Aug 18 2017

Security Cameras in Stairwells

Category: Cameras,Questions and Answers,Security,StairwellsBKeyes @ 12:00 am

Q: What is the Life Safety Code ruling on cameras and speakers in stairwells? Joint Commission was in and cited us on having cameras in the stairwells. We were told by the surveyor that they don’t pertain to the stairwells.

A: The Life Safety Code does not specifically address cameras in the stairwells, but section of the 2012 LSC does limit what penetrations are permitted into an exit enclosure. Conduit is permitted as long as the conduit serves the stairway. This seems to be an interpretation issue, and apparently, the surveyor decided the use of cameras does not fit the description in To me, a camera focused on people using the stairway seems to fit the description of “serving the stairway”, but it really doesn’t matter what I think.

If you can prove the camera installation qualifies as ‘existing’ conditions, then it should be accepted by the accreditor. The definition of ‘exiting’ conditions is any design, construction, or governmental approval that was in existence prior to July 5, 2016 (the date the 2012 LSC was adopted). However, since the 2000 LSC also prohibited new penetrations in stairwells for cameras, it is likely that a surveyor will hold you accountable to what the 2000 LSC required when you were supposed to comply with that edition, and that edition was adopted March 11, 2003. So, if the camera was installed in the stairwell since March 11, 2003, I can see that the surveyor would have a legitimate finding.

Aug 17 2017

Locks on Operating Room Doors

Category: Door Locks,Operating Room,Questions and AnswersBKeyes @ 12:00 am

Q: Our operating rooms were constructed with deadbolt locks on each surgical room. I’m told they did this to keep someone from entering the room during a case. Since this is most likely the path of egress I can’t see this being okay by the LSC. Your thoughts?

A: I would agree with you… But there are quite of few variables here. First of all, is the OR area a suite of rooms? If so, then the doors to the operating rooms do not have to latch, and a thumb-turn handle on the egress side to unlock a dead-bolt would be permitted since there is only one action to operate the door (see of the 2012 Life Safety Code). But, if the operating rooms are not in a suite, then no, you would not be able to have dead-bolt locks because the doors would have to latch (since they open onto a corridor) and that would mean there would be two actions to operate the door: 1) To unlock the dead-bolt, and 2) Unlatch the latchset hardware.

Now section of the 2012 Life Safety Code modified some of that and says existing doors are permitted to have two releasing operations to a room serving not more than 3 occupants, provided it does not require simultaneous operations to unlock the door. But… the typical operating room serves more than 3 occupants, so I don’t see that section working for you.

I would say it boils down to whether or not the OR is a suite of rooms. If yes, then the dead-bolt locks may stay if there is only one action to operate the door. If no, then you have to remove the dead-bolt locks.

Aug 16 2017

Fire Drills for Off-Site Locations

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am

Q: I have a question that is still a little fuzzy regarding fire drills. My hospital is partners with a separate clinic. Several of the clinics throughout the community have hospital employees working there (PT, Imaging etc.) but the building is owned by the clinic. Who is responsible for running drills and testing the emergency operations plan? On a side note, some of the clinics are Rural Healthcare Clinics, so the hospital owns the clinic and it operates under the hospitals CMS number but all of the employees are clinic employees not hospital.

A: Yes… I could see where this would be a fuzzy issue for you. Here is how I suggest you address this issue:

  • Your hospital has an interest in the clinics
  • Your hospital has staff that work in the clinics
  • Your hospital has patients that receive care in these clinics

Therefore; you are responsible for all testing, inspecting, and maintenance of all the fire-safety equipment, and you’re responsible for all drills (EM and fire), as well as meeting the requirements for management plans, EOPs, and policies and procedures.

An AHJ will very likely determine that since you have staff and patients in these facilities, they must fall under the hospital’s rules/standards for Emergency Management, Physical Environment, and Life Safety. That means you need to have copies of the documentation that all of the fire-safety devices were tested and maintained, and copies of all drills were conducted.

Now… if you have a great relationship with your partner clinic, and they perform all of the testing and inspecting requirements, and the drill requirements, then that is fine. You can use copies of their reports as evidence of compliance. But you still need to include these clinics in your management plans and EOP scope of work.

The bottom line is… as long as you have staff and /or patients in these clinics, then your accreditor will very likely expect that you comply with all of the hospital standards at these off-site locations.

Aug 14 2017

Unannounced Fire Drills

Category: Fire Drills,Questions and AnswersBKeyes @ 12:00 am

Q: Somewhere I read that at least 50% of fire drills had to be unannounced. I don’t find that requirement in NFPA Life Safety Code so it may have been a Joint Commission requirement. We use DNV now and announce very few of our drills but I would like to know if there is any such requirement.

A: You are correct in saying that Joint Commission has a standard on this issue, but the Life Safety Code also addresses this as well. Look at section 4.7.4 of the 2012 Life Safety Code. It says drills shall be held at expected and unexpected times to simulate the unusual conditions that can occur in an actual emergency. While this section does not state 50% of the drills have to be unannounced, the assumption is that unexpected equates to unannounced.

Actually, DNV standard PE.2, SR.6 says healthcare occupancies shall conduct unannounced fire drills. So, it appears DNV wants all their fire drills to be unannounced, not just 50% of them. So, it looks like you should be doing all of your fire drills as being unannounced.

Aug 11 2017

Blood Draw in Behavioral Health Corridor

Category: Behavioal Health,Questions and AnswersBKeyes @ 12:00 am

Q: I have a behavioral health unit where the lab technicians have placed a chair in the corridor to draw blood samples from the patients. This chair is left in the corridor at all times, and the corridor is 8 feet wide. Is this a violation and do I need to maintain 8 feet clear width in this corridor?

A: Yes… I believe it is a problem, but not for the reasons you imply.

Section of the 2012 LSC says corridors in psychiatric hospitals are required to have unobstructed clear width of 6 feet; not the traditional 8 feet clear width required in acute care hospitals. So, a chair placed in an 8 foot wide corridor in a psychiatric unit would likely not obstruct the required clear width of 6 feet. However, take a look at section This section sates that corridors must be separated from all other areas of the hospital with partitions. Now, there are 9 exceptions where corridors are not required to be separated from certain areas of the hospital, but none of these exceptions allow areas used for patient sleeping rooms, treatment rooms or hazardous spaces to be open to the corridor.

The question here is; what constitutes a ‘patient treatment room’? Does a chair that is legally placed in the corridor for patient blood draw constitute a patient treatment room or space? Maybe yes, and maybe no. Being an engineer, I cannot make that decision. I suggest you have your clinical staff perform a risk assessment and review the procedures that are being done at this location to determine if it meets the qualifications for ‘patient treatment’. If the results of the risk assessment state that blood draw is not ‘patient treatment’ activities, then have them take the results of that risk assessment to the safety committee and the patient safety committee (if they are not one and the same) and have those committees review and approve the results.

If a surveyor challenges you that the blood draw constitutes ‘patient treatment’ activities open to a corridor, then present the risk assessment. While this is not a guarantee that the surveyor will accept the results of the risk assessment, it will demonstrate to the surveyor that you are aware of this issue and conducted an evaluation and determined it is not ‘patient treatment’ activities.

Aug 10 2017

Immediate Jeopardy Decision?

Category: Accreditation,Questions and AnswersBKeyes @ 12:00 am

Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient to leave the room; only staff may release the door lock. Is this in any way an Immediate Jeopardy situation?

A: Not necessarily… Section of the 2012 Life Safety Code allows doors to be locked in the path of egress where the clinical needs of the patients require specialized security measures or where the patients pose a security threat, provided staff can unlock the doors at all times. Clinical needs locks are permitted for use for psychiatric patients, dementia patients, Alzheimer’s patients and substance abuse patients. A seclusion room in a Behavioral Health unit would likely meet the definition for clinical needs locks, provided staff was watching the patient 24 hours/day.

Aug 09 2017

Cooking Ranges Open to the Corridor

Category: Cooking Appliances,Questions and AnswersBKeyes @ 12:00 am

Q: We have an assisted living and basic care units at our facility. We have 48 total units: 24 on the east side and 24 on the west side. On each wing we have an electric range that is open to the corridor. I have been here 4 years and never have seen them in use. Under the new 2012 Life Safety Code, will we have to put in a suppression system on the units, plus will interlocks have to be installed? Currently we just turn off the breaker to the units. We have microwave units mounted above the stove and they have exhaust fans on them. Can they stay or will we have to put in regular exhaust fans?

A: It depends on what the range is used for….

If you never use it to prepare meals for staff or residents, then the Life Safety Code refers to these devices as food warming devices, and section of the 2012 LSC says where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the presence of the equipment shall not require the area to be protected as a hazardous area. Section 9.2.3 is the requirement for commercial cooking equipment to be protected with NFPA 96 exhaust hood and fire suppression system.

If you do use these ranges for preparing meals for residents, then you must comply with the more restrictive requirements found in section

Aug 07 2017

Hand Washing Sinks in Soiled Utility Rooms

Category: Questions and Answers,Soiled Utility RoomsBKeyes @ 12:00 am

Q: Is it required that all soiled utility rooms have a dedicated sink for handwashing only?

A: The NFPA Life Safety Code and related standards do not address this issue, but according to the 2010 FGI guidelines, a hand-washing sink is not required in a soiled utility room. Section 2.1- specifically omits the requirement of a hand-washing sink for soiled utility room. Now, clean supply rooms would be required to have a hand-washing sink (according to section 2.1-, but not a soiled utility room.

However, the FGI guidelines are not regulations or standards; they are considered guidelines to be used in lieu of any regulation or standard. Therefore, you need to check with your state and local authorities to determine if they have any regulations concerning hand-washing sinks in soiled utility rooms.

Aug 04 2017

Sprinkler Testing Certification

Category: Questions and Answers,Sprinklers,TestingBKeyes @ 12:00 am

Q: I reside in California. Do I need a special license or certificate to perform monthly and quarterly sprinkler systems tests and/or inspections? Primarily, I am interested in main drain tests. I am the fire alarm, technician at a large hospital, and have NICET Level II certification. I have over 20 years of hospital fire experience and I have a State of California weekly fire pump test certificate. From a NFPA standpoint, do I need a license or certificate to perform testing and inspections on water based fire protection equipment (sprinklers)?

A: No. NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems only requires ‘qualified’ people to perform the inspections and testing activities, and ‘qualified’ means being competent and capable, and having met any requirements and training that are acceptable to the AHJ. So, if the state of California has additional requirements for training, such as licensing and/or certification, then you would have to comply with that. But NFPA 25 does not require license or a certificate to perform inspections and testing.

Aug 03 2017

Spare Sprinkler Heads

Category: Questions and Answers,SprinklersBKeyes @ 12:00 am

Q: How many spare sprinkler heads are we required to keep on hand in our hospital? Some people have told us we need 6 of each kind of head we have, and some people have said we only need 6 total heads regardless how many types of heads. What do you say?

A: When it came to spare sprinkler heads, NFPA 13-1999 was misleading and it was often misinterpreted. At one time, accreditation organizations required 6 spare heads of each type, but that was not the intent of the technical committee. The 2010 edition of NFPA 13 has cleared this up. Section of NFPA 13-2010 says a supply of at least six spare sprinklers must be maintained on the premises, but to clarify, Annex section A. says a minimum of two sprinklers of each type and temperature rating should be provided. Also, section does say a supply of dry heads is not required. However, section requires an increase in spare heads if the facility has more than the following thresholds installed:

  • Under 300:         No fewer than 6 spare heads
  • 300 to 1000:        No fewer than 12 spare heads
  • Over 1000:         No fewer than 24 spare heads

Section says there must be a sprinkler wrench for each type of head stored with the spare sprinkler heads, although a single sprinkler wrench could be appropriate for use on multiple sprinklers. Section does require a list of all the sprinklers be included in the spare sprinkler cabinet. This list includes the following:

  • Sprinkler identification number (SIN) or the manufacturer, model orifice (size), deflector type, thermal sensitivity, and pressure rating
  • General description of each sprinkler type, such as:
    • Upright
    • Pendent
    • QR
    • SR
    • Sidewall
  • Temperature rating in °F
  • Quantity of each type of sprinklers maintained in spare cabinet
  • Issue or revision date of the spare sprinkler list.

Find your spare sprinkler cabinet and make sure you meet all of the above requirements.

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