May 27 2016

Linen Chute Doors

Category: BlogBKeyes @ 12:00 am
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Q: My question relates to fire ratings of linen chute doors. Do linen chute doors in an existing structure have to be rated if the room that houses the linen chute is protected by a 2 hour wall and the door for this room is rated at 90 minutes?

A: Yes, according to NFPA 82 (1999 edition) section 3-2.4.1, the chute doors must be fire-rated in a vertical linen chute enclosure. There is no exception in NFPA 82 for the chute doors in a vertical chute that opens into a room that has the same fire resistive rating as the shaft for the vertical chute, to not be fire rated.

Section 8.2.5.3 of the 2000 Life Safety Code which allows shafts to terminate in a room with the same fire resistive rating as the shaft does not apply in this situation because the shaft does not terminate at the room. It continues up through the building and extends (in part) through the roof. However, it may apply for the collection room that is at the bottom of the shaft for the linen chute, provided the room meets all of the requirements of section 8.2.5.3.

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May 24 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 20 2016

Bronchoscopy Procedure Rooms

Category: BlogBKeyes @ 12:00 am
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Q: Are Bronchoscopy procedures to be performed in negative pressure rooms under all circumstances, or can they be performed in OR suites? Does the negative pressure rule only apply to new construction, or does it apply universally to all facilities old and new?

A: According to the 2010 FGI Guidelines for Design and Construction of Health Care Facilities, ventilation requirements for a Bronchoscopy procedure room requires negative air pressure relationship to the surrounding area, and a minimum of 2 outdoor air exchanges per hour and a total of 12 air exchanges per hour. This ventilation requirement must be met regardless where the Bronchoscopy procedure is conducted, which includes the operating rooms. So, to answer your first question: Yes, this requirement applies to all circumstances.

The ventilation requirements found in the 2010 FGI guidelines applies to new construction or renovated areas. It is not a standard, and it does not apply to existing conditions. However, the ventilation requirements for Bronchoscopy procedures have been consistent since the 1996-1997 edition of the guidelines, and perhaps even before that (I only have records back to the 1996-1997 edition). So, if you have constructed or renovated the Bronchoscopy procedure room since 1996-1997, then these ventilation requirements must be complied with.

Some authorities will allow deviance from the FGI guidelines as they are guidelines and not standards. So, if you have extenuating circumstances that requires you to deviate from the FGI guidelines, then contact your AHJ to determine what their expectations are.

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May 18 2016

The New NFPA 25 Standard

Category: BlogBKeyes @ 12:00 am
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Q: Just read your latest post on testing of PIVs and backflows in accordance with NFPA25.  You referenced the 1998 edition.  But aren’t we supposed to be following the newly adopted 2012LSC? I’m looking at it, and it now references the 2011 edition of NFPA25.

A: No… all CMS regulated hospitals are currently on the 1998 edition of NFPA 25. They will not move to the 2011 edition of NFPA 25 until the adoption of the 2012 LSC is effective, which will not happen until July 5, 2016, according to CMS’s final rule. At that point, CMS will expect compliance with the 2011 edition of NFPA 25. However, don’t expect your accreditation organization to be enforcing the new 2012 LSC (and referenced standards, like the NFPA 25) at that time. They have to submit changes to their manual to CMS for approval before they can enforce the 2012 LSC. That process may not be completed until September… or later.

 

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May 17 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 13 2016

Testing Requirements for Backflow Preventers

Category: BlogBKeyes @ 12:00 am
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Q: Many AHJ’s are requiring RPZ backflow devices on sprinkler systems. Is there a testing requirement for these devices? Also, is there a periodic test required for a PIV?

A: Yes, backflow preventers, both double-check and reduced pressure zone (RPZ) type must be tested on an annual basis when connected to sprinkler systems. Sections 9-6.2.1 and 9-6.2.2 NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 edition), require all backflow preventers installed in fire protection system piping to be tested annually at the designed flow rate of the fire protection system in accordance with the following:

  • A forward flow test must be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer;
  • A backflow preventer performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.

Post Indicator Valves (PIV) are control valves, and according to section 9-3.3.1, 9-3.4.1 and 9-3.4.3 of NFPA 25, the must be tested and inspected as follows:

  • Monthly inspections
  • Semi-annual tamper switch test
  • Annual exercise, whereby the valve is fully closed and then fully opened.

And, in case you were not aware, section 9-3.4.2 of NFPA 25 requires a main drain test to be conducted downstream of any valve that is closed and then re-opened for any reason. So it is best that you coordinate the annual main drain test right after the annual control valve exercise.

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May 10 2016

Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

Tags:


May 06 2016

Smoke Detectors in IT Closets?

Category: BlogBKeyes @ 12:00 am
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Q: Do IT closets require a smoke detector no matter the size?

A: If the IT closet is in the healthcare occupancy (hospital), and under normal circumstances, there is no Life Safety Code requirement to have a smoke detector in the IT closet, regardless of the size.

Now, there may be other requirements that may necessitate a smoke detector in an IT closet, such as:

  • Compensating measures for an equivalency;
  • To meet the requirement for a fully smoke-detected building required for delayed egress locks;
  • If the door to the IT closet was held open by a magnetic device that releases the door when the fire alarm system is activated;
  • When state or local codes requires a smoke detector.

If you’re thinking the IT closet is a hazardous area and a smoke detector should be installed: That is not a requirement. Sections 18/19.3.2.1 do not define an IT closet as a hazardous area, and smoke detection is not a requirement for hazardous area. Even if the IT closet qualified as a hazardous area due to combustibles stored in the room, you still do not need a smoke detector.

On the other hand, a smoke detector in an IT closet can provide early warning of a fire, so you may want to consider one.

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May 05 2016

Categorical Waivers and the New 2012 Life Safety Code

Category: Blog,Life Safety Code UpdateBKeyes @ 12:00 am
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10112[1]By now most of you have heard that CMS finally adopted the 2012 Life Safety Code, effective July 4, 2016, which is 60 days from the date CMS posted their final rule (May 4, 2016). While nearly everyone is excited and happy that CMS finally published their final rule, it is raising some questions that previously may not have been addressed.

I received an email from a reader that asked the following:

 

 

Since the 2012 edition of the Life Safety Code has now been adopted by CMS, what implications does that have for organizations that have categorical waivers adopted…and are anxiously awaiting our survey.  We are due for survey before August 31, 2016.   I realize we need to comply by July 4th, so we are in an interesting time slot.  Any guidance you could offer would be appreciated.  Basically, do we keep the waivers until July 4th or what?

This adoption of the 2012 Life Safety Code by CMS does not have any effect on the categorical waivers already invoked by the hospital. Since the concept of invoking a categorical waiver is to be in compliance with a particular section of the 2012 LSC, once the 2012 LSC becomes effective, the categorical waivers no longer apply. They simply ‘go away’ or dissolve.

Now… CMS’s final rule will require hospitals to be compliant with the 2012 Life Safety Code by July 4, 2016. But in reality, this should not be a burden for most hospitals since most of the differences between the 2000 LSC and the 2012 LSC are in the favor of the facilities… meaning there are less restrictions rather than more restrictions.

However, there are a few changes that are more restrictive with the 2012 LSC, such as:

  • All swinging fire-rated doors must be tested and inspected annually;
  • Temporary construction barriers must be 1-hour fire rated (or non-rated if the construction area is fully sprinklered; tarps cannot be used);
  • Pressuring reducing valves on sprinkler systems need to be inspected quarterly.

Technically… CMS is saying the hospital needs to be compliant with these ‘more restrictive’ issues by July 4, 2016. But in reality, there will be some unstated ‘adjustment’ time where the accreditation organizations (AOs) will show leniency towards the more restrictive requirements. How much time? No one knows, but if past indicators are predictors of the future, I would not be surprised that the AOs will not enforce the new requirements until August or September, or maybe even the first of the year.

That’s just my opinion, but that is based on the knowledge that the AOs cannot make changes to their accreditation manual until CMS approves it and CMS takes 60 days to review and approve an AO manual. It would take 30 – 60 days for the AO make their changes and submit them to CMS. So… Assuming the AOs submit their revised manuals to CMS in June, and CMS takes 60 days to approve it… It looks like August or September before the AO can enforce the new requirements of the 2012 LSC.

But… I suggest you get started on compliance with these new more restrictive requirements, if you haven’t already. If you start today, you may be in full compliance with the additional requirements by July 4, 2016.

 

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May 04 2016

I’m Sorry…

Category: BlogBKeyes @ 12:00 am
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Dear Readers…

In a recent post I made a comment that architects are making errors and causing facility managers headaches by calling for 20 minute fire-rated doors in smoke barriers. I was wrong to have said that. While NFPA allows non-rated 1.75 inch thick solid-bonded, wood core doors in smoke barriers; the IBC does not.

Architects have to design the facilities to meet not only NFPA requirements, but often times they have to design to meet IBC requirements as well. The most restrictive requirement must be met, and the IBC requires 20-minute fire rated doors in smoke barriers.

My comment was rather derogatory towards architects, and for that I do apologize. I was allowing my frustration with poorly designed hospitals regarding suites-of-rooms to over-shadow my objectivity with the smoke barrier door issue. I will attempt to be more understanding and fair in the future.

Be assured that this website is intended to discuss NFPA codes and standards as it relates to healthcare facilities, and does not attempt to discuss or reference any other codes or standards. This is because once the facility is constructed, the facility manager is under siege with inspections from multiple authorities that hold them accountable to NFPA codes and standards; not the IBC.

Thank you….

Brad Keyes

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