Carolinas HealthCare System INTERIM LIFE SAFETY MEASURES

Policy Number: CHS 4.04 Page 1 of 7

I.

Summary Statement This plan delineates the responsibility of Carolinas HealthCare System departments and employees to implement Interim Life Safety Measures (ILSM) when Life Safety Code (NFPA 101 2000 edition) deficiencies exist.

II.

Scope and Applicability This document contains information applicable at all Mecklenburg County facilities within CHS.

III.

Background Information A. ILSM are intended to provide a level of safety when there are deficiencies to existing elements of fire safety. Activities reviewed will become ILSM activities if the activity in some manner impairs the following: (1) the exiting requirement(s), (2) fire detection and suppression systems, (3) fire / smoke barriers for greater than the supervised work shift, and (4) increased fire hazards. The Interim Life Safety Measures Project Assessment Matrix will be used to identify ILSM. The review will determine when and to what extent to invoke appropriate ILSM. B. The frequency for inspection, testing, staff training, monitoring, and evaluation will be established by the scope of the ILSM. C. Discovery of potential life safety code deficiencies will be reported to the Facility Safety Officer or to Corporate Services Help Line (704-446-6161 inside Mecklenburg County or 866-446-6161 outside Mecklenburg County) who will notify the appropriate personnel to conduct an assessment to determine further actions. D. The Facility Safety Officer or their designee is responsible for enforcement and inspection of ILSM activities.

IV.

ILSM Team Make-Up/Responsibilities A. Interim Life Safety Measures (ILSM) Team 1. The ILSM Team will consist of the following depending upon the scope of the Life Safety Code deficiency or project: a. OSR Manager b. Plant Operations and Maintenance Team Member assigned to project c. Corporate Safety d. Contractor, if applicable e. Facility Safety Officer 2. Additional members of the ISLM Team, if deemed appropriate by the size or complexity of the project, will include: a. Director or Manager of units or departments directly affected by the project, depending upon the scope of the Life Safety Code.

Carolinas HealthCare System INTERIM LIFE SAFETY MEASURES

3. The ILSM Team will: a. Review the scope of work, construction hazards, and determine (1) related safety issues, and (2) the departments surrounding the work area in order to determine the extent of staff training. b. Coordinate and document the implementation of ILSM, including any inspections, communications and training. Team may request/require assistance from Contractors, Safety Committee, Security, Plant Operations and Maintenance, and others as deemed appropriate. c. Forward a copy of the documentation to the Facility Safety Officer/Safety Committee. 4. OSR Manager a. Perform the Interim Life Safety Measures Assessment (Attachment 1). b. Review the Interim Life Safety Measures Assessment with the appropriate ILSM Team members in order to determine the scope of the ILSM project. Provide drawings for the ILSM Team members, along with a description of the Life Safety Code project and its scope. The drawings will address fire protection features, including the proposed impact of the project on those features. c. Document the findings of the Team. Send a copy to the Facility Safety Officer. d. Notify appropriate Department Managers/Directors of any additional information deemed necessary to clarify and assist those staff members. Follow-up issuance of the form to ensure receipt of all information and ascertain that its clearly understood. e. Ensure that Contractors/Vendors review and comply with this policy. The OSR Manager will oversee the daily inspections made by the contractors if deemed necessary during the duration of the project Interim Life Safety Measures. Send letters of Non-Compliance to vendors / contractors, and take other actions as deemed appropriate to maintain the integrity of ILSM throughout duration. f. Ensure that inspections of the Life Safety Code deficiency or project area are conducted and documented as established by the ILSM Team, and that deficiencies are addressed promptly to ensure the continued safety of the building occupants

5. Corporate Safety a. Review the ILSM Project Safety Assessment with OSR/Project Manager as requested to assist in the determination of the scope in the ILSM project. b. Work with the ILSM Team as needed to help identify the scope of the project and audit process. 6. Plant Operations/Maintenance Member a. Coordinate permitting/fire restrictions with contractor b. Provide pertinent information on existing area affected by ILSM and coordinate system(s) interruptions.

Carolinas HealthCare System INTERIM LIFE SAFETY MEASURES

c. All the duties of OSR Manager in A above for Life Safety Code deficiencies. 7. Contractors a. Review and comply with this policy, and with the permit and notification requirements of the Carolinas HealthCare System Plant Operations and Maintenance Department prior to initiating works involving penetration of the structural features of the building, fire alarm modifications, and/or burning and welding activities. b. If directed by OSR Manager, complete daily inspections during construction process. 8. Facility Safety Officer a. Review and randomly audit ILSM documentation. b. Report status of ILSM as required to the Facility Environment of Care Safety Committee. 9. Directors / Managers a. Ensure staff awareness of life safety deficiencies, resultant ILSM, and compensatory training requirements. Post ILSM Implementation Notice in common-use area for easy reference. b. Periodically review pertinent ILSM information with staff to ensure communication. 10. Employees (not an ILSM Team member) a. If necessary, assist other employees in specific ILSM training to ensure appropriate responses in emergency situations. V. Evaluation of Adherence/Performance of Process A. Contractors and subcontractors who fail to comply with this policy should receive a Notice of Non-Compliance from the OSR Manager. Such notice will require immediate resolution of the problem, and may include a monetary fine, cessation of work until corrections are made, or both, depending upon the severity of the situation. B. Carolinas HealthCare System employees who fail to comply with this policy will be subject to the disciplinary process outlined in Carolinas HealthCare System Safety Policy CHS 1.03, Enforcement of Safety Rules and Regulations, and the CHS personnel policy, ADM 5.02 Disciplinary Action. C. The Facility's Safety Officer and the Corporate Safety Department will coordinate random project audits to ensure that essential personnel understand the scope and implications of the program, and that the intent of this policy is being met. Audit results will be reported to the Facility's Safety Committee. D. The ISLM program will be evaluated annually by the Facility's Safety Committee to ensure program effectiveness and efficiency.

Carolinas HealthCare System INTERIM LIFE SAFETY MEASURES

VI.

Policy Review and Ownership Policy Owner VP Approval GVP, SVP, GSVP, EVP, President Approval Policy Review Plant Operations & Maintenance Ron Smidt, VP Facilities Management Group Zachary Zapack, SVP Facilities Management Group 06/03, 5/06, 6/06, 10/07

VII.

Appendices A. Interim Life Safety Measure Initial Assessment B. Interim Life Safety Measure Implementation Matrix

VIII.

References: A. JCAHO Environment of Care standards B. NFPA 101, Life Safety Code 2000 edition2 C. NFPA 241, Chapter 5 D. Safety Management Program Manual - Life Safety Management Policy #4.05

Carolinas HealthCare System Appendices A

ILSM Initial Assessment

Complete this Assessment Form FIRST to determine if Interim Life Safety Measures required for your alteration, renovation, demolition 1 Blocking an approved exit or obstructing access with a barrier which is not continuously supervised AND cannot be immediately removed in case of fire alarm or emergency egress requirement Fire exit stairs don't discharge directly to exterior or to an approved fire-rated EXIT access (two-hour for most healthcare) Taking a required fire alarm system, including initiating or alarm devices, out of service for more than four hours in a twenty-four hour period [NFPA 101.9.6.1.8, 2000 ed] Taking a required fire suppression system out of service for more than four hours in a twenty-four hour period [NFPA 101.9.7.6, 2000 ed] Significantly lacking or breaching smoke or fire barrier walls, including large penetrations Door requiring positive latching not operating properly (e.g., patient room door, hazardous room door, stair door, vertical chase door) Major renovation of an occupied floor, with some demolition/alterations processes more hazardous than in the occupied area Re-routing of traffic to the Emergency Department, normal access obstructed

Yes

No

Hazardous areas not properly protected with compartmentation or suppression

Note: Any YES answer signifies required Interim Life Safety Measures. If YES then you must document the ILSM measures selected on ILSM Matrix (Appendices B), complete the description of measures on Page 2 of Appendices B, and provide a copy to the buildings Facility Safety Officer and to the Project File. Let Facility Safety Officer know if conditions change. Project Name OSR #

Project (OSR) #________________________________ Campus: _____________________________________ Project Description:_____________________________

Carolinas HealthCare System Interim Life Safety Measures Implementation Matrix (Appendices B) Page 1of 2
At Discretion of ILSM Team

D. Temporary construction partitions are smoke tight and rated appropriately for control of development or spread of fire.

A. Project Manager inspects required exits and paths to egress daily to assure egress is unobstructed.

F. Develop and enforce storage, housekeeping, and debris removal practices that reduce the buildings flammable and combustible fire load to the lowest feasible level.

G. Train personnel to compensate for impaired structural or compartmentalization features of fire safety.

H. Conduct additional training of fire response team.

K. Conduct organizational training of life safety including fire response.

I. Increase hazard surveillance of buildings, grounds, and equipment, with special attention to construction areas, construction storage, and field offices.

Reason For Interim Life Safety Measure:____________ _____________________________________________ Start Date:____________________ Stop Date:____________________ Project/OSR Mgr.:______________________________
(1) Perform the ILSM Initial Assessment (Appendices 1) (2) Use this Implementation Matrix form only if answered YES to item(s) on ILSM Assessment (3) Complete the description of measures on Appendices 2, Page 2 Blocking an approved exit or obstructing access with a barrier 1 which is not continuously supervised AND cannot be immediately removed in case of fire alarm or emergency egress requirement. Fire exit stairs dont discharge directly to exterior or to an 2 approved fire rated EXIT access (two-hour for most healthcare).

X X

B. Ensure free and unobstructed access to emergency services, and for fire, police, and other emergency forces.

E. Provide additional fire-fighting equipment and train personnel in its use.

_____________________________________________

X X

X X X X

X X

3 4 5 6 7 8 9

Taking a fire detection system out of service for more than four hours in a twenty-four hour period. Taking a fire suppression system out of service for more than four hours in a twenty-four hour period. Significantly lacking or breaching smoke or fire barrier walls, including large penetrations. Door requiring positive latching not operating properly (e.g., patient room door, hazardous room door, stair door, vertical chase door). Major renovation of an occupied floor with some demolition/alterations processes more hazardous than in the occupied area. Free and unobstructed access to emergency services, and for fire, police, and other emergency forces. Hazardous areas not properly protected.

X X X

X X X X X X

X X X

X X X

X X X X

X signifies required Measure (3) for the Impairment noted at Left Column. Implementation of specific ILSM Measures to be determined by the ILSM Team. Name the measures and how the measures will be implemented and monitored on next page. Note 1: The ILSM assessment form shall be completed before start of work. If ILSM Assessment indicates need to implement measures then use ILSM Matrix to guide on appropriate measures to implement to protect the building occupants from potential reductions in fire safety or exiting or suppression. Note 2: The Life Safety Code, NFPA 101, 2000 edition, requires that the municipal fire department (or applicable emergency forces group) is notified and a fire watch is provided whenever an approved fire alarm or automatic sprinkler system is out of service for more than 4 hours in a 24 hour period in an occupied building. (International Building Code) Note 3: The columns and rows with Xs reflect required measures, and guide the assessment team in minimum measures to implement. The Assessment team shall determine which measures to implement, who will do so, and how the measures will be monitored. Note 4: The ILSM Initial Assessment form, and Implementation Matrix are addressed in CHS 4.04, the Corporate Safety Policy governing ILSM

L. Conduct a minimum of 2 fire drills per shift per quarter in Local Area if impairments could affect.

C. A temporary but equivalent system shall be provided when any fire alarm, detection, or suppression system is impaired.

J. Conduct a minimum of 2 fire drills per shift per quarter in All Areas if impairments could affect alarm response or evacuation.

Project (OSR) #_______________________________________

Campus: _______________________________________

Carolinas HealthCare System Appendices B

Project Description:_____________________________________________________________________________________________ Reason For Interim Life Safety Measure:____________________________________________________________________________ Start Date:_____________________ Project/OSR Manager:__________________________________ Stop Date:____________________

WRITE BELOW YOUR DETERMINATION OF REQUIRED MEASURES AND HOW YOU WILL IMPLEMENT THEM:

Revised 12-07