Jan 29 2015

Frames for Fire Rated Door Assemblies

Category: BlogBKeyes @ 6:00 am

Label for Fire Door FrameDuring the building tour a surveyor observed a label on a frame for a fire rated door assembly that read “Fire Resistant Frame – This frame is identical in construction to a listed frame.  This frame does not bear a listing mark of a testing laboratory because of size, hardware preparation or other limiting factors specified by the user/owner”.  The surveyor initially decided to cite the organization for not having a frame that has  an hourly fire rating on the fire rated door assembly.

Before the survey report could be finalized, it was brought to the surveyor’s attention that NFPA 80 does not require an hourly rating on fire rated door assembly frames. According to NFPA 80, frames in a fire rated door assembly need to be identified that they are fire rated frames, but they do not have to be listed with a specific fire rating. NFPA 80 requires the door frame to be labeled as a fire rated frame, but it does not require the hourly rating to be on the label. It is apparent that a label that says it is a fire rated frame (but with no hourly rating) is good for up to and including 3-hour fire rated door assemblies. After that, the hourly rating needs to be inserted on the frame label.

In this situation the surveyor relented and the finding was not included in the survey report. Another example where a tactful approach explaining the codes and standards to the surveyor can lead to a successful outcome.

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Jan 22 2015

Battery Powered Emergency Lights

Category: BlogBKeyes @ 6:00 am

images[1]I was recently an interested bystander in a group discussion concerning the proper testing and inspection of a battery powered emergency light fixture located in an operating room. A question was raised as to what the testing and inspection frequency should be for those devices. The person who provided the initial response pointed out that The Joint Commission already made an interpretation on this subject in the June 2007 issue of “The Environment of Care News”. While the EC News is not considered an official interpretation from The Joint Commission, it is an indication on how they survey hospitals on particular issues. [The only ‘official’ interpretations from The Joint Commission are from one of the following sources: 1) The Joint Commission standards; 2) The Joint Commission publication “Perspectives”; 3) The Joint Commission Frequently Asked Questions (FAQs) posted on their website.]

In the June 2007 issue of EC News, The Joint Commission states that battery lighting devices in an anesthetizing location (i.e. operating rooms) in existing healthcare occupancies are considered to be task lighting rather than emergency lighting since they are intended to maintain a minimum level of illumination during the period of power interruption and the establishment of emergency power. They are not considered illumination of the means of egress in that location. The Joint Commission encourages the health care organization to identify them as task lights and determine the appropriate inspection and maintenance procedures and frequency to assure reliable operation when needed.

While I respect the individuals who were involved in this discussion, I don’t see the issue that same way. First of all, why do we tend to go to The Joint Commission as if they are the final authority on all issues concerning Life Safety in healthcare organizations? While they are the largest accreditor of healthcare organization, they are not the final authority, since they are not the only authority for healthcare organizations. The typical healthcare organization may have as many as 5 or 6 different authorities that enforce the Life Safety Code at their facility:

  • The state authority on design and construction
  • The state fire marshal
  • The local fire inspector
  • The healthcare organization’s accreditor
  • The federal agency on Medicare & Medicaid: CMS
  • The healthcare organization’s liability insurance company

No one authority having jurisdiction (AHJ) over-rides another AHJ. If one AHJ wants to interpret the Life Safety Code a specific way, that does not mean the other AHJs have to do so as well.

Normally, battery powered emergency lights would require monthly 30-second tests and annual 90-minutes tests to ensure the batteries are charged. This requirement is found in section 7.9.3 of the 2000 Life Safety Code, but it specifically says it applies to required emergency lighting. The requirement to have battery powered emergency lights in operating rooms is found in section 3- of NFPA 99, 1999 edition. But only new healthcare occupancies are required to comply with this requirement, according to section of the 2000 LSC for new healthcare occupancies; this is not found in the existing healthcare occupancy chapter 19. And Joint Commission did say “existing” healthcare occupancies in their interpretation. This implies that battery powered emergency lights in existing operating rooms are not required, and therefore are not subject to the testing requirements in section 7.9.3.

But what date does “existing” apply? In this case, it would be when the hospital had to comply with the 1994 edition of the LSC, which referenced the 1993 edition of NFPA 99. The 1993 edition of NFPA 99 was the first edition to require emergency lighting in anesthetizing locations. This means, for Joint Commission accredited hospitals, the term “existing” is any date prior to January, 1994. So if the battery powered lights were installed since January, 1994, they would be considered “required” and have to be tested monthly and annually.

Ironically, while The Joint Commission did adopt the 1994 edition of the LSC, the federal agency CMS (or the fore-runner of CMS) never did. They went straight from the 1985 edition to the 2000 edition on March 11, 2003. While the 1985 LSC did reference NFPA 99, it appears to me that the requirement to install battery powered emergency lights in anesthetizing locations did not appear until the 1993 edition of NFPA 99.

If a facility manager wanted to take the time to ask each of their AHJs how they interpret if the battery powered light fixture in their operating rooms are required or not, that would be one way to decide. But even if all but one AHJ says the light is not required an one AHJ says it is required, then the organization is obligated to comply with the most restrictive interpretation, and test the fixture monthly and annually.

My advice is to determine what the most restrictive interpretation would be and follow that. In this case, that would mean the battery powered emergency lights would have to be tested monthly and annually.


Jan 15 2015

More on the CMS S&C Memo Concerning Power Strips

Category: BlogBKeyes @ 6:00 am

12-120-878-TS[1]I received a question from a reader that I was unable to immediately answer. The question dealt with the use of power strips in a business occupancy: Did the categorical waiver to allow the use of power strips described in the  S&C memo 14-46-LSC, issued September 26, 2014 apply to business occupancies? The reader explained that the physician office building where he worked did not have hospital grade receptacles so it did not make sense to him that using UL listed power strips was necessary.

My immediate thought was the CMS issued categorical waiver would only apply to healthcare occupancies because NFPA 99 (2012 edition) does not apply to business occupancies. NFPA 99 is referenced by the healthcare occupancy chapter in section of the 2012 LSC, but it is not referenced by the business occupancy chapters in the same LSC.

But, since I was not sure, I asked the question of a reliable source at CMS and they said the 2012 NFPA 99 Section 3- pertains to the minimum number of receptacles in all Patient Care Rooms.  Patient Care Rooms is defined as any room of a health care facility wherein patients are intended to be examined or treated.  In addition, the 2012 NFPA 99 Section pertains performance criteria and testing for patient-care-related electrical appliances and equipment.  Patient-care-related electrical equipment is defined as electrical equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity.

As these definitions do not make a differentiation based on occupancy,  it is CMS’s understanding that 2012 NFPA 99 power strip requirements would be applicable in all health care facilities in rooms where patients are intended to be examined or treated regardless of occupancy classification.

So, the answer to the question is the categorical waiver applies to all patient care rooms, regardless of the occupancy classification. This means if you want to use power strips in a physician exam room in a medical office building that is a business occupancy, you need to follow the guidelines in the S&C memo and only use UL listed power strips. However, for other areas of the business occupancy that are not considered patient care rooms, the NFPA 99 requirements concerning UL listed power strips do not apply. But it is wise to purchase only UL listed power strips since you cannot control where they may end up.

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Jan 08 2015

Shower Curtains

Category: BlogBKeyes @ 6:00 am

imagesTOY08WZHFor bathrooms and shower rooms that are protected with automatic sprinklers, do the shower curtains require the same open mesh at the top as privacy curtains used in patients rooms? This was a question that I was recently asked, and my feeble mind immediately thought why would the NFPA codes and standards require sprinkler protection in a shower? What’s going to burn in there?

But a review of NFPA 13 (1999 edition) shows there are no exceptions for sprinkler protection in showers when the building is required to be fully protected with automatic sprinklers. (There is for small bathrooms in dwelling units, but that does not apply healthcare occupancies.) And I asked an associate of mine who knows more about sprinkler installations than I, who said showers can be a place that could be used to start a fire so there is a need to provide protection (who would have thought?).

Then I remembered there was an exception concerning shower curtains and after I looked that up, I realized that exception only applied to the requirement found in section of the 2000 Life Safety Code that curtains needing to be flame resistant. So, that didn’t apply. So, after reviewing NFPA 13, I found that the answer would be… it depends. The shower curtains may need the ½ inch open mesh at the top 18 inches of the curtain if the top of the curtain is too close to the sprinkler head.

According to NFPA 13 (1999 edition), there are no exceptions for sprinkler protection in showers, so that means the showers need to have sprinkler protection. This can be achieved by having sprinklers mounted directly inside the showers, or it can be achieved by having sprinklers mounted on the outside of the showers and count on the spray pattern to cover the area of the shower. If the curtain does not have the open mesh at the top, then the top edge of the curtain needs to be a certain vertical distance below and a certain horizontal distance away from the sprinkler head, in accordance with Table 5-

So it is possible that if the top of the shower curtains are mounted far enough below the sprinkler and far enough away from the sprinkler, then the open mesh at the top of the curtain is not required. But if not, then the curtains would need to have the open mesh, as stipulated in the Appendix (Annex) section A-5-


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Jan 01 2015

Are Lit Candles Permitted in Healthcare?

Category: BlogBKeyes @ 6:00 am

candles web 2A reader recently asked me if lit candles are prohibited in a healthcare occupancy? I’ve researched this before but apparently I never posted anything about this subject. No, the Life Safety Code does not prohibit lit candles in healthcare occupancies, but it does address the need to maintain an environment that is reasonable safe from fire. Take a look at section 4.1.1 of the 2000 Life Safety Code, which says this:

“The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:

1)      Protection of occupants not intimate with the initial fire development;

2)      Improvement of the survivability of occupants with the initial fire development.”

Section of the same Code says the hazards of contents (which is the relative danger of the start and spread of fire) shall be determined by the authority having jurisdiction (AHJ) on the basis of the character of the contents and the processes or operations conducted in the building or structure. Furthermore, section says the AHJ shall determine whether the provisions of the LSC are met. This means any one of the many different AHJs that hospitals have to deal with can enforce the lit candle issue as they see fit. While the issue of lit candles are not that common, I have seen accreditation organizations deal with this in different manners.

When I was a surveyor for The Joint Commission, I surveyed a Native American Medical Center in the southwest, and observed the hospital using lit incense as a form of aroma therapy. I called back to the Standards Interpretation Group and asked about it and they said as long as the lit incense was handled correctly in a proper container, they were okay with it. Conversely, I’ve seen lit candles in an office setting which I wrote up as an observation of an unsafe environment.

On a related topic, open flame food warmers such as Sterno and portable cooking appliances using butane gas are considered hazardous by the definition in section of the 2000 LSC which includes heat-producing appliances in the definition of hazardous areas. Section requires hazardous areas to be confined to a room protected with sprinklers, or 1-hour construction; or both if considered new construction. When surveying for the accreditor, I observed many cases where the open flame food warmers were used in rooms and areas that did not qualify as hazardous areas. In at least one situation like that, the Standards Interpretation Group allowed the open flame food warmers if the area was constantly attended by staff and portable fire extinguishers were present. That is an interpretation made by an AHJ, which the LSC allows them to do.

Lit candles used in religious ceremonies in approved candle holders can be considered acceptable by some AHJs if the risk of fire is assessed. A risk assessment can conclude that as long as the hospital staff is present when the candles are lit and the staff has training on the use of portable fire extinguishers, it should be acceptable. But not all AHJs may accept a risk assessment on lit candles, and they would be well within their right to prohibit it.

The candle in the picture above has no business being there. It was located in a physician sleep room inside the hospital and I think there are too many risks to safety in the form of combustibles. Take a look: I see paper plates; plastic packaging; and a can of alcohol-based hand-rub dispenser; and the candle is not necessary. It does not serve a function of therapy and it does not serve a function of spirituality.

Hospitals will have to develop a policy on lit candles if they want to prohibit them, but may expect some push-back from the therapy folks and the religious folks. Perhaps the policy could provide an exception for those purposes, and have the use of lit candles be approved by the Facility Manager or the Safety Officer prior to use.

As always, check with your state and local authorities to determine what regulations they may have on the general use of lit candles.

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Dec 25 2014

Items Stored in a Stairwell

Category: BlogBKeyes @ 6:00 am

photo 1 web 2We should all know that storage of items in an exit enclosure, such as a stairwell, is not permitted by the Life Safety Code. Right? Well… there are exceptions that would allow certain items to be stored in a stairwell, but not all of the authorities having jurisdiction (AHJ) actually recognize these exceptions.

I was recently asked if a hospital could store their evacuation chairs in the alcoves of a stairwell (see the picture to the left). The alcoves are not in the direct path of egress inside the stairwells and appear to have been designed to allow a overlook to the scenery outside the building.

So let’s take a look at section of the 2000 LSC which says the following:

“There shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.”

This section makes it clear that you cannot have enclosed storage space in the exit enclosure, although the exception to this section does allow an enclosed storage underneath the stairs as long as it is separated by barriers with the same fire resistive rating as the exit enclosure and it is accessible from outside the stairs.

Another section ( of the 2000 LSC) says the following:

 “An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.”

The Annex section of says the following:

“The provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be ‘sterile’ with respect to fire safety hazards.”

What this section means is the storage of evacuation chairs would be permitted in the alcove of a stairwell since the alcove is not part of the egress, as long as the stored evacuation chairs would not interfere with egress. But there are surveyors and AHJs that take a much more severe look at this issue.

The above reference is in the Annex section of the LSC which means it is not part of the enforceable section of the code, but it is an explanatory section to help authorities understand the intent of the technical committee who wrote the code. Most AHJs follow what the Annex section says, although they do not have to. The Annex section for does prohibit storage in the stairwell that is “not necessary for safety”, so one could make the point that evacuation chairs are necessary for safety and therefore are permitted to be stored in the stairwell, as long as they do not interfere with egress.

The bottom line is it is apparent that the Life Safety Code does permit the storage of evacuation chairs in an exit stairwell, as long as the chairs are stored in such a way as to not interfere with egress. However, not all AHJs actually agree with this and some do cite hospitals if they have anything stored in the stairwells. If you want to pursue this and store evacuation chairs in the alcove of your stairwells, I suggest you document these sections of the Life Safety Code and show them to any surveyor who questions the practice. It may prevent you from having a citation, or it may not.

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Dec 18 2014

Contractors During a Survey

Category: BlogBKeyes @ 6:00 am

images[3]It has always been my belief that as the surveyor team walks in the front door of the hospital on the first day of the survey, all of the contractors should be walking out the back door. For the most part (and I do understand that there are exceptions), contractors should be sent away once you know there are surveyors in the house. Why? Because they will get you in trouble one way or another.

I recently received an email from a reader who shared this story:

During our triennial survey the life safety surveyor asked me how we knew that the fire alarm system signal was received by our monitoring company. I could not immediately answer the question, but we were lucky to have the service contractor in the building doing his quarterly testing and I suggested we ask him.

The service technician explained that the software in the fire alarm control system will indicate if the alarm is received by the monitoring company within the designated amount of time. I was quite happy with the service technician’s explanation until the surveyor said “Prove that it happened at least quarterly for the past 12 months”.

The service technician said nobody could prove it; we just have to take his word for it. [Wrong answer.] The surveyor asked “Don’t you call them by telephone to confirm they received the signal?” The service technician replied, saying “Well, would you trust me if I said I did call?”

The surveyor was correct to ask the questions that he/she did. The service technician was probably answering them to the best of his ability, but the real problem is the facility manager allowed the surveyor to enter into a conversation with a contractor. During a survey, the hospital staff should try and control the process as much as possible. By allowing a surveyor to ask questions of a contractor, the facility manager lost control of the situation and will suffer any consequences of what a contractor may say.

Contractors are not trained and educated in the regulatory requirements the same way the hospital staff is (or should be). The contractors may not even know or understand the significance of an accreditation survey, or worse, a CMS certification survey. Service technicians have a tendency to take an attitude that they know more about the system they are working on than the hospital does, and for the most part they do. Otherwise, the hospital would not hire them. But the service technician my not know what specific regulations that the hospital must comply with and therefore may say something to a surveyor that may get you in trouble.

I’m not saying you should not be transparent in your processes, but during a survey, you need to control as much as you can of the survey process. This is not unethical or wrong; it is just smart business. Let the surveyor go where he/she wants; let the surveyor ask questions all they want; but eliminate the potential “loose cannons” that are not very well educated on the survey process by sending them home during the survey.

Another reader sent me an email earlier this year explaining that on a day during the accreditation survey a roofing contractor set a pallet of roofing material right in the middle of the exit discharge of a staff entrance/exit to the hospital. Nobody from the hospital was aware that the roofing contractor was about to do that, but the surveyor noticed it as soon as it happened and it went into the survey deficiency report.

When I was a surveyor for The Joint Commission, I would purposely seek out contractors and ask them what training the hospital provided them on fire safety procedures. Ultimately, contractors are expected to know the same fire response procedures as the staff. Invariably they could not answer the question satisfactory and it would be cited in the survey deficiency report.

I know that in some situations you cannot send the contractors home for the duration of the survey, but it seems that a large percentage of them could. At the hospital where I worked as the Safety Officer, I asked the project management team to send the contractors away during the week of the survey (this was when the surveys were announced). The project managers thought that was a good idea, but we were over-ruled by the COO of the hospital, because he did not want the opening of the new renovated unit to be delayed. That ended up being a costly mistake. The hospital had a policy that every contractor had to receive basic safety orientation before they begin their work on the campus of the organization. Unbeknownst to the hospital, the general contractor brought in a sub-contractor to install flooring in one area, and they did not go through the safety training because the general thought it would be “okay” since the sub was only going to be there for one day. Sure enough, the surveyor found that one sub who had not received the safety training which lead to a finding on the survey deficiency report.

You need to control what you can, and sending the contractors away is the smart thing to do during a survey.

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Dec 11 2014

Joint Commission PFI List

Category: BlogBKeyes @ 6:00 am

images4ZUW90XGI received an email from a client who was confused about the changes to the Joint Commission Plan for Improvement (PFI) list found in the Statement of Conditions (SOC). He initially thought the recent CMS imposed changes on the PFI list meant that he should no longer use the PFI list for his life safety deficiencies. Then, he received advice from another consultant that he must list the life safety deficiencies on the PFI list and must do so with 45 days of discovering the deficiencies. He contacted me saying he thought he was in trouble because he was more than 45 past due and asked me for advice.

I responded saying I thought he was receiving some confusing advice, and I did not believe he was in trouble. Here is my take of the Joint Commission PFI program:

  • CMS no longer allows Joint Commission to not cite an organization on the survey deficiency report for a life safety deficiency just because it is listed in the PFI section of the Statement of Conditions.
  • Therefore, Joint Commission will cite all items listed on the SOC PFI list on the survey deficiency report, but will do so on a special section of the report at the end called the Plan for Improvement – Summary, and it looks like this:

Plan for Improvement – Summary

The Plan for Improvement (PFI) items were extracted from your Statement of Conditions™ (SOC) and represent all open and accepted PFIs during this survey. The number of open and accepted PFIs does not impact your accreditation status, and is fully in sync with the self-assessment process of the SOC. The implementation of Interim Life Safety Measures (ILSM) must have been assessed for each PFI. The Projected Completion Date within each PFI replaces the need for an individual ESC (Evidence of Standards Compliance) so the corrective action must be achieved within six months of the Projected Completion Date. Future surveys will review the completed history of these PFIs.

  • No evidence of standards compliance (ESC) is required on findings in the Plan for Improvement – Summary section, such as there would be for ‘normal’ deficiencies cited during the survey on the Requirements for Improvement section.
  • There is no Joint Commission standard that actually requires you to list your life safety deficiencies on the PFI list within 45 days of discovery. Joint Commission wants you to do so, but there is no standard that actually requires you to do it. If you choose to not list your life safety deficiencies on the PFI list, there is no repercussion. The sole purpose of the PFI list now (after the CMS imposed changes), is to provide you with a vehicle to manage your life safety deficiencies. I see the PFI list as a choice: You can manage your life safety deficiencies through the use of the PFI list, or you can manage your life safety deficiencies through the use of your computerized maintenance management system (work orders).
  • If you choose to not list your life safety deficiencies on the SOC PFI list, then you manage the deficiency through your work order system. If the surveyor observes the life safety deficiency during a survey (and the deficiency is not on the PFI list), then he/she will cite it under the ‘normal’ Requirements for Improvement section of the survey deficiency report, and you will need to submit evidence of standards compliance (ESC) within the designated 45 or 60 day timeframe. An acceptable ESC response is to either resolve the life safety deficiency, or to state you will list it on the PFI list with a projected date of completion. But this is all dependent on the surveyor observing the life safety deficiency and citing it on the survey deficiency report.
  • If you choose to list your life safety deficiency on the PFI list, then all the surveyor will do is take the items listed on the PFI list and enter them automatically into the survey deficiency report under the Plan for Improvement section, which does not require an ESC submitted within 45 or 60 days.
  • If you miss the 45 day window to enter a life safety deficiency in the PFI list of the SOC,  that is not a problem. Since there is no Joint Commission standard that says you have to list life safety deficiencies in the PFI list, then there is no standard that says you have to do it within 45 days of discovery. The 45 day rule is just a guideline… a suggestion, if you will. Joint Commission may want you to think it is a rule, but it is not. There are no repercussions if you listed the life safety deficiency on the 50th day, or the 75th day instead.

It’s your decision, but I would advise hospitals to continue to list their life safety deficiencies on the SOC PFI list; but you do not have to. There is no Joint Commission standard that says you have to do so. But there is a slight advantage to list the life safety deficiencies on the SOC PFI list: It will be entered under the Plan for Improvement section of the survey deficiency report which does not require a 45 or 60 day response, as opposed to listing the life safety deficiency under the Requirements for Improvement section which does require a ESC response within 45 or 60 days.

Having it listed under the Plan for Improvement section of the deficiency report will also provide awareness to the CEO/COO suite of the life safety deficiencies that they may not have been aware of otherwise. That may be a good thing… or perhaps it may not.

DON’T FORGET: You will need to assess the life safety deficiency for Interim Life Safety Measures (ILSM) regardless whether or not the deficiency is listed on the SOC PFI list.

I mention all of this because some facility managers may overlook placing a life safety deficiency on their SOC PFI list within the 45 day window of discovery, and feel they are in trouble.

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Dec 04 2014

Medical Gas Shutoff Valves

Category: BlogBKeyes @ 6:00 am

imagesZ7K8PIAPI was recently a bystander amongst a discussion of healthcare facility industry experts, debating the NFPA requirements concerning the accessibility of medical gas shutoff valves in healthcare institutions. The original question asked was where does it specifically state that a medical gas zone valve box cannot have a wheeled obstruction in front it of it? While it is intuitive to keep the area in front of the shutoff valves clear, the question was a good one, as it appears the NFPA codes and standards do not specifically address the requirement to keep it clear.

The discussion that ensued was informative, as various standards were referenced as to support the opinion of the presenter. For example; Joint Commission standard EC.02.05.09, EP 3 says the valves must be accessible. But TJC does not define what ‘accessible’ means. According to the online dictionary, accessible is a place which is able to be reached or entered. So, if a wheeled gurney is placed in front of a medical gas shutoff valve, is it still accessible, if staff can reach over the gurney and actuate the valve? Or, is the shutoff valve still accessible if the gurney can be moved so staff can reach the valves?

The only one who can answer that question is the authority who is enforcing that standard, which is The Joint Commission in this case, but the other accreditation organizations have similar standards and they make their own interpretations as well. According to most of those in the discussion, Joint Commission and the other accreditation organizations are writing up hospitals and ambulatory surgical centers that have anything placed in front of the medical gas shutoff valves.

Another individual referenced NFPA 99, 1999 edition, which governs medical gas systems for healthcare institutions. Section 4- (i) which requires manual shutoff valves in boxes to be installed where they are visible and accessible at all times; the boxes should not be installed behind normally open or normally closed doors, or otherwise hidden from plain view. This description would seem to support the concept that the definition of accessible could include a wheeled object to be placed in front of the valves as long as the valves were accessible. At the least, it doesn’t seem to prohibit that.

But yet another individual said take a look at NFPA 99 (1999 edition), section 4- (d) on zone valves. For sake of clarity, I will repeat it here word-for-word (bold emphasis is mine):

Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet. This valve shall be readily operable from a standing position in the corridor on the same floor it serves. Each lateral branch line serving patient rooms shall be provided with a shutoff valve that controls the flow of medical gas to the patient rooms. Zone valves shall be arranged that shutting off the supply of gas to one zone will not affect the supply of medical gas to the rest of the system. A pressure gauge shall be provided downstream of each zone valve.

The above description is found under a section titled “Zone Valve”. The bolded section in the above description refers to the requirement of a manual shutoff valve that is located on the same story which is readily operable from a standing position in the corridor. That’s not necessarily the zone valve, but why isn’t this description also included in section 4- (i) which describes shutoff valves? The 2012 edition of NFPA 99 further elaborates on ‘Zone Valves’ and describes them in the same way that most people think of shutoff valves.

According to the online dictionary, the word ‘readily’ means without difficulty or delay; easily or quickly. So section 4- (d) of NFPA 99 (1999 edition) makes it pretty clear that the manual shutoff valve for the room outlets must be operated easily, and without delay. Parking a wheeled gurney in front of a medical gas shutoff valve could easily delay the operation of the valve; or at the minimum, it would provide a hindrance to the operation of the valve. Therefore, the wheeled gurney (or any other object) would not be permitted to be placed in front of the medical gas shutoff valves.

I think the accreditation organizations have got this issue correct. Anything that blocks access to a medical gas shutoff valves (whether it is called a shutoff valve or a zone valve) hinders the ‘readily operable’ capability of the medical gas valves, and would be a citable offense.


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Nov 27 2014


Category: BlogBKeyes @ 6:00 am







The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that performs surveys on behalf of CMS.

I recently read your article on Decorations. I thought the advice was really good information. I was contacted by a facility not too long ago that asked me if a large, homemade tapestry brought to a resident’s room would need to be fire retardant if it was hung up. The question from the engineer was valid as it was to be hung as a “decoration”, was made of flammable material and the family wanted to hang it in the corridor. He wanted to know if it should be fire-treated. His argument was focused on not allowing the family to bring it in at all, mostly because he found it objectionable. I related to him the code; how it could be both stringently and loosely interpreted and suggested, as you pointed out, to err on the side of caution and either treat it or suggest to the family it wasn’t allowed by the standard. The main issue was that the family wanted to hang it in the corridor, which I pointed out could potentially affect safe egress. I then asked him what he felt would be a surveyor’s opinion if this same decoration was hung inside the room, or used as a blanket.

I pointed out that many times I am in a facility where the family has brought in a blanket, or other homemade decoration to make their loved ones feel at home during their stay, or possibly their final hours. I stated I view those items based upon the possible risk, and the intent of the standard. More often than not I find they pose no greater risk to the facility’s other occupants than the same person’s bathrobe knitted by their aunt (when solely used or displayed inside their respective room).

Point being that speaking for myself, I view it solely based on each individual situation: If the facility is providing it and it poses a possible risk to the safe housing or evacuation of all occupants, I will look at that risk and evaluate the issue, citing it if it is apparent and substantiated. I will not unnecessarily burden a resident, patient, client, family or staff member for the purpose of removing something that falls within the letter of the rule for the sole purpose of demonstrating that rule. As always, “it depends”.

I find it refreshing that a state surveyor would have compassion and evaluate issues on a case by case basis. But if this is not done carefully, it can lead to inconsistent interpretations and cause problems when AHJs do not agree on the same issue.

I think hospitals have too many AHJs conducting inspections and surveys in their facility, as it often leads to differences of opinion on how an issue should be interpreted by the AHJs. Ultimately, the hospitals often have to ‘do-over’ a construction project because they receive poor advice from an architect, or an incorrect interpretation from an AHJ.

No wonder healthcare costs so much…

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