Oct 30 2014

Cellophane Bags on Sprinklers

Category: BlogBKeyes @ 6:00 am

imagesZ6JZWAQ6I was conducting a mock survey at a hospital and during the building tour I came to their maintenance shop. They had a spray paint booth and in the booth was a sprinkler head.  Over the sprinkler head was what looked like a plastic bag. I said you can’t cover up the sprinkler heads with plastic bags like that, even in a spray booth. The hospital facility manager told me he received permission from their state agency that it was permissible to cover the sprinkler heads to keep paint overspray from covering the heads.

I knew the state agency people so I called them and asked if they in fact said that. It turns out they did, and they referenced NFPA 25 (1998 edition) section 2-4.1.5, which says:

Sprinklers protecting spray coating areas shall be protected against overspray residue. Sprinklers subject to overspray accumulation shall be protected using plastic bags having a maximum thickness of 0.003 inches (0.076 mm) or shall be protected with small paper bags. Coverings shall be replaced when deposits or residue accumulate.”

Hmm… That just didn’t seem right to me. Plastic bags wrapped around the sprinkler heads? I understand that you do not want paint overspray on the sprinkler head, but plastic? NFPA 25 says you cannot have any foreign material on sprinkler heads, and now the same standard says you can in spray booths? Well, I had to let it go since the NFPA standard permits it.

Fast forward to the 2011 edition of NFPA 25. The technical committee at NFPA addressed this issue and they changed the standard… a little. Now, section says sprinklers subject to overspray accumulations shall be protected using cellophane bags having a thickness of 0.003 inches or less, or thin paper bags. Now NFPA 25 no longer says plastic bags, but says cellophane bags or thin paper bags must be used when protecting sprinklers from overspray. According to the commentary in the NFPA 25 handbook, here is the reason why:

“Testing has shown that lightweight cellophane or paper bags will not adversely affect the operation of the sprinkler. Sprinklers protected by the lightweight cellophane or paper bags may require more frequent inspection than the annual inspection outlined in to prevent excessive buildup on the bags. Depending on the use of the spray coating area, the inspection and subsequent replacement of the bags may need to be done daily. In prior editions, NFPA 25 allowed the use of a plastic bag, but this was changed due to concerns about the potential for a plastic bag to shrink prior to sprinkler activation and disrupt the discharge pattern.”

So… My suspicions were partly justified. A plastic bag on a sprinkler head would melt and disrupt the spray pattern of the sprinkler. I thought it could delay the sprinkler head from operating, especially if it coated the thermal sensing bulb (or solder) and act as an insulator. Anyway, once the new 2012 LSC is adopted, then it will reference the 2011 edition of NFPA 25, and the covers to protect the sprinklers from overspray due to a spray paint booth must be cellophane or paper. And, they need to be changed frequently, perhaps as much as daily, depending on the use of the spray booth.

Today, I would just recommend the hospital remove the spray booth all-together, from their building. It doesn’t seem that the risk of failure to change out the bags once they are accumulated with paint, is worth the advantage of having a spray paint booth.




Oct 23 2014

Infant Abduction Locks

Category: BlogBKeyes @ 6:00 am

Hospitals want to keep their nurseries, mother/baby units, and pediatric units secure, so they lock the doors. This causes a problem with the Life Safety Code because you can’t lock the doors in the path of egress in a hospital, other than three exceptions: 1) Clinical needs locks, which nurseries, mother/baby units, and pediatric units do not qualify; 2) Delayed egress locks; and 3) Access-control locks. Access-control locks really do not lock the door in the path of egress because a motion sensor will automatically unlock the door as a person approaches. So, in this situation the doors can only be locked using the delayed egress provision (found in section of the 2000 Life Safety Code).

But hospitals want the infant security systems used on the babies. These systems have a bracelet that is attached to the baby, and some have bracelets to attach to the mother as well. If the bracelet gets too close to the exit door, an alarm will sound and the door will lock. The problem is, these infant security systems do not comply with any of the three exceptions for locking the doors in the path of egress, listed above. Even if the doors will unlock on a fire alarm the hospital says, that is still not enough to qualify for the any of the three exceptions.

But then the hospital says their accreditation organization approved this door locking arrangement. Why should it be considered non-compliant if the accreditor allows it?  Sorry… just because the accreditation organization says it is okay, still does not make it compliant with the requirements of the Life Safety Code. When the state agency who surveys on behalf of CMS takes a look at it, they will not be as benevolent as the accreditor, and they will cite it as a deficiency.

So, to be compliant with the Life Safety Code, when the doors lock because the bracelet gets too close to the door sensor, the doors should lock into a delayed egress mode (again… see section in the 2000 Life Safety Code). Then it would be legal. But the 2012 LSC has made a change in this area and will allow locks on doors for the specialized protective measures for the safety of the occupants (see section 18/ in the 2012 LSC). This will allow you to lock the doors without delayed egress, provided you meet the requirements listed in that section. CMS has already approved categorical waivers to allow hospitals to begin using this new section of the 2012 LSC before they adopt it.

Take a look at your locks that are used on the nurseries, pediatric, mother/baby units, and even the ICUs and the ERs. If they are not delayed egress, then take a look at the CMS categorical waivers and consider modifying the doors to meet those requirements.

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Oct 16 2014

Fire Alarm System Interface Relays

Category: BlogBKeyes @ 6:00 am

Fire Alarm Interface RelayOut of sight is out of mind. It is the master illusionist’s greatest asset. He gets you looking at something that is distracting your attention away from the object at hand, and before you know it he makes it seem that through a magical intervention, something appears. Or disappears. Or… whatever. The point is, while your attention is located elsewhere, something else happened that you did not notice.

When I was a kid they called that a trick. Actually, it still is a trick, but now they call it something else, like an illusion. Harry Houdini was first called a magician before he was called an escape artist. But I don’t remember seeing anything in print where they called him an illusionist. The word “illusionist” sounds so much nicer and professional for today’s environment than “magician”. But, I digress… That seems to have very little to do with what I want to share today.

A review of the survey deficiency reports indicates surveyors are looking for documentation that the hospital has tested the interface relays and modules on the fire alarm system. I guess that’s the bridge between the illusions and the interface relays: You can’t see them. The interface relays are “out-of-sight and out-of-mind”. If you can’t see them, you tend to forget they are there, and then they are not included in the fire alarm testing report.

Many facility managers rely on the fire alarm contractor to provide a complete test report without actually checking what was tested. This is a grave mistake. No offense to fire alarm testing contractors, but you should never rely on their advice or opinion on the level of testing. You (as the facility manager) have to be smarter than the fire alarm testing contractor to ensure they did everything correctly. They don’t necessarily know what codes and standards (or what editions) you need to comply with, but you should know. That makes you the expert.

Not long ago I was consulting in a hospital and reviewing their fire alarm test report. The report failed to indicate that they tested their interface relays. I asked the facility manager about it and he called the sales representative from the fire alarm testing contractor who happened to be nearby. He stopped in while I was there and I asked him why they did not test the interface relays. He said he knew they were supposed to be tested, but told me (and this is a direct quote): “The hospital would not let me test them”. This surprised the facility manager and myself, and the sales rep explained further.

“We had to bid our services to the hospital based on a request for proposal. Nothing in the request indicated that the interface relays were included. We submitted a bid strictly based on what was requested in the proposal. Had we added anything that was not requested, we would not have been awarded with the contract.”

Some would say that the fire alarm testing contractor was unethical for not informing the hospital of all the items that needed to be tested that were not included in the RFP. I don’t know if that is unethical or not, but I will tell you this: That hospital got exactly what it asked for in the RFP. Unfortunately.

So, back to the point: Get those fire alarm interface relays included in the fire alarm testing process and document each one individually, with a “Pass” or a “Fail” notation. Here is a list of the most common interface relays used in hospital fire alarm systems:

  • Magnetic hold-open devices
  • Air handler shutdown
  • Kitchen hood suppression system
  • Elevator recall
  • Magnetic locks
  • Fire pump
  • Smoke dampers
  • Clean agent suppression systems
  • Sprinkler dry pipe/pre-action systems
  • Overhead rolling fire doors

Take a look at your latest fire alarm test report. Does it include interface relays? If not… better get on the phone to the company or individual conducting the testing for you.

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Oct 09 2014

Tamper Resistant Electrical Receptacles

Category: BlogBKeyes @ 6:00 am

images[5]Every surveyor has his/her own specialty that they like to look for during a survey. I know of one surveyor that writes up every hospital he surveys if the fire alarm panel is not marked with the electrical panel number and circuit that feeds the power to the fire alarm system. It’s a requirement, but he’s the only surveyor that I know who is writing it.

Another surveyor that I know is very astute on construction type to the point where he wrote up a hospital for having combustible siding on the exterior of the building. The hospital was 20 years old and the plywood siding was original. They were upset because for two decades the siding was never an issue, then all of a sudden ‘Boom’; it’s a problem. The hospital contacted the architect who originally designed the hospital, and he wrote a thundering letter of protest. That one I checked with NFPA and it turns out the surveyor was correct. The hospital will have to remove the combustible siding or submit an equivalency or a waiver request.

When I surveyed for The Joint Commission, I remember paying special attention to how fire dampers were installed at the hospitals I surveyed. I did this because the hospital where I worked got cited for improperly installed fire dampers by the state agency conducting a validation survey on behalf of CMS. I learned the hard way on the proper method of installing fire dampers, and used that newly gained knowledge when I surveyed.

Which leads me to the issue concerning tamper resistant electrical outlets. I don’t think you will see any specific standard in a Joint Commission, HFAP or DNV, manual (or in a CMS CoP for that matter) on tamper resistant electrical outlets, but this issue is being observed on more and more survey reports. Apparently, some surveyors have a strong background in the National Electric Code (NFPA 70) and uses that knowledge during surveys.

If you are not already doing so, please be checking the electrical receptacles in pediatric areas to be sure they are the tamper resistant type. Section 19.5.1 of the 2000 Life Safety Code requires compliance with section 9.1, and section 9.1.2 requires compliance with NFPA 70 National Electric Code (1999 edition). Article 517-18(c) of NFPA 70 says the receptacles rated for 15 or 20 amps, 125 volts, intended to supply patient care areas of pediatric wards, rooms, or areas in healthcare facilities, shall be listed tamper resistant or shall employ a listed tamper resistant cover.

 The areas where tamper resistant receptacles are required are areas where children are likely to found; which include areas outside of a pediatric unit such as the cafeteria, main lobby, waiting rooms, and play areas. The tamper resistant receptacles would not be required in adult patient rooms, corridors, physician consultation rooms, etc., as these areas, even if children are present, would have supervising adults present.

It is not wrong, or unethical for a surveyor to cite an organization on an issue just because he/she has special knowledge about that issue. After all; the hospital is required to comply with that issue, right? What’s frustrating is there usually is no warning that some surveyors are looking for a particular issue and it surprises facility managers when it happens. No one likes those kinds of surprises.

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Oct 02 2014

Private Fire Service Mains

Category: BlogBKeyes @ 6:00 am

imagesS9VJZMEONFPA 25 (1998 edition), section 4-3.1 has a requirement listed to test the Private Fire Service Mains once every 5 years. The standard says the test must be performed on exposed fire service mains and underground fire service mains. The handbook that accompanies the NFPA 25 standard explains this water-flow test on the private fire service mains applies to only private exposed and underground fire service mains that are outside the facility, such as piping to a private fire hydrant. The piping inside the facility is covered under a different section of the NFPA 25 standard.

The Annex section A-4-3.1 of NFPA 25 says this flow test can be performed through yard fire hydrants; a fire department connection (once the check-valve is removed); and other connections. Typically, the test is conducted at a fire hydrant that is connected to the private fire service mains due to it accessibility. The test must be able to measure flow in gallons per minute (GPM), and the results are measured against the original acceptance data. The key thing to understand at your facility is whether or not you own the fire hydrants that are close to your building, or if they are owned by the city or municipality. Surprisingly, many facility managers simply do not know. If they are privately owned, then you need to conduct the 5-year private fire service main flow test.

Nat all surveyors are asking to see this documentation during a survey, but it is becoming a more frequent request. Remember: The 2000 Life Safety Code, section 9.7.5 requires compliance with the entire NFPA 25, so everything in the standard must be followed as long as you have the equipment.

Not all accreditation organizations are consistent in reviewing this documentation, but as time progresses, you will see more and more surveyors ask to review this test report. This 5-year private fire service main water-flow test should not be confused with the annual water-flow of the private fire hydrants and the 5-year internal inspection of sprinkler piping.

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Oct 01 2014

CMS Issues Categorical Waiver on Power Strips

Category: BlogBKeyes @ 3:00 pm

12-120-878-TS[1]CMS issued a new S&C memo 14-46 in late September that made allowances for healthcare organizations to utilize power strips in patient care areas.

CMS has determined that the 2000 edition of the Life Safety Code contains provisions on the use of power strips in health care facilities that may result in unreasonable hardship for providers or suppliers. Further, CMS says an adequate alternative level of protection may be achieved by compliance with the 2012 edition of the Life Safety Code, which has extended allowances on the use of power strips in patient care areas.

CMS has determined that the 1999 edition of NFPA 99 Standard for Health Care Facilities, section 3- (d)(2) which requires a sufficient number of receptacles located so as to avoid the need for extension cords or multiple outlet adapters, is outmoded and unduly burdensome. NFPA 99 is referenced in part by the Life Safety Code. Power strips are also known as multiple outlet adapters, multiple-plug adapters, and relocatable power taps.

CMS says by contrast, the 2012 edition of NFPA 99 has extended allowances for use of power strips in ‘patient care rooms’, which replaces the term ‘patient care areas’.

The requirement in the 1999 edition of NFPA 99 for sufficient receptacles to be located in all patient care areas as to avoid the need for power strips has been removed in the 2012 edition. In place, the 2012 edition has increased the minimum number of receptacles in patient care rooms for new construction.

Effective immediately, CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas/rooms, if the provider/supplier complies with all applicable 2012 NFPA 99 power strip requirements and with all other 1999 NFPA 99 and 2000 Life Safety Code electrical system and equipment provisions.

A patient care room is defined as any room in a health care facility wherein patients are intended to be examined or treated. This definition appears to include operating rooms and procedure rooms as well.

The CMS S&C memo 14-46 describes basic requirements that health care facilities must comply with in order to use the new categorical waiver.

  • Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section of the 2012 NFPA 99.
  • Power strips may be used in a patient care vicinity to power rack-mounted, table-mounted, pedestal-mounted or cart-mounted patient care related electrical equipment assemblies, provided all of the conditions are met in section They do not have to be an integral component of manufacturer tested equipment.
  • Power strips may not be used in a patient care vicinity to power non-patient care-related electrical equipment, such as personal electronics.
  • Power strips may be used outside of the patient care vicinity for both patient care-related equipment and non-patient care-related equipment.
  • Power strips providing power to patient care-related electrical equipment must be Special Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.
  • Power strips providing power to non-patient care-related electrical equipment must be Relocatable Power taps (RPT) listed as UL 1363.

The categorical waiver is available to all health care providers and suppliers and need only to document their decision to use the waiver, stating that they comply with all of the requirements to do so. This document must be provided to the surveyor team at the entrance conference. Organizations wishing to use the categorical waiver need not apply for them or wait until they are cited to use them.

To review the CMS S&C 14-46 memo, follow this link:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-46.pdf

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Sep 25 2014

The FGI Guidelines

Category: BlogBKeyes @ 6:00 am

fgi[1]Recently, the issue of whether or not the FGI guidelines were enforceable in certain situations came up for discussion. To be sure, the FGI guidelines are guidelines: They are not standards or code requirements. CMS and the accreditation organizations expect hospitals to design their new construction and renovation projects in accordance with the current edition of the FGI guidelines or applicable state and local standards if more restrictive. If there is a physical reason why the hospital cannot meet the FGI guidelines, then that must be discussed with their state and local authorities having jurisdiction over hospital construction, and any variances from the FGI guidelines must be approved by them.

Existing conditions in hospitals do not have to meet the requirements of the most current edition of the FGI guidelines, including the ventilation and air-pressure requirements. Existing conditions in hospitals must comply with the requirements of the FGI guidelines edition (or the AIA guidelines if older) at the time the facility was designed. So, as an example if an operating room was designed 20 years ago, it would only have to meet the 15 air changes per hour requirement of the guidelines enforced at that time; not the 20 air changes per hour required in the 2014 FGI guidelines for new construction.

I was contacted recently by a hospital that was doing some renovation in their operating rooms, and wanted to know if they had to update their HVAC system to meet the current FGI guidelines on air changes per hour. Apparently, they would have to install a whole-new HVAC system in order to meet the 2010 or 2014 FGI requirements. They said they were updating their medical gases, room lights, installing new floors, and installing some special equipment, but it wasn’t a gut-and-replace job. The FGI guidelines has a section at the beginning of the book that describes when an entire upgrade needs to be done, but this isn’t something that I should be answering for this hospital. They needed to contact their state and local authorities to determine what they would require.

Accreditation organizations like The Joint Commission, HFAP, and DNV do not approve construction or renovation projects. Their job is to assess the hospital for compliance with all applicable codes and standards. The accreditation organization standards do reference the FGI guidelines, but only as a reference; not as a standard. If a hospital has a letter on file from their state and local authorities allowing the deviation from the FGI guidelines, then surveyors should not cite the deviation from the FGI guidelines.

It is critically important for the hospital to retain all documentation from their state or local authorities at the hospital location, and be able to retrieve them during a survey.


Sep 18 2014

Decorations or Communications?

Category: BlogBKeyes @ 6:00 am

Combustible decorations on bulletin board Web 2The 2000 Life Safety Code, section 18/ is pretty clear when it states combustible decorations are not permitted in healthcare occupancies unless they are flame-retardant. Flame-retardant decorations can be purchased, but you need to maintain some sort of documentation that the decorations are flame retardant, such as the original packaging. Then it can be presumed that the decorations are acceptable.

At the hospital where I used to work, the maintenance supervisor purchased huge Christmas wreaths for decorating the main lobby. They were made of plastic materials and fortunately for him, he retained the documentation from the manufacturer that they were flame retardant. He actually stapled the documentation to the back of the wreath so it would always be available for review.

If you do not have any documentation that the decorations are flame retardant, then plastic, fabric, paper, and wood-based decorations could very well be cited as combustible decorations. Artificial flowers, whether they are plastic or fabric, can be considered to be combustible if there is no documentation that states otherwise.

Surveyors are not consistent in enforcing this issue. Some surveyors don’t pay much attention to this at all, while other surveyors only cite the more obvious combustible decorations, such as wreaths made from twigs, sticks and grape vines. However, I have seen some survey reports where the surveyors cited all plastic artificial flowers in the hospital.

But what about those bulletin boards frequently found on the nursing units? Many times these bulletin boards are layered with multiple pieces of combustible paper. Are these a violation of the LSC as well? Not necessarily. If the paper that is posted on the bulletin board is truly used for communication (i.e. memos, notices, and other communications), then it is not considered a decoration and therefore is not a violation of section 18/

However, many times the bulletin board will be decorated for a particular holiday, or a special event. In these situations, if the bulletin board is decorated with combustible material, then it has crossed the line from communication to decoration, and should be considered for a citation under section 18/ This is always a judgment call by the surveyor, and the less there is for the surveyor to judge, the better off you will be.

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Sep 11 2014

Exit Discharge Illumination

Category: BlogBKeyes @ 6:00 am

images3LU8KUQ0I was talking to a hospital facility manager recently and he was miffed that a surveyor cited him for not having emergency power lighting on the exit discharge outside the hospital. He has been at this hospital for nearly 30 years and takes any deficiency as a personal affront to his abilities as a facility manager. Besides, he told me, this has never been a problem before so why is it a problem now? (I hear that a lot!)

Section 7.8.1 of the 2000 Life Safety Code requires the exit discharge to be illuminated all the way to the public way. Sections 18/ requires emergency lighting in accordance with section 7.9, which requires emergency power for illumination of the exit discharge to the public way. The definition of public way is:

“A street, alley, or other similar parcel of land essentially open to the outside air deeded, dedicated, or otherwise permanently appropriated to the public for public use and having a clear width and height of not less than 10 feet.”

Under most interpretations from the accreditation organizations, the parking lot of a hospital can be considered to meet the requirements of a public way, even though it may not be “deeded to the public”. So, the path of the exit discharge to the parking lot would need to have illumination that is fed from normal power and emergency power. But the illumination for the parking lot would not have to be emergency power illumination, since the requirement is to have emergency power illumination only to the public way, not at the public way. This is a generalized interpretation, and it may or may not apply to all situations. You need to determine before your next survey if your exit discharge lighting meets this requirement.

Also, the illumination source needs to be arranged so the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candles. This means you need two-bulb fixtures, or multiple single-bulb fixtures. The issue of LED fixtures is an interesting one. Technically, a LED fixture is comprised of many LED lamps, so I could see a single LED fixture as qualifying as a multiple lamp fixture. I haven’t heard of any authority say anything to the contrary, at least.

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Sep 04 2014

Exit Sign Monthly Inspections

Category: BlogBKeyes @ 6:00 am

Access Control Locks WEb 2Why is it that hospital facility managers are often surprised when surveyors ask to see the documentation that their exit signs were inspected on a monthly basis? Probably because no one has ever asked to see that documentation before. If that is the case, then the facility manager appears to be preparing for a triennial survey based on the results of the previous survey, which is a dangerous strategy to follow.

Section 7.10.9 of the 2000 Life Safety Code requires exit signs to be inspected monthly to ensure that the sign is in fact illuminated. This inspection can be done when the exit sign is illuminated by normal power or emergency power, but is not required to be checked under both sources of power. The inspection is to ensure the sign is illuminated, and the lamps inside the sign are not burned out, or the circuit is not de-energized.

Some facility managers try to argue this requirement away by saying their exit signs are LED and therefore the lamps never burn out. Well, LED lamps do burn out, but it just takes forever to do it. Unfortunately, the 2000 LSC does not have an exception to NOT inspect exit signs for illumination if they are equipped with LED lamps.

Perhaps facility managers are surprised when surveyors ask to see the exit sign inspection documents because The Joint Commission does not have a specific standard or EP that addresses the issue. That does not mean a Joint Commission surveyor cannot ask to see that documentation, though. But Joint Commission is not the only authority that hospitals have to be concerned with. How about CMS; or their state health departments; or the local fire inspector; or their insurance company? Surveyors for those entities could very well ask to see that documentation.

If you are not already inspecting your exit signs on a monthly basis for illumination, then I suggest you get started. Develop a monthly PM work order that has your maintenance staff or security staff looking at each exit sign, and recording whether or not it passed or failed its inspection.

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