Aug 28 2014

Comments on Corridor Clutter

Category: BlogBKeyes @ 6:00 am

Randy Snelling, the Chief Physical Environment Officer, for DNV-GL Healthcare Inc. spoke at the recent ASHE annual conference in Chicago, and I thought his views on corridor clutter were worth repeating here…

“I read in the ASHE magazine recently an article written by a surveyor who listed the top 5 findings he saw during a survey”, says Snelling. “The first thing he identified was corridor clutter. I threw the magazine across the room. I thought, ‘Man, where are we? This is 2014 and we’re still talking about corridor clutter? Really? Come on!’ Why is corridor clutter still happening in hospitals? Because the senior leadership is not stepping in. The facility manager does not have the clout with those clinicians up on the floors where the corridor clutter occurs. But who does? Senior leadership. And if you’ve got corridor clutter problems, it’s not a life safety problem, it’s a ‘C’ suite problem. And our hospitals know it. I don’t think we’ve had a corridor clutter finding in over a year. Now, what happens? Well, we come in and the hospital makes an announcement overhead welcoming the DNV survey team, and everything gets moved out of the corridor. But that happens with everybody else too, with HFAP and TJC and CMS. So why are we seeing this? I think it is because since we are in the hospital every year our hospitals do not have as much to move out of the corridors as other accredited hospitals. This ends up being a problem with Leadership rather than a problem with the facility manager.”

I consider Randy to be a friend and we talk frequently about accreditation issues. I think his view on corridor clutter on the nursing units is spot on, in that senior leadership needs to back the facility manager (or safety officer) on Life Safety Code issues that are out of their capability. Having been a Safety Officer at a hospital for years I can relate to this problem. I rarely felt the support from the ‘C’ suite and felt I had to struggle with certain basic life safety requirements (such as corridor clutter) on my own.

I did eventually take a different approach by spending time on the nursing units observing the nurses day-to-day operations. This made me realize their needs better and they eventually saw me as one who wanted to help, rather than the enemy who was always telling them to move their equipment out of the corridors. I was able to apportion capital funds to build alcoves in certain locations, and they in turn kept the corridor free from clutter.

But most hospitals probably still struggle with corridor clutter issues and without the senior leadership stepping in and backing the facility manager by insisting items be stored in alcoves and storage rooms, this problem will not go away. I predict it will get worse when the 2012 Life Safety Code is finally adopted, since the new LSC allows certain unattended items to be placed in corridors that are at least 8 feet wide. That will create a struggle for everyone as most staff will not understand what pieces are permitted and what pieces are not permitted.

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Aug 21 2014

Comments on Electronic Documentation From a State Inspector

Category: BlogBKeyes @ 6:00 am

I never know who is reading (or not reading) my blog, but recently I received the following comment from a state department of public health individual who inspects hospitals. He had this to say concerning my recent article on electronic documentation:

On your article for electronic documentation, our finding is the documentation will have to have  all the pertaining information required. I do not accept any electronic documentation on a survey, such as TELS, in replacement of the documentation provided by the inspection company for sprinklers, fire alarm, or any other entity required to perform quarterly, semi annual, or annual inspections. For internal items by qualified personnel such as generator testing, emergency lighting testing, emergency evacuation/fire drills or monthly smoke detection inspection/testing, I do accept electronic versions if they contain all the elements such as those you noted in your article. It has been brought to my  attention on many surveys that some of the larger facilities who work between different states are suggesting to their maintenance personnel that they do strictly electronic entries and not keep hard copy records. My response is always the same: “It depends”. Whomever is the AHJ for the locale, region, or state will be the one to make that determination.

I appreciate his insight and comments. If you similarly have comments on any of my articles or Q&As, please feel free to send me a note.


Aug 14 2014

Corridor Doors vs. Cross-Corridor Doors

Category: BlogBKeyes @ 6:00 am

Cross Corridor door web 2I have seen many facility managers (and surveyors for that matter) incorrectly refer to a door as a ‘corridor door’. It appears that they believe as long as the door is accessible from the corridor, then it must be a corridor door. That is not always the case, but it is understandable as corridor doors may be confusing.

A corridor door is a door that separates a room from a corridor, and they are usually mounted parallel to the corridor. Corridor doors are often found on entrances to patient rooms, utility rooms, offices, dining rooms, and the like. Corridor doors are often (but not always) a single-leaf door.

A cross-corridor door is a door that separates a corridor from another corridor, and they usually are mounted perpendicular to the corridor. They are typically used as privacy doors, smoke compartment barrier doors, and fire-rated doors in a horizontal exit or an occupancy separation. Cross corridor doors are usually (but not always) double-leaf doors, and if considered new construction, must be double egress, meaning one leaf swings in one direction and the other leaf swings in the opposite direction.

In reviewing accreditation organization survey reports, I have read where surveyors often refer to ‘corridor doors’ when they really mean something else. According to the Life Safety Code, a corridor door is not required to have a self-closing device (closer), unless it also doubles as a door to a hazardous room, a smoke compartment barrier door, or a fire-rated door. Also, a corridor door must latch, while a smoke compartment barrier door does not have to latch. If a door serves more than one purpose, then the most restrictive requirements must apply.

When referring to the many different types of doors that are accessible from the corridors, always refer to them by their most restrictive requirements:

  • Fire-rated doors to hazardous rooms, exit enclosures, horizontal exits, and occupancy separations
  • Smoke compartment barrier doors
  • Corridor doors to hazardous rooms, or non-hazardous rooms
  • Privacy doors

A privacy door that is a cross-corridor door is not required to latch, or be self-closing; but a privacy door that is a corridor door would be required to latch, since the requirements for a corridor door are more restrictive.

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Aug 07 2014

Missing Ceiling Tiles

Category: BlogBKeyes @ 6:00 am

Missing Ceiling Tiles Web 3Most healthcare organizations have acoustical tile and grid suspended ceilings in a large part of their facilities. They are relatively inexpensive, and allow access to the many mechanical systems that are located above the ceiling. So, why is their such a fuss about a missing ceiling tile, or gaps in the ceiling?

The reason why is the ceiling is an integral part of the smoke detection system and the sprinkler system. When a fire occurs, the smoke and heat rises until it meets the ceiling, then the smoke and heat travels horizontally until it encounters a smoke detector or a sprinkler head. If there is a missing ceiling tile, then the smoke and heat will rise up through the hole where the tile was located and fill up the space above the ceiling before it attempts to activate a detector or sprinkler. This impairs the ability of the smoke detector and the sprinkler head to function and surveyors will likely cite the organization.

Likewise, if the ceiling has broken tiles, or misaligned tiles, or gaps greater than 1/8 inch caused by anything (such as data cables temporarily run up through the ceiling), this too is a problem that surveyors will likely identify.

 However, a missing ceiling tile or a cracked tile with gaps greater than 1/8 inch are not Life Safety Code violations if the room or area does not contain sprinklers or smoke (or heat) detectors. Technically speaking, there is no impairment with a missing ceiling tile if there are no sprinkler heads or smoke detectors present. Now, there may be an Infection Control issue since the space above the ceiling is typically very dirty, but to be sure, it is not a violation of the NFPA codes and standards.

Ceiling tiles often become stained or damaged from water leaks, and maintenance staff typically remove the tiles before they fall to the floor. It is imperative that a ceiling tile is replaced as soon as the leak is repaired, even if you don’t have the correct ceiling tile in stock. Use any tile to prevent an impairment to sprinklers and smoke detectors.

Make sure you access your facility for any missing ceiling tiles or cracked tiles with gaps larger than 1/8 inch.


Aug 05 2014

Research for an Article

Category: BlogBKeyes @ 6:00 am

imagesJCU1DVQ4I would like to do some research for an article that I want to write about and I am addressing this appeal to those of you who have an active role in a facilities management department (or related department) in a hospital.

I am interested in learning what surveyors are looking for and finding in respect to sprinkler inspection, testing and maintenance at your facility. As you know, NFPA 25 is the primary document for inspection, testing and maintenance for water-based sprinkler systems and it appears that not all of the accreditation organizations (AO) are enforcing it the same way. Many of you are Joint Commission accredited and some of you are HFAP or DNV accredited. It would be interesting to learn if there are differences between the AOs, and if there are, what those differences may be. Also, if you recently had a CMS validation survey performed by a state agency, I would be interested in learning what they identified as well.

There is a form that you can use as a comparison tool that identifies what NFPA 25 (1998 edition) actually requires for inspection, testing and maintenance of water-based sprinkler systems. This tool is located under the “Tool” heading, and then search under the “Life Safety Document Review Session” heading. It would be interesting to find out if there is anything on the form that the surveyors decided not to ask to see documentation of compliance. Feel free to use it as a tool comparing it with your AO / state agency survey experience.

So, if you are interested in participating, please respond back to me at:   with your comments on what the surveyors/inspectors identified on your survey deficiency report as well as what they stated unofficially, in regards to inspection, testing and maintenance of your water-based fire protection system. I will keep your comments anonymous in the article unless you grant me permission to quote you.

If possible, I would like your reply by August 18, 2014.

Thank you…..

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Jul 31 2014

Smoke Compartment Barrier Door Gaps

Category: BlogBKeyes @ 6:00 am

Smoke compartment barrier doorsI want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor doors that are not fire-rated or used in a smoke compartment barrier are permitted to have gap clearances up to ½-inch in smoke compartments that are protected with sprinklers. In this memo they have conflicting points; the subject line of the memo stated: “Permitted Gaps in Corridor Doors and Doors in Smoke Barriers”, but in the content of the memo they say “This information does not apply to doors in smoke barriers, which have other requirements.”

Click on this link to access this CMS memo:

To be clear, the maximum gap for the proper clearance of smoke compartment barrier doors is 1/8 inch; not ½ inch, and it is not dependent on whether or not the smoke compartment is sprinklered. Sections 18/ of the 2000 LSC references section 8.3.4 of the same code and the Annex section of says the maximum gap for smoke compartment barrier door clearances is 1/8 inch.

The CMS memo addressed corridor doors that are not fire-rated or located in a smoke compartment barrier. Corridor doors are those doors which separate a room or an area from the corridor. Can a corridor door also be a fire-rated door or a door in a smoke compartment barrier? Yes, certainly; and in those situations the more restrictive requirements must apply.

The bottom line: Doors in smoke compartment barriers must not have gap clearances that exceed 1/8 inch per the 2000 LSC. The CMS S&C memo 07-18 only applies to non-fire-rated corridor doors that are not located in a smoke compartment barrier.

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Jul 24 2014

New vs. Existing Conditions

Category: BlogBKeyes @ 6:00 am

10100[1]At times we struggle to decide when do new construction requirements (chapter 18 of the LSC) apply and when do existing conditions (chapter 19 of the LSC) apply. CMS seems to go on the principal that anything constructed on or before the date that they adopted the latest edition of the LSC will be considered existing, and anything constructed after the date they adopted the LSC will be considered new. For the current 2000 edition of the LSC, that date is March 11, 2003.

But the Annex section of 1.4 in the 2000 LSC specifically says anything designed to meet the requirements of a prior edition of the LSC must be required to meet those conditions for the life of the building. So, if a previous edition of the LSC (such as the 1985 edition) required a new hazardous room to be sprinklered and protected with 1-hour barriers, then that room must be maintained with sprinklers and 1-hour barriers for the life of the room, and does not qualify for the less restrictive smoke resistant barriers for an existing hazardous area in the 2000 edition of the LSC. This can get confusing, because one does not always know when a hazardous room was created. Also, there are other examples such as smoke compartment barrier construction, and corridor door latching that can apply to this requirement as well.

As a default, many (but not all) authorities having jurisdiction will follow CMS’s lead and use the date March 11, 2003 as a general date to determine new vs. existing when they do not have prior knowledge of when a feature of life safety was constructed or what was required by prior editions of the LSC. Accreditation organizations do not expect their surveyors to spend much time during a survey to research when a feature of life safety was constructed, but if this information is provided for them, here is how they may interpret the LSC:

Research shows that CMS adopted the 1967 edition of the LSC in 1971, and then the next update was the adoption of the 1985 edition in 1988. Then, as mentioned, the next update was the adoption of the 2000 edition on March 11, 2003. For now, we have prior knowledge on the following issues:

Hazardous Areas

The 1967 LSC required new construction hazardous areas to be either 1-hour fire rated or protected with automatic sprinklers; not both. The 1985 LSC similarly said new construction hazardous areas could be either 1-hour fire rated or protected with sprinklers, but did specify that certain rooms had to have both. Therefore, it is possible that certain hazardous rooms constructed prior to March 11, 2003 did not have to be both 1-hour fire rated and be protected with sprinklers, while certain other hazardous rooms did.

So, for purposes of assessing compliance with the 2000 LSC, if the hazardous room is one of the following, then the date to decide if new or existing requirements apply is March 11, 2003:

  • Boiler room and fuel-fired heater room
  • Laundry rooms greater than 100 square feet
  • Repair shops

However, if the hazardous room is one of the following, then the date to decide if new or existing requirements apply is January 1, 1988:

  • Soiled linen rooms
  • Paint shops
  • Trash collection rooms
  • Rooms greater than 50 square feet used for the storage of combustibles

Smoke Compartment Barriers

The 1967, 1985, and the 2000 editions of the LSC require new construction smoke compartment barriers to be 1-hour fire rated with non-fire-rated doors. The 2000 LSC allows existing smoke compartment barriers to be 30-minute fire rated. Therefore, for the purpose of assessing compliance with the 2000 LSC the date to decide if new or existing requirements apply is January 1, 1971. Every smoke compartment barrier constructed on or after January 1, 1971 must meet new construction requirements, and constructed to 1-hour fire rated, with non-fire-rated doors.

Corridor Latching

The 1967, 1985 and the 2000 editions of the LSC require new construction corridor doors to be positive latching. The 2000 LSC allows existing corridor doors to be held shut with a device capable of keeping the door closed with a force of 5 foot-pounds. Therefore, for the purpose of assessing compliance with the 2000 LSC the date to decide if new or existing requirements apply is January 1, 1971. Every corridor door constructed on or after January 1, 1971 must meet new construction requirements and have positive latching hardware.

Again; most accreditation organizations do not expect their surveyors to spend much time figuring out when a particular hazardous room, smoke compartment barrier, or corridor door was constructed. But, if the hospital is claiming existing conditions on these issues, and they provide a date of construction which is inconsistent with the above stated dates, then an issue may exist whereby you may not qualify for existing conditions.


Jul 18 2014

Register Your Wireless Medical Telemetry Band Devices With ASHE

Category: BlogBKeyes @ 6:00 am

ASHE[1][The following information is taken from an online ASHE Advocacy notice, published July 17, 2014, and reprinted here for your information.]

The Federal Communications Commission (FCC) has issued a Report and Order that will result in TV Channel 37 being available for use by unlicensed devices. To protect your Wireless Medical Telemetry Service (WMTS) devices, it is essential to be registered with ASHE.

All hospitals using WMTS devices must be registered with the American Society for Healthcare Engineering. Hospitals that fail to register devices are at risk for harmful interference to the operation of their wireless medical telemetry equipment.

The FCC requires registration before an organization operates a WMTS system in the TV Channel 37 band (and in the upper bands of 1395-1400 MHz and 1427-1432 MHz). If a WMTS system is not registered, the FCC considers it to be unlicensed and not entitled to protection from interference caused by other transmitters.

In June, the FCC issued the Report and Order that will result in TV Channel 37 being made available for use by new unlicensed devices. This action may cause harmful interference to unregistered WMTS devices operating on TV Channel 37 (608–614 MHz). The FCC feels that technical parameters can be developed to protect registered WMTS users from this interference, but this protection will be available only to registered WMTS systems.

ASHE is the designated WMTS coordinator and maintains a dataset of WMTS users for the FCC. ASHE will also assist with development of technical parameters to maximize protection for registered WMTS users.

If your hospital operates WMTS devices, make sure your facilities are registered with ASHE by taking the following steps:

  • Share this advisory with your clinical and biomedical engineering professionals, critical care physicians, nursing staff, and risk managers.
  • Check to confirm that your hospital is registered.
    • If your hospital is not registered, register your WMTS equipment now.
    • If your hospital is registered, verify that the equipment and locations listed in the database are accurate and complete.
  • For more information, visit

The American Hospital Association (AHA) and ASHE will continue to work closely with the FCC and FDA to ensure that interference does not compromise patient care and safety.

If you have questions, please contact ASHE Engineering & Compliance Director John Collins at or 312-422-3805.

Jul 17 2014

Follow-Up on Documentation

Category: BlogBKeyes @ 5:00 am

imagesIDI1GACXMy recent series of articles on Documentation created quite a bit of response. One individual had this question:

“What is your opinion of documentation being kept electronically rather than in hard copy format?  We will have things organized and easy to find and search, but I don’t want to go through the process of electronic files if a surveyor is going to request hard copies.”

My understanding is most authorities will accept electronic documentation provided it meets all of the requirements for documentation. Many AHJs have specific requirements concerning what’s included in the documentation, such as:

Testing & Inspection- Documentation.

Unless otherwise stated, testing, inspection and maintenance documentation must include, at the minimum, the following information:

  1. Name of individual performing the activity
  2. Affiliation of the individual performing the activity
  3. The signature of the individual performing the activity
  4. Activity name
  5. Date(s) (month/day/year) that activity was performed
  6. The frequency that is required of the activity
  7. The NFPA code or standard which requires the activity to be performed
  8. The results of the activity, such as ‘Pass’ or ‘Fail’

An electronic signature typically would be acceptable in lieu of a hand-written signature. That usually means the technician performing the work would have to enter the data in order to create the electronic signature. Most authorities would not accept an electronic signature from a data-entry person in lieu of the technician performing the work. Most authorities also would not accept a data-entry person issuing an electronic signature of another individual, such as a jpg picture of a signature. However, pdf copies of documentation with all of the above requirements is acceptable. Essentially, it would be similar to a photo-copy of a report.

There are stories of the data-entry person not being present during the survey and they were the only one with the passcodes to access the data, or with the knowledge on how to retrieve the data. I also witnessed a situation where weekly reports were turned into a clerical person to enter the data into the computer. The clerical person allowed the reports to accumulate and the data was not entered during the week that the test/inspection was performed. The data-entry person used the ‘default’ date stamp provided by the software platform when the data was entered, which effectively said the test/inspection was not performed during the required time-period.

It is difficult to attach follow-up reports to electronic copies, such as ILSM assessments or repair work orders to a particular LSC deficiency. With paper files, they can easily be inserted into a binder or a folder.

Bottom line: Electronic documentation is permitted, but most hospitals realize the risks do not out-weigh the rewards. I am not a fan of electronic documentation because I have witnessed the problems with using them. But as with all technology, time is needed to work out the problems and make improvements. I’m an old man, and perhaps the younger generation has already implemented solutions to this problem.

I welcome your feedback on the use of electronic documentation.

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Jul 10 2014

Kitchen Hood Fire Suppression System

Category: BlogBKeyes @ 5:00 am

imagesWAHA2STKThe fire suppression system that is required to be mounted in kitchen cooking hoods is typically a wet-chemical extinguishing system that automatically releases the extinguishing agent when the system detects a fire. Back in the early 1990’s the common system used then was a dry-chemical system but was found to be ineffective in extinguishing certain cooking-oil based fires. While NFPA, CMS and the Accreditation Organizations has not prohibited the use of dry-chemical extinguishing systems in kitchen cooking hoods, most state authorities have. There was a major undertaking in the fire extinguishing industry to replace all dry-chemical system with the better suited wet-chemical systems.

 The kitchen hood fire extinguishing system is required to be maintained semi-annually and the fusible links replaced annually. However, the owner’s representative (i.e. facility manager) is required to perform monthly inspections of the cooking hood extinguishing system. These requirements can be found in NFPA 17A, 1999 edition (for wet-chemical systems), and at a minimum, the quick check inspection must verify:

  • The extinguishing system is in its proper location
  • The manual actuators (pull stations)  are not obstructed
  • Tamper seals are intact on the pull station
  • The semi-annual maintenance tag is clearly visible and in place
  • There is no obvious physical damage or condition that would prevent operation
  • The pressure gauge is in the operable range
  • The nozzle blowoff caps are intact and undamaged
  • The hood, duct, and protected cooking appliances have not been replaced, modified or relocated

A record of this monthly inspection is required to be maintained, and is usually documented on the semi-annual inspection tag tied to the manual pull station that activates the system.

One of the lessor-known items that surveyors like to do during the building tour is interview a kitchen staff individual who works near the cooking hood, on whether or not they have received training on the correct operation of the hood extinguishing system. Another question surveyors like to ask is where does the kitchen staff individual go to manually activate the extinguishing system? A negative answer on either question will likely result in a finding under a staff fire safety training standard.

Take a look at NFPA 17A (1999 edition) and make sure you are doing two basic things:

  1. Conduct monthly inspections of all cooking hood suppression systems.
  2. Train all kitchen staff on the correct operation of the cooking hood suppression system.

Also, make sure the extinguishing system is being maintained on a semi-annual basis.

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