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.

Medical Gas Shutoff Valves

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

Un-Sprinklered High Rise Hospital

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.

Sprinkler System Pressure Gauges

Q: My question has to do with the pressure gauges for our fire sprinkler system. We just had some out of date pressure gauges replaced by a new sprinkler contractor. They removed the 3 1/2 inch gauges and replaced them with 2 inch gauges. Upon further inspection I noticed that the gauges had no UL or FM listing. They have on the back a CRN aka Canadian Registration Number. Can this type of gauge be used?

A: The Canadian Registration Number (CRN) is a number issued by each province or territory of Canada for the design of a boiler, pressure vessel or fitting. The CRN identifies the design has been accepted and registered for use in that province or territory. You are in Florida, so there is no requirement in the USA for a CRN. According to NFPA 13-2010, the standard on the installation of sprinkler systems, section 8.17.3.3 says the pressure gauges must be listed and must have a maximum limit not less than twice the normal system working pressure at the point where installed. It is apparent that the Canadian Registration Number is not the same as a listing from an independent testing laboratory, so I would say the gauges that were installed at your facility would not be acceptable.

Clearance Around Equipment

Q: What does the NFPA codes and standards require for clearances around electrical panels, fire alarm pull stations, and med gas panels?

A: The National Electrical Code (NFPA 70, 2011) section 110.26 requires 36 inches clearance around electrical equipment and controls. NFPA does not have a set distance that fire alarm pull stations and med gas stations (shutoff valves) must be maintained, but most authorities ‘borrow’ the 36 inch rule from NFPA 70 and apply it to the fire alarm pull stations and med gas shutoff valves.

It makes sense.

Control Valve Tamper Switches

Q: Please explain why The Joint Commission standard EP 1 identifies control valve signal devices and valve tamper switches as different pieces of equipment? The only difference I can see would be the bolt-on type tamper used to supervise an OS&Y valve as opposed to a butterfly type valve with a built-in tamper switch. Either way, they do the same thing as sprinkler control valves which are supervised by the fire alarm system, but the EP defines them, and the testing requirements for each differently. Why?

A: I’m not sure which EP 1 you are looking at, but EC.02.03.05, EP 1 says: “At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). The completion date of the tests is documented.” Nowhere does this EP differentiate between add-on after-market tamper switches for OS&Y valves, and those butterfly type valves which have a tamper switch built inside it. As far as the standard is concerned, a tamper switch is a tamper switch. EC.02.03.05, EP 2 does allow tamper switches to be tested every six months.

The EC.02.03.05, EP 1 and EP 2 are based on NFPA 72 which requires supervisory signal devices such as pressure switches and temperatures switches to be tested quarterly, but does allow tamper switches (which are supervisory signal devices) to be tested semi-annually. Why do tamper switches get a break? I don’t know… the NFPA 72 handbook does not say.

Testing Requirements for Backflow Preventers

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.

Private Fire Service Mains

imagesS9VJZMEONFPA 25 (1998 edition), section 4-3.1 has a requirement listed to test the Private Fire Service Mains once every 5 years. The standard says the test must be performed on exposed fire service mains and underground fire service mains. The handbook that accompanies the NFPA 25 standard explains this water-flow test on the private fire service mains applies to only private exposed and underground fire service mains that are outside the facility, such as piping to a private fire hydrant. The piping inside the facility is covered under a different section of the NFPA 25 standard.

The Annex section A-4-3.1 of NFPA 25 says this flow test can be performed through yard fire hydrants; a fire department connection (once the check-valve is removed); and other connections. Typically, the test is conducted at a fire hydrant that is connected to the private fire service mains due to it accessibility. The test must be able to measure flow in gallons per minute (GPM), and the results are measured against the original acceptance data. The key thing to understand at your facility is whether or not you own the fire hydrants that are close to your building, or if they are owned by the city or municipality. Surprisingly, many facility managers simply do not know. If they are privately owned, then you need to conduct the 5-year private fire service main flow test.

Nat all surveyors are asking to see this documentation during a survey, but it is becoming a more frequent request. Remember: The 2000 Life Safety Code, section 9.7.5 requires compliance with the entire NFPA 25, so everything in the standard must be followed as long as you have the equipment.

Not all accreditation organizations are consistent in reviewing this documentation, but as time progresses, you will see more and more surveyors ask to review this test report. This 5-year private fire service main water-flow test should not be confused with the annual water-flow of the private fire hydrants and the 5-year internal inspection of sprinkler piping.

Fire Hydrants

Fire Hydrant with Missing CapI ran across this fire hydrant while I was in southern California. It appears to me that the organization has failed to conduct basic routine inspections since the cap is missing from one of the hose connections. One of the reason why the caps are there in the first place is to prevent individuals from stuffing trash into the hydrant, thereby making it inoperable when they are needed.

NFPA 25 (1998 edition) is the standard which fire hydrants need to be maintained, tested and inspected. NFPA 25 defines hydrants in three configurations:

– Wall hydrants

– Dry barrel hydrants

– Wet barrel hydrants

For the purpose of this posting, we will only discuss the dry barrel and wet barrel hydrants.

Dry barrel hydrants are the most common type used, and are specified in environments where freezing temperatures could cause ice to form in the barrel. There is a control valve at the bottom of the barrel, well below the frost line. When water is needed, a fire fighter will connect a hose to one of the threaded connections and then will turn the valve stem at the top of the hydrant which will release water to the barrel and eventually to the hose outlet. When the control valve is closed, there is a relief valve at the bottom of the barrel (below frost line) to relieve the water from the barrel, so it can drain.

Wet barrel hydrants (like the one in the picture) are used in environments where freezing conditions are not a concern. Each outlet on the wet barrel hydrant has a control valve. Water pressure is maintained in the barrel and when an outlet valve is opened, water will flow.

Annual Inspection 

Not all fire hydrants located on a hospital campus may belong to the city. A discussion with the municipal water department will reveal which hydrants are the city’s and which hydrants belong to the healthcare organization. After you determine which hydrant you are responsible for, the following inspection program must be conducted annually, and after each operation. For dry barrel hydrants:

  • Accessibility:   Make sure the hydrant is accessible for fire fighters
  • Leaks:  Inspect for leaks. May represent a faulty control valve; damage due to freezing; or a faulty drain
  • Cracks:   Inspect for cracks which may be caused by freezing
  • Tightness of outlets:   Lubricate as needed
  • Worn nozzle threads:    Repair or replace
  • Worn control valve operating nut:   Repair or replace
  • Availability of operating wrench:   Make sure a wrench is available.

For wet barrel hydrants:

  • Accessibility:   Make sure the hydrant is accessible for fire fighters
  • Leaks:  Inspect for leaks. May represent a faulty control valve
  • Tightness of outlets:   Lubricate as needed
  • Worn nozzle threads:    Repair or replace
  • Worn control valve operating nut:   Repair or replace
  • Availability of operating wrench:   Make sure a wrench is available.

images[2]Hydrants have to be flow-tested annually to ensure proper operation. Each hydrant must be opened fully (slowly) and allow water to flow until all foreign material has been flushed, or until one minute has passed, whichever is longer. Then the hydrant control valve is closed and for dry barrel hydrants, ensure water drains from the barrel. Allow up to 60 minutes for the water to drain. This flow test is commonly accomplished with a Hose Monster (see picture at left) for safety.

Hydrant caps need to be lubricated annually to ensure they are in good operating condition if they are ever needed. During the winter months, keep snow and ice from accumulating around the hydrant to allow clear access for fire fighters.

 

 

 

 

no_parkingAnd don’t park your cars next to a hydrant, or it will end up looking like this: