Temperature and Humidity Log

Q: How often are we required to log the room temperature, humidity levels, and air changes in our OR’s? Is this required daily, each shift, hourly? What about the other rooms like Sterile Processing and others, how often do we need to log them?

A: It depends on your accreditation organization, and to a lesser extent, the surveyor.

For Joint Commission, their standard EC.02.05.01, EP 15 says in critical care areas (i.e. operating rooms, special procedure rooms, isolation rooms, sterile supply rooms, etc.) the ventilation system must provide appropriate temperature, humidity, air-pressure relationships, and etc., based on the edition of the FGI guidelines used at the time of design. This standard does not say how often these factors need to be checked. But there are some other professional organizations such as AORN and CDC that offer opinions on how frequent. Joint Commission surveyors will expect the hospital to have adopted some frequency that is consistent with these other professional organizations, or at least have conducted a risk assessment to determine how frequent these issues need to be checked and logged.

For non-critical care areas, such as soiled utility rooms and clean utility rooms, incorrect air pressure relationships would be scored under EC.02.06.01, EP 1, but this standard is like EC.02.05.01 in that it also does not say how frequently these rooms need to be checked. Again, surveyors would expect you to follow professional organization guidelines or your own risk assessment for testing frequency.

If you’re HFAP accredited, standard 11.07.03 covers all temperature, humidity and air-pressure relationship requirements, and similar to Joint Commission, HFAP does not specify the frequency of checks. They also identify AORN and FGI Guidelines as standards to follow, but they will accept a facility-based risk assessment to determine testing frequencies, within reason.

It is up to the individual surveyors to determine if your risk assessment is acceptable and reasonable. If they believe it is, then you should be fine. If they do not feel it is acceptable, they may discuss this issue further and a finding may be cited.

As far as DNV goes, I believe they are similar to the above.

Generator Annual Load Test

Q: My client installed a generator in a Phase 1 project that does not and will not for some time be able to meet the requirements for the 30% load during the monthly test due to low current loading. As I understand it, 8.4.2.3 in NFPA 110 allows you to do the monthly test as is and do a supplemental annual test yearly as outlined which would then meet the requirement for the monthly test. Is that the proper interpretation as the generator will not meet the 30% requirement until some unknown future date?

A: Yes… section 8.4.2.3 of NFPA 110-2010 is the correct reference when any one of the monthly tests cannot meet the requirement for at least a 30% load. The annual test must be conducted within 12 months of the first monthly test that was incapable of meeting the 30% load requirement, and then no more than 12 months from the last annual load test.

Your client should continue to conduct the monthly load tests (not less than 20 days and not more than 40 days) with the available load. For the annual load test, a supplemental load (i.e. load bank) of not less than 50% of the nameplate kW rating for 30-minutes and a supplemental load of 75% of the nameplate kW rating for 60-minutes must be conducted, for a total test of 90 continuous minutes.

The cool-down period for the generator is not part of this 90-minute test.

Gas Storage Ventilation

Q: In the 1999 Edition of NFPA 99, it mentions for medical gas storage systems more than 3,000 cubic feet, if the door opens to an exit access corridor, louvered openings shall not be used and a mechanical ventilation system shall be required. I cannot find that requirement in the 2012 edition of NFPA 99 regarding not using a louvered door in an exit access corridors. Has it been eliminated, or am I just missing it? If it was eliminated, do you know why?

A: In a way they eliminated it and in another way they did not. Yes, they did delete the language that says doors that open onto an exit access corridor cannot have louvers for ventilation. But that does not mean you can now have louvers in doors to exit access corridors. Section 5.1.3.3.2 of the 2012 NFPA 99 is the section for central storage in quantities greater than 3,000 cubic feet of compressed medical gas, and for gas manifold systems.

You will notice that ventilation requirements are no longer under section 5.1.3.3.2. You will find ventilation requirements for medical gas storage under section 9.3.7, and specifically section 9.3.7.5.2 describes natural ventilation which now limits the ventilation openings to be directly to the outside atmosphere without ductwork. This precludes the possibility of louvers in a door to an exit access corridor.

And, NFPA 99 requires a fire-rated door for medical gas storage rooms and gas manifold rooms. Louvers are not permitted in fire-rated doors.

There is still an option of using natural ventilation or mechanical ventilation, and plenty of rules for both.

O2 Cylinder Storage

Q: Can full oxygen cylinders be stored in a hospital soiled utility room?

A: Yes… however, anything stored in a soiled utility room is considered soiled. That would require staff to clean the O2 cylinder before using it on a patient, and the likely hood of that happening every time is not very good.

Most surveyors will have a problem with full O2 cylinders stored in a soiled utility room because of that issue and would expect the hospital to have a policy or at least a written procedure on the proper cleaning of each cylinder before use.

It is best to not store full O2 cylinders in a soiled utility room. Now, empty O2 cylinders stored in a soiled utility room should not be a problem because they would not be used on patients.

Mechanical Room Exit Signs

Q: Is there a code that states every mechanical room needs an ‘Exit’ sign? I am being pressed to do so and I understand if the exit is obvious you don’t need a sign.

A: No… there is not. But section 7.10.1.5.1 of the 2012 LSC says access to exits shall be marked by approved signs in all cases where the exit or the way to reach the exit is not readily apparent to the occupants. So, one way this is interpreted, if you’re standing inside the mechanical room and the entrance door to the mechanical room (which also is an exit access) is not readily apparent, then you will need ‘Exit’ signs.

This is actually a very simple test that a surveyor can do while touring your facility… If the surveyor cannot see the entrance door when he/she stands anywhere in the mechanical room, then that is a clear indication the room needs to have the way to reach the exit marked. But if you can always see the entrance door, then one can say the way to reach the exit is readily apparent.

It is recommended that you use the internally illuminated ‘Exit’ signs connected to EM power, rather than trying to get by with externally illuminated signs.

Window Frame Rating

Q: Can you verify what a window frame rating should be in a 1-hr load bearing wall? Does the frame need to maintain the 1-hr rating of the wall or can it be 45-minutes? This window is in a load bearing wall that separates a corridor from an office.

A: Since windows are openings in fire-rated barriers, I turn to NFPA 80-2010, section 17.1.3 on window frames. This section says fire window frame assemblies must be permanently labeled for such use. The Annex section of A.17.1.3 says the labeled assembly includes the frame and can include a ventilator, glazing material, retaining members, mullions, and hardware, if applicable.

The label reading ‘Fire Window Frame’ includes the design and construction of the frame, ventilator, glazing material retaining numbers, and hardware. Table 8.3.4.2 of the 2012 Life Safety Code provides the minimum fire protection ratings for opening protectives in fire-rated barriers. According to “Exit Access Corridors” on this table, fire window assemblies in 1-hour corridor walls are permitted to be ¾ hour fire rated. So the frame would also be ¾ hour rated.

Clean Utility Rooms

Q: What is the guidance on clean utility rooms and door closers? Under 50 square feet no closer is required, but over 50 square feet a closer is required? Does the clean utility room being located inside a suite make any difference? The normal supplies in there could be considered combustible based on the NFPA definition.

A: You have the 50-square foot limit correct, but it does not matter if the clean utility room is located in a suite or not. It still must meet section 18/19.3.2.1 for hazardous areas. If it is a new clean utility room, then it must be 1-hour fire-rated and be protected with sprinklers. However, the room may meet an exception found in section 43.7.1.2 (2), regarding rehabilitation. A change in use of a space in an existing healthcare occupancy does not have to meet new construction requirements for hazardous areas, provided the space does not exceed 250 square feet and the entire building is protected with sprinklers. But the space does have to meet the requirements for hazardous areas for existing conditions, which is 1-hour fire rated construction, or if the room is fully protected with sprinklers, then the door just needs to be self-closing and smoke resistant.

Fire Alarm System Strobes

Q: I work in a healthcare facility and we are in need to find an answer to a question regarding strobe lights. When we test our fire alarm system, and we silence the alarm, the strobe lights do not continue to flash. We were told that this is not “code” and the lights need to continue to flash even if system is silenced. I cannot seem to find this located in any part of the Life Safety Codes. Also, this is an older facility, so at some point/date do some healthcare facilities get grandfathered in if this is a newer code?

A: No… older facilities do not get to be grandfathered, or in any other way, exempt from complying with the code.

Section 19.7.1.4 of the 2012 Life Safety Code requires the transmission of the fire alarm signal during a fire drill. That means you cannot silence the audible alarms and you cannot disable the visual (i.e. strobe) notification devices. If you are doing either during a fire drill, then you are non-compliant and need to discontinue this practice and make sure the audible notification devices and the visual notification devices operate properly during each fire drill.

Now, having said that, there is one exception that you may qualify for and that is found in section 19.7.1.7 of the 2012 Life Safety Code, which says when drill are conducted between 9:00 pm and 6:00 am a coded announcement is permitted to be used instead of the audible alarms. But, the visual notification devices (i.e. strobes) must operate.

Statement of Conditions PFI List

Q: We are expecting Joint Commission at our hospital soon. Since they will no longer look at the PFI lists, is it advisable to keep our current open PFIs open on their website? I was informed to close out the open PFIs and document under “Other” that they are closed since we are no longer required to report them to TJC. But, I do not want to close out open PFIs on the TJC website for this reason. Please advise.

A: It is totally up to you and your organization. It is true that Joint Commission has said the Statement of Conditions PFI section is no longer part of the survey process, and their surveyors will no longer look at the PFIs you have written. For the record, Joint Commission is encouraging hospitals to continue to use the PFI section in the SOC in order to manage their Life Safety Code deficiencies. In fact, the accreditor has recently said that they will even allow Environment of Care deficiencies to be placed on the SOC PFI section for you to manage. Joint Commission does not have any immediate plans to eliminate the PFI section from the SOC because they feel it is a useful tool for you to use to manage your deficiencies.

But if it were me, I would likely discontinue using the PFI section in the SOC because I think the computerized maintenance management system that most hospitals have would be a better tool to manage my deficiencies. And, I see no reason to leave Life Safety Code deficiencies listed on a Joint Commission document for their surveyors to look at, if I don’t have to. I know Joint Commission says their surveyors will not look at the PFIs you’ve written, but how do we know for sure that they won’t? In your case, I would not have a problem closing out the current PFIs using the “Other” choice.

Quarterly Test of Main Drain

Q: Has the frequency for the main drain testing changed from annually to quarterly?

A: Yes… but not for all the main drain test locations. The new 2012 LSC now references the 2011 edition of NFPA 25, and section 13.2.5.1 of NFPA 25-2011 requires once per quarter, one (not all) main drain test must be conducted on a system riser located downstream of the backflow preventer when the sole water supply is through a backflow preventer. This test must record the static water pressure, the residual water pressure, and the time required to restore water pressure to static pressure. This test is conducted with the fire pump off (if so equipped) and the jockey pump on.

You still must conduct an annual main drain test on all of the system risers.

Equipment in an Alcove

Q: We have an alcove in our surgery center that we are wanting to place patient refrigerator, ice machine, coffee pot. Currently there isn’t a door- it is an alcove. Is this acceptable or do these items need to be behind a door? Our surgery center has badge access, but this is in an area where patient family members are allowed.

A: If the equipment in the alcove is truly out of the required width of the corridor, then I don’t see any problem with it. Just because it is a refrigerator, ice machine or coffee pot should not make a difference. These items are not considered to be hazardous so they are not required to be kept in a designated hazardous room.

Now, if the surgery center is a suite of rooms, then of course there are no corridors inside a suite, and maintaining a certain corridor width is not required.

Fire Extinguishers

Q: Are portable fire extinguishers required in business occupancies?

A: Yes… Section 38.3.5 of the 2012 Life Safety Code says portable fire extinguishers must be provided in every business occupancy in accordance with 9.7.4.1. Section 9.7.4.1 references NFPA 10 for installation, inspection, and maintenance of portable fire extinguishers.

Exiting from Hospital into Medical Building

Q: A main circulation corridor in a Hospital (Institutional Use I-2, 8′ wide) passes thru the 2-Hr Use Group separation of adjacent medical offices (Business Use B) and re-enters the Institutional zone (2-Hr wall) for egress to a fire egress stair. Building has automatic sprinkler system. Are egress corridor movements between Institutional and Business Use permitted? Must all sections of that corridor sequence maintain a consistent width of 8′ clear?

A: [Boy… I wish you architects would use NFPA nomenclature instead of IBC…]. If I understand your question correctly, my reply would be yes… you can exit from the hospital into a business occupancy, but there are extenuating circumstances. Section 6.1.14.1.2 of the 2012 LSC says when an exit access (i.e. corridor) from an occupancy traverses another occupancy, the multiple occupancy must be treated as a mixed occupancy. For you, that means the most restrictive occupancy requirements apply, which in your case would be healthcare occupancy.

So, this means everything required for healthcare occupancy must be met in the business occupancy building, such as:

  • Construction type
  • Fire alarm system
  • Sprinklers
  • Fire-dampers/smoke dampers
  • Corridor width
  • Corridor doors
  • Fire safety plans
  • Door latching and locking requirements
  • Etc.

However, if you can call the 2-hour fire barrier separating the healthcare occupancy from the business occupancy, a horizontal exit, then you would not have to meet the requirements of healthcare occupancy, in the business occupancy building.

Waivers and Equivalencies

Q: When do I complete an FSES equivalency request, before the survey or after the survey? Where do I find the forms need to complete an FSES equivalency? What is the different between an FSES equivalency and a waiver?

A: Keep in mind that waiver and equivalency requests are no longer completed prior to the survey. Since CMS made changes to how they approve waivers and equivalencies, you may only submit a waiver request or an FSES equivalency request to your accreditation organization (AO i.e. Joint Commission) or state agency after that entity has cited you for a specific Life Safety Code deficiency.

The main differences between a standard waiver request and an FSES equivalency request is in a standard waiver request, you are asking permission from CMS to not have to comply with a particular LSC requirement based on a significant hardship (often times financial), and you are not required to provide any evidence that your facility has an equivalent level of safety based on other features of life safety.

However, in an FSES equivalency request, you are asking permission to not have to comply with a particular LSC requirement based on an engineering evaluation that demonstrates your facility has an acceptable level of safety even with the deficiency cited by the surveyor. The engineering assessment is made using a specific form called the Fire Safety Evaluation System (FSES) and is found in NFPA 101A-2013. This is a separate document from the Life Safety Code, but evaluates your level of compliance with the 2012 Life Safety Code.

The person conducting the engineering evaluation of the facility using the FSES worksheets (found in NFPA 101A-2013), has to be knowledgeable and experienced in the process. As you can imagine, this would likely require the typical hospital to use an architect, engineer or consultant who has the requisite experience. This will often drive the cost of an FSES equivalency request to the point where it is far more cost effective to just submit a standard waiver request.

Waivers and equivalency requests are submitted to the entity who cited you for the LSC deficiency. If they agree with your request, they will send it on to the appropriate CMS Regional Office for approval. This approval process can take anywhere from a week or two, to many months. Once approved, the waiver or equivalency request is only valid until the next triennial survey, and at which time it becomes invalid. The surveyor will determine if the LSC deficiency still exists and if so, you will be cited again. So, in the big-picture of things, it is best to make plans to eventually resolve the deficiency because if you don’t, you will be cited again, and there is no guarantee that a waiver or equivalency request will be approved a second time.

Another type of waiver request is the Time-Limited Waiver (TLW) request, and it differs greatly from the standard waiver request. Whereas in a standard waiver request you are seeking permission to not have to comply with a particular LSC requirement, a TLW request confirms that you will resolve the LSC deficiency cited, but you just need more time to do so. CMS has a rule under Title 42: Public Health in the Code of Federal Regulations (CFR) that states the following regarding resolving a deficiency cited by their agents:

Ordinarily a provider or supplier is expected to take the steps needed to achieve compliance within 60 days of being notified of the deficiencies but the survey agency may recommend that additional time be granted by the Secretary in individual situations, if in its judgment, it is not reasonable to expect compliance within 60 days, for example, a facility must obtain the approval of its governing body, or engage in competitive bidding. [§488.28(d)]

When a hospital cannot resolve a LSC deficiency within the 60-day window after a survey then they may submit a TLW request to CMS through their AO or state agency that requests additional time to resolve the deficiency. You would follow the specific instructions to submit a TLW from your AO or state agency.

You would follow the instructions in NFPA 101A-2013 to conduct the engineering evaluation for the FSES equivalency request.

Fire Door Inspector

Q: My accreditation organization has a standard that says “testing and inspection of fire door assemblies needs to be conducted by a qualified person.” By what specifically do they mean when they say “qualified” and where are we able to find where they define their interpretation of what qualified is?

A: You will find the interpretation of what ‘qualified’ means under section 5.2.3.1 of NFPA 80-2010, which says functional testing of fire doors and window assemblies must be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. You may hire this responsibility out to a contractor with this knowledge and understanding, or you may assign the responsibility to test the fire doors to one of your own staff individuals, provided you ‘qualify’ them by determining they have the knowledge and understanding to perform this test.

If you decide on the latter, you need to document this decision by describing why you believe this individual has this knowledge and understanding of fire door operating components, and retain that document in case the surveyor asks to see how you qualified that individual. Your own staff individual could be qualified based on a certification course they may have taken (please understand there is no requirement that the person conducting the fire door inspections be certified, but it can be a good source of education), or the individual may be qualified simply because they have worked on doors for years and have accumulated this knowledge and understanding. The key is you may need to defend this decision, so it is best to document the decision and retain that to show to a surveyor.