Entries by BKeyes

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 more »

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 more »

Strange Observations – Part 39

Continuing in a series of strange things that I have seen while consulting at hospitals… Okay… this was not taken at a hospital. This AC condensing unit was suspended from 2x4s for a restaurant in a small town in Iowa. Ugh. Being a former HVAC guy, this makes my skin crawl. Forward this picture to your HVAC more »

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 more »

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 more »

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 more »

Strange Observations – Part 38

Continuing in a series of strange things that I have seen while consulting at hospitals… This hospital wanted to ‘fence off’ access to the MRI when it was not staffed. Apparently, they did not have a side-hinged swinging door assembly available, so they went with this removable gate. The problem is, the gate is not side-hinged, and more »

Tank Farm Lighting

Q: Is there a regulation that requires lighting in the oxygen tank farm at a healthcare facility? A: From a means of egress point of view, perhaps not. It would depend on the size of the tank farm, and whether you had an aisle in the tank farm itself. According to section 7.8.1.1 of the more »

Privacy Curtains

Q: Several residents in our LTC home have had a screw installed in the track for the privacy curtain, so that they do not slide. My concern is that this would impede their evacuation of the room. I can’t find anything relating to this in the NFPA life safety code. A: Yes… You are correct: more »

Retainage of Records

Q: Does CMS or Joint Commission require Administration and Board information to be kept archived? For how long? A: I am not aware of any CMS or Joint Commission regulation that requires hospitals to retain administration records for any certain length of time. However, don’t be in a hurry to dispose of such records. During more »