Sep 23 2015

Heat Detector Spacing From an Air Diffuser

Category: BlogBKeyes @ 12:00 am

Heat Detector imagesALEXIFM2A reader recently asked me where in NFPA 72 does it say that heat detectors have to be a minimum of 36 inches away from an air diffuser. He could not find the standard reference and asked if I could point him in the right direction.

Well…. I think he had a point, since there is no requirement in NFPA 72 that says heat detectors have to be 36 inches away from air diffusers. Section 2-3.5.1 and section A-2-3.5.1 of NFPA 72-1999 says spacing for detectors from air diffusers (supply and return) must be 3 feet. This section (NFPA 72 2-3) is referring specifically to smoke detectors, and section NFPA 72 2-2 refers specifically to heat detectors and there is no similar language in section 2-2 concerning minimum distance from air diffusers for heat detectors.

Therefore, one can conclude that heat detectors do not have to comply with the 3 foot spacing from air diffusers like smoke detectors. But that is not how all of the AHJs interpret this. The actual spacing (3 feet) for smoke detectors is found in the Annex section of the standard which is explanatory information and not part of the enforceable standard. But AHJs are free to use this information in the Annex section in determining compliance with the standard. Therefore, AHJs can interpret this section how they want, and many of the AHJs interpret that you need to maintain 3 feet from air diffusers for both smoke and heat detectors.

If you get cited, you can fight the finding by pointing out the reference in the Annex section is only for smoke detectors, but ultimately the AHJs get to interpret this the way they want, and you may end up losing anyway.

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Jun 11 2015

Clarification on Oxygen Cylinder Finding

Category: BlogBKeyes @ 12:00 am


images[5] (2)My good friend Gloria Legere shared the following clarification that she wrote for a client hospital. The finding by the surveyor read:


There were full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock.

Gloria’s clarification read:

The report of survey findings cited that at the xxx location, “there were full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock”.

NFPA 99-1999 section 4-, which parallels the accreditation organization  standard, requires that gas cylinders should be stored in such a way that staff retrieving them in a hurry will not have to make a decision about which cylinders are full and which are not.  The accreditation organization published an article that cautioned hospitals to make sure full and partial or empty cylinders are physically separated to prevent staff confusion when retrieving a cylinder during an emergency.

The Hospital’s policy on storage of medical gas cylinders follows the requirements set forth by the NFPA and the accreditation organization for the storage of medical gas cylinders, however, the requirements of both the NFPA and the wording from the accreditor’s article cited, stress that the delineated storage requirements are to “prevent staff confusion when retrieving a cylinder during an emergency”.

The findings cited from our triennial survey indicate “full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock”.  The cylinders located on the loading dock are not ‘in storage’ for patient use.  The cylinders, located on the loading dock area, are in a state of flux of shipping and receiving; either being delivered or retrieved by the delivery company or are overflow of product that exceeds the storage capabilities within the hospital. The cylinders are not accessible by staff caring for patients and patient care is never delivered in this area. Once the cylinders are brought into the hospital for use, the cylinders are appropriately stored in the designated racks in the patient care areas which differentiate by both location and signage separating the full cylinders from in-use/empty cylinders so that there would never be confusion by staff when retrieving oxygen cylinders for use in emergency situations or daily need.

The reply from the accreditor:

The clarifying evidence was accepted for observation 1 based on the cylinders being located on the loading dock and not interior to the building 


So the lesson learned here is to know and understand the codes and standards you are being surveyed against. Surveyors try and do the best job that they can, but they are not the final authority on the interpretation of the standards. It would have been interesting to know what the surveyor would have done if the above documentation was presented during the survey. Would the surveyor accepted the issue on the spot or would the surveyor have continued to document the finding?

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Apr 30 2015

Fire Drills in an ASC

Category: BlogBKeyes @ 1:00 am

images0XCM788RI spoke at an Infection Control conference last week in St Louis, sponsored by the Excellentia Advisory Group. There were 13 different presentations made but mine was the only one that was not traditionally an IC subject matter. I was asked to make a presentation on how the Life Safety Code relates to Infection Prevention in the Ambulatory Surgical Centers. At first, I was reluctant to accept this speaking engagement because I was not sure how I was going to draw the connection between compliance with the Life Safety Code and how it actually impacts the Infection Prevention program in an ASC. But, I did accept the invitation and I researched the LSC and came up with a what I think was an interesting presentation.

Keep in mind, my audience was a room full of RNs who typically do not have any Life Safety Code compliance experience. So, I decided to take the approach that compliance with the LSC is just basic patient safety compliance, and identified many of the requirements that surveyors would be looking for.

At the end of my presentation I had time to take a few questions. One lady asked if they had to activate the building fire alarm system when they conducted a fire drill. I replied that yes, technically they would, since section of the 2012 LSC requires it. They said that is a problem since the ASC shares the building with other tenants who are not part of their healthcare network.

I replied that they had a few of options: 1) They could coordinate with all of the other tenants prior to the fire drill alerting them of the pending alarm. The other tenants could conduct their own drill at that time if they chose; or 2) They could investigate to see if the fire alarm control panel can bypass the occupant notification appliances in the other tenants during their drill; or 3) They could conduct a risk assessment that identifies the hardship involved in sounding the building fire alarm system and conduct the drill without activating the alarm. This would have to be reviewed and approved by the ASC safety committee, and possibly a surveyor would accept that.

I asked if they thought they could use one of those scenarios, and they thought #3 would be the only possible solution. I asked why, and they said there was a massage parlor directly above their ASC and they didn’t believe they could get the cooperation from them and all the other tenants so they could activate the fire alarm system when they conducted a fire drill each quarter. I replied that I thought they had a pretty good case for a risk assessment since nobody wanted to see clients from the massage parlor escaping down the stairs during a fire alarm.

Uhm… the strange things I see (or don’t see) in this business.

All-in-all, I thoroughly enjoyed my day at the conference and I got to meet many interesting people.

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Apr 09 2015

Let’s Take a Break…

Category: BlogBKeyes @ 1:00 am

images[3]Just a note today informing you I need to take a break from my regular blogs for a while. Due to an increase in workload, speaking engagements, a commitment to write another book (which I am way behind on), family obligations, spring cleanup around the homestead, and a bathroom that my wife says needs to be remodeled, I will not be posting any regular Thursday articles for a while. There will still be the Monday Q&As that we have all come to love.

I know that some of you have sent me questions that I simply have not had the time to respond to yet. I ask for your patience as I will eventually get to each one.

I appreciate your understanding.

Thank you…

Apr 02 2015

New vs. Existing Construction for Ambulatory Healthcare Occupancies

Category: BlogBKeyes @ 1:00 am

A reader asked me recently what the Life Safety Code differences were between a new construction ambulatory healthcare occupancy, and an existing construction ambulatory healthcare occupancy. I did not immediately know, so I took the time to research this and I was surprised to learn what the differences (or non-differences) were.

The differences between new construction and existing construction of ambulatory healthcare occupancies are not monumental, but rather subtle. According to the 2000 Life Safety Code, here are some comparisons:

Description Chapter 20 New Construction Chapter 21 Existing Construction
Construction Type No restrictions for 1 story facilities; Building of two or more stories limited to Type 1 (443), Type I (332), Type II (222), Type III (211), Type IV (2HH), Type V (111). Type II (000), Type III (200), and Type V (000) are permitted if the entire building is protected with sprinklers.  Same
Occupant Load 100 square feet/person Same
Special Locking Arrangements Only permitted on exterior doors Same
Clear Width of Corridor 44 inches Same
Travel Distance between room and exit 100 feet Same
Travel distance between any point in a room and exit 150 feet Same
Travel distance increased for sprinklered buildings 50 feet Same
Emergency Power from Generators as per NFPA 99 Required when general anesthesia or life-support equipment is used. Same
Hazardous Areas Must meet the requirements of 8.4 and be protected with sprinklers, or protected with 1-hour construction Same
Anesthetizing Locations Must be protected in accordance with NFPA 99 Same
Fire alarm systems Manually initiation required Same
Portable fire extinguishers Required Same
Sprinkler System Not Required Same
Corridors Openings in corridor walls such as mail slots and pass-through windows permitted in windows and doors provided the opening is not more than 20 square inches. The opening may increase to 80 square inches if the room is protected with sprinklers. No Restrictions/No Requirements
Subdivision of Building Space Ambulatory healthcare occupancies must be separated from other occupancies with 1-hour fire rated barriers with ¾ hour fire rated doors Same
Smoke Compartmentation The ambulatory healthcare occupancy must be divided in to not less than two smoke compartments. Facilities less than 5,000 square feet that are protected by a smoke detection system are exempt. Facilities less than 10,000 square feet and protected by sprinklers are exempt. Same
Smoke Compartment Size Not less than 15 square feet area (net) must be provided for every occupant in the ambulatory healthcare facility on either side of the smoke compartment barrier. Smoke compartments are limited to 22,500 square feet in size. Travel distance to reach a smoke compartment barrier doors must not exceed 200 feet. No Restrictions
Fire Drills Required quarterly on all shifts Same
Combustible decorations Prohibited, unless they are flame retardant Same
Portable Space Heating Devices Prohibited, unless the heating elements do not exceed 212°F and only used in non-sleeping staff and employee areas. Same



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Mar 19 2015

Stairwell Signage

Category: BlogBKeyes @ 1:00 am

In Case of Fire Web 2If you were a bit surprised by the wording of the sign to the left… You’re not alone. I had to do a double-take when I first saw it, as it certainly got my attention.

The sign is a marketing strategy by the Stairwell Signage Solutions company in Palm Beach Gardens, Florida, and is re-printed here with permission. The sign is an ominous warning to facility managers that their existing stairwell signage may not be compliant with the new 2012 Life Safety Code.

When the new 2012 LSC is adopted facilities will have to comply with the following requirements, found in section


  • New enclosed stairwells serving three or more stories and existing enclosed stairwells serving five or more stories must have stairwell identification signs (previously, the 2000 LSC only required stairwells serving five or more stories to have stairwell identification signs);
  • The stairwell must be provided with identification signs inside the enclosure at each floor landing;
  • The signage must indicate the floor level;
  • The signage must indicate the terminus of the top and the bottom of the stairwell;
  • The signage must indicate the stairwell name (identification);
  • The signage must indicate the floor level of, and the direction to, the exit discharge;
  • The signage must be located inside the enclosure approximately 60 inches above the floor landing in a position that is visible when the door is open or closed;
  • The signage must be continuously illuminated with emergency power back-up capability (this was not previously required);
  • The floor level designation must be tactile in accordance with ICC/ANSI A117.1 (this was not previously required);
  • The signage must be painted or stenciled on the wall or on a separate sign securely attached to the wall (this was not previously required);
  • The name of the stairwell must be located at the top of the sign in minimum 1 inch tall lettering (this was not previously required);
  • Stairwells that do not provide roof access must read ‘NO ROOF ACCESS’ underneath the name of the stairwell in 1 inch tall lettering (this was not previously required);
  • The floor level number must be located in the middle of the sign in 5 inch tall numbers (this was not previously required);
  • The identification of the lower and upper terminus of the stairwell must be located at the bottom of the sign in 1 inch tall lettering (this was not previously required).

The phrase ‘this was not previously required’ is referring to the 2000 LSC. If you would like to contact Stairwell Signage Solutions, contact Stephen Salzberg, at


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Mar 12 2015

Occupational Therapy Cooking Equipment

Category: BlogBKeyes @ 1:00 am

physical-rehab-lab[1]A reader recently inquired about a residential style stove/oven used in their new hospital for occupational therapy patients. He wanted to know if this residential style stove was required to have a commercial-style exhaust hood, complete with fire suppression equipment. He also wanted to know if the room where the stove was located was required to have smoke detectors and a Class K fire extinguisher.

A residential style stove/oven that is used for occupational therapy purposes is not a cooking appliance; it is therapy equipment. As long as only rehab patients are using the stove and staff does not use the stove for their personal use, the case can be made to a surveyor or an inspector that the equipment is not cooking equipment, and is not subject to meeting the requirements of section 9.2.3 of the 2000 LSC for fire suppression.

Also, section of the 2000 LSC says domestic cooking equipment that is used for food-warming or limited cooking does not have to be equipped with the fire suppression equipment required by section 9.2.3. Typically, the only residential style stove/oven appliance found in a hospital is located in the rehab/therapy unit and is used for occupational therapy; not food preparation. Whatever a patient would be doing at the stove would be considered ‘limited cooking’.

Also, section 9.2.3 of the 2000 LSC references NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (1998 edition), which is the standard for fire suppression for cooking hoods, only applies to commercial cooking equipment. A residential style stove/oven used for occupational therapy is not a piece of commercial cooking equipment, so based on that interpretation, NFPA 96 does not apply.

And, if those points don’t change the mind of an over-zealous surveyor, according to NFPA 96, fire suppression systems are not required in cooking appliances that do not produce grease laden vapors. The presumption is an occupational therapy patient would not be frying up a pound of bacon, or other food products that produce grease laden vapors. And if they are, then perhaps there should be some means to catch the grease laden vapors.

A Class K fire extinguisher would not be required to be mounted within 30 feet of the residential style stove/oven that is used for occupational therapy since it does not involve combustible cooking oils or fat. NFPA 10 (1998 edition) states Class K extinguishers are only required when there is a potential for fire from cooking oils and fats that are combustible. Again, the presumption is there would not be a deep fat fryer or other appliances that would use combustible cooking oils in the occupational therapy program.

There is no requirement for any smoke detectors in or around the room that contains the residential style stove/oven used for occupational therapy purposes. I would strongly suggest that there not be any detectors in this area, unless there are other reasons for them. Any smoke generated from burnt food may cause unwanted alarms.

I also suggested to the reader that he write up a risk assessment or a policy (or management plan) identifying the above points as evidence that their facility gave this some serious consideration, and have their Safety Committee review and approve it. If challenged by a surveyor, they could present their risk assessment, policy or management plan indicating that they’ve done their due diligence and the conclusion is the equipment does not have to comply with NFPA 96 for exhaust hood or fire suppression systems.

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Mar 05 2015

More on Temporary Construction Barriers

Category: BlogBKeyes @ 1:00 am

I received an email from a reader who described a problem with their temporary construction barriers. He told me the following:

During construction and renovation projects our hospital uses drywall for temporary construction barrier walls. Our contractors are very ruff on these walls and constantly put holes in them. Our contractors have asked us if they could begin using fire retardant plywood for our temporary construction barrier walls for purposes of increased durability. Our infection control department did not have any issues with this. Would the use of fire retardant plywood be acceptable to with the Life Safety Code to use as temporary construction barrier walls in our hospital?

Non-Negative Air Barrier Web 2This is one of those issues that everyone does not agree on. Some authorities having jurisdiction (AHJ) may permit it and some may not. But when offering advice on Life Safety Code compliance, one must consider what the actual language of the code and standards say, and any interpretations made by AHJs.

According to the NFPA codes and standards, fire resistant plywood is not an acceptable temporary barrier for construction. Take a look at of the 2000 LSC which requires compliance with NFPA 241 (1996 edition) during construction. Section 2-2 says the following:

“Only noncombustible panels or flame-resistant tarpaulins or approved materials of equivalent fire-retardant characteristics shall be used.”

Fire resistant plywood is not noncombustible and it is not flame-resistant tarpaulins, so it does not qualify on that account. Now, section 2-2 does say “approved materials of equivalent fire-retardant characteristics” would be permissible. The fire-resistant plywood would seem to comply with this statement, but the key word is “approved”. The fire resistant plywood would have to be approved by all the AHJs that regulate the healthcare facility. That would be the following:

  • The federal government (CMS)
  • The accreditation organization (i.e. Joint Commission, HFAP, DNV)
  • The state AHJ on design and construction
  • The state fire marshal
  • The local fire inspector
  • The insurance company

Getting one of those AHJs to accept the fire resistant plywood as being acceptable is possible; but getting all of the AHJs to accept this, is improbable. Even if 5 of 6 AHJs accepted it, the organization would still have to comply with the lone AHJ who would not accept it.

Another consideration that is much less flexible in interpretation is section of the 2000 LSC, which says:

“All interior walls and partitions in building of Type I and Type II construction shall be of noncombustible or limited combustible materials.”

Again, fire resistant plywood is neither noncombustible or limited combustible materials. Therefore, from this code section’s point of view, fire resistant plywood would not per permitted, even on a temporary basis, and even if it was ‘approved’ by an AHJ.

My advice to this individual is to stick with the steel studs and gypsum board temporary construction barriers because once the new 2012 LSC is adopted, the updated edition of NFPA 241 will require 1-hour fire rated temporary construction barriers (with 3/4 hour fire rated doors that self-close and positively latch) where the construction area is not protected with sprinklers; or NFPA 241 will require non-rated noncombustible (or limited combustible) temporary construction barriers where the construction area is protected with sprinklers. It is important to understand that the new NFPA 241 will no longer permit the flame retardant tarpaulins (i.e. flame retardant plastic visqueen).

I also suggest to this individual that he should find a way to impress upon the construction people that the temporary barriers must be properly maintained; or find construction people who will be glad to have your work and comply with your requirements.

Remember: Those construction people work for the hospital; not the other way around.


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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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