Are You Taking Advantage of Suites?

There are so many reasons why implementing suites in a health care facility is so beneficial and it is as simple as understanding the requirements for suites. Here’s a general overview:

All suites:

  • Travel distance from any point to an egress door is limited to 100 ft.
  • Second means of egress can be through adjoining suites, stairs, or exterior doors.
  • Unless a small area, two means of egress are required.
  • A Suite cannot create a dead end corridor in excess of 30 ft.

Patient Sleeping Suites (ICU, NICU, CCU, Some general nursing units if properly designed):

  • Limited to 5,000 sq. ft.
  • Or up to 7,500 sq. ft. if sprinkler protected, and complete smoke detection OR direct supervision.
  • Or up to 10,000 sq. ft. if sprinkler protected, complete smoke detection AND direct supervision.

Patient Non-Sleeping Suites (ED, OR):

  • Limited to 10,000 sq. ft.

There are other nuances and applying the CMS waiver for suites under the 2012 Edition of the Life Safety Code® is required. But with the proper application, reduction in requirements for corridor storage and door hardware can be a major benefit.

Life Safety Drawing Compliance

When it comes to life safety plans for your facility it is important to remember that these plans also impact various disciplines. Having incorrect or outdated information could result in spending budget funds needlessly. Having the correct information on your life safety plans is necessary for your facilities department to maintain the proper areas of your building and to remain in compliance with codes.

Some examples of areas in which there may be a maintenance impact include fire and smoke doors, fire/smoke dampers, and fire-rated/ smoke barriers.

Some examples of discipline impact may include plumbing, electrical, HVAC, and IT. These all require knowing where fire-rated/smoke barrier locations are to ensure that penetrations are sealed properly. Since health care facilities are always changing, having up to date plans during renovations and construction is essential for understanding a building’s egress flow and possible ILSMs issues that could arise.

In order to be complaint with The Joint Commission, your facility’s life safety drawings must meet the following requirements:

  • Noted Approved Equivalencies
  • A legend with identifiable Fire Life Safety features
  • Fire-rated barrier locations
  • Smoke Compartment /Smoke Barrier Locations
  • Type of suite, locations and sizes
  • Chute locations
  • Hazardous area locations
  • Shaft locations
  • Areas of the extent of sprinkler protection

These plans should be part of the working documentation for your facility and should also be easily accessible when requested.

Compliance Issues You May Be Missing

Health Care compliance is not the easiest concept to grasp. Just when you think you have all the items covered something changes or you missed a small detail. These changes and details are also the items that surveyors can zero in on during inspections. Here are a few compliance issues that you may be missing:

  • Main Drain Test Comparison – Each main drain test should be compared to the original test, or the oldest test that you have, to see if anything within the system has changed. Comparing the testing to only the previous year may not catch a problem that is developing slowly over time. See Chapters 6 and 12 of the 2002 edition of NFPA 25.
  • Code Reference and Frequency for Testing – In June of 2010 The Joint Commission required all testing documentation to have the Code reference and testing frequency included in the documentation. Review all of your testing documentation to ensure that all code references and testing frequencies are added. See EC News.
  • CMS Waivers – In August of 2013, CMS released a document outlining the acceptable requirements from the 2012 Edition of the Life Safety Code that can now be used by Health Care facilities. These are beneficial waivers that should at least be reviewed by all health care facilities. See S&C: 13-58-LSC for further information.

Ensuring that you facility is meeting these compliance items will go a long way in helping to show inspectors that you have your facility’s compliance under control.