Jun 22 2018

ABHR Dispensers

Category: BlogBKeyes @ 12:00 am
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Q: We currently have ABHR installed on the outside of our patient bays and would like to install an additional dispenser in the patient bay itself (at the point of use). If an ABHR container is installed on the wall on the outside of the patient bay next to the door, can a dispenser be installed on the other side of the wall on the inside of the bay next to the door (they would mirror each other; one interior and one exterior). I did measure the distance between the two from interior to exterior and it is only 1 ft. wrapped around. What is the interpretation of the 4-foot dispenser separation requirement? Just want to make sure we are in compliance with LSCs!

A: The interpretation I received is the ABHR dispensers need to be separated by 4 feet (horizontally), including a wrap-around a door frame. So, what you described (ABHR dispensers separated by only 1-foot, but on separated sides of the wall) would not be permitted.

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Jun 21 2018

Strange Observations – Part 31

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things that I have seen while consulting at hospitals…

This one is confusing…

You have a standard backflow preventer in the water supply line for the very small sprinkler system.

Those valves for the backflow preventer would need to have tamper switches…. right?


Jun 20 2018

Temperature & Humidity Monitoring

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Q: Where do I find in the code that tells me where required temperature and humidity must be monitored? We have our accreditation organization here, and they mentioned our Sterile Processing and Clean Utility rooms require this monitoring. I have looked at the FGI manual and looked at AHSRAE 170-2008 table which have the guideline perimeters, and this list has several locations with temperature and humidity perimeters. Are these all required to be monitored? I haven’t found any specific reference in the Life Safety Code that says which areas are required to be monitored. Any help would be appreciated.

A: You won’t find it in the Life Safety Code, because it does not directly regulate air temperature, humidity, or air pressure relationships. This is left to other standards, guidelines and regulations. For instance; CMS has a standard for acute-care hospitals under §482.41(c)(4) that says “There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.” In the Interpretive guidelines section for this standard it says acceptable standards such as AORN and FGI should be incorporated into hospital policy. The accreditation organizations will have standards of their own that compliment what CMS is saying. So, some sort of standard must be used by the hospital. If not the FGI Guidelines (which references the ASHRAE 170 standards on design of ventilation), then some other standard must be used. This means if the state or local AHJ had more restrictive requirements you would have to comply with those requirements. It appears your AO is expecting the hospital to meet at a minimum, the FGI requirements for ventilation.  To answer your question, yes these other locations must be monitored to ensure you have the proper HVAC ventilation. If you don’t monitor them, then how do you know if they are correct? But you won’t find this information referenced in the Life Safety Code.

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Jun 18 2018

Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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Q: Is there a code in the 2012 LSC about testing electrical receptacles around hospital beds?

A: Well… actually, that would be in the NFPA 99-2012 code/standard, and the answer is yes, all receptacles in patient care rooms must be tested. But the frequency of that test is different, depending on whether the receptacle is a hospital-grade receptacle or not.

Section 6.3.4.1.1 says hospital-grade receptacles must be tested after initial installation, replacement, or servicing of the device.

Then section 6.3.4.1.3 says receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, must be tested at intervals not exceeding 12 months.

But section 6.3.4.1.2 does say additional testing of receptacles (including hospital-grade receptacles) in patient care rooms shall be performed at intervals defined by documented performance data. This means you do have to test hospital-grade receptacles at a frequency determined by the healthcare organization based on information such as historical data, risk assessments, or manufacturer’s recommendation.

So, if you do install hospital-grade receptacles in the above locations, then you do have to test them after the initial installation, but at intervals that you get to determine.

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Jun 15 2018

Non-Patient Care Electrical Equipment

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Q: What required inspections are needed for non-patient care electrical equipment and at what intervals should they be completed in. I cannot find anything definitive in NFPA 99 – 2012.

A: CMS will expect that you conduct the maintenance activities (i.e. PM’s) as recommended by the manufacturer, for all electrical equipment regardless if it is considered patient care or non-patient care equipment. In addition, this electrical equipment must be on the facility’s inventory of equipment.

This is based on CFR §482.41(c)(2) which is also known as A-0724 in the State Operations Manual (SOM) Appendix A. This document is available at no charge by searching “CMS SOM Hospitals”. Since it is a CMS standard, then all of the accreditation organizations and state agencies must have standards that are equal to that.

So, the answer to your question is: Whatever the manufacturer recommends, you must comply. And this is based on a CMS requirement, not an NFPA 99 requirement.

CMS does offer an Alternative Equipment Management (AEM) program that would allow you to conduct PM activities that differ from the manufacturer’s recommendations, but there are a lot of challenges to this AEM program and it is not for everyone. You can read all about it in CFR §482.41(c)(2).

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Jun 14 2018

Strange Observations – Part 30

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things that I have seen while consulting at hospitals…

This picture is a cousin to last week’s picture…. you have a ball valve in the sprinkler supply line and there are no tamper switches.

Also, the clean linen on the left appears to be too close to the sprinkler deflector… a minimum of 18-inches clearance must be maintained.


Jun 13 2018

Elevator Shaft Construction

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Q: We have a hospital that was built in 2008. We believe there is an elevator construction issue. When they built the elevator shafts they put smoke detectors inside at the top but no sprinklers. On the three exterior sides of the shaft (non-door side) they have cinder block wall. On the interior wall (door side) they have some cinder block construction but they also have in sporadic places two pieces of plywood with glue creating a 2-hour fire rated wall. The other issue is in between the glue there are holes or air pockets. Is this acceptable to use plywood to create a 2-hour fire rated wall or does it have to be cinder block top to bottom? Our construction type is Type II (222) and the elevator shaft serves 8 stories.

A: No… it is not acceptable to use plywood as part of the construction of a 2-hour fire-rated wall. First of all, Type II buildings are not permitted to have combustible construction on their structural members. NFPA 220-2012, section 4.3.1 says Type I and Type II construction must be those types in which the fire walls, structural elements, walls, arches, floors, and roofs are of approved noncombustible or limited combustible materials. Plywood is combustible, even if it is fire-retardant. So, the plywood has to go, and must be replaced with non-combustible materials in order to complete the 2-hour fire rated elevator shaft. NFPA 13 does not require sprinklers in a non-combustible elevator shaft that does not use hydraulic fluids. Assuming it is a traction elevator (i.e. cables and pulleys), then the elevator shaft is not required to be sprinklered. But to answer your question, the plywood is a problem and should not be there.

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Jun 12 2018

Dead-Bolt Locks on Entrance Doors

Category: BlogBKeyes @ 12:00 am
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Q: A while ago, you made a posting that said a deadbolt lock on a door in the means of egress (such as an aluminum-framed glass sliding door at the entrance of the hospital) would be permitted as long as the door is not a fire-rated door and has no other releasing devices such as a lever, knob or crash-bar. I do not believe that is true, as a deadbolt lock with a thumb-turn should not be permitted in the mean of egress. Please advise…

A: After reconsideration, I believe you are correct. I looked up the commentary under 7.2.1.5.10 in the 2012 LSC Handbook, and it says this about the releasing device on the door:

“Examples of devices that might be arranged to release latches include knobs, levers, and bars. This requirement is permitted to be satisfied by the use of conventional types of hardware, whereby the door is released by turning a lever, knob, or handle or by pushing against a bar, but not by unfamiliar methods of operation, such as a blow to break glass…. The operating devices should be capable of being operated with one hand and should not require tight grasping, tight pinching, or twisting of the wrist to operate.”

It is rather obvious that a standard deadbolt lock with a thumb-turn device does require a tight grasping, twisting of the wrist to operate. So, I agree with you that it would not be permitted in the arrangement as described.

Thanks for bringing this to my attention… I do apologize for the confusion and misinformation.

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Jun 11 2018

Stairwell Exit Locked Door

Category: BlogBKeyes @ 12:00 am
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Q: Can a stairwell door that leads to the outside of a hospital be locked with a lock that requires a code to unlock it? I seem to recall that the doors could be on magnets that release upon activation of the fire alarm and that have a touch pad that releases the doors within 15 seconds.

A: No… it can’t. According to 19.2.2.2.4 of the 2012 LSC, doors in the means of egress must not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted as follows:

  • Delayed egress locks (7.2.1.6.1)
  • Access-control locks (7.2.1.6.2)
  • Elevator lobby locks (7.2.1.6.3)
  • Clinical needs locks (19.2.2.2.5.1)
  • Specialized protective measure locks (19.2.2.2.5.2)

I don’t know where in the hospital this stairwell exit door is located, but let’s assume it does not qualify for clinical needs locks (psychiatric care patients), specialized protected measure locks (OB, Peds, Nursery, ICU, ER), and elevator lobby locks. That leaves delayed egress locks, which requires the entire building to be sprinklered, and access-control locks which do not lock the door in the path of egress, just in the path of ingress, neither of which allows the use of key-pads to unlock the door in the path of egress.

If you decide to use one of the approved exceptions for door locking, please make sure you read the appropriate section of the Life Safety Code and comply with everything it requires. Most surveyors are pretty well informed on the LSC requirements for door locks and they will hold you accountable.

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Jun 08 2018

Medical Gas Shutoff Valves

Category: BlogBKeyes @ 12:00 am
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Q: As a hospital security assessor, I am concerned about the availability of hospital gases in Behavioral Health Units. It would be easy for a patient to pull the tab off the plastic covering on the window and tamper with the gases. Would it be permissible to install a clear locking door with hardened glass in place of the plastic panel and provide access to the locked box via scan card with the caveat that the door would automatically unlock open during a fire event?

A: One has to ask why would there be medical gases on a behavioral health unit? Do you treat acute-care patients there? However, if you have them there, then you need to deal with them.

Your question appears to address the medical gas shutoff valves, or zone valves as they are often called. According to NFPA 99-2012, section 5.1.4.8, zone valves have to be visible, accessible and readily operable from a standing position in the corridor. NFPA 99-2012 does not prohibit the use of special locking arrangements for access to the zone valves.

I think you have a legitimate concern, especially if you document this concern in a risk assessment. But I suggest you contact your authorities having jurisdiction, and ask them if it would be permitted. At a minimum, I suggest you ask:

  • Your accreditation organization
  • Your state agency in charge of hospital design and construction
  • Your local building authorities
  • Your state or local fire marshal

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