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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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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