The following Questions and Answers were previously published in the Healthcare Life Safety Compliance newsletter, and all answers were provided by Brad Keyes.
Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital?
A: The monthly inspection and annual maintenance requirements for the portable fire extinguisher is the same for all occupancies, and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:
- Make sure extinguisher is in its designated place
- Make sure the access to the extinguisher is not obstructed
- Make sure the operating instructions on the nameplate is legible and facing outward
- Make sure the safety seals and tamper indicators are not broken or missing
- ‘Heft’ the extinguisher to determine fullness (pick it up and hold it)
- Examine the extinguisher for obvious damage, corrosion, leakage or clogged nozzle
- Make sure the pressure gauge (if so equipped) is in the normal operating range
- For wheeled units, check the condition of the tires, wheels, carriage, hose, and nozzle
- Make sure the HMIS label is in place
This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable) and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. An annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection is required. A 12 year hydro-test of the extinguisher is also required.
Q: We completed our hospital sprinkler installation in 1994, and most of the sprinklers that were installed were quick response sprinklers. Now I hear at an ASHE conference that we need to replace all of these sprinklers. I thought we had 50 years before we replace them. Why do we need to do that so soon?
A: NFPA 25 (1998 edition), section 2-3.1.1 requires quick response sprinklers to either be replaced or have a sample size tested, 20 years after installation. The sample size is a minimum of 4 sprinklers, or 1% of the individual sprinkler sample installed, whichever is greater. If just one sprinkler in the sample size fails, then all of the remaining sprinklers have to be replaced. If the samples pass, then the quick response sprinkler must be re-tested every 10 years thereafter. Most hospitals find it more cost effective to just remove all the QR sprinklers and replace them with new ones every 20 years. Comparatively, standard response sprinkler do not have to have a sample size tested until 50 years after installation. But the Life Safety Code requires quick response sprinklers (or residential style sprinklers) in smoke compartment containing patient sleeping rooms. Quick response sprinklers and standard response sprinklers are not allowed to be installed within the same four walls (room, area, hallway). You cannot ‘mix’ quick response with standard response sprinklers, because they will not respond the same in the event of a fire. The quick response sprinklers may discharge quicker than the standard response sprinklers, which may actually prevent the standard response sprinklers from activating at all. Surprisingly, I find this problem frequently.
Q: Are we supposed to have smoke detectors in the corridors of our hospital? I see the Statement of Conditions ask if we have smoke detectors in our corridors, which leads me to believe it is a requirement that we need to meet.
A: That depends on other factors. The Life Safety Code does not require smoke detectors in hospital corridors, although it does require them in limited care facilities corridors with some exceptions. However, your local or state authorities may have regulations that require the smoke detectors in corridors. Also, if you have an equivalency approved by an authority having jurisdiction it’s possible that one of the compensating measures was to install smoke detectors in the corridors. So, while the Life Safety Code does not require smoke detectors in the corridors of a hospital, other factors may. That’s why the statement of conditions is interested in knowing if you have them.
Q: We have an attached building that houses an ambulatory surgical center and the building is classified as a business occupancy. We want to convert it from business occupancy to healthcare occupancy so we can have overnight patient care sleeping accommodations. What should we be concerned about?
A: It is classified as business occupancy and you have an ambulatory surgical center in the building? That doesn’t seem right, but I’m glad you’re going to fix that problem. Construction type is one of the many issues that must be dealt with in converting a building from business occupancy to healthcare occupancy, but there are other issues to consider as well. The first thing that needs to be understood is, changing from business to healthcare means the building has to meet new construction requirements found in chapter 18 of the 2000 Life Safety Code, not in chapter 19 which is for existing construction. Therefore, here is a quick summary of the things to investigate to ensure you are in compliance with chapter 18, mainly because these items may not be required in business occupancy. (NOTE: This is not an all inclusive list):
- Construction Type requirements (as already noted)
- Occupant load factors are different for healthcare
- Means of egress components are more restrictive for healthcare, such as fire escape stairs are not permitted
- Means of egress doors have different locking arrangements that actually favor healthcare
- Stair width for existing is 44 inches while the business occupancy building may have been constructed to lessor standards
- Horizontal exits, while not required, if used in the renovated business occupancy cannot have any penetrations (duct, conduit, etc.)
- Corridor width MUST be 8 feet wherever inpatients are housed or treated, but may be 44 inches wide where inpatients would never be (such as a basement support services or administration).
- The minimum clear width of the doors in a means of egress is 41.5 inches, which is far wider than what you would find in a business occupancy
- Healthcare allows the use of suites, both for sleeping arrangements and non-sleeping arrangements which is a great benefit to the hospital
- Dead-end corridors are only permitted to be 30 feet in healthcare while they are permitted to be 50 feet in business
- Travel distances to an exit is less in a healthcare occupancy as compared to a business occupancy
- Emergency lighting is required in healthcare
- Protection from hazards is more restrictive with healthcare
- Medical gases must be in compliance with NFPA 99 (1999 edition) which means a Level 1 piped system would have to be installed for a surgery
- Interior finish requirements are more restrictive, but this is not usually a problem
- A fire alarm system is required, with more devices and appliances than what a business occupancy would require
- The entire building would have to be sprinklered with quick response sprinklers
- Corridors in healthcare are required to be separated from all other spaces, while there is no requirement for corridors in business
- There are multiple examples where spaces may be open to the corridor in healthcare that the hospital may take advantage of
- Corridor walls have construction requirements
- Corridor doors have certain requirements
- Healthcare requires each floor to be subdivided into at least two smoke compartments and there are specific construction requirements for the compartment barriers and doors
- Utilities must comply with section 9.1, which includes gas, electrical and emergency power
- Healthcare facilities must have Level 1 emergency power as described and prescribed in NFPA 99. This requires significant changes to life safety branch and critical equipment branch, which business occupancies would not have to comply with.
- The healthcare facility must have evacuation plans and relocation plans and fire drills once per quarter per shift
- Combustible decorations are not permitted in healthcare
- Portable heating devices are not permitted in patient care areas
That’s just a quick list of things but I’m sure there are more items in greater detail that you would need to comply with as well. As you can see, this is a large undertaking to convert a building that was never intended to be healthcare occupancy into a hospital. Most organizations choose to build a brand new building when they realize the cost in converting an existing building.
Q: Our administration wants us to discontinue applying bar-code labels on each extinguisher in our facility, and begin applying the labels on the cabinets and walls where the extinguishers are located. Do you see this being an issue for us down the road?
A: It would be interesting to understand why your administration wants this change made. I have seen bar-coding done both ways: label the extinguisher vs. label the location of the extinguisher. I don’t see it as a problem, either way. NFPA 10 (1998 edition) section 4-3.4.3 says records of the monthly inspection must be kept on a tag or label attached to the extinguisher; on an inspection checklist maintained on file; or in an electronic system (e.g. bar coding) that provides a permanent record. The standard does not say the bar-code label has to be on the extinguisher, so logic says it can be located near the extinguisher. This is subject to state and local authorities’ interpretation of the standard, as they may want the label in a specific location. I personally would want to label the asset rather than the asset location.
Q: We have an Ambulatory Surgical Center (ASC) located in a one story nonsprinklered building, and is separated from a physician’s office. The exit access from the ASC leads into a corridor which is within the physician’s practice. Since this corridor is not technically part of the ASC, is the ASC responsible for having the corridor wall opposite from the occupancy separation to be 1-hour fire rated?
A: You raise an excellent point: Once you leave the ambulatory health care occupancy and enter a different occupancy type, does the means of egress have to comply with ambulatory health care requirements? According to sections 20/18.104.22.168 of the 2000 edition of the Life Safety Code (LSC), the answer is yes. This section says all means of egress from ambulatory health care occupancies that traverse non-ambulatory health care spaces must conform to requirements of the LSC for ambulatory health care occupancies. The exception to this requirement would be if the barrier between the ambulatory health care occupancy and the contiguous occupancy qualifies as a horizontal exit, then the means of egress in the contiguous occupancy does not have to meet the more rigorous requirements for ambulatory health care occupancy, provided the means of egress is not through a high-hazard area. Horizontal exits are required to be 2-hour fire rated. So, how does this apply to you? If your ASC qualifies as new construction (built after March 11, 2003), then the means of egress in the physician area (outside of the ASC) must have 1-hour fire rated walls that extend from the floor to the deck above (unless they terminate at a ceiling that is also 1-hour fire rated); or if the building is protected with automatic sprinklers throughout; or the barrier between the ASC and the physician’s offices is a 2-hour fire rated horizontal exit. If the ASC qualifies as existing construction (built on or before March 11, 2003) then there are no requirements for the corridors, and what you currently have would be acceptable.
Q: Are portable fans permitted in patient care areas? At times, a patient may become too warm and the normal HVAC system does not provide adequate cooling.
A: The use of portable fans in patient care areas has evolved to become more of an Infection Control issue than a physical environment issue. Most accreditation organizations do not have specific standards that prohibit the use of portable fans in patient care areas, but that does not mean you can. You need to develop a policy or process whereby your Infection Control practitioner evaluates the risks associated with the use of fans in patient care areas, and establishes their position. The major concern is the potential of the fans to spread airborne contaminants around in the area where used; and whether the fan was cleaned before each use. Fans may also be a red flag to surveyors that a temperature control or ventilation problem exists, which can impact equipment and overall patient care. The issue of the cords needs to be addressed so they are not a tripping hazard, and floor-mounted portable fans cannot be set on top of other equipment, such as tables or chairs.
Q: How are we supposed to deal with patient owned equipment that is brought into the hospital, such as laptop computers, hairdryers, and electric razors? Are we required to maintain a record of electrical checks?
A: CMS and the accreditation organizations do not specify what your process should be on how to inspect patient owned equipment. As previously mentioned, NFPA (1999) section 7-22.214.171.124 does provide guidance on initial electrical inspections. But first, conducting a risk assessment is a proper course of action to determine whether patients should be allowed to bring in their own equipment. The accreditation organizations expect healthcare facilities to develop a process to address patients’ personal equipment that would be included in the medical equipment management plan. This process should use risk criteria based on equipment function, physical risks associated with the use, and incident history. Documentation of some sort would be expected to prove to a surveyor that the initial inspection and subsequent risk assessments were conducted.
Q: How does CMS and the accreditation organizations look at preventive maintenance of household electrical items, such as lamps and coffee makers used by staff in the hospital? Do I need to remove them from the facility?
A: No, you do not need to remove those items from your facility, but CMS and the accreditation organizations will expect that you follow accepted practices of conducting initial electrical checks on all equipment used in the hospital, but additional follow-up preventive maintenance (PM) activities would be up to you. NFPA 99 Health Care Facilities (1999 edition) has guidance on this issue under section 7-126.96.36.199, which requires the leakage current for facility owned appliances (e.g. housekeeping or maintenance appliances) that are used in a patient care vicinity and are likely to contact the patient must be measured. The leakage current shall be less than 500 microamperes. Household or office appliances not commonly equipped with grounding conductors in their power cords shall be permitted provided they are not located within the patient care vicinity. For example, electric typewriters, pencil sharpeners, and clocks at nurses’ stations, or electric clocks or TVs that are normally outside the patient care vicinity but might be in a patient’s room, are not required to have grounding conductors in their power cords. The patient care vicinity is defined as a space for the examination and treatment of patients which extends 6 feet beyond the normal location of the bed, table, chair, treadmill, or other device that supports the patient during examination and treatment, and extends to 7 feet 6 inches above the floor. After the initial electrical current check, conduct a risk assessment to determine if these household types of equipment are required to have periodic planned maintenance activities or only be addressed on an as-needed basis.
Q: I was always under the impression that no storage was allowed in mechanical rooms within hospitals. Now I work at a hospital that allows ladders and supplies to be stored in mechanical rooms. Is this allowed?
A: All I can say is it is not a NFPA violation to store items in mechanical rooms, as long as it is done properly. Obviously, storing combustible or flammable items must be accomplished in approved storage rooms, and the typical mechanical room may not qualify for these hazards. But then again, perhaps a mechanical room could qualify to store combustibles. Sections 188.8.131.52 for new construction and 184.108.40.206 for existing conditions of the 2000 edition of the LSC describe the requirements for storing combustibles. It does not make sense to store a bunch of cardboard boxes full of paper filters in a mechanical room that also houses fuel-fired equipment. But why can’t you store those same boxes of filters in a mechanical room for air handlers that does not have any fuel-fire equipment, and qualifies as a hazardous room under the code sections referenced? The NFPA codes and standards do not prohibit it. Where hospitals get ‘pinched’ on this issue, is they don’t do their homework. A mechanical room that was never designed to double up as a storage room may not qualify as a storage room for combustibles. If you alter (or change) the use of a room or area, the room or area must comply with the requirements for new construction. This means if a hospital decides to start storing combustibles in an AHU mechanical (with no fuel-fired equipment), now the room must be protected with 1-hour fire rated barriers, and also be protected with automatic sprinklers. If the room in question does not meet these requirements, then the hospital is exposed for a citation. Another issue is access. Even if the same AHU mechanical room described above qualifies as a hazardous room, if there are so many items stored in the mechanical room that obstructs access to the mechanical equipment, then that is a problem and the hospital could be cited as well