Statement of Conditions PFI List

Q: We are expecting Joint Commission at our hospital soon. Since they will no longer look at the PFI lists, is it advisable to keep our current open PFIs open on their website? I was informed to close out the open PFIs and document under “Other” that they are closed since we are no longer required to report them to TJC. But, I do not want to close out open PFIs on the TJC website for this reason. Please advise.

A: It is totally up to you and your organization. It is true that Joint Commission has said the Statement of Conditions PFI section is no longer part of the survey process, and their surveyors will no longer look at the PFIs you have written. For the record, Joint Commission is encouraging hospitals to continue to use the PFI section in the SOC in order to manage their Life Safety Code deficiencies. In fact, the accreditor has recently said that they will even allow Environment of Care deficiencies to be placed on the SOC PFI section for you to manage. Joint Commission does not have any immediate plans to eliminate the PFI section from the SOC because they feel it is a useful tool for you to use to manage your deficiencies.

But if it were me, I would likely discontinue using the PFI section in the SOC because I think the computerized maintenance management system that most hospitals have would be a better tool to manage my deficiencies. And, I see no reason to leave Life Safety Code deficiencies listed on a Joint Commission document for their surveyors to look at, if I don’t have to. I know Joint Commission says their surveyors will not look at the PFIs you’ve written, but how do we know for sure that they won’t? In your case, I would not have a problem closing out the current PFIs using the “Other” choice.

Quarterly Test of Main Drain

Q: Has the frequency for the main drain testing changed from annually to quarterly?

A: Yes… but not for all the main drain test locations. The new 2012 LSC now references the 2011 edition of NFPA 25, and section 13.2.5.1 of NFPA 25-2011 requires once per quarter, one (not all) main drain test must be conducted on a system riser located downstream of the backflow preventer when the sole water supply is through a backflow preventer. This test must record the static water pressure, the residual water pressure, and the time required to restore water pressure to static pressure. This test is conducted with the fire pump off (if so equipped) and the jockey pump on.

You still must conduct an annual main drain test on all of the system risers.

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.

Strange Observations – Part 35

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

This is pretty easy to spot… A sprinkler hanger used to support copper medical gas pipe.

Not permitted….

Fire Extinguishers

Q: Are portable fire extinguishers required in business occupancies?

A: Yes… Section 38.3.5 of the 2012 Life Safety Code says portable fire extinguishers must be provided in every business occupancy in accordance with 9.7.4.1. Section 9.7.4.1 references NFPA 10 for installation, inspection, and maintenance of portable fire extinguishers.

Exiting from Hospital into Medical Building

Q: A main circulation corridor in a Hospital (Institutional Use I-2, 8′ wide) passes thru the 2-Hr Use Group separation of adjacent medical offices (Business Use B) and re-enters the Institutional zone (2-Hr wall) for egress to a fire egress stair. Building has automatic sprinkler system. Are egress corridor movements between Institutional and Business Use permitted? Must all sections of that corridor sequence maintain a consistent width of 8′ clear?

A: [Boy… I wish you architects would use NFPA nomenclature instead of IBC…]. If I understand your question correctly, my reply would be yes… you can exit from the hospital into a business occupancy, but there are extenuating circumstances. Section 6.1.14.1.2 of the 2012 LSC says when an exit access (i.e. corridor) from an occupancy traverses another occupancy, the multiple occupancy must be treated as a mixed occupancy. For you, that means the most restrictive occupancy requirements apply, which in your case would be healthcare occupancy.

So, this means everything required for healthcare occupancy must be met in the business occupancy building, such as:

  • Construction type
  • Fire alarm system
  • Sprinklers
  • Fire-dampers/smoke dampers
  • Corridor width
  • Corridor doors
  • Fire safety plans
  • Door latching and locking requirements
  • Etc.

However, if you can call the 2-hour fire barrier separating the healthcare occupancy from the business occupancy, a horizontal exit, then you would not have to meet the requirements of healthcare occupancy, in the business occupancy building.

Waivers and Equivalencies

Q: When do I complete an FSES equivalency request, before the survey or after the survey? Where do I find the forms need to complete an FSES equivalency? What is the different between an FSES equivalency and a waiver?

A: Keep in mind that waiver and equivalency requests are no longer completed prior to the survey. Since CMS made changes to how they approve waivers and equivalencies, you may only submit a waiver request or an FSES equivalency request to your accreditation organization (AO i.e. Joint Commission) or state agency after that entity has cited you for a specific Life Safety Code deficiency.

The main differences between a standard waiver request and an FSES equivalency request is in a standard waiver request, you are asking permission from CMS to not have to comply with a particular LSC requirement based on a significant hardship (often times financial), and you are not required to provide any evidence that your facility has an equivalent level of safety based on other features of life safety.

However, in an FSES equivalency request, you are asking permission to not have to comply with a particular LSC requirement based on an engineering evaluation that demonstrates your facility has an acceptable level of safety even with the deficiency cited by the surveyor. The engineering assessment is made using a specific form called the Fire Safety Evaluation System (FSES) and is found in NFPA 101A-2013. This is a separate document from the Life Safety Code, but evaluates your level of compliance with the 2012 Life Safety Code.

The person conducting the engineering evaluation of the facility using the FSES worksheets (found in NFPA 101A-2013), has to be knowledgeable and experienced in the process. As you can imagine, this would likely require the typical hospital to use an architect, engineer or consultant who has the requisite experience. This will often drive the cost of an FSES equivalency request to the point where it is far more cost effective to just submit a standard waiver request.

Waivers and equivalency requests are submitted to the entity who cited you for the LSC deficiency. If they agree with your request, they will send it on to the appropriate CMS Regional Office for approval. This approval process can take anywhere from a week or two, to many months. Once approved, the waiver or equivalency request is only valid until the next triennial survey, and at which time it becomes invalid. The surveyor will determine if the LSC deficiency still exists and if so, you will be cited again. So, in the big-picture of things, it is best to make plans to eventually resolve the deficiency because if you don’t, you will be cited again, and there is no guarantee that a waiver or equivalency request will be approved a second time.

Another type of waiver request is the Time-Limited Waiver (TLW) request, and it differs greatly from the standard waiver request. Whereas in a standard waiver request you are seeking permission to not have to comply with a particular LSC requirement, a TLW request confirms that you will resolve the LSC deficiency cited, but you just need more time to do so. CMS has a rule under Title 42: Public Health in the Code of Federal Regulations (CFR) that states the following regarding resolving a deficiency cited by their agents:

Ordinarily a provider or supplier is expected to take the steps needed to achieve compliance within 60 days of being notified of the deficiencies but the survey agency may recommend that additional time be granted by the Secretary in individual situations, if in its judgment, it is not reasonable to expect compliance within 60 days, for example, a facility must obtain the approval of its governing body, or engage in competitive bidding. [§488.28(d)]

When a hospital cannot resolve a LSC deficiency within the 60-day window after a survey then they may submit a TLW request to CMS through their AO or state agency that requests additional time to resolve the deficiency. You would follow the specific instructions to submit a TLW from your AO or state agency.

You would follow the instructions in NFPA 101A-2013 to conduct the engineering evaluation for the FSES equivalency request.

Fire Door Inspector

Q: My accreditation organization has a standard that says “testing and inspection of fire door assemblies needs to be conducted by a qualified person.” By what specifically do they mean when they say “qualified” and where are we able to find where they define their interpretation of what qualified is?

A: You will find the interpretation of what ‘qualified’ means under section 5.2.3.1 of NFPA 80-2010, which says functional testing of fire doors and window assemblies must be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. You may hire this responsibility out to a contractor with this knowledge and understanding, or you may assign the responsibility to test the fire doors to one of your own staff individuals, provided you ‘qualify’ them by determining they have the knowledge and understanding to perform this test.

If you decide on the latter, you need to document this decision by describing why you believe this individual has this knowledge and understanding of fire door operating components, and retain that document in case the surveyor asks to see how you qualified that individual. Your own staff individual could be qualified based on a certification course they may have taken (please understand there is no requirement that the person conducting the fire door inspections be certified, but it can be a good source of education), or the individual may be qualified simply because they have worked on doors for years and have accumulated this knowledge and understanding. The key is you may need to defend this decision, so it is best to document the decision and retain that to show to a surveyor.

Time Allowed for Repairs

Q: What are the time frames for repairing life safety deficiencies found during routine inspections? How much time would be allowed to repair emergency exit signs, or failed smoke detectors?

A: Well… if you’re talking about resolving a deficiency that was cited on a survey report, you have 60-days from the time you receive the report. This is actually a mandate from CMS under CFR 488.28(d). But CMS (and the accreditation organizations, or AO) understand if additional time is required, due to the need of obtaining approval from your governing body, or engaging in competitive bidding, as examples.

If you need more time and the deficiency is a LSC deficiency, then you have the option of requesting a Time-Limited Waiver, a Standard Waiver, or a FSES Equivalency. Each AO has their own instructions and procedures for you to follow when requesting one of these.

But if you conduct your own assessment and find certain items deficient, then you are not obligated to resolve the deficiency within the 60-day window. Most AOs will expect you to resolve the deficiency in a reasonable amount of time.

If all you need to do is install four new ‘Exit’ signs, then a month or so is reasonable. But a year would not be considered reasonable.  A failed smoke detector should not take more than a month or so, unless it is such a special item that delivery time is excessive.

Other than the 60-day window after a survey, I’ve never seen a set time-limit for life safety repairs. All of the AHJs I’ve worked with are willing to work with you. If you need extra time due to extenuating circumstances, they will be understanding.

Whatever is reasonable… Most AHJs will work with you on this, as long as the time-frame is reasonable.

Emergency Department Corridor Width

Q: What is the minimum acceptable clearance required in an Emergency Department corridor? Currently there is a crash cart stored for rapid accessibility and the distance directly in front of it is effectively reduced to slightly over 72-inches allowing enough room for a stretcher still to pass. The cart is on wheels and can be quickly easily rolled out of the way as might be needed.

A: Is the Emergency Department a suite of rooms? If yes, then you have nothing to worry about. There are no corridors inside a suite of rooms, even though what looks like a corridor is actually a communicating space. But you do have to maintain aisle width clearance and section 7.3.4.1.1 of the 2012 LSC says the minimum aisle width is 36-inches. So it looks like you have that covered with the 72-inches clearance.

However, if the Emergency Department is not a suite, then you must maintain corridor width requirements. But how wide is the corridor required to be in the Emergency Department? Well… that depends, based on the occupancy classification of the Emergency Department, and whether or not you have any inpatient sleeping rooms in the area. Section 18.2.3.4 (1) permits the clear width of a corridor to be 44-inches if the corridor is not intended for the housing, treatment or use of inpatients.

Now, before you say you don’t have any inpatients in the Emergency Department, remember that CMS has interpreted all Emergency Departments that provide observation beds must be healthcare occupancies, as they consider observation beds to be sleeping accommodations and therefore must meet inpatient requirements. So, if you have observation beds in the Emergency Department, then you must maintain corridor width of 8-feet.

 

But if you don’t have any observation beds in the Emergency Department, then 44-inches is your clear width requirement and it looks that you’ve made that.

Strange Observations – Part 33

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

Equipment rooms can be a major source of findings for surveyors.

Mostly because equipment rooms are often out-of-sight / out-of-mind. And because often times no-one is assigned to maintain the equipment rooms in safe condition.

Here we have a trash cart and a water machine obstructing access to electrical panels and a fire extinguisher.

Battery Powered ‘Exit’ Signs

Q: Do ‘Exit’ signs with battery backup require the same testing as emergency lighting in the path of egress as indicted in section 7.10.9.1 of the 2012 Life Safety Code?

A: Well… yes, but not exactly. Section 7.10.9.1 of the 2012 Life Safety Code requires all ‘Exit’ signs to be visually inspected for operation of the illumination sources at intervals not to exceed 30 days. That is a visual inspection and is not a 30-second test or an annual 90-minute test that you’re alluding to.

But section 7.10.9.2 says ‘Exit’ signs connected to, or provided with, a battery-operated emergency illumination source must be tested and maintained in accordance with 7.9.3, which is the section that requires a 30-second monthly test and a 90-minute annual test of the battery system. So, you’re correct in that battery powered ‘Exit’ signs need to be tested monthly and annually just like battery powered emergency lights, but you just had the wrong code reference.

Fire Extinguisher Signs

Q: I was wondering if there was a specific regulation that states exactly where fire extinguisher signs need to be located. Is there a difference between patient area and staff area? Looking over the new Life Safety Code regulations I have not been able to get a specific answer on where signage location is mandatory.

A: The only thing I can find is section 6.1.3.3.2 of NFPA 10-2010, which says where visual obstructions of fire extinguishers cannot be completely avoided, means shall be provided to indicate the extinguisher location. The Annex section says acceptable means of identifying the fire extinguisher locations include arrows, lights, signs, or coding of the wall or column.

 So, while there is no direct requirement to install signs over fire extinguishers, you may do so. However, be aware: Some AHJs will expect signs identifying the locations of all extinguishers once you start using signs. Their logic is, if you use signs to identify the location of some extinguishers, then your staff will expect to see signs for all extinguishers.

The AHJs do have the right to interpret the code as they see fit. I suggest you ask your AHJs to see if they would require all of the extinguishers have signs.

Strange Observations – Part 32

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

I get it… I understand that many people like to decorate their work area to help brighten up the day for everyone.

I like those people… They are the happy, cheerful, positive, encouraging type of individuals.

But keep an eye on them, as they will eventually start decorating features of Life Safety that will get you in trouble.

Still another reason to do frequent rounding inspections (i.e. monthly) in all areas.

Occupancy Separation

Q: I am a consultant hired by a health system to review a potential building they want to purchase. The architect on this project tells me that the building is NFPA 220 construction type II (111) which is basically a 1-hour rated assembly. The building is a fully sprinklered three story building, and has a mixed use including business and ambulatory healthcare occupancies. The health system is planning on buying the building and is looking to put a free-standing emergency clinic on the first floor which you’ve said needs to be healthcare occupancy. The second floor is a business occupancy. Here’s where it gets strange and I want to make sure I’m not crazy. The floor separation between the first and second floors in this case (business and healthcare) would need to be two-hour fire rated. But Type II (111) buildings have one-hour fire rated floors. I’ve received a drawing from the architect that states the construction type as II (111), but it shows the floors being upgraded to two-hour fire rated construction. The question is, can we have a two-hour floor supported by a one hour steel frame?

A: From my point of view, if they can document that the floor is 2-hour fire rated, then that should be enough for an AHJ to approve the separation between healthcare and business occupancies. I would view it as this: The floor is 2-hour fire rated, and it meets the requirements for a separation between healthcare and business occupancies, and it meets the requirements for Type II (111) construction type. Now, my opinion does not count, so I suggest they get an interpretation from their AHJs, including their accreditation organization.

By the way… CMS was the one who said in late 2016 that Emergency Departments need to be healthcare occupancies. Since then, they have modified their position a bit. Now they are saying an ED must be healthcare occupancy if they provide patient observation rooms. CMS’ rationale is if the patient is sleeping in an observation bed, then that should qualify it as healthcare occupancy. (I don’t agree, but my opinion does not count.) CMS does concede that an ED may be classified as ambulatory healthcare occupancy provide there are no observation beds.