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3 Health Care Facility Code Questions Answered by ASHE Experts

Wednesday, June 13, 2018


Do you often find yourself in the trenches of deciphering health care facility codes to stay in compliance? If you are a health care facility professional, you know the challenge of navigating the tangled web of health care codes and standards. What makes your job even tougher: Conflicting interpretations from authorities having jurisdiction.

ASHE’s advocacy team continues to make efforts to help unify health care facility codes and standards and offer clarification to the community. The Just Ask ASHE platform offers an opportunity to get answers and guidance for your codes and standards questions from ASHE’s team of experts. Here is a sampling of three common questions answered by Just Ask ASHE codes and standards experts in its most recent webinar (free to ASHE members).

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Q1: What will be needed to document compliance with the Chapter 43 of the Life Safety Code®? Will a checklist for the 7 categories be acceptable?

A1: Essentially, documentation should be produced by the design professional who is handling the project for you. The facility itself should not have to produce specific documentation unless an internal design professional is doing the work for you. A few tips: 1) Make sure the designer identifies the work area since the code applies to the area where you are doing work (unless it is in reconstruction category, you may have supplemental requirements). 2) Define the category of work. Chapter 43 is unique because it progressively increases what you have to do based upon what you are proposing to do.

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Q2: The 2012 edition of the Life Safety Code® allows a 6-inch corridor projection while the 2010 edition of ADA allows for a 4-inch corridor projection. Is there a clear position on how this conflict will be surveyed?

A2: The way CMS addresses this issue based on their adoption of the 2012 issue of the code is that facilities have to comply with ADA requirements where required to do so. However, CMS doesn’t really enforce ADA requirements. From a CMS perspective, and potentially a Joint Commission perspective, it is likely that the corridor projections of the LSC would apply, which has corridor projections for items like alcohol based hand rub dispensers and charting areas. Maintaining egress is important. What is known: People tend not to walk up against a wall, but usually a 6 to 12-inch distance, which is why the LSC doesn’t see consider it an issue. On the other hand, ADA might be concerned with someone with a sight impairment. An annex of subsequent editions of the LSC states, “If you have a projection more than 4-inches from a wall, you can put a cane detection device in.” But some individuals in the disability community disagree. This is something you would have to discuss with regulators you work with. ASHE is not aware that the Joint Commission cites for this issue, but please contact ASHE if you have experienced otherwise. ASHE is working to resolve this conflicting code.

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Q3: Are security cameras allowed in exit stairways?

A3: This is a popular question. There is nothing in the 2012 edition of the Life Safety Code® that specifically allows for security cameras, so it is advised to err on side of caution. NFPA 101 says to “limit penetration into exits and closures,” which stairwells are defined as. Some state security cameras may limit electrical conduits serving exit enclosures. But, progress is being ade. The newest edition of NFPA 101 is going to require the use of stairwell monitoring systems for high-rise buildings with occupancies above a certain number (potentially 4,000). This indicates they are heading in the direction of allowing more security cameras in exit stairways in the future. Furthermore, in the 2012 edition of LSC, there is an annex note (A71321 Parens10ParensC); within this note it states, “...wiring serving equipment permitted by the authority having jurisdiction to be located within the exit enclosures, such as security systems...” This shows there is language in the 2012 edition that states subject to the AHJ, you could have security system wiring penetrate into the exit enclosure. The Joint Commission says you have to request an equivalency for it, but understand they are acting as an agent of CMS and CMS wants to address it as a certain allowance. It is advised to retain equivalency paperwork so that if you are cited, you can respond by presenting it with your formal response.

Do you need clarification on a health care facility code or standard?
You can participate in the public forum of Just Ask ASHE Just Ask ASHE at the 2018 ASHE Annual Conference in Seattle to get answers to your specific questions and learn from your peers’ questions, too.

The session takes place on Wednesday, July 18, but other popular codes and standards forums will take place at the event, too, including updates from the Joint Commission, DNV-GL and HFAP. Attendees can also visit the Codes and Standards Counters onsite for one-on-one support.

Click here to register for the conference

ASHE members can also participate in free quarterly webinars for Just Ask ASHE. Participants can submit their questions via an anonymous chat feature. Questions are then fielded by ASHE advocacy and subject matter experts who offer advisory assistance. For formal, official interpretations, it is recommended to submit questions to the appropriate code/standard development organization.

Click here to learn more about participating in Just Ask ASHE webinars.

In this article: Credits to answers provided by Just Ask ASHE codes and standards experts:

  • Jonathan Flannery, MHSA, CHFM, FASHE, FACHE, Senior Associate Director of Advocacy, ASHE
  • Jonathan Hart, P.E., Principal Fire Protection Engineer, NFPA
  • James Kendig, MS, CHSP, CHCM, CHEM, LHRM, Field Director, Survey Management and Development Accreditation and Certification Operations, The Joint Commission
  • William Koffel, FSFPE, P.E., President, Koffel and Associates


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