Mar 19 2015

Stairwell Signage

Category: BlogBKeyes @ 1:00 am
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In Case of Fire Web 2If you were a bit surprised by the wording of the sign to the left… You’re not alone. I had to do a double-take when I first saw it, as it certainly got my attention.

The sign is a marketing strategy by the Stairwell Signage Solutions company in Palm Beach Gardens, Florida, and is re-printed here with permission. The sign is an ominous warning to facility managers that their existing stairwell signage may not be compliant with the new 2012 Life Safety Code.

When the new 2012 LSC is adopted facilities will have to comply with the following requirements, found in section 7.2.2.5.4:

 

  • New enclosed stairwells serving three or more stories and existing enclosed stairwells serving five or more stories must have stairwell identification signs (previously, the 2000 LSC only required stairwells serving five or more stories to have stairwell identification signs);
  • The stairwell must be provided with identification signs inside the enclosure at each floor landing;
  • The signage must indicate the floor level;
  • The signage must indicate the terminus of the top and the bottom of the stairwell;
  • The signage must indicate the stairwell name (identification);
  • The signage must indicate the floor level of, and the direction to, the exit discharge;
  • The signage must be located inside the enclosure approximately 60 inches above the floor landing in a position that is visible when the door is open or closed;
  • The signage must be continuously illuminated with emergency power back-up capability (this was not previously required);
  • The floor level designation must be tactile in accordance with ICC/ANSI A117.1 (this was not previously required);
  • The signage must be painted or stenciled on the wall or on a separate sign securely attached to the wall (this was not previously required);
  • The name of the stairwell must be located at the top of the sign in minimum 1 inch tall lettering (this was not previously required);
  • Stairwells that do not provide roof access must read ‘NO ROOF ACCESS’ underneath the name of the stairwell in 1 inch tall lettering (this was not previously required);
  • The floor level number must be located in the middle of the sign in 5 inch tall numbers (this was not previously required);
  • The identification of the lower and upper terminus of the stairwell must be located at the bottom of the sign in 1 inch tall lettering (this was not previously required).

The phrase ‘this was not previously required’ is referring to the 2000 LSC. If you would like to contact Stairwell Signage Solutions, contact Stephen Salzberg, at imagemaven@aol.com.

 

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Mar 12 2015

Occupational Therapy Cooking Equipment

Category: BlogBKeyes @ 1:00 am
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physical-rehab-lab[1]A reader recently inquired about a residential style stove/oven used in their new hospital for occupational therapy patients. He wanted to know if this residential style stove was required to have a commercial-style exhaust hood, complete with fire suppression equipment. He also wanted to know if the room where the stove was located was required to have smoke detectors and a Class K fire extinguisher.

A residential style stove/oven that is used for occupational therapy purposes is not a cooking appliance; it is therapy equipment. As long as only rehab patients are using the stove and staff does not use the stove for their personal use, the case can be made to a surveyor or an inspector that the equipment is not cooking equipment, and is not subject to meeting the requirements of section 9.2.3 of the 2000 LSC for fire suppression.

Also, section 18.3.2.6 of the 2000 LSC says domestic cooking equipment that is used for food-warming or limited cooking does not have to be equipped with the fire suppression equipment required by section 9.2.3. Typically, the only residential style stove/oven appliance found in a hospital is located in the rehab/therapy unit and is used for occupational therapy; not food preparation. Whatever a patient would be doing at the stove would be considered ‘limited cooking’.

Also, section 9.2.3 of the 2000 LSC references NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 edition), which is the standard for fire suppression for cooking hoods, only applies to commercial cooking equipment. A residential style stove/oven used for occupational therapy is not a piece of commercial cooking equipment, so based on that interpretation, NFPA 96 does not apply.

And, if those points don’t change the mind of an over-zealous surveyor, according to NFPA 96, fire suppression systems are not required in cooking appliances that do not produce grease laden vapors. The presumption is an occupational therapy patient would not be frying up a pound of bacon, or other food products that produce grease laden vapors. And if they are, then perhaps there should be some means to catch the grease laden vapors.

A Class K fire extinguisher would not be required to be mounted within 30 feet of the residential style stove/oven that is used for occupational therapy since it does not involve combustible cooking oils or fat. NFPA 10 (1998 edition) states Class K extinguishers are only required when there is a potential for fire from cooking oils and fats that are combustible. Again, the presumption is there would not be a deep fat fryer or other appliances that would use combustible cooking oils in the occupational therapy program.

There is no requirement for any smoke detectors in or around the room that contains the residential style stove/oven used for occupational therapy purposes. I would strongly suggest that there not be any detectors in this area, unless there are other reasons for them. Any smoke generated from burnt food may cause unwanted alarms.

I also suggested to the reader that he write up a risk assessment or a policy (or management plan) identifying the above points as evidence that their facility gave this some serious consideration, and have their Safety Committee review and approve it. If challenged by a surveyor, they could present their risk assessment, policy or management plan indicating that they’ve done their due diligence and the conclusion is the equipment does not have to comply with NFPA 96 for exhaust hood or fire suppression systems.

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Mar 05 2015

More on Temporary Construction Barriers

Category: BlogBKeyes @ 1:00 am
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I received an email from a reader who described a problem with their temporary construction barriers. He told me the following:

During construction and renovation projects our hospital uses drywall for temporary construction barrier walls. Our contractors are very ruff on these walls and constantly put holes in them. Our contractors have asked us if they could begin using fire retardant plywood for our temporary construction barrier walls for purposes of increased durability. Our infection control department did not have any issues with this. Would the use of fire retardant plywood be acceptable to with the Life Safety Code to use as temporary construction barrier walls in our hospital?

Non-Negative Air Barrier Web 2This is one of those issues that everyone does not agree on. Some authorities having jurisdiction (AHJ) may permit it and some may not. But when offering advice on Life Safety Code compliance, one must consider what the actual language of the code and standards say, and any interpretations made by AHJs.

According to the NFPA codes and standards, fire resistant plywood is not an acceptable temporary barrier for construction. Take a look at 19.7.9.2 of the 2000 LSC which requires compliance with NFPA 241 (1996 edition) during construction. Section 2-2 says the following:

“Only noncombustible panels or flame-resistant tarpaulins or approved materials of equivalent fire-retardant characteristics shall be used.”

Fire resistant plywood is not noncombustible and it is not flame-resistant tarpaulins, so it does not qualify on that account. Now, section 2-2 does say “approved materials of equivalent fire-retardant characteristics” would be permissible. The fire-resistant plywood would seem to comply with this statement, but the key word is “approved”. The fire resistant plywood would have to be approved by all the AHJs that regulate the healthcare facility. That would be the following:

  • The federal government (CMS)
  • The accreditation organization (i.e. Joint Commission, HFAP, DNV)
  • The state AHJ on design and construction
  • The state fire marshal
  • The local fire inspector
  • The insurance company

Getting one of those AHJs to accept the fire resistant plywood as being acceptable is possible; but getting all of the AHJs to accept this, is improbable. Even if 5 of 6 AHJs accepted it, the organization would still have to comply with the lone AHJ who would not accept it.

Another consideration that is much less flexible in interpretation is section 19.1.6.3 of the 2000 LSC, which says:

“All interior walls and partitions in building of Type I and Type II construction shall be of noncombustible or limited combustible materials.”

Again, fire resistant plywood is neither noncombustible or limited combustible materials. Therefore, from this code section’s point of view, fire resistant plywood would not per permitted, even on a temporary basis, and even if it was ‘approved’ by an AHJ.

My advice to this individual is to stick with the steel studs and gypsum board temporary construction barriers because once the new 2012 LSC is adopted, the updated edition of NFPA 241 will require 1-hour fire rated temporary construction barriers (with 3/4 hour fire rated doors that self-close and positively latch) where the construction area is not protected with sprinklers; or NFPA 241 will require non-rated noncombustible (or limited combustible) temporary construction barriers where the construction area is protected with sprinklers. It is important to understand that the new NFPA 241 will no longer permit the flame retardant tarpaulins (i.e. flame retardant plastic visqueen).

I also suggest to this individual that he should find a way to impress upon the construction people that the temporary barriers must be properly maintained; or find construction people who will be glad to have your work and comply with your requirements.

Remember: Those construction people work for the hospital; not the other way around.

 

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Feb 26 2015

Expert Witness

Category: BlogBKeyes @ 5:00 am
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imagesXLH1EQVPI received a telephone call recently from a lawyer that asked me if I would be willing to serve as an expert witness in a pending litigation suit. The situation of the lawsuit is a patient who was admitted to the inpatient psychiatric unit of a hospital busted the protective cover over the fire alarm manual pull station, and activated the fire alarm system. The entrance doors to the psychiatric unit unlocked on the fire alarm, and the patient ran out, climbed to the roof of the facility and jumped off.

Now the family of the patient is suing the hospital and the fire alarm company who installed the interface between the door locks and the fire alarm system. The plaintiff’s lawyer is arguing that the interface should never have been installed and the doors should not have unlocked upon activation of the fire alarm system. I agree with the plaintiff’s lawyer, but the problem is, it was the defense’s lawyer who contacted me.

The two major codes and standards that apply in this situation are the NFPA 72 National Fire Alarm Code (1999 edition), and the NFPA 101 Life Safety Code (2000 edition). The Life Safety Code (LSC) allows clinical needs locks on doors in the path of egress, but only in healthcare occupancies (hospitals). They are not permitted in any other occupancy. These types of locks are permitted where the “clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times”. Clinical needs locks are permitted for Behavioral Health units, such as psychiatric and Alzheimer units, to prevent patients from leaving the unit unauthorized, and potentially harming themselves or others.  Clinical needs locks requires all staff who work on that unit (which includes physicians, nurses, aids, clerical, maintenance, foodservice, housekeeping, etc.) to have a key or device to unlock the door on their person at all times. [Code reference: 19.2.2.2.4, Exception No. 1, 2000 edition of the LSC].

But when it comes to connecting those clinical needs locks to the fire alarm system so they automatically unlock on a fire alarm activation, the codes are not so clear. Other permissible locks, such as delayed egress locks and access control locks, are required by code to be connected to the fire alarm system and automatically unlock the door whenever there is an alarm. However, there is no such similar language for clinical needs locks to unlock on an alarm. In addition, NFPA 72 section 3-9.7.1 and 3-9.7.2 says if you have a lock on an exit door it must be connected to the fire alarm system, and it must unlock the door on a fire alarm. However, the exception to 3-9.7.2 essentially says this is not required if an AHJ says so, or if another code says so. So, we go back to the Life Safety Code, and we see that delayed egress locks and access control locks are required to unlock on an alarm, but the section on clinical needs locks is very silent on the subject. When a code is silent on a subject that means it is open for interpretation. Therefore, section 3-9.7 of NFPA 72 does not apply to clinical needs locks in a hospital, because the interpretation Life Safety Code permits it. It is documented that psychiatric patients are astute enough to actuate a fire alarm to unlock the exit doors. Therefore, the code is available to be interpreted in such a way to not require clinical needs locks to unlock the doors in the path of egress on activation of the fire alarm system provided all staff carry a key to unlock the door in case of an emergency.

But who makes that interpretation? Usually the authorities having jurisdiction (AHJ) makes that interpretation. Section 4.6.1.1 of the 2000 LSC says the AHJ shall determine whether the provisions of the LSC are met. But when the AHJ does not issue an interpretation, then it is up to the individual organization’s to decide. As far as I know, there is no national AHJ for healthcare that has it written in their standards that clinical needs locks should not be connected to the fire alarm system. Therefore, the hospital needs to ask the question: Based on the potential risk to patient safety, is it best to connect the door locks on the psychiatric unit to the fire alarm system so they unlock upon activation of the fire alarm system?

I declined the offer to be an expert witness for the defense, and suggested they settle the lawsuit out of court.

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Feb 19 2015

Electrical Panels

Category: BlogBKeyes @ 6:00 am
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imagesCATTF4OXThere are quite of few issues concerning electrical panels that need to be addressed during a survey. Hospitals frequently take electrical panels for granted and overlook some of the more obvious requirements. Surveyors are better educated and prepared to evaluate your electrical panels during the survey.

Access to electrical panels must not be obstructed. There must be at least 36 inches clearance in front of the electrical panels and at least 30 inches clearance to one side of the electrical panel. The width of the electrical panel is included in the 30 inch side clearance.

While there are no direct standards that say the electrical panels must be locked, the risk of unauthorized access by unscrupulous individuals who could turn off circuit breakers controlling vital functions is a risk that must be addressed. In other words; access to the electrical panels should be secure, unless the healthcare organization has conducted a risk assessment that addresses the risk of unauthorized access. An example where a risk assessment may indicate an unlocked electrical panel is acceptable is where the circuit breakers in the panel do not serve a vital function of safety.

Circuit breakers are required to be labeled as to the circuits that they serve, or are required to be labeled as “Spares”. In older healthcare facilities this may be a problem since renovations may change what is served by the circuits and the breaker schedule may not be up to date. A breaker turned “Off” because it is a spare still needs to be labeled as such.

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Feb 12 2015

Trash Containers with Lids?

Category: BlogBKeyes @ 6:00 am
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imagesOMMZ5LLSAn off-site clinic far from the main hospital will be part of the accreditation survey. Currently they have open trash cans (wastebaskets) throughout the building. The staff at the offsite locations has been told that they need to replace all these open trash cans with trash cans that have lids. They were told this was a requirement by the accreditation organization. What do you say?

Be assured… there are no NFPA codes or standards that require trash receptacles with lids. If NFPA ever required it, they did away with that requirement long time ago. Likewise, there are no Physical Environment standards from the accreditation organizations that require lids on wastebaskets either.

Now, there may be Infection Control concerns for trash containers to have lids, but that would be an assessment made by the organization’s Infection Control practitioner. That may be evaluated by the surveyors, so it is suggested that the IC people address this where necessary. But there is no direct Physical Environment standard that requires lids on trash receptacle from a fire-safety stand-point.

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Feb 05 2015

Fire Extinguisher Documentation

Category: BlogBKeyes @ 6:00 am
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fire-extinguisher-sm[1]A surveyor recently cited an organization stating the hospital did not have a document indicating all of the portable fire extinguishers were inspected on a monthly basis. The surveyor asked for a document whereby the organization knows where each portable fire extinguisher is located, and assurance that each extinguisher received its monthly inspection. The hospital did not have such a document and the surveyor cited them for non-compliance with the standard that addresses portable fire extinguishers.

A subsequent conversation with the facility manager of the organization revealed that every portable fire extinguisher that the surveyor inspected did in fact have an annual maintenance tag with the monthly inspections properly identified on each extinguisher. Apparently, the surveyor thought the hospital should have a master list indicating the locations of each portable fire extinguisher, along with documentation that they were inspected monthly. This master list indicating the locations of all the fire extinguishers is a fine idea, but it is not a requirement for compliance with any NFPA code or standard, nor any accreditation organization’s standard. This is what is called “Best Practice” and is not required to be enforced upon the healthcare organizations. Best Practice may be shared with the organization by the surveyor as a suggestion on how they may make improvements, but it is not a requirement. Be assured that NFPA codes and standards do require documentation of the monthly inspections of the fire extinguishers, but they do not stipulate how that inspection is to be documented. Some hospitals like to use the bar-code method to document the inspection, but the most common approach to document this monthly inspection is to mark the date (month and day) along with the initials of the inspector on the annual maintenance tag attached to the extinguisher.

This finding was removed from the survey report during the clarification process.

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Jan 29 2015

Frames for Fire Rated Door Assemblies

Category: BlogBKeyes @ 6:00 am
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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
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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 3-3.2.1.2 of NFPA 99, 1999 edition. But only new healthcare occupancies are required to comply with this requirement, according to section 18.5.1.3 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.

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Jan 15 2015

More on the CMS S&C Memo Concerning Power Strips

Category: BlogBKeyes @ 6:00 am
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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 18.5.1.3 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 3-3.2.1.2(d)2 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 10.2.3.6 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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