The hospital designs and manages the physical environment to comply with the Life Safety Code.

(1)

The hospital maintains current and accurate drawings denoting features of fire safety and related square footage. Fire safety features include the following: - Areas of the building that are fully sprinklered (if the building is partially sprinklered) - Locations of all hazardous storage areas - Locations of all fire-rated barriers - Locations of all smoke-rated barriers - Sleeping and non-sleeping suite boundaries, including the size of the identified suites - Locations of designated smoke compartments - Locations of chutes and shafts - Any approved equivalencies or waivers

(2)

The hospital maintains current Basic Building Information (BBI) within the Statement of Conditions (SOC).

(3)

The hospital meets the applicable provisions of the Life Safety Code (NFPA 101- 2012 and Tentative Interim Amendments [TIA] 12-1, 12-2, 12-3, and 12-4). Note 1: Outpatient surgical departments meet the provisions applicable to ambulatory health care occupancies, regardless of the number of patients served. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The provisions of the Life Safety Code do not apply in a state where the Centers for Medicare & Medicaid Services (CMS) finds that a fire and safety code imposed by state law adequately protects patients in hospitals. Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: In consideration of a recommendation by the state survey agency or accrediting organization or at the discretion of the Secretary for the US Department of Health & Human Services, CMS may waive, for periods deemed appropriate, specific provisions of the Life Safety Code that would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. Note 4: All inspecting activities are documented with the name of the activity; date of the activity; inventory of devices, equipment, or other items; required frequency; name and contact information of person who performed the activity; NFPA standard(s) referenced for the activity; and results of the activity.

(4)

The hospital has written fire control plans that include provisions for prompt reporting of fires; extinguishing fires; protection of patients, staff, and guests; evacuation; and cooperation with firefighting authorities.

(5)

The hospital maintains written evidence of regular inspection and approval by state or local fire control agencies.

(6)

For hospitals that use Joint Commission accreditation for deemed status purposes: Regardless of the provisions of the Life Safety Code, corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited on these doors.

(7)

When the hospital installs alcohol-based hand rub dispensers, it installs the dispensers in a manner that protects against inappropriate access.

(8)

When a sprinkler system is shut down for more than 10 hours, the hospital either evacuates the building or portion of the building affected by the system outage until the system is back in service, or the hospital establishes a fire watch until the system is back in service.

(9)

Buildings have an outside window or outside door in every sleeping room. For any building constructed after July 5, 2016, the sill height does not exceed 36 inches above the floor. Note 1: Windows in atrium walls are considered outside windows for the purposes of this requirement. Note 2: The sill height requirement does not apply to newborn nurseries and rooms intended for occupancy for less than 24 hours. Note 3: The sill height in special nursing care areas of new occupancies does not exceed 60 inches.