C A&Courtemanche & Associates HEALTHCARE SYNERGISTS

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Environment of Care – Life Safety Code Specialist

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Life Safety Code Specialist

Initial group of 50 specialistsJoined existing surveyors for January

2005 training– Collaborative education with ASHE

Reserved for Hospitals with 200 or more beds (as identified on application)– One Day Survey– For organizations with multiple

buildings, target will be one with most beds

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Life Safety Code Specialist Target Areas

Life Safety Code / Statement of Conditions

Features of Fire ProtectionInterim Life Safety MeasuresEmergency Power SystemsPiped Medical Gases and Vacuum

Systems

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Life Safety Code / SOC

Current Statement of ConditionsOrganization needs to make

“sufficient progress” towards previously approved corrective actions– If “sufficient progress” has not been

made, organization could face CONDITIONAL ACCREDITATION

TIP – Let surveyor know of any LSC equivalency immediately

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Features of Fire ProtectionPortable Fire ExtinguishersWater-based fire protection systemsFire alarmsFire doors / windowsAir conditioning and ventilation

systemsFire hosesLife Safety CodeTIP – Make sure there is no debris or

equipment leaning on fire extinguishing systems

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Interim Life Safety Measures (ILSM)ILSM Policy in placeCriteria to identify deficiencies and

hazards– When and to what extent all 10

components applyTIP – Be proactive and be ready to

share this information with your surveyor

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Emergency Power SystemsGenerator TestingTransfer switchesBattery powered lightsStored Emergency Power Supply

System REMEMBER – Generator testing –

No more than 40 days after last test, and not less than 20 days

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Medical Gas and Vacuum SystemsMaintenance ProgramTesting Documentation

– Cross-connection– Pipe security– Pressure

TIP = Policy and Procedure or Plan for installation of new and replacement piping

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Life Safety Code Specialist AgendaFacilities Maintenance Review

– Focused Document ReviewFacility Orientation

– Statement of Conditions / PFI– Building Plans

Surveyor Planning SessionLSC Building TourMeeting with Survey Team

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Other Links to Survey Process

Sharing of information with survey team– Focus review of items at other

buildings by other surveyors– Environment of Care Tracers

Focus is on Life Safety Code, but also will review closely related EC standards