Life Safety Standards

Question 1

The Joint Commission uses the _____ edition of the NFPA’s Life Safety Code as the source of the key structural components.

Answer 1

2012

Question 2

LS.01.02.02 is

Answer 2

Interim Life Safety Measures

Question 3

CMS or CMS Crosswalk

Answer 3

These crosswalks allow facility professionals to understand how the accreditation standards align with the CMS Conditions of Participation (CoP’s) and Code of Federal Regulations (CFR) and how these align with the adopted codes and standards.

Question 4

*Maintains Drawings denoting features of fire safety and related sq ft.
*Resolve deficiency within 60-day of Survey Related Plan for Improvement.
*Retains Documentation
*The hospital maintains Basic Building Information within the Statement of Conditions.

Answer 4

LS.01.01.01 - The hospital designs and manages the physical environment to comply with the Life Safety Code.

Question 5

BBI

Answer 5

Basic Building Information

Question 6

SOC

Answer 6

Statement of Conditions; used in a management process that continually identifies, assesses, and resolves Life Safety Code deficiencies.

Question 7

SPFI

Answer 7

Survey Related Plan for Improvement

Question 8

*The hospital has a written ILSM policy that covers situations during construction
*Notifies the fire department when LSC cannot be corrected
*Trains personnel to compensate for impaired structural or compartmental fire safety features

Answer 8

LS.01.02.01 - The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.

Question 9

*Doors to patient sleeping rooms are not locked unless there is a specialized need.
*Walls containing horizontal exits are fire rated for two or more hours.
*The capacity of the means of egress is in accordance with NFPA 101-2012 7.3 + 18/19
*Every corridor provides access to at least two approved exits in accordance with NFPA 101-2012 7.4, 7.5, + 18/19

Answer 9

LS.02.01.20 - The hospital maintains the integrity of the means of egress.

Question 10

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

Answer 10

LS.02.01.03

Question 11

All existing hazardous areas have doors that are:

Answer 11

Self closing, or automatically closing.

Question 12

The hospital provides and maintains fire alarm systems:

Answer 12

LS.02.01.34

Question 13

The hospital provides and maintains systems for extinguishing fires. The fire alarm system monitors approved automatic sprinkler system components, is connected to water flow alarms.

Answer 13

LS.02.01.35

Question 14

There are __ inches or more of space between the sprinkler to the top of storage.

Answer 14

18 in.

Question 15

The travel distance from any point to the nearest portable fire extinguisher is __ feet or less.

Answer 15

75 feet.

Question 16

The hospital provides and maintains special features to protect individuals from the hazards of fire and smoke. High-rise buildings (over 75 feet tall) have an approved automatic sprinkler system that meets the requirements of NFPA 101-2012

Answer 16

LS.02.01.40

Question 17

LS.02.01.50

Answer 17

The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.

Question 18

LS.02.01.70

Answer 18

The hospital provides operating features that conform to fire and smoke prevention requirements. Smoking restrictions, Draperies or curtains, upholstered furniture, decorations.

Question 19

Building and fire protection features are designed and maintained to minimize fire, smoke, heat. Applies to ambulatory health care occupancy (AHCO), Outpatient surgical in TJC accredited hospital.

Answer 19

LS.03.01.10

Question 20

The hospital maintains integrity of the means of egress. Applies to ambulatory health care occupancy (AHCO), Outpatient surgical in TJC accredited hospital.

Answer 20

LS.03.01.20

Question 21

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. - Applies to ambulatory health care occupancy (AHCO), Outpatient surgical in TJC accredited hospital.

Answer 21

LS.03.01.30

Question 22

The hospital provides and maintains special features to protect individuals from the hazards of fire and smoke. Applies to ambulatory health care occupancy (AHCO), Outpatient surgical in TJC accredited hospital.

Answer 22

LS.03.01.40

Question 23

LS.03.01.70

Answer 23

The hospital provides and maintains operating features that conform to fire and smoke prevention requirements. Applies to ambulatory health care occupancy (AHCO), Outpatient surgical in TJC accredited hospital.

Question 24

The hospital maintains the integrity of the means of egress. (Business Occupancy)

Answer 24

LS.05.01.20

Question 25

T-F; Interior open stairways and ramps are permitted to serve as part of the egress system if not more than one level below the street floor. (Business Occupancy)

Answer 25

True.

Question 26

The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke. (Business Occupancy)

Answer 26

LS.05.01.30

Question 27

The hospital provides and maintains fire alarm systems. (Business Occupancy)

Answer 27

LS.05.01.34

Question 28

The hospital provides and maintains equipment for extinguishing fires.
(Business Occupancy)

Answer 28

LS.05.01.35

Question 29

Needs to be __+ inches between the bottom of the sprinkler and any stored items. (Business Occupancy)

Answer 29

18+ inches of space.

Question 30

The travel distance to the nearest fire extinguisher is __ feet and under. (Business Occupancy)

Answer 30

75 feet and under

Question 31

T or F; Hazardous areas must be surrounded with a one hour fire barrier and under. (Business Occupancy)

Answer 31

True with exception - can be a smoke resistive barrier with automatic sprinklers.

Question 32

In existing facilities dead end corridors must be less than 50’ and less than 20’ in new facilities. (business occupancy)…

Answer 32

Unless the building is fully sprinklered.

Question 33

Any door with a fire rating of ___ minutes should not be covered with decorations. (business occupancy)

Answer 33

45+