Feb 26 2015

Expert Witness

Category: BlogBKeyes @ 5:00 am

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:, 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 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

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

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.


Feb 05 2015

Fire Extinguisher Documentation

Category: BlogBKeyes @ 6:00 am

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

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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