplace.com.

Q: You say sprinkler impairments do not require a fire watch until the sprinklers are impaired for 10 hours, but you did not include the fire alarm system with that. Can we apply the same 10 hours to fire alarm system impairments?

Brad Keyes: No, you cannot. The standard that allows a 10-hour wait for a fire watch for sprinklers is specific for sprinklers. It's found in NFPA 25, which is specific for sprinklers. There is a requirement in the Life Safety Code® (LSC) that does say if the fire alarm system is impaired for four or more hours in a 24-hour period, then you need to do a fire watch. So that still applies. So the fire alarm system is not included in that 10 hours. They are limited to four hours in a 24-hour period.

Q: In sleep labs where there is a requirement for supervision, are cameras allowed in place of direct supervision?

BK: The LSC does not address closed-circuit TV cameras in lieu of direct supervision. It doesn't address it one way or the other. That's going to be an individual interpretation by the authorities. The problem with that is that you're going to need all of the authorities in the jurisdiction to approve that before you can safely go with that, and that's not likely to happen. Where the accreditation organization says "sure, that's fine, we're okay with that," the state agency may not. Then you have to follow the most restrictive. So, since the LSC does not address it, I would say don't plan on doing it unless you get permission from all of your authorities.

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