LSC Waivers

2480 - LSC Waivers (Rev. 1, 05-21-04) 2480A - General (Rev. 1, 05-21-04) In some cases, certain provisions of the LSC might not be met, although the facility provides a reasonable degree of fire safety. Exceptions to the LSC are permissible if: • The waiver would not adversely affect patient health and safety; and • It would impose an unreasonable hardship on the facility to meet specific LSC provisions. Although compliance with the LSC would generally be easier for a new facility than for an existing building, there may be an occasional situation that would justify the granting of a waiver in new construction. For example, in the course of drawing up building plans, an architect will often discuss prospective design features with State Building Department officials and licensure authorities. It is not unusual for these authorities to grant approval for innovative design features that, while not in strict conformity with the LSC, nevertheless provide an equivalent degree of protection. In such circumstances, a waiver may be appropriate. When it is not readily practical for an institution to comply fully with all the individual requirements of the LSC, the fire authority evaluates the degree of enforcement necessary to provide a reasonable measure of safety. In making this recommendation, it considers whether the intent of the LSC is met. 2480B - Meeting Intent of LSC (Rev. 1, 05-21-04) The requirements of the LSC are directed to a series of factors or areas. These may be classified as follows: 1. Fire Load - All materials which might contribute to the fuel aspect of a fire within the building and requirements pertaining to construction, interior finish, draperies, furnishings, and building service equipment; 2. Fire Containment - Those elements which tend to restrict the spread of flame, smoke, or fire gases throughout the building, such as corridor wall construction, subdivision of floor areas, and protection for vertical openings; 3. Fire Extinguishment - Elements which help to put out the fire as quickly as possible. They include alarm systems, portable extinguishers, sprinkler systems, and special requirements for protection of hazardous areas; 4. Evacuation - Those elements which facilitate the removal of occupants from the scene of the fire. They include details of the emergency plan and exiting capability from the building; 5. Operating Features - The administrative and operational features such as housekeeping techniques, smoking regulations, and the fire emergency plan which, if not properly implemented, could result in hazardous fire situations; The following additional considerations should also be evaluated by the fire authority since they may have an important bearing on the safety of patients in facilities which request a waiver: 1. Staffing considerations such as staff-patient ratios, staffing patterns, and scope of staff training to handle fire emergencies; 2. Availability and adequacy of compartment and horizontal exits, such as areas to hold patients during a fire emergency; 3. Location and number of ambulatory and nonambulatory patients; 4. Availability, extent, and type of automatic fire detection and fire extinguishment systems provided in the facility; 5. Means for notifying the fire department in case of fire; and 6. Effectiveness of fire department (e.g. types of equipment available, number of personnel normally responding to a fire call, distance to the nearest fire station, and normal response time of the fire department). The total fire safety of a building is dependent upon the combined effect of the factors mentioned above. Each building is a unique problem from a fire safety point of view and should be evaluated by the fire authority on its own merits. Not all requirements are of equal importance in all situations. If it can be established that a particular deficiency does not materially affect the overall level of safety, it is reasonable to hold that the fire safety characteristics of the facility have not been compromised and that the intent of the LSC has been met. 2480C - Elements Considered in Determination of Unreasonable Hardship (Rev. 1, 05-21-04) In cases in which patient safety would not be adversely affected by a waiver, consider the following factors in evaluating the issue of unreasonable hardship: • Estimated cost of the installation; • Extent and duration of the disruption of normal use of patient areas resulting from construction work; • Estimated period over which cost would be recovered through reduced insurance premiums and increased payment related to cost; • Availability of financing; and • Remaining useful life of the building.