Questions and Answers

The following Questions and Answers were previously published in the Healthcare Life Safety Compliance newsletter, and all answers were provided by Brad Keyes.

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Recording the Monthly Fire Extinguisher Inspections

BKeyes : August 28, 2015 12:00 am : Fire Extinguishers, Questions and Answers

Q: Brad, how does the date need to be recorded on the fire extinguisher tags for the monthly inspection? Does the year need to be included on the inspection tag of the portable fire extinguisher along with the month and day for each inspection?

A: Depending on which authority having jurisdiction (AHJ) is inspecting your facility, yes the year needs to be recorded along with the month and day for every monthly inspection. Joint Commission’s standard EC.02.03.05, EP 15 requires the completion dates for each monthly inspection to be documented. According to Webster’s Dictionary, the phrase ‘date’ means “Time stated in terms of the day, month, and year.” So, technically, Joint Commission is asking that the tag have the day, month and year recorded. But, usually the accreditor allows the year to be omitted as long as the tag has the year pre-printed on it.

Other AHJs may not be as lenient. Many state agency surveyors for the Centers for Medicare & Medicaid Services (CMS) are asking to see month/day/year for every monthly and annual inspection (even if the tag has the year pre-printed), and a signature of the individual performing the service.

Many fire extinguisher service companies like to use a rubber stamp in lieu of the actual signature on the tag for the individual performing the annual maintenance, which is compliant with NFPA 10 (both 1998 edition and 2010 edition) on portable fire extinguishers. However, I have heard of many state agency surveyors for CMS who do not accept the rubber stamp and want a signature of the individual performing the service on each tag.

My advice is to inform the fire extinguisher service company to discontinue using the rubber stamp and have the service technician sign the tags. This will avoid any potential disagreement and squabble about what’s right and what’s wrong later when the surveyors come snooping around. It’s really all dependent on the individual surveyor.

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Immediate Jeopardy

BKeyes : August 24, 2015 12:00 am : Bed Maintenance, Immediate Jeopardy, Medical Equipment, Questions and Answers

Q: We recently heard of a facility receiving an “immediate jeopardy” because their beds and stretchers had not had annual preventative maintenance. This is part of our Equipment Management plan and we are in the process of double checking to ensure we are indeed following our defined process; however, we are curious as to whether the “immediate jeopardy” citing is possible for this deficiency.

A: The concept of what qualifies for an Immediate Jeopardy (IJ) is somewhat subjective. CMS has a document called “Appendix Q – Guidelines for Determining Immediate Jeopardy” (available by Googling that document) that identifies certain issues and triggers for IJ. Essentially, CMS identifies an IJ situation as “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.” The Guideline continues to provide situations and examples whereby an IJ may occur, but this list is only a guide and is not conclusive. The lack of PM on beds is not included on the list. You ask if citing a lack of PMs on beds as an IJ is possible, and the answer is yes… but only if the surveyor has reason to believe that the lack of PMs is has caused or likely will cause serious injury to the patient. Is it possible? Yes. But I don’t see this as probable. The concept of “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident” is very subjective. What may be an IJ to one surveyor, may not be an IJ to another. Until your question, I’ve never heard of an IJ situation for a lack of PMs on beds.

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Changes in How ABHR Dispensers Are Regulated

BKeyes : August 21, 2015 12:00 am : Alcohol Based Hand-Rub Dispensers, Questions and Answers

Q: I read an article you wrote on alcohol based hand rub (ABHR) dispensers for FacilityCare.  We have had a question come up about changes in the regulations concerning the locations of ABHR dispensers in hospitals; are there any changes to the restrictions?  Do you know anything about this?  It is an issue for us right now as we have a vendor installing and relocating over 500 dispensers in our hospital and need to be sure we understand the regulations correctly.

A: There will be changes on how ABHR dispensers will be regulated when the new 2012 LSC is finally adopted. The changes do not involve the elimination of regulations concerning ABHR dispensers, but the changes will make it a bit easier to have more of them in your corridors.

The changes involve the number of dispensers permitted within a single smoke compartment. Currently under the 2000 LSC, you are only permitted 10 gallons of the ABHR product in dispensers within any one smoke compartment. So, for a 1 liter ABHR dispenser, that means you are limited to 37 dispensers per smoke compartment (3.7 liters per gallon x 10 gallons = 37 liters). This means, if you have a smoke compartment that has 30 patient sleeping rooms, and you have one dispenser in each room, that only leaves you with 7 ABHR dispensers to be located in other areas of the smoke compartment. Not a desirable situation.

When the new 2012 LSC is finally adopted, the new rule will allow one dispenser per room (not limited to a patient sleeping room) to not be included in the total aggregate quantity of 10 gallons of ABHR product in dispensers, per smoke compartment. That means, in the same scenario listed above, those 30 ABHR dispensers in each patient sleeping room now do not count towards the aggregate total of 10 gallons of product in dispensers per smoke compartment, which leaves you with 30 more ABHR dispensers to place around the smoke compartment. A very much improved situation.

The new rule will also allow a total aggregate of 1135 oz. of aerosol ABHR product in dispensers, which equates to something like 63 – 18 oz. dispensers per smoke compartment. The new rule also allows ABHR dispensers in Ambulatory Care occupancy corridors (it didn’t before), but it does not address business occupancy corridors, which means it is not permitted.

My advice is add only the number of dispensers permitted under the current code (10 gallons in ABHR dispensers maximum per smoke compartment, including those in the rooms) and do not install the additional dispensers that will be permitted with the new code, until the new 2012 LSC is adopted

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Fake Smoke Detectors

BKeyes : August 17, 2015 12:00 am : Fake Smoke Detector, Questions and Answers

Q: Are fake smoke detectors permitted to be installed in a hospital according to NFPA codes and standards? I discovered that our Security department installed a manufactured security camera that is built into a fake smoke detector and the question is whether or not the NFPA codes and standards permit this. These security cameras/fake smoke detectors are mounted on the ceiling and look like the real thing.

A: No, they are not permitted based on multiple regulatory reasons. First of all, most states have regulations that prohibit fake smoke detectors. The state where you are located has the following regulation: “New criminal penalties will be in effect as of January 1, 2009, for persons who manufacture, install or sell any device or object that appears to be a smoke detector, sprinkler head, carbon monoxide alarm, heat detector or any other similar device used for life safety or fire protection but in fact is not capable of performing such function.” Secondly, section of the 2000 Life Safety Code says: “Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.” Now, this section does not specifically prohibit a fake smoke detector, but it does prohibit inoperative life safety devices. The Annex section addresses this much better than I could explain it: “A. Examples of such features include automatic sprinklers, fire alarm systems, standpipes, and portable fire extinguishers. The presence of a life safety feature, such as sprinklers or fire alarm devices, creates a reasonable expectation by the public that these safety features are functional. When systems are inoperable or taken out of service but the devices remain, they present a false sense of safety.” The annex addresses the ‘reasonable expectation’ (underline mine) of protection that could bring liability concerns to the owner. If your state or local authority prohibits the fake smoke detector, then it is not permitted. If the state or local authority does not have a regulation prohibiting it, then I would say a fake smoke detector is not permitted as it provides a reasonable expectation by the public that the device is functional. Even if the fake detector with a security camera is mounted next to a real smoke detector that is operable, I would have problems with the fake one since it is obvious to the public and it is inoperative.

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Nursing Home Temperatures

BKeyes : August 14, 2015 12:00 am : Nursing Home, Questions and Answers, Temperature

Q: My loved one is in a nursing home and needs additional heat in the winter time, what do I do? The building seems to be at a comfortable temperature, but my family member needs extra heat. Is there a heating blanket that passes code? 

A: The CMS State Operations Manual for Nursing Homes, sub-parts 483.70(c) and 483.70(h) requires a ‘comfortable’ environment for the resident. However, CMS does not define what temperature dictates a comfortable environment. Check with the state that the nursing home is located and determine if they have temperature limits for nursing homes. Enter “state regulations for nursing homes” in your internet search engine and include the name of the state the nursing home is located. They may have their state licensing requirements available for download and you can see if they have temperature ranges specified for the residents.

The temperature of the facility is typically set and controlled by nursing home staff, who are active and walking about, performing duties. The residents of the nursing home are typically sedentary and therefore inactive. This difference can cause the workers to be over-heated when the temperature is raised to satisfy the residents, or the residents are uncomfortable when the temperature is set to satisfy the workers. It is a problem that is not easy to resolve. 78° may be a comfortable temperature for residents who are inactive, but would be too warm for workers who are scurrying about. Likewise, 72° may be a comfortable temperature for workers but may be too cool for residents. If you set the temperature in the middle at 75°, you may have a better chance of satisfaction, but ultimately, someone will be uncomfortable. It is not uncommon to see workers wear summer clothing in the middle of winter.

Portable heating devices, such as a space heater are not permitted in patient care areas, according to CMS rules and the NFPA Life Safety Code section 19.7.8 (2000 edition). Electric blankets are not directly addressed by NFPA codes and standards, but it is a good bet that the nursing home would not (or should not) permit them, as they can be dangerous in an institutional setting. Cords can become easily and quickly damaged from moving beds and rolling carts, creating the potential for sparks from electrical shorts. Temperature settings on the control can be fixed too high, or accidentally increased by the resident causing epidermis damage. Hospitals that I consult with typically do not allow electric blankets, and I would not recommend their use in a nursing home. Perhaps warm blankets from a blanket warmer may be a temporary solution to the problem.

The nursing home has an obligation to provide a comfortable environment for your loved one. If you feel there is an inadequate response to your concerns by the nursing home, you can file a complaint at CMS for conditions that you believe are sub-par based on the State Operations Manual for nursing homes:

I’m sorry if this is not the answer that you are looking for, but I do not believe there are portable heating devices for a nursing home resident that would be permitted under CMS rules and NFPA Life Safety Code standards.

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Corridor Width

BKeyes : August 10, 2015 12:00 am : Corridors, Questions and Answers

Q: Can you give me the NFPA Life Safety Code (2000 edition) reference showing 8 foot required width in egress corridors in an existing healthcare occupancy?

A: There is no direct LSC reference that requires 8 feet wide corridors in existing hospitals. But; it’s an interpretation. Section of the 2000 Life Safety Code says corridors have to be at least 4 feet wide in existing healthcare occupancies. Section 4.6.7 says when you make alterations, you must meet new construction requirements. Section requires 8 feet wide corridors in new construction healthcare occupancies. So, let’s say you have 7 foot wide corridors in an existing hospital. That’s legal. But the minute you make an alteration (including storing something non-combustible in the corridor) now it must meet the requirements for new construction, which is 8 feet. So, the correct way of stating corridor width in existing healthcare occupancies is the corridor must be free and clear up to 8 feet wide. If the corridor is 7 feet wide: That’s okay as long as the width is free and clear.

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Post Indicator Valves

BKeyes : August 7, 2015 12:00 am : Control Valves, Questions and Answers, Sprinklers

Q: I have 3 Post Indicator Valves (PIV) and 1 Wall Post Indicator Valve (WPIV). I’m not finding anything in NFPA in regards to the testing frequency. My PIVs and WPIV do not have Tamper Switches. Are these required to be tested once a week or once a month?

A: NFPA 25 (1998 edition), sections 1-3.9 and 9-3.1 define a control valve as a valve that controls the flow of water to a water-based fire protection system. A Post Indicator Valve (PIV) does control water to the fire protection system; so therefore, a PIV is a control valve by definition.

According to section 9-3.3.1 in NFPA 25 (1998 edition), all control valves are required to be inspected weekly, unless they are chained and locked, or ‘supervised in accordance with other NFPA standards’, then they need to be inspected monthly. The inspection is to confirm the following:

  • Ensure the valve is in the normal position (open or closed)
  • Properly sealed, locked or supervised
  • Accessible
  • Appropriate wrenches are provided (i.e. PIV)
  • Free from leaks
  • Properly identified

According to section 9-3.4 of NFAP 25, control valves are required to be tested on an annual basis (which is defined by the accreditation organizations to be 12 months from the previous test, plus or minus 30 days). Each control valve must be operated through its full range and returned to its normal position. In other words, each valve must be closed; then opened. After the closed/open exercise, PIVs must be opened until spring or torsion is felt on the rod, indicating that the rod has not become detached from the valve. PIVs and OS&Y valves must be backed a ¼ turn from the fully open position to prevent jamming.Control valves (and this includes PIV) must be electronically supervised, according to section of the 2000 edition of the Life Safety Code (LSC). Chains and locks are fine if you want them, but they are not an acceptable substitute for electronic supervision (tamper switches). Tamper switches must be tested on a semi-annual basis, which means 6 months from the previous test, plus or minus 20 days.

I would say your 3 PIV and 1 WPIV are non-compliant with the LSC requirements for electronic supervision; and furthermore, it is extremely dangerous for your hospital not to electronically monitor those valves. What if an unauthorized individual closed one of those non-supervised PIV (or WPIV) and you had a fire in the facility? There would be no water for the sprinklers after the static pressure was released from the piping. My advice is to get this resolved as soon as possible, and to start an Interim Life Safety Measure (ILSM) today and continue until the valves are electronically supervised, that includes once-a-shift daily inspections of those valves to ensure they are open.

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Sprinklers in an Air Handler Room

BKeyes : August 3, 2015 12:00 am : Mechanical Rooms, Questions and Answers, Sprinklers

Q: Do air handler mechanical rooms located at the top of a hospital, and are healthcare occupancies, require sprinkler systems?

A: Yes… if the rest of the hospital is required to be sprinklered. There is nothing in the code or standards that allows the air handler mechanical room to not be sprinklered when the rest of the hospital is required to be sprinklered. But, the mechanical room is not required to be sprinklered if the hospital itself is not required to be sprinklered. This is dependent on the date when the hospital was constructed; the date of the most recent renovation in the mechanical air handler room; the construction type; and any approved equivalencies you may have.

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Nursing Home Sprinklers

BKeyes : July 31, 2015 12:00 am : Nursing Home, Questions and Answers, Sprinklers

Q: Can you clarify for me if the elevator equipment room is required to be sprinklered and have a shunt trip installed in our nursing home.

A: Yes, elevator equipment rooms are required to be sprinklered in all new and existing nursing homes, as per the CMS S&C memo 09-04 issued October 3, 2008. The S&C memo requires all existing and new nursing homes to be fully protected with automatic sprinklers. The CMS memo refers to NFPA 13 (1999 edition) as the standard to be used for the installation of sprinklers, and unfortunately for you, neither NFPA 13 nor the CMS S&C memo has any exemptions for elevator equipment rooms to be protected with sprinklers.

Section 5-13.6.2 of NFPA 13 very clearly states that sprinklers are required in the elevator hoistways and mechanical rooms. However, the Annex section for 5-13.6.2 refers to ASME A17.1 Safety Code for Elevators and Escalators which requires shunt-trip shutdown of the electrical supply upon or prior to the application of water in the elevator machine room or hoistway. The intent is to interrupt the power supply before significant sprinkler discharge.

So, it looks to me that you need to have those sprinklers installed. If you have a local authority telling you not to install sprinklers in the elevator hoistway or mechanical rooms, you need to inform them that you are under federal direction and they need to allow you to do so.


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Ambulatory Healthcare Occupancies

BKeyes : July 27, 2015 12:00 am : Ambulatory Care Occupancy, Questions and Answers

Q: How do I determine if our outpatient facility is an ambulatory healthcare occupancy?

A: Based on what the 2000 Life Safety Code says, an ambulatory healthcare occupancy is a building or portion thereof used to provide services or treatment simultaneously to four or more patients that: 1) Provides on an outpatient basis, treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; or 2) provides on an outpatient basis, anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others. Ambulatory healthcare facilities shall be separated from other tenants and occupancies by walls and barriers not less than 1-hour fire resistance rating. The ambulatory healthcare facility shall be divided into not less than two smoke compartments. Facilities of less than 5,000 square feet and protected with approved automatic smoke detection system do not have to be subdivided, and facilities of less than 10,000 square feet and protected throughout by an approved, supervised automatic sprinkler system do not have to be subdivided into two smoke compartments. Not less than 15 net square feet per ambulatory healthcare facility occupant shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounges and other low hazard areas on each side of the smoke compartment for the total number of occupants in adjoining compartments. I also bring to your attention that in their proposed rule to adopt the 2012 Life Safety Code (issued in April, 2014) CMS stated they will seek to change the rules that govern ambulatory healthcare occupancies. Currently it requires four or more persons incapable of self-preservation to be classified as an ambulatory healthcare occupancy. If CMS gets their way that will be reduced to 1 or more persons incapable of self-preservation will require an ambulatory healthcare occupancy, and all of the above LSC references would apply. The big thing here is the 1-hour fire rated separation barriers and the ambulatory healthcare area divided into at least two smoke compartments. That would be a substantial cost to retroactively install those barriers after the area is occupied.

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