Jan 30 2018

Category: Blogcreekside @ 10:21 am
Share


Jun 15 2018

Non-Patient Care Electrical Equipment

Category: BlogBKeyes @ 12:00 am
Share

Q: What required inspections are needed for non-patient care electrical equipment and at what intervals should they be completed in. I cannot find anything definitive in NFPA 99 – 2012.

A: CMS will expect that you conduct the maintenance activities (i.e. PM’s) as recommended by the manufacturer, for all electrical equipment regardless if it is considered patient care or non-patient care equipment. In addition, this electrical equipment must be on the facility’s inventory of equipment.

This is based on CFR §482.41(c)(2) which is also known as A-0724 in the State Operations Manual (SOM) Appendix A. This document is available at no charge by searching “CMS SOM Hospitals”. Since it is a CMS standard, then all of the accreditation organizations and state agencies must have standards that are equal to that.

So, the answer to your question is: Whatever the manufacturer recommends, you must comply. And this is based on a CMS requirement, not an NFPA 99 requirement.

CMS does offer an Alternative Equipment Management (AEM) program that would allow you to conduct PM activities that differ from the manufacturer’s recommendations, but there are a lot of challenges to this AEM program and it is not for everyone. You can read all about it in CFR §482.41(c)(2).

Tags:


Jun 14 2018

Strange Observations – Part 30

Category: BlogBKeyes @ 12:00 am
Share

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

This picture is a cousin to last week’s picture…. you have a ball valve in the sprinkler supply line and there are no tamper switches.

Also, the clean linen on the left appears to be too close to the sprinkler deflector… a minimum of 18-inches clearance must be maintained.


Jun 13 2018

Elevator Shaft Construction

Category: BlogBKeyes @ 12:00 am
Share

Q: We have a hospital that was built in 2008. We believe there is an elevator construction issue. When they built the elevator shafts they put smoke detectors inside at the top but no sprinklers. On the three exterior sides of the shaft (non-door side) they have cinder block wall. On the interior wall (door side) they have some cinder block construction but they also have in sporadic places two pieces of plywood with glue creating a 2-hour fire rated wall. The other issue is in between the glue there are holes or air pockets. Is this acceptable to use plywood to create a 2-hour fire rated wall or does it have to be cinder block top to bottom? Our construction type is Type II (222) and the elevator shaft serves 8 stories.

A: No… it is not acceptable to use plywood as part of the construction of a 2-hour fire-rated wall. First of all, Type II buildings are not permitted to have combustible construction on their structural members. NFPA 220-2012, section 4.3.1 says Type I and Type II construction must be those types in which the fire walls, structural elements, walls, arches, floors, and roofs are of approved noncombustible or limited combustible materials. Plywood is combustible, even if it is fire-retardant. So, the plywood has to go, and must be replaced with non-combustible materials in order to complete the 2-hour fire rated elevator shaft. NFPA 13 does not require sprinklers in a non-combustible elevator shaft that does not use hydraulic fluids. Assuming it is a traction elevator (i.e. cables and pulleys), then the elevator shaft is not required to be sprinklered. But to answer your question, the plywood is a problem and should not be there.

Tags: ,


Jun 12 2018

Dead-Bolt Locks on Entrance Doors

Category: BlogBKeyes @ 12:00 am
Share

Q: A while ago, you made a posting that said a deadbolt lock on a door in the means of egress (such as an aluminum-framed glass sliding door at the entrance of the hospital) would be permitted as long as the door is not a fire-rated door and has no other releasing devices such as a lever, knob or crash-bar. I do not believe that is true, as a deadbolt lock with a thumb-turn should not be permitted in the mean of egress. Please advise…

A: After reconsideration, I believe you are correct. I looked up the commentary under 7.2.1.5.10 in the 2012 LSC Handbook, and it says this about the releasing device on the door:

“Examples of devices that might be arranged to release latches include knobs, levers, and bars. This requirement is permitted to be satisfied by the use of conventional types of hardware, whereby the door is released by turning a lever, knob, or handle or by pushing against a bar, but not by unfamiliar methods of operation, such as a blow to break glass…. The operating devices should be capable of being operated with one hand and should not require tight grasping, tight pinching, or twisting of the wrist to operate.”

It is rather obvious that a standard deadbolt lock with a thumb-turn device does require a tight grasping, twisting of the wrist to operate. So, I agree with you that it would not be permitted in the arrangement as described.

Thanks for bringing this to my attention… I do apologize for the confusion and misinformation.

Tags:


Jun 11 2018

Stairwell Exit Locked Door

Category: BlogBKeyes @ 12:00 am
Share

Q: Can a stairwell door that leads to the outside of a hospital be locked with a lock that requires a code to unlock it? I seem to recall that the doors could be on magnets that release upon activation of the fire alarm and that have a touch pad that releases the doors within 15 seconds.

A: No… it can’t. According to 19.2.2.2.4 of the 2012 LSC, doors in the means of egress must not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted as follows:

  • Delayed egress locks (7.2.1.6.1)
  • Access-control locks (7.2.1.6.2)
  • Elevator lobby locks (7.2.1.6.3)
  • Clinical needs locks (19.2.2.2.5.1)
  • Specialized protective measure locks (19.2.2.2.5.2)

I don’t know where in the hospital this stairwell exit door is located, but let’s assume it does not qualify for clinical needs locks (psychiatric care patients), specialized protected measure locks (OB, Peds, Nursery, ICU, ER), and elevator lobby locks. That leaves delayed egress locks, which requires the entire building to be sprinklered, and access-control locks which do not lock the door in the path of egress, just in the path of ingress, neither of which allows the use of key-pads to unlock the door in the path of egress.

If you decide to use one of the approved exceptions for door locking, please make sure you read the appropriate section of the Life Safety Code and comply with everything it requires. Most surveyors are pretty well informed on the LSC requirements for door locks and they will hold you accountable.

Tags: ,


Jun 08 2018

Medical Gas Shutoff Valves

Category: BlogBKeyes @ 12:00 am
Share

Q: As a hospital security assessor, I am concerned about the availability of hospital gases in Behavioral Health Units. It would be easy for a patient to pull the tab off the plastic covering on the window and tamper with the gases. Would it be permissible to install a clear locking door with hardened glass in place of the plastic panel and provide access to the locked box via scan card with the caveat that the door would automatically unlock open during a fire event?

A: One has to ask why would there be medical gases on a behavioral health unit? Do you treat acute-care patients there? However, if you have them there, then you need to deal with them.

Your question appears to address the medical gas shutoff valves, or zone valves as they are often called. According to NFPA 99-2012, section 5.1.4.8, zone valves have to be visible, accessible and readily operable from a standing position in the corridor. NFPA 99-2012 does not prohibit the use of special locking arrangements for access to the zone valves.

I think you have a legitimate concern, especially if you document this concern in a risk assessment. But I suggest you contact your authorities having jurisdiction, and ask them if it would be permitted. At a minimum, I suggest you ask:

  • Your accreditation organization
  • Your state agency in charge of hospital design and construction
  • Your local building authorities
  • Your state or local fire marshal

Tags: ,


Jun 07 2018

Strange Observations – Part 29

Category: BlogBKeyes @ 12:00 am
Share

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

Ugh. How did this ever get installed?

All sprinkler control valves are required to have tamper switches.

I suspect this is a single sprinkler head taken off of the domestic water line for a remote space. But even still, you have to have sprinkler control valves that have tamper switches.


Jun 06 2018

Monthly Fire Pump Test

Category: BlogBKeyes @ 12:00 am
Share

Q: I have always tested my fire pumps on a weekly basis, but now I’ve heard from a consultant there is a new standard that says only a monthly run is required. Is this true?

A: Yes, it is. With the adoption of the 2012 Life Safety Code, the 2011 edition of NFPA 25 is now the standard to use regarding inspection, testing and maintenance of sprinkler systems. Section 8.3.1.2 of NFPA 25-2011 now allows electric-motor driven fire pumps to be tested under no-flow conditions on a monthly basis rather than weekly, which was required under previous editions of NFPA 25. However, engine-driven fire pumps still must be tested weekly.

Tags: ,


Jun 05 2018

Inpatients in Outpatient Locations

Category: BlogBKeyes @ 12:00 am
Share

Q: Back in June of 2017, you posted an article about “Inpatients in Outpatient Locations”, but I am unable to access that posting. Can you re-post that article as I am interested in what you have to say about inpatients being treated in outpatient areas.

A: Yeah… I pulled that posting from my website because it had inaccurate information in it. That was an “Oops” on my part. I believe in my original posting (which is now gone) I said it was not permitted to take inpatients out of a healthcare occupancy, into an adjoining ambulatory healthcare occupancy or an adjoining business occupancy for treatment or exam. I based this thought on CMS’ position that one or more outpatients in an ASC requires the ASC to be classified as an ambulatory healthcare occupancy, instead of the four-or-more that NFPA says. For some reason, I thought this carried over to non-ASC ambulatory healthcare occupancies, which I found out it does not.

So, to be sure, section 19.1.3.4.2 of the 2012 LSC does say ambulatory care facilities, medical clinics, and similar facilities that are contiguous to healthcare occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. But the key point here, is the inpatients must be capable of self-preservation. This means they are capable of getting up out of the wheelchair or off of the gurney under their own power and exit the building without assistance from others. Most inpatients in a healthcare occupancy (at least the traditional hospital and nursing home healthcare occupancy) are not capable of self-preservation. So be extra careful by ensuring staff only take those inpatients that are capable of self-preservation into adjoining non-healthcare occupancies for treatment or exam.

I apologize for the confusion and misinformation.

Tags:


Jun 04 2018

Addressable Fire Alarm Systems?

Category: BlogBKeyes @ 12:00 am
Share

Q: Are you aware of any accrediting organization requiring the hospital to have an addressable fire alarm system installed? If so, what organizations? Please explain the rationale and any supporting code behind this decision. Background: A hospital currently has a fully functional zone fire alarm system installed but heard that accrediting organizations are requiring addressable systems. In my review of NFPA 101 2012, I cannot find anything in chapters 18 or 19 that would differ from the 9.6 reference to NFPA 72 2010.

A: There is no NFPA Life Safety Code requirement for you to have an addressable fire alarm system. There is a requirement that the hospital have a fire alarm system that meets the requirements of 19.3.4 of the 2012 LSC, but that does not include being an addressable system. As far as I know, Joint Commission, HFAP, and DNV do not require an addressable fire alarm system, and CMS does not require an addressable fire alarm system.

Now, a state or local law may exceed the NFPA minimum and require an addressable fire alarm system, but you would have to check with your state and local authorities to find that out.

Tags:


Next Page »