Oct 17 2017

Support Your Local Infection Control Practitioner

Category: Infection Control,Questions and AnswersBKeyes @ 12:00 am

A ‘Conversation’ Regarding Environmental Services Closets

Q #1: Are housekeeping closets considered clean or dirty rooms and what type of supplies can you store in them? EVS is being advised by Infection Prevention that these are considered dirty and we cannot stores supplies, such as toilet paper, paper towels, trash bags, etc. Thanks in advance for any information you can provide.

A #1: I would agree with your IC people. Their opinion over-rides anything else. They’re the ‘boss’ when it comes to infection control issues, and if they say the room is ‘dirty’ then you cannot store clean supplies in there.

Q #2: Okay then going by that “policy” that means the EVS carts are also dirty, since they are of course stored in the EVS closets, and that then means the cleaners cannot carry supplies on the carts, which is what they are designed for?  I have been cleaning hospitals for 30 years and no offense but this does not make any sense at all.

A#2: Hey… it’s your IC people’s policy… not mine.

Ask them how they want you to deal with this. There is a difference with the cleaning supplies that are stored on the EVS carts, compared with the stacks of paper towels and toilet paper stored in these rooms. The general public does not come into contact with the EVS carts and the supplies on the carts, but they do come into contact with the paper towels and toilet paper. I can see the difference.

I would argue with the IC people that the cleaning supplies on the EVS carts are indeed ‘dirty’ but they can still be used to clean rooms, because the contents inside the cleaning supply bottles are clean. The paper towels and the toilet paper should be kept in a clean environment, but I would argue that the trash bags are dirty as soon as they are used, so there is no reason to store them in a clean environment.

All is well…. Just talk it out with the IC people. They are there to safeguard the health of your staff and patients. Work with them, not against them.

Oct 16 2017

Portable Storage Racks

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

Q: We have a surveyor that says if we have portable storage racks against the perimeter walls and have items stored closer than 18 inches of the ceiling but the sprinkler is 4 feet away, we are in violation of the LSC. He states since the racks are not fixed to the wall, that this is the reason. Is he correct?

A: It’s not an issue of being correct; it’s an issue of interpretation. I would agree with the surveyor’s interpretation. Even though the actual standard in NFPA 13 does not explain it in this detail, the interpretation makes sense. The rack against the wall which is secured (or at least it is not mobile) stays in place and can have items stored up to the ceiling and still be compliant. However, the rack that is mobile (i.e. it has wheels) can be moved around and can obstruct the spray pattern of the sprinkler.

It makes sense to me, but remember; it doesn’t matter what I think. The surveyor represents the AHJ and it matter what he thinks. You can try to appeal the decision if you want, and you might succeed. But the interpretation actually makes sense to me.

Oct 13 2017

Storage in a Corridor

Category: Corridors,Questions and Answers,StorageBKeyes @ 12:00 am

Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and beds and other equipment (usually broken chairs) are being stored on one side of the breezeway for more than 30 minutes, would this be allowed as long as the width is maintained at 8ft or greater?

A: Yes… it would be permitted according to section of the 2012 Life Safety Code, provided the items stored in the corridor allow for a clear width of 8 feet in the corridor, and the items stored does not constitute a hazardous area. So, combustible items such as furniture would not be permitted if the total area of the stored furniture exceeds 50 square feet. Also, flammables would not be permitted to be stored in the corridor.

Another thing to look at is if the corridor could possibly be used by inpatients. If so, then the clear width must be maintained at 8 feet. But if there is no chance of inpatients using this connector corridor, then the required width would be 44 inches.

Oct 12 2017

AEM Program for Fire Alarm and Sprinklers

Category: AEM Program,Fire Alarm,Questions and Answers,SprinklersBKeyes @ 12:00 am

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the fire system inspections could be considered preventive maintenance or at least the means to determine what maintenance needs to be completed. Can we use the CMS AEM program to alter our PM activities on the fire alarm and sprinkler systems?

A: You cannot use the CMS AEM program for Fire Alarm inspection and testing requirements. The CMS S&C letter 14-07 that describes the AEM program says the following regarding when the AEM program is not appropriate: “Other CoPs require adherence to manufacturer’s recommendations and/or set specific standards. For example: The National Fire Protection Association Life Safety Code (LSC) requirements incorporated by reference at 42 CFR 482.41(b) has some provisions that are pertinent to equipment maintenance, and compliance with these requirements are assessed on Federal surveys.”

So… you must follow the NFPA requirements specified for sprinkler and fire alarm testing and inspection, and the AEM program is not applicable.

Oct 11 2017

Gas Fired Ventless Fireplaces

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

Q: Are gas-fired ventless fire places permitted in nursing homes?

A: I would say they are not permitted, but it has a lot to do whether or not the gas ventless fireplace is considered to be a heating device by the AHJ. According to section of the 2000 edition of the LSC, it says fuel-fired heating devices must be connected to a chimney or a vent. The key issue here is whether or not the gas ventless fireplace is considered a heating device or not. I know many people consider gas fireplaces as aesthetic devices only, but they do produce heat even though that may not be the reason they are requested, so I would say the ventless devices are not permitted.

If I were the AHJ and you asked me, I would say no. But you can ask all 5 or 6 of your AHJs and see what they say, but if only one of the bunch says no, then you cannot do it. If you wanted to install a gas fireplace that is vented, you would have to do so in an area that is separated from patient sleeping areas by a 1-hour fire rated barrier. You would also have to meet other NFPA standards for construction found in section 9.2.2 of the 2012 edition.

Oct 10 2017

Power Strips

Category: CMS,Power Strips,Questions and AnswersBKeyes @ 12:00 am

Q: There is so much discussion on the proper use of power strips that it can cause confusion amongst even the seasoned facility managers. There is absolutely no guarantee that the different power strips will remain in their ‘designated areas’. The OR is much easier to control, but as technology quickly progresses, the space between patient care vicinities and non-patient care vicinities quickly losing the defined lines. What’s your thoughts on the power strip issue?

A: I do see your point that power strips may be difficult to control as they may move around the hospital, in and out of patient care vicinities. And I respect your comment that there is confusion on the proper use of power strips. But I find CMS’ explanation regarding power strips under their K-Tag 920 to be refreshingly simple:

  • Power strips in a patient care vicinity are only used on movable patient-care related electrical equipment and are permanently attached to the equipment, and are UL 1363A or UL 60601-1.
  • Power strips in a patient care vicinity may not be used for non-patient-care related electrical equipment, such as personal electronics, except in long-term care resident rooms that do not use patient-care related electrical equipment.
  • Power strips for patient-care related electrical equipment must meet UL 1363A or UL 60601-1.
  • Power strips for non-patient-care related electrical equipment in the patient care rooms, but outside of the patient care vicinity, must meet UL 1363.
  • In non-patient care rooms, power strips meet other UL standards.

Section 3.3.139 defines “patient care vicinity” as a space, within a location intended for the examination and treatment of patients, extending 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extending vertically to 7-foot 6-inches above the floor.

It appears K-Tag 920 is permitting qualified personnel to permanently attach UL 1363A or UL 60601-1 power strips to movable patient-care related electrical equipment, provided it meets section of NFPA 99-2012, which is:

  • The power strip is permanently attached to the equipment assembly;
  • The sum of the ampacity of all appliances connected to the outlets does not exceed 75% of the ampacity of the flexible cord supplying the outlets;
  • The ampacity of the flexible cord is in accordance with NFPA 70-2011, National Electrical Code.
  • The electrical and mechanical integrity of the assembly is regularly verified and documented.

This section does not explain what makes one “qualified”, so that determination should be left to the AHJ and the healthcare facility. While NFPA 99-2012 does not specify how frequent “regularly verified” means, the general consensus is annually, based on annual receptacle inspection requirements in Chapter 6.

You will note that section (5) was deleted per Tentative Interim Amendment (TIA) 12-5.

K-Tag 920 is also clear that outside of a non-patient care room (i.e. OR, PACU, procedure room, patient sleeping room, etc.) CMS no longer regulates which UL power strip to use on non-patient-care related electrical equipment, other than it must be UL listed. That means a power strip used at a nurse station on office equipment, or in an office environment does not have to be UL 1363, UL 1363A, or UL 60601-1; it just has to be UL listed.

Oct 09 2017

Exiting Through a Shell Space

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

Q: Where in the ambulatory health care occupancy chapter of the Life Safety Code does it permit to have a means of egress from an ASC or a suite within the ASC be through a shell space or machine room? Is this allowed assuming that the proper signage and emergency lights are in place.

A: No… The path of egress cannot extend from a corridor into a room to get to an exit. Section of the 2012 Life Safety Code does not allow this. Also, section says exiting is not permitted through a hazardous room. So, if the shell space is used for storage then you cannot have a path of egress through the shell space. In ambulatory health care occupancies, any room used for storage is considered a hazardous room.

You cannot exit from a suite directly to another room. All required exits from a suite must lead to an exit access corridor, or to a horizontal exit, or to an exit stairwell, or to a direct exit.

Now, if you constructed an exit access corridor in the shell space to separate the stored items from the corridor, then that would be acceptable.

Oct 05 2017

Mobile OR Trailer

Category: Operating Room,Questions and Answers,TrailerBKeyes @ 12:00 am

Q: A hospital is building a small addition that will serve as a corridor to a mobile OR unit. ICC construction type of addition is I-B. The mobile OR will be attached to this corridor with a water tight seal. I am researching this issue based on the IBC and IFC, but was hopeful you could help me with the Life Safety Code and best practices when it comes to issues such as connection of fire alarm system and rating of doors between the mobile OR and the new corridor and/or the main hospital.

A: What I can tell you would likely be the same thing that your design professional is telling you. Let’s examine three distinct issues concerning hospitals, additions and trailers:

Occupancy Classification

What occupancy classification have you designated the OR trailer? Healthcare occupancy? Ambulatory healthcare occupancy? That would drive the classification of the addition to connect the hospital to the trailer. If the OR trailer occupancy classification is the same as the addition and the area of the hospital here it connects to, then there would not be a requirement for a 2-hour fire rated barrier separating occupancies. However, if the occupancy classification is different between the hospital and the addition, or if the occupancy classification is different between the addition and the OR trailer, then a 2-hour fire rated barrier is required.

Building Construction Type

You say the addition is ICC Type I-B which is comparable to NFPA 220 Type II (222) construction type. When a healthcare occupancy building connects to another building with a construction type that is less that what the first building’s construction type is, it must have a 2-hour fire rated vertical barrier separating the different construction types. Trailers are typically not constructed to meet the Type II (222) construction type of hospitals. Otherwise, they would likely be too heavy to transport on wheels. That means the construction type of the trailer is likely going to be less than the Type II (222) of the addition, and a 2-hour fire rated barrier is required to separate the addition from the trailer. This can be done at the end where the addition connects to the trailer. What about the construction type for the trailer? Since it houses patients, it has to comply with the construction type requirements found in chapter 18 for healthcare occupancy and/or chapter 20 for ambulatory healthcare occupancy. This means the trailer may have to be protected with sprinklers. How are you going to connect fire protection water to a portable trailer? You may be able to utilize a clean agent fire suppression system in lieu of water-based sprinklers, but which clean agent is suitable in a  location where a patient is incapable of self-preservation?  I’m no expert on fire suppression systems, but I suspect FM-200 and other clean agent  suppression systems are not suitable for this application. What does your state agency in charge of hospital construction say about this?

Means of Egress

You say the addition is going to serve as a corridor between the hospital and the OR trailer. Is it designated a corridor? If so, then the OR trailer must be separated from the addition because patient treatment activities are not permitted to be open to the corridor. What about exiting? If the addition is a corridor, there must be an exit near the end of the corridor where the OR trailer connects to the addition. Otherwise, you would have a long dead-end corridor, and chapter 18 of the LSC does not allow a dead-end corridor greater than 30 feet. Is it possible to designate the addition and the OR trailer as a suite of rooms? That would help with corridor clutter, as if the addition is a corridor (and not a suite) then you must maintain 8 feet clearance if the addition is a healthcare occupancy. A suite designation may not be possible depending on the travel distance from the furthest point in the OR trailer to a door in the hospital to an exit access corridor, as that is limited to 100 feet.

But what about exiting from the OR trailer? You will need stairs with handrails on both sides of the stairs even if you are using a lift system to raise the patient into the trailer. As far as connections for fire alarm system, I would be surprised if the manufacturer of the OR trailer does not have a recommendation. You would need to have all of the required fire alarm occupant notification devices as well as the initiation devices connected to the main hospital fire alarm system. I have dealt with issues involving healthcare trailers before (although this is the first time I’ve heard of a portable OR) and they are a challenge. Be aware that if you only get your state and/or local AHJ to approve the installation, you may still have a problem with your accreditor and/or your state CMS agency. It would be best to discuss this project with every AHJ you have to determine what they are going to require that you must install.


Oct 04 2017

Fire Safety Inspections

Category: Fire Safety Plan,Questions and AnswersBKeyes @ 12:00 am

Q: Can testing and inspections of features of life safety be completed in-house or does a third party need to complete them? I would like to know which areas need to be inspected by a third party and which areas can be inspected by our own maintenance staff.

A: My first response to your question is there are no NFPA or accreditation standards or regulations that require you to have an outside contractor (third party) perform any of the fire-safety testing and inspection requirements. But, the reality of it is, it is not likely that you can do all of this with your own staff. Take the fire alarm testing requirements. The technicians performing inspections, testing, maintenance and service on the fire alarm system must be certified or licensed to do so, or they need to be employed by an organization that is certified or licensed. This is a NFPA requirement, and is frequently enforced by the CMS and accreditation surveyors. However, certified and licensed fire alarm technicians are not very common among hospital facilities departments, so this is usually contracted out.

For other features of life safety that need to be tested and inspected, NFPA and the accreditation organizations do not require a certification or license for the technicians performing the task. But the technician does need to have knowledge and experience in order to perform the task, and again, it is not likely that a typical hospital facilities department will have staff with all of this knowledge. And besides, given all that is required, does your staff even have the time to test and inspect all of the features of life safety if they did have the knowledge?

So, the reality is, hospitals typically contract out most of the testing and inspection, but they frequently do perform some of the more routine (and mundane) items like quarterly Fire Department Connection inspections. Now, in contrast to this last statement, I have a couple of clients who are huge, and they do have the resources to hire certified technicians and perform all of the testing and inspection of features of life safety themselves. But my observation is the facilities department must be well-funded in order to achieve this level of self-testing and inspection. As always, please check with your state and local authorities to see if they have more restrictive requirements.

Oct 02 2017

Fire Drills in Operating Rooms

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

Q: What are the requirement for operating room fire drills per Joint Commission, CMS, and AORN? Are operating room fire drills required to evacuate patients?

A: I cannot speak to what AORN suggests for fire drills, but keep in mind their standards are voluntary since they are a professional organization and not an authority having jurisdiction. On the other hand, CMS and Joint Commission’s standards are regulatory compliance and they are not optional; you must comply with them.

Joint Commission says the following under standard EC.02.03.03 for fire drills:

  • Drills are conducted once per shift per quarter in buildings defined as healthcare occupancy
  • Drills are conducted quarterly in buildings defined as ambulatory health care occupancy
  • Evacuation of the patients during the drill is not required
  • In buildings leased or rented by the hospital, drills are only required in the areas that the hospital occupies
  • In freestanding buildings classified as business occupancies, drills are conducted once per every 12 months
  • At least 50% of the drills are unannounced when quarterly fire drills are required
  • The conditions for fire drills are varied, and the drills are held at unexpected times
  • During fire drills, staff participate in the drill in accordance with the hospital’s fire response plan
  • Drills that are conducted between the hours of 9:00 pm and 6:00 am may use an alternative method to notify staff instead of activating the audible alarms of the fire alarm system
  • After the drill, the drill must be critiqued to evaluate the fire safety equipment, the fire safety building features, and the staff’s response to the drill. This evaluation must be documented.

CMS refers to the Life Safety Code, and in addition to the above, section 19.7.1 of the 2012 Life Safety Code says the following:

  • Fire drills in healthcare occupancies must include the transmission of a fire alarm signal
  • Fire drills in healthcare occupancies must simulate emergency fire conditions
  • Bedridden patients are not required to be moved during drills

All of the above would apply to any and all drills conducted at the healthcare facility, including those conducted in the operating rooms.

So, to answer your specific question, for fire drills in an operating room, the above regulations would require you to do the following:

  • Conduct fire drills in operating rooms and ensure that staff participate in the drill in accordance with your fire response plan. This may mean they are engaged in a drill that originates in their particular room, or perhaps the drill originates in another room, but they must respond to the drill. Their response may very well be different.
  • The drill must include the activation of the fire alarm system. This is a requirement. If the drill is conducted between 9:00 pm and 6:00 am, the audible notification devices (horns, bells, chimes) may be silenced.
  • The drill must include simulated conditions. This can be a pretend fire in a waste container or an electrical pretend fire. Some organizations use a revolving red light to simulate a fire condition.
  • At least 50% of the drills are unannounced. This means you cannot page “Code Red – This is a drill” during the drill, since that announces it is a drill.
  • Simulated patients must be moved to another smoke compartment during the drill. If relocating the simulated patient in the OR is not feasible due to the simulated surgery in progress, then alternative action must be taken to protect the patient.
  • Observers are needed to critique the response of the staff, the response of the fire alarm system, and the response of the building’s fire-safety features. The LSC and the Joint Commission standards do not say where you observe and how many observers you have, but logic dictates that you need to observe where the simulated fire is at, and in other compartments. How many other compartments? There is no direction on how many other compartments so you get to decide.
  • The fire drill critique must be documented, and the expectation is the summary of the drill is reported to the Safety Committee.

However, Since CMS adopted the 2012 edition of NFPA 99, they are now enforcing the new requirement for fire drills in OR surgery found in section of NFPA 99-2012, which requires annual fire drills in operating rooms and surgical suite locations.

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