Negative Air-Pressure

Q: I’m butting heads with our Infection Control group regarding holes in construction barriers. They have started requiring the contractors to make the construction sites negative air-pressure, which is fine, if they have access to the outside of the building. If there isn’t any way to vent to the outside they want to install filters in the construction barrier so they can exhaust filtered air into the corridors. Our construction sites are fully sprinkled so we are not required to have fire barriers but I can’t find anywhere in the code that it says they can put holes in the corridor walls to exhaust air through. I’m telling them that if they put holes in the barrier I might as well hang beaded curtains because we don’t have a smoke separation anymore. What do you think?

A: I guess it depends on the level of construction, demolition or renovation. I like the idea of poking a hole in the corridor wall and exhausting through a HEPA filter into the corridor to create a negative air pressure in the construction area. That is a common process where there is no access to the outdoors. I don’t see a problem with this… just make your ILSM assessments for a corridor that no longer resists the passage of smoke and keep that exhaust fan w/HEPA filter running 24/7. Don’t let them turn it off.  Sometimes, IC people don’t like the airflow into the corridor because it stirs up the air in the corridor. But if your IC people are okay with this, then that would be considered best practice. I think you’re over-reacting… The Infection Control people are correct on this one.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by:

Cabinets in a Corridor – Part 2

Q: Is there a codified requirement for doors in a cabinet mounted in a hospital egress corridor? We have worked on projects when a nurse server; i.e., pass through cabinet, was required by the local AHJ to have positive latching on the cabinet door in order to protect the sanctity of the egress corridor. But when it is just a typical cabinet (non-pass through), is there a danger to the egress corridor if the cabinet doors do not have positive latching?

A: The only code requirements that I can think of are corridor obstruction and projection. A nurse server that has an open pass-through to the patient room from the corridor is required to have a door that meets the requirements of 19.3.6.3 of the 2012 LSC for corridor doors, such as positive latching, 1¾-inch thick solid-bonded wood core, and resisting the passage of smoke, because it needs to separate the corridor from the patient room. I think a typical cabinet that does not have a pass-though would not have to have a door that is positive latching because positive latching is only required when the door is separating a corridor from a room. If there is no pass-through, then there is no need for a positive latching door.

Christmas Garland

Q: We are a fully sprinkled hospital. Is it permissible to hang Christmas garland from the ceiling, as long as we stay away from sprinkler heads and abide by the 30% rule? Does the garland need to be fire-retardant?

A: According to section 19.7.5.6 (4) of the 2012 Life Safety Code, combustible decorations such as photographs, paintings, and other art are permitted as long as they are attached directly to the walls, ceiling, and non-fire-rated doors provided the following is complied with:

  • Decorations on non-fire-rated doors not interfere with the operation of any required latching of the door;
  • Decorations do not exceed 20% of the wall, ceiling and door areas inside any room or space of a smoke compartment that is not protected with sprinklers;
  • Decorations do not exceed 30% of the wall, ceiling and door areas inside any room or space of a smoke compartment that is protected with sprinklers;
  • Decorations do not exceed 50% of the wall, ceiling and door areas inside patient sleeping rooms having a capacity not exceeding four persons in a smoke compartment that is protected with sprinklers;

According to the Annex section A.19.7.5.6 (4):

  • The percentage of decorations should be measured against the area of any wall or ceiling where the decorations are located, and not the aggregate total of all walls, ceilings, and doors;
  • The decorations must be located such that they do not interfere with the operation of any doors, sprinkler, smoke detector, or any other life safety equipment;
  • The term “Other art” might include hanging objects or three-dimensional items.

While the Annex section of the Life Safety Code is not considered to be part of the requirements of the enforceable code, it is considered explanatory material intended for informational purposes only. It provides guidance to the readers of the LSC on what the reasoning was by the Technical Committee when that section of the code was written. Most authorities having jurisdiction (AHJ) follow what the Annex says but they are not under any obligation to do so.

So, let’s break this down into steps:

  1. Garland is not the same as a photograph or a painting, but may likely comply with the definition of ‘Other art’ as explained in the Annex.
  2. Some surveyors may believe that garland that is suspended from the ceiling and allowed to ‘droop’ may be considered to not be attached directly to the ceiling as section 19.7.5.6 (4) requires.
  3. Non-fire-retardant garland attached directly to the ceiling appears to be permitted based on what the Annex says, provided it does not take up more than 30% of the ceiling space from which it is attached.
  4. The garland cannot interfere with the sprinklers so you would have to comply with section 8.6.5.1.2 and 8.6.5.2.1.3 of NFPA 13-2010 for ceiling mounted obstructions. Quite honestly, this will be pretty difficult to meet with hanging garland in a corridor.

The problem with all of this is not every surveyor will agree that garland qualifies as ‘Other art’. You can show them what the Annex says, but remember that they are not under any obligation to comply with what the Annex says. Most AHJs do, but you may get a rouge surveyor who simply does not agree and will cite it if they observe it. And, as stated above, it is very challenging to suspend something like garland from the ceiling in a corridor and not interfere with the sprinklers. Make sure you follow NFPA 13-2010 carefully.

All in all, it would be easier to not permit it in your facility.

Sprinklers in Patient Room Lockers

Q: Are sprinklers required in patient room lockers for existing facilities?

A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be sprinklered.

Strange Observations – Electrical Panel Clearance

Continuing in a series of strange things that I have seen while consulting at hospitals…

Remember I have been saying that clearance must be maintained in front of electrical panels for 36 inches, from the floor to the top of the electrical equipment? No?

Well, it does, and it applies to electrical panels such as this.

Smoke Detector Disabled

Q: If a smoke detecting device is disabled for a breathing treatment (often for several days), what sort of fire watch, notification or signage is necessary?

A: None. Fire watches are not for a single device taken out of service, or for a single device found to be impaired. According to section A.9.6.1.6 of the 2012 LSC, it is not the intent of the Life Safety Code to require notification of the AHJ or evacuation (or fire watch) for the portion of the building affected for a single nonoperative device or appliance.

Also, section 9.6.1.6 of the 2012 LSC says where a required fire alarm system (not a single device) is out of service for 4 or more hours in a 24-hour period then an approved fire watch should be conducted. If this smoke detector is located in a healthcare occupancy, there may be a good chance that it is not a required device. Many designers add smoke detectors throughout hospitals where the LSC does not actually require them. In my opinion, you would need to have a branch or circuit disabled on a fire alarm system before a fire watch is required.

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Cabinets in a Corridor – Part 1

Q: It appears that the LSC allows up to 50 square feet of unprotected storage but also includes language that suggests it may need to be protected in accordance with 8.7 depending on the level of hazard. It is my experience that storage in a nurse station (even if combustible) is acceptable because it is located in a normally monitored and occupied area. But what about PPE or patient information storage in closed cabinets away from a nurse station? Would this decision be left to the AHJ?

A: In a scenario as you described, I believe it is all about the cabinet and doors. Is the cabinet mounted in such a way that it projects into the corridor by more than 4 inches? If so, that would be a problem. If the doors to the cabinet were to be left open, would the doors project into the corridor more than 4 inches? If so, that too would be a problem. As long as the square footage of the stored items is less than 50 square feet, I don’t see a problem. The cabinet door would not have to meet the requirements for corridor door (i.e. resist the passage of smoke, positive latching hardware, 1¾-inch thickness, solid bonded wood core) as long as the LS drawings delineated that the corridor wall ran behind the cabinet.

Illuminated Pumpkin – CORRECTION

On October 23, 2018, I posted a picture of this illuminated pumpkin and wrote that the extension cord could not be used since Article 400.8 (3) of NFPA 70-2011 says flexible cords could not be used as a substitute for fixed wiring. But just recently, a reader asked why this illuminated pumpkin would not qualify for Article 590.3(B) that permits extension cords on holiday decorations for up to 90-days.

After reviewing NFPA 70-2011, I discovered I was incorrect in my original posting and thanked the reader for bringing this to my attention. I then made changes to the original posting to ensure the correct code interpretation was stated.

To be sure, NFPA 70-2011, Article 590.3(B), says extension cords are permitted to be used for holiday decorations up to 90-days. But Article 590.2(A) does say all other requirements of the code would have to be met. implying the extension cord would have to be listed by a national listing agency (i.e. UL). Also, Article 590.2(B) says temporary wiring is acceptable if it is approved based on the conditions of use. So, you would not be able to abuse the concept of an extension cord used on holiday decorations.

This also means that individual organizations could have policies specific to their staff that limit or prohibit the use of extension cords on holiday decorations beyond what NFPA 70-2011 provides.

I apologize for this error, and appreciate the reader for bringing this to my attention.

Extension Cords

Q: Under CMS, is it possible to use a UL listed power cord (extension cord), permanently attached to the equipment assembly providing it meets the ampacity requirements? If yes, what UL listing? UL 1363 A and UL 60601-1 are only power strips and I’m looking for a single outlet configuration that meets the UL requirements.

A: No…. According to NFPA 70-2011, Article 400.8, flexible cords cannot be used as a substitute for fixed wiring.

Strange Observations – Wall Sconce Projection

Continuing in a series of strange things that I have seen while consulting at hospitals…

Do you ever think about your corridor wall sconce light fixtures projecting more than 4-inches into the corridor…?

I do.

[Hey… AH: I made that change that you suggested.]

Fire Hose Valves

Q: We recently had our fire sprinkler inspection and was informed by the vendor that with the new 2012 LSC updates, every fire hose connection valve weather it is 1½ inch or 2½ inch needs to be tested and operated annually to verify they are in working order. We have had our fire hoses removed quite some time ago per recommendation from our local fire department. Are these fire hose valves (which are not used) still required to be tested?

A: Yes… but not as you say. First of all, removing the occupant use fire hoses does not mean the fire hose valves will not be used. The fire department will bring their own hoses in to hook up to your standpipe system. Secondly, the fire hose valves must be inspected quarterly, and the fire hose valves that are 2½ inches are required to be tested annually, and the fire hose valves that are 1½ inches are required to be tested once every 3-years.

Take a look at NFPA 25-2011, section 13.5.6.1 for quarterly inspections and section 13.5.6.2 for annual/3-year testing requirements. Just because you removed your occupant use fire-hoses does not relieve you of the responsibility of testing, inspecting and maintaining your fire hose valves. You have them – then you must maintain them.

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Door Frames

Q: I had an independent Life Safety inspection and during the inspection the inspector cited me for my 2-hour fire door frames not having a fire rating visible. I explained that we went to a fire rated continuous hinge on these doors that covered the labels. He said that that was not enough, he needed to see a label. Should I remove each hinge and take a picture of the fire rating labels?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

A: This topic has come up before, and I asked some AHJs about it since the answer is not found in the codes and standards.  The consensus was that the label should be documented with photos before the hinges are installed – close-up photos to show what is written on the label, and wider photos to show the location of the door.

I’m sure it’s a pain to get this documentation now, but I think that’s the only way to do it for a retrofit situation unless you want to have the doors relabeled.  For new doors and frames, the labels can be applied in another location – on the frame head, and for the doors – either on top or on the lock edge.