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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Business Occupancy Testing

BKeyes : October 5, 2015 12:00 am : Business Occupancy, Questions and Answers, Testing

Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual fire drill but what about the testing of fire alarm system and sprinkler system?

A: Assuming the two-story office building that you refer to is classified as a business occupancy, the requirements for testing, inspection and maintenance are found in section of the 2000 Life Safety Code, which refers to section 9.6. Section requires the fire alarm system to be tested, inspected and maintained in accordance with NFPA 72 (1999 edition). Likewise, section 9.7.5 requires required sprinkler systems to be maintained in accordance with NFPA 25 (1998 edition). If your sprinkler system is not a ‘required system’, you still need to maintain it, according to The testing, inspection and maintenance requirements found in NFPA 72 and NFPA 25 are the very same requirements that healthcare occupancies need to comply with. The bottom line is: You need to test, inspect and maintain the fire alarm system and the sprinkler system in a business occupancy at the very same frequency and level as you would in a hospital.

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Do Table Top Exercises Count as Fire Drills?

BKeyes : October 2, 2015 12:00 am : Fire Drills, Questions and Answers

 Q: Do table top exercises count as a fire drill? We are updating our old policies and traditionally it has been allowed to have tabletops count as a fire drill, as long as half of them were actual Evacuation Fire Drills.

A: No, table top exercises, while they can be very helpful in the planning phase, are not an acceptable substitute in lieu of actually performing the fire drill. The reason why is you are required to perform multiple functions during a fire drill:

  • Evaluate staff’s response to a fire situation, both at the point of the alarm and away from the point of the alarm
  • Evaluate the building’s response to the fire alarm
  • Evaluate the fire alarm’s response to the drill
  • Confirm that the alarm signal was transmitted to the fire department during the drill

In short: How are you going to confirm and evaluate all of that if you do not perform the drill?

Actual fire emergencies are usually an acceptable substitute in performing a fire drill, provided you still are able to make all of the evaluation and confirmations. However, that is not easy to do when you and your staff are responding to an actual alarm.

Sorry, but you still must perform the required amount of fire drills in your facility. And by the way, many accreditation organizations have changed the way they define time. The phrase ‘quarterly’ used to mean you could perform the fire drill anytime during the calendar quarter. Now, Joint Commission and HFAP will require you to perform a fire drill 3 months from the previous drill, plus or minus 10 days. That will require more planning and organization on your part.

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Smoke Detectors in Existing Facilities

BKeyes : September 28, 2015 12:00 am : Questions and Answers, Smoke Detectors

Q: Are existing healthcare occupancies required to have smoke detectors if they are fully sprinklered?

A: Smoke detectors are required in certain areas of healthcare occupancies, but they are not dependent upon whether or not the facility is sprinklered. But what type of healthcare occupancy are you referring to? A hospital? A nursing home? There are slightly different requirements for smoke detectors depending on the use of the healthcare occupancy. For example: A hospital is not required to have smoke detectors in the corridors or patient sleeping rooms but according to the 2000 edition of the Life Safety Code, a hospital is required to have smoke detectors in the following areas:

  • Within 5 feet of a door held open by a magnet, or the entire area served by the door is protected with smoke detectors;
  • In areas open to the corridor that are not directly supervised;
  • In elevator lobbies, mechanical rooms, and shafts where the elevator travels more than 25 feet in any direction above or below the level best served by the responding fire fighters;
  • In the room where a fire alarm panel (including NAC panels) is located, if the room is not continuously occupied;
  • Any other area where smoke detectors are installed to satisfy a local or state requirement, or an equivalency approved by an authority.

In addition to the above, new construction in nursing homes are required to have smoke detection in the corridors.

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Extra Fire Drills for ILSM

BKeyes : September 25, 2015 12:00 am : Fire Drills, ILSM, Questions and Answers

Q: Joint Commission standard LS.01.02.01, EP 11 requires the hospital to perform an additional fire drill during periods of Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction. This standard goes on to say that the need for additional fire drills is based on the criteria in the hospital’s ILSM policy. Let’s suppose that a hospital has deficiencies in the Life Safety Code that lasts only for two, three, four days or maybe even a week. Would the hospital still be required to perform an additional drill for such a short duration of Life Safety Code deficiency? What if the hospital’s Safety Committee decides to state that as part of their ILSM policy criteria, it won’t conduct an additional fire drill per shift per quarter unless the Life Safety Code deficiency lasts beyond a certain amount of time, say maybe a month. It seems to me that a Safety Officer would be on the hook for an additional drill per shift per quarter if ILSMs are only in place for a week is overkill and would serve only to further desensitize staff to its fire alarm system.

A: Joint Commission’s standard LS.01.02.01, EP 11 is not prescriptive, meaning they choose not to specify when the extra fire drill needs to start to compensate for a certain deficiency. They don’t even tell you which deficiency the extra fire drill is even required. That is left up to you to decided and state in your ILSM policy.

I tend to think like you, in that the extra fire drill per shift per quarter does not make sense for a short-term LSC deficiency. But when is a LSC deficiency short-term and when is it considered long term? Perhaps a better approach is to ask: “When will the extra fire drill per shift per quarter be required?” Once you decide when the extra fire drill is required, that should help you decide how soon you need to implement the extra fire drill.

When I was the Safety Officer at the hospital where I worked, I felt the extra fire drill was needed when an exit was obstructed or the access to an exit was obstructed. The reason I believed this, is when you do a fire drill one of the items you are assessing is that staff knows the proper way to evacuate patients (using simulated patients, of course). If the path is obstructed, they need to know the alternative path and be able to demonstrate that. The extra fire drill should assesse the staff’s knowledge on evacuation routes.

Some LSC deficiencies aren’t as obvious so you need to ask yourself “Should I conduct an extra fire drill for this deficiency?” for all of the possible scenarios of LSC deficiency that you could have. Set up a Q&A for all the potential LSC deficiencies that you may encounter at your hospital, then ask yourself is an extra fire drill necessary. Here is an example:

  • Failed fire dampers?                                                   I would say no.
  • Obstructed exit?                                                          I would say yes.
  • Unsealed penetrations in a fire/smoke barrier?          I would say no.
  • Fire alarm pull stations not working?                         I would say yes.
  • Smoke detectors not working?                                  I would say no.
  • Obstructed access to an exit?                                     I would say yes.
  • An inoperative fire pump?                                         I would say no.

Ask yourself: “Would the staff benefit from an extra fire drill if this feature of life safety was not working?” I would say obstructed exits, obstructed access to exits, and inoperative fire alarm pull stations are easy to say ‘yes’ to… but the others? I’m not so sure as I don’t think the staff would benefit from an extra fire drill for an inoperative fire pump, or a failed fire damper. The next question is: “When do I begin the extra fire drills?” Well, if you have defective pull stations or an obstructed exit, you are going to do education and awareness training to the staff affected by these deficiencies. The purpose of the extra fire drill is to assess the staff’s knowledge of these LSC deficiencies after you have conducted the education and training. So, what is reasonable for an obstructed exit? A month after the exit became obstructed? I would say not. Maybe a week after the exit becomes obstructed, but I would say not any more than a week. The sooner the better, as you (the Safety Officer) want to know for sure that the staff knows about the LSC deficiency and takes appropriate alternative action. But this is my opinion, and you need to take this to your Safety Committee and let them offer their suggestions before you finalize your policy. Document this assessment in the form of a matrix, spread sheet or a written narrative in your ILSM policy, and have your Safety Committee review it and approve it. Then the surveyor can only hold you to what your policy says you should do.

Just as a reminder… The extra fire drills for ILSM purposes need to be conducted in the area(s) affected by the LSC deficiency. That means if you have an obstructed exit discharge due to construction, you need to perform the extra fire drills in all areas affected by the deficiency. That may mean you are doing multiple extra fire drills per shift per quarter, until the LSC deficiency is resolved. Also, each fire drill needs to activate the building’s fire alarm system, but during the hours of 9:00 pm and 6:00 am you are not required to activate the audible signals on the fire alarm system.

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Portable Space Heaters

BKeyes : September 21, 2015 12:00 am : Portable Space Heaters, Questions and Answers

Q: Are portable heaters permitted in long term care facilities in offices and other locations?

A: Portable space-heating devices are prohibited in healthcare care occupancies (such as hospitals, nursing homes, limited care facilities and hospice centers with more than 12 beds), with the exception of those portable heaters whose heating elements do not exceed 212 degrees F which are only permitted in smoke compartments which do not contain sleeping rooms, or patient care or treatment. For free standing medical offices which are classified as business occupancies, then the Life Safety Code has no restrictions on portable heaters. But if those offices are located in the healthcare occupancy, then you must comply with the above requirements. Depending on your authorities having jurisdiction, portable heaters may not be permitted even in areas that do not contain patient care, treatment or sleeping beds.

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Tips on Sprinklers for Water Curtains

BKeyes : September 18, 2015 12:00 am : Questions and Answers, Sprinklers

Q: Got any tips for a novice on how to navigate through the Life Safety Code? I’m interested in specifics on sprinkler placement for water curtains.

A: NFPA 13 (1999 edition) is the standard for the installation of water-based sprinklers referenced by the 2000 edition of the Life Safety Code. There are many rules on how to install sprinklers, such as:

  • The maximum distance a sprinkler can be installed below a ceiling is 12 inches (with some exceptions)
  • The minimum distance a sprinkler can be installed below a ceiling is 1 inch
  • The maximum spacing between two sprinklers is determined by the rating on the sprinkler head (usually 15 feet, but there are other spacing distances depending on the manufacturer)
  • The minimum spacing between two sprinkler is 6 feet
  • The maximum distance a sprinkler can be installed from a wall is ½ the maximum spacing between two sprinklers
  • The minimum distance a sprinkler can be installed from a wall is 4 inches
  • The coverage area (measured in square feet) of a single sprinkler is determined by the design density and the manufacturer’s rating of the sprinkler
  • The horizontal distance between a sprinkler head and a ceiling mounted obstruction is a sliding ratio based on the vertical distance the obstructions is mounted below the sprinkler deflector
  • The minimum vertical distance a shelf or items stored on a shelf can be to a sprinkler deflector is 18 inches
  • Sidewall sprinklers cannot be installed more than 6 inches or less than 4 inches below a ceiling (with some exceptions)
  • Maximum area of protection, maximum wall length and maximum spacing between horizontal sprinklers is different than pendant or upright sprinklers, and is dependent on the design density
  • Baffles are permitted between sprinklers when the sprinklers are mounted less than the minimum allowable distance allowed
  • The values mentioned above change for extended coverage sprinklers

I tell you all of the above to show you that there are many individual factors about installing sprinklers that have to be considered in order to design a fire protection system. The bottom line… This is a job for a professional engineer. That is why most AHJs require a PE stamp on all sprinkler designs submitted to them for approval.    

The best way to learn about the Life Safety Code is to experience it on a daily basis. What I mean by that is to have a position in an organization that actively works for compliance with the LSC, such as a Safety Officer or a Facility Manager position… someone who oversees the compliance with the LSC in their facility. Pick up the LSC book and read it, starting with one of the occupancy chapters (12 – 42; chapter 19 is reserved for existing hospitals). Understand that the first 11 chapters are considered basic chapters (or ‘core’ chapters) that apply to all occupancy chapters. Also understand that when there is a conflict between the core chapters and an occupancy chapter, the occupancy chapter rules. Look for some basic Life Safety Code Boot Camp seminars, taught by ASHE, NFPA and Joint Commission Resources.

I hope this information is helpful. Welcome to the world of Life Safety Code compliance. It is a learning experience that will last a lifetime.

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Fire Drill Observers

BKeyes : September 14, 2015 12:00 am : Fire Drills, Questions and Answers

Q: We are getting ready to complete our fire drill schedule and need clarification. When conducting fire drills how many remote fire zone/smoke areas are required to be observed and findings recorded? We could not find anything specific in the standards that address this.

A: You won’t find the answer in the current edition of the Life Safety Code or the accreditation standards because it isn’t there. It used to be in the standards back years ago, but the requirements to have observers in other zones during fire drills were dropped. What is now required for fire drill observation is generally identified as staff who work in buildings where patients are housed or treated must participate in drills according to the hospital’s fire response plan. That does not mean a fire drill has to be conducted on every unit. It means staff must participate in fire drills according to your fire response plan. Most hospitals use the acronym R.A.C.E. to describe their fire response plan, which requires staff to confine the fire by closing doors. So, if the fire is on the 4th floor west wing, staff on the 1st floor east wing can only close doors based on the fire response plan. How do you confirm that staff participated in a fire drill on a particular unit? By sending someone to walk through and observe if they closed the doors. Since the standard does not say all staff must participate in all drills, then I see no reason to have observers in every unit during every fire drill. I see a more realistic approach of having a program of observing every unit at least once per year. Depending on the physical size of your hospital, you might be able to observe every unit once per year with just a couple of observers per drill. So, the bottom line is you still need to confirm that staff participated in the drills, which usually equates to having observers… it’s just that the accreditation standards do not specify how many units need to be observed during a drill.

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CMS Requirements on Ventilation Testing

BKeyes : September 11, 2015 12:00 am : CMS, Questions and Answers, Ventilation

Q: What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals? I see where we are supposed to test and know what ACH is required, but I have not seen at what frequency we are to test. 

A: You raise a very interesting point. CMS seems to have a different philosophy when it comes to writing standards, than say, The Joint Commission, HFAP or DNV. CMS does not write into their standards as much detail or specifics as the accreditors do. CMS does rely heavily on their written Interpretive Guidelines and Survey Procedures that they include with their standards. At times, these Interpretive Guidelines and Survey Procedures have very useful and detailed information.

In regards to ventilation requirements, CMS standard §482.41(c)(4) says “There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas”. That’s all it says in the standard, which is not much to go on. But their Interpretive Guidelines for this standard says: Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the Facilities Guidelines Institute (FGI) should be incorporated into hospital policy.”

So, CMS is saying in their Interpretive Guidelines that the FGI Guidelines must be followed for ventilation requirements. But it is important to understand that the FGI Guidelines are not retroactive to existing conditions, but are used for the design of new construction or renovated areas. For existing conditions, you need to be compliant with the laws, regulations and FGI Guidelines (or AIA Guidelines, if the area is that old) that were in affect at the time the area was designed or renovated.

If your existing area can meet the current FGI Guidelines, then that is great and you’re in good shape. If your existing area cannot meet the current FGI Guidelines, then you need to determine what regulations or guidelines were in effect at the time the area was constructed. If you meet those ventilation requirements, and you can document that, then you’re in good shape.

Now, to answer your direct question: “What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals?” The answer is…CMS does not specify how frequent you need to check the ACH rates, and neither does the FGI Guidelines appear to specify how frequently you need to check your ACH rates. But that does not mean you do not have to perform periodic checks. The answer is… You get to decide how often you check the ACH rates, but it better be based on reasonable assumptions. The state agency surveyors who will survey your hospital on behalf of CMS will have expectations on how often you check the ACH. I could offer suggestions, but ultimately you need to know and follow what your state agency inspectors expect. I suggest you contact them and discuss this issue with them to understand what their expectation will be.

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Life Safety Drawings

BKeyes : September 7, 2015 12:00 am : Drawings, LSC, Questions and Answers

Q: Should the official Life Safety drawings for an existing space within a hospital show the rating on a fire barrier as it was originally built or as it is required to be rated according to the Life Safety Code? We have a soiled utility room that was required to be sprinklered and constructed with smoke resistant partitions according to the code in effect at the time it was constructed, but it was constructed to 1-hour fire resistance rated walls and a 45 minutes rated door. What should the Life Safety drawings reflect for the fire rating of the soiled utility room walls?

A: This may be a tricky question to answer. To be sure, Life Safety drawings are not construction drawings, so the actual type of construction for the barrier is not what is needed. The concept of Life Safety drawings is to indicate what fire-rating the Life Safety Code requires the barriers to be. This is not the same as saying the Life Safety drawings should reflect what fire rating the walls were constructed to. A case in point is in the lower level of a hospital, it is quite common for designers to specify cement block walls for the corridors since there is so much support services traffic in these areas. The walls where carts and pallets commonly travel will stand up to a lot more abuse than steel stud and gypsum board walls. But cement block walls often have a fire-rating of 2-hours or more, but that is not why cement block walls were chosen. The Life Safety Code may only require non-rated smoke resistant walls in the corridor, so that is what the Life Safety drawings should say; not the actual fire rating of 2-hour (or more). A surveyor will hold you accountable to what your Life Safety drawings say; so it is best to only identify what the Life Safety Code requires for the walls and barriers, rather than what they were actually constructed to. In the case of your soiled utility room that qualifies as existing conditions, I suggest the Life Safety drawings should reflect what is required for existing conditions.

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Joint Commission Clarification of Findings

BKeyes : September 4, 2015 12:00 am : Clarification, Joint Commission, Questions and Answers

Q: We recently had a survey which resulted in multiple Life Safety findings. We want to clarify away some of these findings, and were told we can only clarify the ‘C’ category findings. Is this true?

A: No, I would not say that statement is true. Any finding may be clarified after the survey as long as the organization provides sufficient evidence that they were in compliance with the standard at the time of the survey. All ‘A’ and ‘C’ listed elements of performance that received a finding from the surveyor may be appealed to the accreditor with an explanation as to why the hospital believes they were compliant. This is called the clarification process, and organizations have ten (10) days to submit their clarifications once the survey report has been posted.

However, standards with ‘C’ elements of performance do have the additional advantage of clarification if the organization can prove they were compliant with at least 90% of the items covered under the standard prior to the survey. Take the example that corridor doors are required to latch (LS.02.01.30, EP 11); If the hospital regularly examines their corridor doors and has documentation that demonstrates at least 90% of the corridor doors did latch, then that information may be used in a written clarification and any finding of a corridor door not latching would eventually be vacated if the accreditor accepts the clarification.

In order to take advantage of this additional ‘C’ EP clarification process, the documented evidence of compliance must be gathered prior to the survey. This would require the organization to have a monitoring program in place that evaluates various features of life safety on a routine basis. That is why the old Building Maintenance Program (BMP), which is optional, is so important as it provides a documented history of compliance at any given time.  Many hospitals choose not to implement a BMP because it no longer provides any direct relief of a finding during the survey, but the program still provides the historical evidence needed for a clarification. And, it is a very good self-assessment program of your features of life safety.

The clarification process seems to be hit and miss, at times. It is dependent on a well-crafted written response with the evidence needed to vacate the finding. The staff in the Standards Interpretation Group at the accreditation organization does not always approve the clarifications the same way. It may depend on who is actually reviewing the clarification.

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