Jan 30 2018

Category: Blogcreekside @ 10:21 am
Share


Apr 26 2018

Strange Observations – Part 23

Category: BlogBKeyes @ 12:00 am
Share

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

 

This may be a little difficult to see, but we have a picture of a domestic water pipe suspended from a sprinkler pipe. Sprinkler pipe cannot be used to suspend anything else.

Like I said last week… Keep an eye on those contractors. They will do something silly if you don’t keep an eye on them.


Apr 25 2018

Pharmacy Door Locks

Category: BlogBKeyes @ 12:00 am
Share

Q: Is it a common practice to keep pharmacy access controlled doors so they will not unlock on a fire alarm activation? Texas Pharmacy board requirements to secure medications is the reasoning behind this setup, which I feel is wrong. Narcotics are secured within the pharmacy area in a narcotics room, so the requirement for securing narcotics and meds is compliant, but I believe the main pharmacy door should release in the event of a fire alarm activation. Our fire alarm system is designed to activate as general alarm so all electrically locked doors other than the pharmacy release. Is there a standard or exception that will allow this type of set-up? The doors can be manually released from the inside, but my concern is the obstacle created by the access control when an emergent response is required.

A: You may be confusing the old NFPA 72 requirement that all doors in the required means of egress equipped with electrical locks have to unlock on a fire alarm signal. At one time, NFPA 72 did require that, but the Life Safety Code always over-rides referenced standards when there is a conflict. In actuality, the Life Safety Code governs in a situation like this. Besides, the technical committee for NFPA 72-2010 made a change to this requirement. In section 21.9.2 of NFPA 72-2010, it says electrically locked doors in a required means of egress must unlock as prescribed by other codes, laws, and standards. This is different than what previous editions of NFPA 72 said, and now NFPA 72-2010 is clear that it differs to other codes, laws, and standards (i.e. the Life Safety Code) regarding the need to unlock a electrically locked door in the means of egress during a fire alarm. There are only five (5) exceptions to 19.2.2.2.4 of the 2012 Life Safety Code, which says doors in the path of egress must not be locked:

  1. Delayed egress locks (7.2.1.6.1) which requires the door to unlock on a fire alarm signal
  2. Access-control locks (7.2.1.6.2) which requires the door to unlock on a fire alarm signal
  3. Elevator lobby locks (7.2.1.6.3) which requires the door to unlock on a fire alarm signal
  4. Clinical needs locks (19.2.2.2.5.1) which does NOT require the door to unlock on a fire alarm signal
  5. Specialized protective measure locks (19.2.2.2.5.2) which does require the door to unlock on a fire alarm signal.

But pharmacies would not qualify for clinical needs locks (used on psychiatric units), elevator lobby locks, or specialized protective measure locks (used on OB/nursery units, ICUs and ERs). That leaves delayed egress locks or access-control locks which must unlock the door on a fire alarm signal. So, your assessment is correct in that the pharmacy door in the required means of egress cannot remain electrically locked during a fire alarm signal. If you examine the Texas Pharmacy board requirements carefully, it probably says the pharmacy must be secured against unauthorized entry… not egress.

What many people forget: The Life Safety Code governs when it comes to the means of egress and over-rides other standards and codes. Getting out of the building in the event of a fire is paramount supersedes other laws, codes or standards. Why don’t you change the locks on the pharmacy doors and eliminate the electrical locks and install standard passage locks (not deadbolt locks) that do not require more than one action to operate the door? This way, the door would not be locked in the path of egress (getting out of the pharmacy) but would remain locked against unauthorized entry during a fire alarm. This is what I see other hospital pharmacies do.

Tags: ,


Apr 24 2018

Second Chance to Attend a Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
Share

Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed… Did you want to attend this educational event but missed your chance to register??

Not to worry…. Now you can attend another Keyes Life Safety Boot Camp scheduled for May 22 & 23, 2018 in Kalamazoo, MI. It’s the very same content, the very same presenters, but is sponsored by Compliance One.

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.

Date: May 22 & 23, 2018

Location: Downtown Kalamazoo Michigan

600 E. Michigan Ave., Suite A, Kalamazoo, MI 49007

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
• Challenges in Implementing the New Requirements of the 2012 LSC • 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; and former Joint Commission LS surveyor.

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

Cost: $889.00 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.

Register: To register for this event, go to www.complianceonebootcamp.com.

Register Early: Seating is limited – Previous boot camps have sold out.  Registration will close on May 2.

Bring your own copy of the 2012 Life Safety Code!

Questions? Contact Ali Rogers, Marketing Manager, ali.rogers@complianceonegroup.com; 866-779-3235

Exclusively sponsored by:

Tags:


Apr 23 2018

Corridor Obstruction for Construction

Category: BlogBKeyes @ 12:00 am
Share

Q: Can an existing 8-foot wide corridor be reduced in width to 4 feet by temporary construction barriers?

A: Yes, but you will need to conduct an assessment for Alternative Life Safety Measures (or Interim Life Safety Measures as one accreditation organization calls it). All of the AHJs understand there will be times when you will need to have non-compliance with the Life Safety Code during periods of construction, maintenance, or emergency repairs.

It is understandable that you will need to build a ‘bump-out’ in an existing corridor of an occupied unit, in order to conduct demolition, and reconstruction, which will obstruct the required width of the corridor during the period of construction. The Life Safety Code already has considered this situation and section 4.6.10.1 of the 2012 LSC permits buildings to be occupied during periods of construction provided that ALSMs (or ILSMs) are in place.

So, when you know that the corridor needs to be obstructed for the purpose of construction, you assess the situation for ALSM (ILSM) and you follow what your ALSM (ILSM) policy requires you to do. For a corridor obstruction, it is likely that you would be required to do:

  • Staff education on the obstruction, informing them of alternative routes for exiting
  • Daily inspections, looking for accumulation of debris, supplies or other items
  • An additional fire drill in the affected area to ensure staff understands that an alternate route for exiting is required

There may be other measures that need to be implemented, such as additional education, or additional fire-extinguishment devices. Once the assessment is conducted, it must be recorded and available for review by surveyors.

Tags: ,


Apr 20 2018

Eye-Wash Risk Assessment

Category: BlogBKeyes @ 12:00 am
Share

Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document?

A: There is no set form to use for risk assessments. You can just get a group of stakeholders together and discuss the issue and the proposed solution and then write down what you discussed.

If you want a form that is based on the seven (7) steps recommended by The Joint Commission, go to my website, click on “Tools” and download the risk assessment form.

Tags: ,


Apr 19 2018

Strange Observations – Part 22

Category: BlogBKeyes @ 12:00 am
Share

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

I used to work in the construction trades. I like to think that workers in the construction trades know better than to do something silly like this.
The sprinkler pipe is suspended from the frame-work for the overhead door. All sprinkler pipe has to be suspended from the building structure.

Oh well…. I seem to remember I didn’t know how to install a fire damper properly for a long time.

Keep an eye on those construction people… they don’t always know what the code and standards require.


Apr 18 2018

Means of Egress Illumination

Category: BlogBKeyes @ 12:00 am
Share

Q: We have a chapel/activity room that is used for bingo and worship services. Can you please tell me what the minimum illumination of the walking surface in foot-candles is required for this area?

A: Section 7.8.1 of the 2012 Life Safety Code discusses the requirements for the illumination of the means of egress. Keep in mind that the means of egress includes aisles and is not limited to just corridors. Therefore, the aisles inside the chapel/activity room would be required to meet the minimum illumination requirements. Normally, the minimum illumination requirement at the floor level (other than stairwells) is 1-foot candle according to section 7.8.1.3 (2), but a chapel/activity room would qualify as an assembly occupancy and the LSC allows less lighting levels of 0.2-foot candle during periods of performances or projections involving direct light. But 1-foot candle is not very much illumination and is about the brightness of a lit match. So, maintaining the minimum illumination requirements in the means of egress is achievable. Check with other governmental regulations to see if there are greater requirements for illumination of the means of egress. I’ve been told that OSHA requires a minimum of 5-foot candles of illumination for the means of egress.

Tags: ,


Apr 17 2018

Second Chance to Attend a Keyes Life Safety Boot Camp

Category: BlogBKeyes @ 12:00 am
Share

Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed… Did you want to attend this educational event but missed your chance to register??

Not to worry…. Now you can attend another Keyes Life Safety Boot Camp scheduled for May 22 & 23, 2018 in Kalamazoo, MI. It’s the very same content, the very same presenters, but is sponsored by Compliance One.

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.

Date: May 22 & 23, 2018

Location: Downtown Kalamazoo Michigan

600 E. Michigan Ave., Suite A, Kalamazoo, MI 49007

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
• Challenges in Implementing the New Requirements of the 2012 LSC • 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; and former Joint Commission LS surveyor.

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

Cost: $889.00 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.

Register: To register for this event, go to www.complianceonebootcamp.com.

Register Early: Seating is limited – Previous boot camps have sold out.  Registration will close on May 2.

Bring your own copy of the 2012 Life Safety Code!

Questions? Contact Ali Rogers, Marketing Manager, ali.rogers@complianceonegroup.com; 866-779-3235

Exclusively sponsored by:

Tags:


Apr 16 2018

Un-Sprinklered High Rise Hospital

Category: BlogBKeyes @ 12:00 am
Share

Q: I am a consultant and I have a client who has a new high rise hospital that is not fully sprinklered. The plans for this hospital were approved and stamped by the local building officials after 2003 and the building construction completed in 2010. Would the entire building have been required to be fully sprinklered when it was constructed?

A: I would say so. Depending on who they are accredited by, and what state they are in, they could be cited for not being 100% sprinklered, since the building design was approved after the 2000 Life Safety Code was adopted. For example, if they are Joint Commission accredited, Joint Commission had been adopting the new editions of the Life Safety Code soon after NFPA published them, up to and including the 2000 edition. So, that means since the 1991 edition of the Life Safety Code was the first edition to require all new construction healthcare occupancies to be fully protected with sprinklers, this building would have been required to be sprinklered if they were Joint Commission accredited. Also, most states adopt new versions of the LSC as they are published, so from a state viewpoint this building would likely have been required to be 100% sprinklered as well.

CMS adopted the 2000 edition of the LSC in March, 2003. Previously they were on the 1985 edition which did not require new construction to be protected with sprinklers. So, for CMS certified hospitals, the start date for new construction required to be sprinklered was March, 2003. For Joint Commission accredited hospitals, it would have been when they adopted the 1991 edition of the Life Safety Code. So, it is apparent someone did not get the word that a newly constructed high-rise hospital that had their design stamped by the local authorities after 2003, is required to be fully sprinklered.

Yep… that is a citation waiting to be written. Could even be a Condition Level Finding. Better advise them to get started in completing the sprinkler installation as soon as possible.

Tags: ,


Apr 13 2018

Refrigerators

Category: BlogBKeyes @ 12:00 am
Share

Q: Generally, is it permitted to use a refrigerator in offices in healthcare facilities when considering fire safety? I ask because more and more offices are starting to request refrigerators.

A: The Life Safety Code does not regulate where appliances like refrigerators may be placed, other than they may not obstruct the required width of the means of egress. I would think refrigerators in an office should not be any problem, other than temperature control of the office.

 

But check with your state and local authorities to see if they have other restrictions.

Tags:


Next Page »