By Brad Keyes / Special to Healthcare Facilities Today

Q: We are in the window for our accreditation survey and our state has not adopted the 2012 Life Safety Code yet. How do we prepare for the accreditation survey if they are utilizing the 2012 LSC for the inspection?

A: The accreditation organization will not enforce the new requirements of the 2012 Life Safety Code until November 1, 2016, as per CMS directive in the S&C memo 16-29. That means you have a period of leniency between July 5 (when the 2012 LSC becomes effective) and November 1 (when the new requirements of the 2012 LSC are enforced) whereby you can take the advantages of the 2012 LSC (i.e. semi-annual testing of waterflow switches, and monthly testing of fire pumps) without having to meet the new requirements of the 2012 LSC (i.e. annual testing of fire doors, quarterly inspections of fire hose valve connections, 5-year internal inspection of sprinkler piping). However, be prepared on November 1 to meet all of the new requirements found in and referenced by the new 2012 LSC.  

It does not matter what edition of the LSC that your state has adopted or is enforcing. You must follow the most restrictive requirement required by all of your AHJs. So, if your state is still on the 2000 LSC, then you must do the quarterly waterflow switch testing and the weekly fire pump test, even though the 2012 LSC does not require this.  

Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs