Jan 19 2018

Generator Testing

Category: BlogBKeyes @ 12:00 am

Q: We have a generator that doesn’t meet the 30% load for the monthly run so we have to do an annual run with the load at 50% for 30 min and 75% for 60 min for a 90-minute continuous run. Our contractor did the annual run but he ran it with 52 % for 30 min , 75% for 30 min and 81% for 30 min, then he continued to run it for 2½ more hours dropping the percentages as he went for 4 continuous hours at not less than 30%. My question is does these meet the intent of the standards for both an annual and a 3-year load test?

A: Yes… I would say the test as you described meets both the annual requirements and the 3-year test requirements. The generator load testing requirements are minimum load settings, and it is permitted to exceed these minimums.

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Jan 18 2018

Strange Observations – Part 9

Category: BlogBKeyes @ 12:00 am

Continuing in a series of strange things that I have seen when consulting at hospitals…

The odd thing about this situation is the receptacle has been changed out since the fire, but they didn’t do anything to repair the wall or to paint over the burn marks.

And this was in a very busy storage room with lots of boxes… the staff that was with me had no idea that this was there.

Jan 17 2018

Hazardous Area in Surgery

Category: BlogBKeyes @ 12:00 am

Q: Are clean cores for operating room suites considered hazardous thus required to be separated by a 1-hour fire-rated barriers? I have a client who was informed by their accreditation organization that their existing clean (sterile) core area needed to be upgraded to provide a 1-hour separation. The space is typically occupied and is larger than 100 square feet in a building fully protected by automatic sprinklers.

A: It depends… Is the hospital storing combustible supplies in the core area? If so, then the core area must meet the requirements for hazardous areas. Combustible supplies commonly found in core areas of Surgery are:

  • Paper-wrapped utensils that have been sterilized and waiting for use in surgery
  • Dressing, bandages, sutures, and medical equipment and supplies that are packaged in plastic, cardboard, chip-board, and paper
  • Other supplies that create a hazardous environment

The next issue is, does the hazardous area have to meet new construction requirements to be 1-hour fire rated and be fully sprinklered, or does the hazardous area qualify for the lesser requirements for existing conditions of being protected with 1-hour fire rated construction or smoke resistant construction and being fully sprinkelred? The answer to that question lies in which edition of the Life Safety Code was in effect at the time the core area was constructed or last renovated. If the core area was constructed or last renovated since the 1985 edition of the Life Safety Code was in effect, then yes, the core area is required to be protected with both 1-hour fire-rated construction and be fully sprinklered. (The 1985 edition was adopted by CMS, or the fore-runner of CMS, around January, 1988.) Subsequent editions of the Life Safety Code required new construction hazardous areas to be both 1-hour fire-rated protected and sprinklered. However, if the core area was constructed or last renovated before the 1985 edition of the Life Safety Code was in effect, then the core area is considered existing construction by today’s standards and qualifies for the existing conditions standards of being smoke resistant construction and fully sprinklered.


Jan 16 2018

Positive Alarm Sequence

Category: BlogBKeyes @ 12:00 am

I was reviewing some new standards and came across the Positive Alarm Sequence (PAS) issue for fire alarm systems, that the 2012 LSC now permits in fully sprinklered healthcare occupancies (see 18/ and of the 2012 Life Safety Code), provided it is in accordance with NFPA 72-2010.

The PAS (section of NFPA 72-2010) is designed to allow the facility a 3-minute delay in annunciation of the fire alarm signal, to allow them time to investigate whether the alarm is a nuisance alarm. The PAS option first became available for use on non-healthcare occupancies in the 2003 edition of the LSC, and then became available for use in healthcare occupancies in the 2006 edition. It is now available to all healthcare occupancies, ambulatory healthcare occupancies, and business occupancies since CMS adopted the 2012 Life Safety Code on July 5, 2016. So, this is something that may be a new concept to many facility managers.

The sequence of operation for the PAS is as follows:

  1. The fire alarm control panel must have the PAS feature an integral part of the programmable control system of the panel. The PAS is not a feature that can be used on older systems that were not originally equipped with it.
  2. To initiate the PAS operation, the signal from an automatic fire detection device selected for PAS operation shall be acknowledged at the fire alarm control unit by trained personnel within 15 seconds of annunciation. Usually any general alarm fire alarm initiating device would activate the PAS operation.  Supervisory or “off normal” conditions wouldn’t activate the PAS.  The only time you wouldn’t have an alarm event activate the PAS would be a general evacuation device, like a key switch monitored by the fire alarm system, that’s intended to signal an immediate evacuation of the hospital.
  3. If the signal is not acknowledged within 15 seconds, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  4. If the PAS operation is initiated in accordance with, trained personnel shall have an alarm investigation phase of up to 3-minutes to evaluate the fire condition and reset the system. The term ‘trained individuals’ means you need to have individuals who are trained to respond properly and immediately. No certifications or licenses are required for this function. The training includes in-house procedures that involve investigation within a certain timeframe, as well as training on use of the fire alarm annunciator and how the PAS is programmed to operate.
  5. If the system is not reset during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  6. If a second automatic fire detection device selected for PAS is actuated during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  7. If any other fire alarm initiating device is actuated, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  8.  The system shall provide means for bypassing the PAS.

Obviously, in order for the PAS operation to function properly, someone needs to be near the fire alarm control panel or a remote annunciator, so the trained individual who’s monitoring the system may take the appropriate action. If your fire alarm control panel or a remote annunciator is not continuously monitored, then the PAS function would not be suitable for your facility.

The 3-minute phase of investigation to evaluate the alarm condition, can be done with multiple individuals. An example may be one individual at the control panel and one in the field, communicating via walkie-talkies in order to make a decision to reset the panel before the 3-minutes expire, or to allow the alarm annunciation to continue.

Although the PAS function is permitted, caution is recommended before you implement this operation. The PAS can devolve into an automatic reset by the staff to give them more time to investigate, with the intent of pulling a manual station if there is indeed a problem, or worse, to let it go back into alarm as a means of verification.

If you are wondering whether or not CMS allows PAS operation the answer is yes, they do. Although CMS has not officially commented on this issue, they have to allow it since it is permitted by the 2012 LSC. Unless they specifically dis-allow something that is permitted by the LSC, then it is permitted, as long as it applies to the applicable occupancy. Unless they say otherwise, they follow NFPA to the letter. Examples of them saying otherwise involved the 4-inch corridor projection issue (vs. 6-inch what LSC allows); roller latches in certain corridor doors (2012 LSC still allows roller latches in certain corridor doors); and 1 or more patients incapable of self-preservation in Ambulatory Health Care Occupancies (vs. 4 or more). They have published S&C memos or addressed these issues in the Final Rule to adopt the 2012 LSC.

This means your accreditation organizations will allow PAS operations as well, unless of course they specifically have said they dis-allow it. For Joint Commission accredited organizations, their new EP 4 under LS.02.01.34 (2018 CAMH manual) specifically does permit PAS operation, in buildings that are fully protected by sprinklers.

Before you make plans or changes to implement PAS operation, check with your state and local authorities to determine if they have any restrictions on the use of PAS operation.

Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL, contributed to this article. You may reach Gene at generowe@affiliatedinc.com


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Jan 15 2018

Photoluminescent ‘Exit’ Signs

Category: BlogBKeyes @ 12:00 am

Q: Can illuminated ‘Exit’ signs be replaced with photoluminescent ‘Exit’ signs? If so, does this eliminate the requirement for monthly inspections of ‘Exit’ signs?

A: Photoluminescent ‘Exit’ signs are permitted, provided they meet the requirements of of the 2012 Life Safety Code, which requires constant illumination from an external source while the building is occupied. Since the hospital is occupied 24-hours per day, then this means the source of illumination must be constant.

The source of illumination must be connected to emergency power for healthcare occupancies. You really don’t gain anything by using photoluminescent ‘Exit’ signs over traditional internally illuminated ‘Exit’ signs because section requires all ‘Exit’ signs to be inspected monthly to ensure they still have a source of illumination.

I do not recommend using photoluminescent ‘Exit’ signs because they are greatly misunderstood and are typically installed in areas that are not compliant.


Jan 12 2018

Battery Powered Emergency Lights

Category: BlogBKeyes @ 12:00 am

Q: We have chosen to install some extra battery egress lights in our hospital that are not required. One of these areas is our stairways. 100% of the lighting in our stairways is served by the hospital’s generators including the circuits that feed the egress lights. We installed the battery egress lights to help keep people calm and avoid falls during the ~5 second transition to generator power. Do we need to do 90-minute annual testing on battery lights served by generator power? We will continue the 30-second monthly testing, but the 90-minute testing is difficult as all lighting in the stairway must be turned off during testing. Also, these lights will never see a 90-minute outage. NFPA 101 2012 says an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Since these are not required, I am hoping that as these lights do not need the annual test.

A: Well, I’m sorry to say, but section of the 2012 LSC says if you have an existing feature of life safety that is not required by the LSC but is obvious to the public then you must maintain it or remove it. I think we’d all agree that battery powered emergency lights would be obvious to the public. According to the NFPA standards, maintaining it includes the monthly 30-second test and the annual 90-minute test.

You say the 90-minute test will be difficult since the normal power to the battery powered emergency lights are on the same circuit as the stairwell lighting. Well, I see your point. You cannot turn off the circuit to the stairwell lighting for 90 minutes… that would be the wrong thing to do. I suggest you install a toggle switch on the battery powered emergency light fixture, preferably on top where it cannot be inadvertently turn off. This toggle switch will turn off the normal power to the battery powered emergency lights and you can perform the 90-minute test without interrupting normal power to the stairwell lights.

So, you must test those battery powered lights, even if they are not required. Personally, I like your thinking… providing battery powered lights for the 5 seconds or so of darkness in the stairwell, even though you don’t have to.


Jan 11 2018

Strange Observations – Part 8

Category: BlogBKeyes @ 12:00 am

Continuing in a series of strange things that I have seen when consulting at hospitals…

Did you notice they did not say ‘cigarette butts’? I guess that was to be politically correct. Don’t want to offend anyone.

Jan 10 2018

New vs. Existing Construction

Category: BlogBKeyes @ 12:00 am

Q: Our hospital facility was constructed under the new construction chapter 18 in 2000 Life Safety Code, but is now considered existing conditions under the 2012 Life Safety Code. We have a soiled linen room that is greater than 100 square feet, and is sprinkled, and the door needs to be replaced due to damage. Does the door still need to be a 45-minute fire-rated door assembly, now that the facility is in the existing category of chapter 19?

A: Yes, it does, because sections 4.5.8 and of the 2012 LSC says once a feature of life safety is required by the LSC, you must maintain that for the life of the building unless the new construction requirements change and no longer require it. Also, section says the existing feature of life safety cannot be removed where such feature is a requirement for new construction. So, you need to replace it with a properly rated fire door assembly for new construction. The reason there is an existing healthcare chapter that does not require a ¾ hour fire-rated door on a hazardous room, is it is for the older hospitals that built hazardous rooms when they were not required to be 1-hour fire rated. They are permitted to remain in use without having to meet the new construction requirements. But since your facility was constructed under the 2000 LSC that did require 1-hour fire rated hazardous rooms, you need to maintain that for the life of the building.


Jan 08 2018

Hazardous ER Department

Category: BlogBKeyes @ 12:00 am

Q: In a hospital emergency department, can the corridors be 6 feet wide? Can the hospital install an 18-inch deep lockable computer cabinet in the 8 foot ED corridor?

A: Well… It depends.

If you claim the ER is a suite, then there would be no problem with a cabinet in the 8-foot wide hallway…. Because there are no corridors in a suite. What looks like a corridor in a suite is a communicating space and you would only have to maintain 36-inches clearance for aisles.

But if the ER is not a designated as a suite, then you must maintain corridor widths. But the required width of the corridor is different depending on the occupancy classification of the ER. CMS has said that Emergency Departments must be classified as healthcare occupancies (HCO) if the ER has patient observation beds. CMS’s logic on this is if patients are under observation in the ED, then they consider this patient sleeping accommodations. In this logic, then all areas providing patient sleeping accommodations must be healthcare occupancies, and the required width of the corridor must be 8-feet.

However, CMS does permit the Emergency Department to be classified as an ambulatory health care occupancy (AHCO) if the ER does not contain any patient observation beds. Then the corridor width is only required to be 44-inches wide.

But keep in mind, the maximum corridor projection permitted by CMS is 4-inches. If your ER is not designated as a suite, then you must maintain corridor widths (either HCO widths of 8-feet, or AHCO widths of 44-inches) and you cannot have corridor projections more than 4-inches, and the cabinet would not be permitted.

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Jan 05 2018

Corridor Doors

Category: BlogBKeyes @ 12:00 am

Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?

A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage.

I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency. Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in the corridor. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.

You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.

I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustible stored in those patient rooms, you have a big problem. The room would have to comply with section (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

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