LENEXA, KS –REMEDI8®, the national leader in passive fire protection and a true partner in compliance needs, announces the availability of the REMEDI8 Total Compliance® program, a comprehensive proactive sustainable code compliance solution that helps healthcare facilities stay on top of compliance while producing significant long term savings. The action-oriented approach offers the ultimate life safety assurance program for healthcare facility fire safety needs that ensures facilities meet and exceed regulatory standards. Offering a one-stop-shop from inspection, to repair, to replacement, Total Compliance allows facility staff to focus their attention on creating and maintaining a healing environment for patients and visitors.
Through ongoing compliance services and operational efficiencies, REMEDI8 ensures seamless compliance, long-term savings, and a solid investment in a business’s growth and success. The multi-year Total Compliance program strategically spreads expenses over time, reducing both yearly costs and the upfront financial burden. With a fixed price over multiple years, facilities do not face price inflation risks and predictable costs over multiple years makes budgeting easier.
The Total Compliance program covers more than 20 components, including a focused life safety assessment; comprehensive life safety assessment; and life safety drawing updates, as well as enhanced door, damper, and barrier survey, inspection, and sampling. Users can select from among the areas of compliance to let REMEDI8 Total Compliance put their facility on the path of proactive code compliance. The program can also be completely tailored to facility-specific needs.
Designed to be proactive, Total Compliance helps catch deficiencies and enables staff to correct them before they are identified by regulatory surveyors. Capturing data over multiple years helps better understand the cause of deficiencies so REMEDI8 can create a customized mitigation plan.
About REMEDI8® REMEDI8® specializes in helping our customers navigate and maintain the complex world of safety and compliance. REMEDI8 has developed customized processes and procedures to successfully Inspect, Repair, Re-Label, and formally Report on key Life Safety issues around Fire Doors, Fire Dampers and Fire Barrier. Under the guidance of former CMS and Joint Commission Surveyors, REMEDI8 has developed specialized reporting that specifically addresses maintaining and reporting on Fire Door, Fire Damper, and Firestopping for Healthcare facilities. For more information, visit https://www.myremedi8.com/.
Securing Funding for Fire Safety in Healthcare Facilities
By Mickey Eberts, CEO of REMEDI8®
Ensuring fire safety in healthcare facilities is crucial to safeguarding the well-being of patients and staff and maintaining regulatory compliance. However, acquiring the necessary funding can present significant challenges. Balancing competing maintenance priorities and justifying investments in fire safety against revenue-generating healthcare services can be a formidable task for facilities directors. In light of these obstacles, what strategies have proven successful in securing the necessary funding for fire safety?
Difficulty of Securing Funding
The first step in addressing this challenge is understanding why securing funding for fire safety can be difficult. Healthcare facilities are often under significant financial strain, with rapid increases in expenses for labor, drugs, supplies, and equipment, as well as the impact of economy-wide inflation.
Key Challenges Hospital budgets under financial strainCompeting priorities, including pressure to invest in medical technology and revenue-generating initiativesFacilities directors may have limited experience and expertise in finance and/or fire safety
The American Hospital Association reported in 2023 that the growth in hospital expenses has been more than double the increases in Medicare reimbursement for hospital care. Over half of U.S. hospitals ended 2022 at a financial loss, according to Kaufman Hall’s Operating Margin Index.
What’s more, fire safety budget requests must compete with many other priorities, including the purchase of costly new technology – an MRI machine or a surgical robot – aimed at achieving strategic goals of expanding patient care capacity, increasing revenue, and keeping up with competitors.
Fire Safety is Crucial
Investing in fire safety may not be glamorous, but it remains crucial and indispensable. Of course, fire safety is absolutely critical for all types of buildings. However, when it comes to healthcare facilities, the stakes are even higher. These complex, busy facilities house vulnerable individuals, many of whom have limited mobility. Moreover, the staff-to-patient ratio may be inadequate for prompt evacuation during a fire, putting lives at risk. Additionally, there are hazardous chemicals and electrical devices present, further exacerbating the dangers.
Although hospital fires are rare, their consequences can be devastating. According to the National Fire Protection Association (NFPA), there were an average of 1,210 hospital fires per year in the US between 2012 and 2023, resulting in an average of $14 million in annual direct property damage.
Despite these alarming statistics, fire safety is sometimes overlooked or underfunded in hospitals due to limited financial resources and competing priorities. In April, an incident vividly highlighted the urgency of life safety. A devastating fire broke out at Beijing Changfeng Hospital, the flagship facility of a publicly traded medical care group with branches across China. This tragic event claimed the lives of 29 individuals and left 42 others injured.
The fire erupted when a spark ignited flammable construction materials during a renovation project. An investigation by China’s State Council concluded that the fire compartments failed to effectively contain the spread of the fire allowing the fire and smoke to rapidly engulf the premises.
Barrier Management
Strategies for Securing Funding Gain a comprehensive understanding of the budgeting process at your hospitalCultivate a strong working relationship with the CFOCollaborate with a strategic partnerExperienced in unique challenges of performing fire safety barrier construction, repair, and remediation in healthcare facilitiesExpert at navigating compliance and hospital budgeting challengesDevelop compelling, well-documented fire safety budget proposalsSeek Capital FundsSubmit budget requests early and often
The fire compartments that failed in Changfeng play a critical role in hospitals’ life safety strategy. Unlike office buildings and residential housing, which are designed for swift evacuation during fires, hospitals employ a defend-in-place approach, because of limited patient mobility. This involves isolating different sections of the building to safeguard occupants until they can be rescued by first responders or until active fire suppression methods, such as sprinklers, can eliminate the danger.
To ensure the effectiveness of the defend-in-place approach, it is crucial to consistently implement barrier management, specifically by utilizing passive fire protection and fire stopping. These measures confine the spread of heat, flame, smoke, and harmful gasses. It is of utmost importance to remain vigilant and promptly address any issues. Effective compartmentation consists of three essential components — fire doors, smoke dampers, and wall integrity.
Fire door compliance is challenging because doors and hardware are subjected to constant use and need continual attention to correct misalignment, dents, holes, and deficiencies. Healthcare facilities require comprehensive surveying, labeling, and repair for all fire-rated doors to avoid compliance gaps and safety risks.
Fire damper compliance is a less visible, but crucial component of life safety that is too often overlooked. Dampers are the first line of defense against flame, smoke, and heat during a fire. While inspections are only required every six years for hospitals (one year after installation), and every four years for nursing homes and long-term care facilities, just one faulty damper can have catastrophic consequences.
Fire barrier compliance requires vigilance. With regular building maintenance and upgrades, facilities may be left with non-compliant holes and barrier penetration that compromise fire safety. Improperly maintained penetrations of floor assemblies facilitate the rapid vertical spread of smoke and fire within a building.
Proven Strategies to Secure Funding
In addition to the challenges mentioned earlier — constrained hospital financial resources and competing priorities — facilities directors often face another hurdle: limited experience with corporate budgeting processes.
Moreover, hospital facilities directors typically ascend from one of the building trades, such as HVAC or electrical, and therefore may lack expertise in fire barrier management practices and compliance requirements.
For these reasons, healthcare facility directors often develop long-term relationships with strategic partners specializing in healthcare facility fire safety. These partners provide essential services for life safety system inspection, installation, and maintenance, as well as planning and reporting required for compliance and budgeting.
Facilities managers can effectively secure funding for life safety by implementing these six proven strategies.
1. Understand the Budgeting Process:
Gain a deep understanding of your hospital or hospital network’s budgeting process. Familiarize yourself with the financial objectives, strategies, challenges, and both short-term and long-term goals. Learn the budget cycle, the decision-making process, and policies for allocating capital and operating funds.
2. Build a Strong Relationship with the CFO:
Develop a strong working relationship with your hospital’s Chief Financial Officer (CFO). Familiarize yourself with the CFO’s priorities, preferred approach, and information requirements.
3. Collaborate with a Strategic Partner:
Work with a strategic partner who specializes in healthcare facility fire safety. Select a partner who not only has skilled inspectors and technicians, but importantly, a partner who also shares your goals and can assist you in navigating the complexities of hospital budgeting processes.
Budget requests need to be based on a comprehensive understanding of your facility’s fire barrier systems and their current state of compliance. This includes identifying any deficiencies, evaluating the age and condition of existing systems, and determining necessary repairs or upgrades. Highlight the safety risks and financial consequences of deficiencies and non-compliance.
5. Seek Capital Funds:
Strategically structure budget proposals to maximize opportunities to secure capital funding. By proactively addressing fire safety measures with comprehensive capital-funded projects, hospitals can ensure the well-being of their patients, staff, and infrastructure. Investing in a proactive, comprehensive fire safety program is more efficient than dealing with problems reactively after a failed compliance inspection, avoiding costly emergency situations and piecemeal corrections.
Additionally, CapEx provides a financial benefit to the hospital by allowing for more funds to be raised and depreciated over extended periods of time. This funding strategy can help alleviate the strain on the hospital’s budget and provide long-term financial stability.
6. Submit Budget Requests Early and Often:
Timing is crucial. Ensure that you submit requests in a timely manner, as required by the budgeting process, typically around six months prior to the start of the fiscal year. Familiarize yourself with the capital committee’s meeting schedule and align your submission accordingly. Additionally, it is worth noting that funds often become available throughout the year, particularly toward the end of the fiscal year. Therefore, it is advisable to regularly update and resubmit your requests.
These strategies have proven effective in ensuring that fire safety remains a priority, despite the many challenges facing hospitals today. By proactively managing your budget and effectively advocating for necessary funds, you can help maintain long-term financial stability for your organization while also promoting the safety of patients, staff, and visitors.
FOR IMMEDIATE RELEASE CONTACT: Kristin Nugent McNeil, Gray & Rice Inc. 617-367-0100 ext. 148 kristin.nugent@mgr1.com
REMEDI8® Provides Comprehensive Fire Door Services for a Variety of Industry Verticals
LENEXA, KS – REMEDI8®, the national leader in passive fire protection and a true partner in compliance needs, provides comprehensive and streamlined fire door inspections to make compliance easy. In accordance with NFPA 80 standards, fire doors must be inspected annually. To make this process as painless as possible, companies across healthcare, education, correctional facilities, commercial and hospitality, entertainment, government, and industrial sectors can partner with REMEDI8 for a seamless 13 point inspection and repair process.
Organizations often face a range of deficiencies in their fire doors. These can include holes or openings in the fire-rated door assembly, latching hardware failure, missing gasketing or silencers, clearance issues and a variety of other defects. To quickly identify and remediate these defects, REMEDI8 provides a 13 point inspection with steps ranging from ensuring that no holes or breaks exist in surfaces to ensuring that the signage affixed to a door meets requirements. REMEDI8 also provides updated life safety drawings noting each door location for The Joint Commission surveys in healthcare and offers fire door and frame, and fire exit device labeling/relabeling services. On top of this, REMEDI8 also provides targeted repair services to ensure only the parts needed to meet compliance are replaced, cutting costs for companies.
By partnering with REMEDI8, companies can ensure that fire doors always operate as needed and can provide crucial protection inside a building during a fire emergency. Functioning fire doors keep escape routes, such as corridors, clear from fire, giving occupants of the building a longer period to escape in the event of an emergency and better access for fire emergency personnel. Fire doors also protect the remainder of the building from further damage during a fire.
Fire door inspections are more than a compliance measure, they are a way of building robust safety and communicating to clients, customers, and employees that a company puts people’s welfare first. Personnel from facility directors and managers to compliance officers and plant operations directors make the right choice for their organization and its people when they partner with REMEDI8 for fire door services.
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About REMEDI8®
REMEDI8® specializes in helping our customers navigate and maintain the complex world of safety and compliance. REMEDI8 has developed customized processes and procedures to successfully Inspect, Repair, Re-Label, and formally Report on key Life Safety issues around Fire Doors, Fire Dampers and Fire Barrier. Under the guidance of former CMS and Joint Commission Surveyors, REMEDI8 has developed specialized reporting that specifically addresses maintaining and reporting on Fire Door, Fire Damper, and Firestopping for Healthcare facilities.
REMEDI8 Highlights Mobile Containment Unit for Infection Control in the Healthcare Industry
HEPA-10X mitigates the spread of infection in high-risk healthcare environments
LENEXA, KS – REMEDI8®, the national leader of fire protection and health and safety systems, highlights its HEPA-10X for infection control in high-risk healthcare settings. The HEPA-10X has been expertly designed for effective control and maximum efficiency. Its interior and exterior powder coating not only enables easy cleaning and maintenance but also maximizes the system’s durability, ensuring longevity. Plus, the unit comes pre-assembled and ready for immediate use, minimizing installation costs and other startup barriers.
The HEPA-10X extends to 10 feet in height with a 6-foot fully extendable ladder capability, making it ideal for tall ceilings. Its 2-speed power switch and HEPA filtration system offers a fully-integrated HEPA filter with a variable power switch. Additionally, its One-Step Lift and Lock mechanism makes it easy for one person to move the unit within a facility and set it up again in less than 30 seconds. These features are designed to make the HEPA-10X a seamless integration into healthcare environments—offering users flexibility and adaptability without much downtime.
The unit also comes with a 25-foot retractable power cord and built-in electrical outlets, making for easier storage and enabling easy maintenance with plug-in capabilities for technician tools. With over 300 expert technicians serving all 50 states, REMEDI8® provides complete compliance coverage to customers nationwide.
You can learn about REMEDI8’s Mobile Containment Units here: https://www.myremedi8.com/product-containment-solution/
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About REMEDI8®
REMEDI8® specializes in helping our customers navigate and maintain the complex world of safety and compliance. REMEDI8 has developed customized processes and procedures to successfully Inspect, Repair, Re-Label, and formally Report on key Life Safety issues around Fire Doors, Fire Dampers and Fire Barrier. Under the guidance of former CMS and Joint Commission Surveyors, REMEDI8 has developed specialized reporting that specifically addresses maintaining and reporting on Fire Door, Fire Damper, and Firestopping for Healthcare facilities.
REMEDI8 Highlights Mobile Containment Unit for Dust Control
DUST-10C mitigates dust in construction and other debris-heavy environments
LENEXA, KS – REMEDI8®, the national leader of fire protection and fire protection and compliance solutions, highlights its DUST-10Cfor dust containment in a variety of settings. The DUST-10C has been expertly designed for effective control and maximum efficiency. Its interior and exterior powder coating not only enables easy cleaning and maintenance but also maximizes the system’s durability, ensuring longevity. Plus, the unit comes pre-assembled and ready for immediate use, minimizing installation costs and other startup barriers.
The DUST-10C extends to 10 feet in height with a 6-foot fully extendable ladder capability, making it ideal for tall ceilings while still offering easy access. Additionally, its One-Step Lift and Lock mechanism makes it easy for one person to move the unit within a building and set it up again in less than 30 seconds. These features are designed to make the DUST-10C a seamless integration into contracting and building environments—offering users flexibility and adaptability without much downtime. Plus, the DUST-10C Mobile Containment Unit offers convertibility for HEPA filtrations, giving contractors and other professionals the option to incorporate a HEPA air filtration system to a dust mitigation unit. The unit also comes with a pass-through power cord opening.
Its easy-to-clean design and flexibility make the DUST-10C unit ideal for general contractors and other professionals working in dust and debris-producing environments. With over 300 expert technicians serving all 50 states, REMEDI8® provides complete compliance coverage to customers nationwide.
You can learn about REMEDI8’s Mobile Containment Units here: https://www.myremedi8.com/product-containment-solution/
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About REMEDI8®
REMEDI8® specializes in helping our customers navigate and maintain the complex world of safety and compliance. REMEDI8 has developed customized processes and procedures to successfully Inspect, Repair, Re-Label, and formally Report on key Life Safety issues around Fire Doors, Fire Dampers and Fire Barrier. Under the guidance of former CMS and Joint Commission Surveyors, REMEDI8 has developed specialized reporting that specifically addresses maintaining and reporting on Fire Door, Fire Damper, and Firestopping for Healthcare facilities.
REMEDI8® Highlights Fire Barrier Management Survey and Remediation Services
Correct Costly Mistakes and Address Risks Before They Happen
LENEXA, KS – REMEDI8®, the national leader of fire protection and compliance solutions, is proud to highlight its comprehensive fire barrier management survey and remediation services for healthcare facilities. With ongoing building maintenance and renovations, healthcare facilities risk dangerous non-compliant barrier penetrations. REMEDI8® corrects these costly mistakes and addresses risk before they happen with tailored end-to-end surveys, remediation, and maintenance programs for firestopping systems.
REMEDI8® provides a comprehensive solution:
A thorough sweep of fire barriers for non-compliant penetrations, scab patching, and head-of-wall issues
Identification of missing J-box covers and cables on sprinkler lines
Labeling of each penetration with UL system, material type, date, and technician’s name
Physical and/or digital reports including plans noting location of work, and before and after photographic documentation of each penetration
Certified, factory and field trained technicians knowledgeable with all firestopping products (STI, HILTI, 3M)
From surveying to innovative reporting, maintenance, and repair, REMEDI8® provides complete compliance coverage with over 300 certified and highly skilled technicians serving healthcare facilities in all 50 states.
“At REMEDI8®, we are committed to helping our clients maintain a safe and compliant environment,” said Mark Pavlacka, EVP of Operations at REMEDI8®. “Our barrier management survey and remediation services address the unique needs of each client, ensuring their facilities meet the highest standards of fire protection.”
REMEDI8® specializes in helping our customers navigate and maintain the complex world of safety and compliance. REMEDI8 has developed customized processes and procedures to successfully Inspect, Repair, Re-Label, and formally Report on key Life Safety issues around Fire Doors, Fire Dampers and Fire Barrier. Under the guidance of former CMS and Joint Commission Surveyors, REMEDI8 has developed specialized reporting that specifically addresses maintaining and reporting on Fire Door, Fire Damper, and Firestopping for Healthcare facilities.
Barrier Companies Rebrands as REMEDI8 Four Fire and Life Safety Businesses Now Unified Under Single Brand
Lenexa, Kan. – January 23, 2023 – Barrier Companies, a nationwide fire and life safety services company that specializes in helping customers navigate and maintain the complex world of safety and compliance, has announced a strategic rebranding to REMEDI8. The new name unifies four businesses – Barrier Compliance Services, Prevent Life Safety Services, Fire Door Solutions and United Fire Doors – under one brand, which reflects the strength of the combined business’ mission to provide value to customers and assist with code compliance.
Barrier Companies acquired Prevent, a fire and life safety company serving customers primarily in healthcare settings throughout California, Texas and Arizona later that year. To further build out the company’s national service capability, Barrier Companies acquired two additional fire and safety compliance businesses in July 2022.
These were Fire Door Solutions, a local peer to Barrier Companies based in Stilwell, Kansas a leading provider of fire and life safety compliance services and solutions primarily for the healthcare facilities market nationwide, and Florida-based United Fire Door Inspection, a specialized provider of inspection services in the Southeast.
“As REMEDI8, we are a truly unified company with a simple goal: to save lives and protect property by helping our customers achieve 100% life safety compliance,” said Mickey Eberts, Chief Executive Officer of REMEDI8. “Our new identity incorporates the best attributes of each entity and speaks to our goal by emphasizing our comprehensive scope of services, our experienced technicians and our national footprint.”
REMEDI8 is also introducing a new visual brand identity to complement its name change. Taking design cues from the merged companies, it includes an updated logo and color palette that is indicative of the strategic direction of the company. Visit www.myREMEDI8.com to explore the new website and brand.
Barrier Companies’ remaining subsidiaries: Barrier Technologies, Barrier Compliance Services (construction division), Facilities Management Solutions and Pencon will continue to operate under their current brands.
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Media Contact: Sonya Witherow Marketing Manager switherow@myREMEDI8.com
About REMEDI8 REMEDI8 specializes in helping customers navigate and maintain the complex world of safety and compliance. REMEDI8 has developed customized processes and procedures to successfully Inspect, Repair, Re-Label, and formally Report on key Life Safety issues around Fire Doors, Fire Dampers and Fire Barrier. Under the guidance of former CMS and Joint Commission Surveyors, REMEDI8 has developed specialized reporting that specifically addresses maintaining and reporting on Fire Door, Fire Damper, and Firestopping for Healthcare facilities. For more information visit: https://www.myREMEDI8.com/
All deficiencies must be addressed within 60 days of being identified
The Joint Commission will no longer review open items and will not issue PFI lists as a part of their reports
Requests for extensions will be handled by the Regional Centers for Medicare & Medicaid Services (CMS)
In the past, many facilities have used The Joint Commission’s findings to build ongoing Plans for Improvement to address the deficiencies found. Now that a hard deadline of 60 days is being imposed, this method is no longer practical. Knowing that Joint Commission inspections are thorough, preemptive measures are necessary to ensure compliance.
Steps healthcare facilities can take to be proactive with this major change: 1. Assessments – utilized primarily by owners and contractors to:
Develop a remediation budget
Determine the extent of an issue
Ensure compliance on a project or facility
Using a certified and reputable contractor to assess the existing condition of barriers prior to The Joint Commission inspections is now more important. The findings of the assessment are then used to develop an internal Plan for Improvement. Identifying and addressing deficiencies before being under the “60-day” clock is crucial.
2. Staying up to date on the latest “hot items” Building Codes, Fire Codes and NFPA are consistently evolving and are formally updated every 3 years. Prepare for compliance by staying up to date on the existing standards and codes including:
Doors within Rated Barriers:The tolerances of the vertical gap and undercut of the door must be ensured. The doors must have proper identification of being fire-rated. Other issues include the door being self-closing and having positive latching.
Fire/Smoke Dampers: Dampers used to maintain rated barriers need to be tested to ensure functionality. The sealing around dampers is also highly scrutinized. A common deficiency found is intumescent fire-stopping being used to seal around dampers which goes against the U.L. approved manufacturer installation requirements of most dampers.
Missing/Removed Fireproofing: This is a deficiency that has been often identified recently. Fireproofing that is removed to attach clamps for hangers to support mechanical equipment must be replaced. This issue can commonly be found throughout a facility.
Fire Barrier Management: Ensure fire-rated wall penetrations (mechanical, plumbing, electrical, etc) have been repaired and sealed to keep their rating.
3. Engaging a specialty contractor to remediate deficiencies Employing a certified contractor like REMEDI8 to identify deficiencies prior to The Joint Commission prepares your facility to pass inspection. Remediation of deficiencies can be budgeted, and scheduled for the needs of the facility. The documentation provided by a qualified contractor like us can make The Joint Commission inspections less daunting. By using a containment contractor such as REMEDI8 that provides both assessments and utilizes in-house employees for field installation and remediation, facilities can be assured of receiving quality and can more closely monitor and control schedule, cost, and compliance.
In December of 2020, The Joint Commission issued new life safety code requirements for business occupancies in healthcare. The new requirements will take effect July 1, 2021, for organizations that are accredited through Hospital, Critical Access Hospital, and Behavioral Health and Human Services programs.
The new standards address building and fire protection features that are designed and maintained to minimize the effects of fire, smoke, and heat. This includes but is not limited to the following:
Fire-rated doors, barriers, and partitions
Protection of vertical openings
Protection of pipes, conduits, cables, and more with approved fire-rated materials
Clearing means of egress for fire emergencies
These new standards mark the first time that the accreditation process will include Life Safety requirements that are applicable to business occupancy areas in healthcare facilities.
According to the NFPA, a health care business occupancy is an area where there are no overnight stays and where three or less individuals are cared for and rendered incapable of self-preservation at any given time by the virtue of their treatment. Once a building is considered to be a business occupancy the new Life Safety requirements for business occupancy will apply.
The Joint Commission has recommended that facilities create a Building Maintenance Program as a best practice measure to address these areas. Building Maintenance Programs created to address these areas and issues must be structured to meet the new and existing compliance standards. For a complete list of the new standards and their requirements visit The Joint Commission’s website.
REMEDI8 can assist your healthcare facility with identifying deficiencies in these areas prior to your next survey. Using a containment contractor like REMEDI8 that provides assessments and utilizes highly trained and certified in-house employees for field installation and remediation, ensures your healthcare facility will receive quality service, as well as, insights that allow you to control your schedule, cost, and compliance.
Contact REMEDI8 today at 855-714-FIRE (3473) to proactively identify deficiencies in your healthcare facility’s business occupancy areas.
When it comes to Life Safety Standards, one size does not fit all. At present, healthcare organizations are required to comply with the 2012 edition of the National Fire Protection Association’s NFPA 101®, also known as the Life Safety Code® (“LSC”) [1]. This iteration of the LSC was adopted in 2016 by the Centers for Medicare & Medicaid Services (“CMS”).
Since 2012, however, there have been two subsequent publications of the LSC, in 2015 and 2018, that include revisions, many of which provide some clarity to healthcare organizations and some of which add additional complexity. These are important because, although CMS may not enforce the new requirements at this time, they are likely to be adopted in the future and should be minimally considered and other Agencies Having Jurisdiction (“AHJ”) may choose to apply these new standards.
We spoke with Kirk Kaiser, Partner of REMEDI8, about the jurisdictional differences among AHJs.
“There is a real focus by health care facilities administrators to assure compliance with the LSC, but the other AHJ can cite you for violations if your facility doesn’t comply with their requirements.”
A good example is a recent announcement by The Joint Commission of new requirements extending the LSC coverage of fire safety and means of egress during fire emergencies to Business Occupancies. For facilities that are accredited through the Joint Commission, the new standards become effective as of July 1, 2021.
The term “business occupancy” is defined by the NFPA as, “ used for account and record-keeping or the transaction of business other than mercantile.” (NFPA 101 §3.3.134.3) The Life Safety Book for Health Care Organizations noted, “This is a very broad definition, but as it applies to health care, the definition refers to a facility where no one stays overnight and where three or fewer individuals are rendered incapable of self-preservation at any given time by virtue of their treatment.”
The shielding of pipes, conduits, bus ducts, and air ducts
Doors are required to remain free of signs and decorations other than informational signs
The establishment of width requirements for corridors and passageways
Means of egress illumination obligations and distance limits
Alcohol-based hand rubs storage and handling requirements
Conditions requiring fire alarms and fire extinguisher location rules
Sprinkler and sprinkler location mandates
Kaiser noted, “The extension of the Life Safety rules into health care organization’s business occupancies is one of the most significant recent developments, but certainly not the only one.”
One issue that caused some confusion in the past appears to have been clarified in the recent 2021 version of LSC. Historically, facilities have been required to perform annual fire door inspections even when those fire doors are located in barriers that do not have a fire-resistance rating. In that case, the LSC was interpreted so as to consider the doors a life safety feature “obvious to the public.” This interpretation was consistent with NFPA 101 (2012) section 4.6.12.3 which requires: “… existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.” However, LSC 2021, section 4.6.12.4, is now interpreted as exempting from NFPA 80 (NFPA’s Standards for Fire Doors) doors or door frames that are provided in a fire barrier, which are not required to have a fire-resistance rating pursuant to the life safety plans. While CMS does not recognize these subsequent editions of LSC, they can potentially be used to justify equivalent life safety levels if cited during an accreditation inspection.
There are also a few examples of revisions that responsible facility managers (RFAs) should be aware of that add some complexity. The first is a codification of a best practice in use in most healthcare facilities. For new healthcare occupancies, LSC 2018, §18.2.4.4.2, requires that a smoke barrier door must not serve as the sole exit access point from any space in a smoke compartment. This requirement prohibits a smoke barrier from traversing the wall of a room with a single exit access door.
Another 2018 revision by the CMS which applies to ongoing healthcare facility maintenance, may lead to some confusion among RFAs. According to the new revisions, CMS will look to inspect firewalls only once during a one to three – year period. Meanwhile, at least one other AHJ, Fire Marshalls, who enforce International Fire Code Section §703.1, are required to conduct a formal inspection every year.
A modification of the LSC that is also of note, LSC 2018, §18/19.3.6.3.1, provides that the corridor door latching provisions must be applied to nurse server cabinets and pass-through openings in corridor walls. The section also details the door clearance requirements, which differ for new and existing healthcare residences. This was language that appeared earlier in the annex and now has been moved into the code.
Kirk Kaiser offered this advice for healthcare facility managers, “With the recommencement of CMS audits last August, and the resumption of some of the COVID related construction work at healthcare facilities, there will undoubtedly be more inspections by AHJs. RFAs would be wise to engage with an experienced firm to conduct a LSC audit that encompasses all the related fire and life safety requirements before these audits reveal compliance issues.”
REMEDI8 provides complete turnkey services including inspections, documentation, reporting, repairs, complete facility remediation, and training. Whether you’re looking for assistance with your door maintenance program or want our complete line of services, we’ll customize a solution that fits your unique needs.
[1] Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA
