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Life Safety Code Survey

Process for Hospitals

Henry Kowalenko
Design Standards Unit
Rules and Regulations
ƒ The following rules and regulations are used when
surveying a facility
ƒ Illinois Hospital Licensing Requirements
77 IL Administrative Code 250
ƒ Center for Medicare and Medicaid Services (CMS)
CFR 485.623d Standard: Life Safety from Fire
NFPA 101 Life Safety Code (2000 Edition)
Chapter 19, Existing Healthcare Occupancies
National Fire Protection Association
ƒ Illinois Plumbing Code
225 ILCS 320 February , 2004
ƒ Illinois Accessibility Code
71 Illinois Administrative Code 400
Survey Process
ƒ CMS Survey
ƒ Sample Validation Survey or Full Survey Due to
ƒ Unannounced
ƒ Clinical (nurses)
ƒ Life Safety Code (architects)
ƒ Survey all healthcare occupancies
ƒ Survey business occupancies
ƒ Billing under the hospitals provider number
ƒ Buildings can be onsite or offsite
ƒ NFPA 101- Chapter 39, “Existing Business Occupancies”
Survey Process

ƒ The IDPH inspector will be escorted on a

tour of the facility. The following items
should be available:
ƒ Keys to all areas
ƒ Ladder
ƒ Flashlight
ƒ Small floor plan
ƒ Fire barriers and ratings
ƒ Suite designations
ƒ Exits
Survey Process
ƒ The inspector will conduct a review of the
following documentation:
ƒ Fire drill records
ƒ Fire alarm inspection
ƒ Emergency generator
ƒ Fire extinguishers
ƒ Kitchen hood suppression systems
ƒ Fire and emergency policy procedures
Survey Process
ƒ During the inspection, the fire alarm and
sprinkler systems will be tested.
ƒ Fire alarm testing will include
ƒ Pull stations – the facility will need to have keys
available to reset the fire alarm
ƒ Smoke detectors - functional test (no magnets),
canned smoke needs to be available
ƒ Sprinkler testing will include
ƒ Water flows (if sprinklered)
Plan of Correction - PoC
ƒ Corrective action for each deficiency
ƒ Clearly identify what will be done
ƒ Don’t say “completed”
ƒ When will it be complete – month/day/year
ƒ If the corrective action requires a number of steps, identify
the steps and when they will be complete. Example:
ƒ Hire consultant…………..month/day/year
ƒ Review solutions………...month/day/year
ƒ Bid work…………………..month/day/year
ƒ Start work…………………month/day/year
ƒ Work complete,,,,,,,,,,,,,,,,,month/day/year
Plan of Correction-PoC
ƒ Who will be responsible
ƒ Don’t use proper names
ƒ Director of Facilities, etc,

ƒ Must have reasonable time frame

ƒ Interim Life Safety Measures (ILSM)
ƒ Additional fire drills
ƒ Additional fire extinguishers
ƒ Fire watch
ƒ Use the forms provided
ƒ Essential
Plan of Correction-PoC
ƒ LSC Monitoring Surveys
ƒ Onsite inspections to verify compliance
ƒ Based on the PoC
ƒ Unannounced
ƒ Surveys continue until PoC is complete
Alternate Compliance
ƒ Fire Safety Evaluation System (FSES) –
NFPA 101A (2001 Edition)
ƒ FSES may be used when prescriptive
compliance cannot be achieved
ƒ The FSES is based on a point system
ƒ Not typically accepted for new construction
Licensure Surveys
ƒ Plan review process completed
ƒ Receive a letter indicating reviews are done, submit
ƒ How do we know your done with construction?
ƒ Pre-occupancy Checklist
ƒ 7-10 days review of certification
ƒ Certifications deemed complete
ƒ On-site survey scheduled - announced
ƒ Federally mandated surveys take precedence
Licensure Surveys
ƒ On-site inspection process identical to
CMS survey
ƒ The extent of survey will vary according to the
scope of work
ƒ IDPH will issue a letter of deficiencies cited
ƒ Provider/architect to respond
ƒ Re-visit may be necessary
Licensure Survey
ƒ Occupancy letter
ƒ Date of occupancy
ƒ Stipulations (if any)
ƒ Emergency repair
ƒ IDPH notification
ƒ Plan/specification submittal
ƒ Full compliance with code
Licensure Survey
ƒ Phased projects - temporary occupancy
ƒ 7-item request must be submitted and
deemed acceptable
ƒ On-site inspection required
ƒ Systems must be in compliance (HVAC,
sprinkler, electrical, etc)
ƒ Complete pre-occupancy checklist must be
submitted for the final phase of a project
ƒ On-site inspection
Common Deficiencies

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Design Standards Unit
ƒ Staff Engineers
ƒ Justin Dammerman Donald Hall
ƒ Contact information
ƒ Phone 217-785-4264
ƒ Fax 217-782-0382
ƒ Email (for general questions only)
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