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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Offsite Clinic Fire Alarm System

BKeyes : June 29, 2015 1:00 am : Business Occupancy, Fire Alarm, Questions and Answers

Q: We have an offsite physician’s clinic with a fire alarm system that is tied into our main hospital campus control center and is monitored 24/7. Are we required to do quarterly off-premises monitoring transmission equipment testing at both facilities or just at our main campus?

A: Since this is a business occupancy there is no requirement to monitor the fire alarm, and have off-premises monitoring transmission equipment. However, if you do have the off-premises monitoring transmission equipment, then you must maintain and test it accordingly. The requirement to perform quarterly testing of the off-premises transmission equipment is found in NFPA 72 (1999 edition, for those organizations that need to comply with the 2000 edition of the Life Safety Code),  and the testing requirement is found in Table 7-3.2. If the offsite clinic is accredited by one of the accreditation organizations, or certified by CMS, then the requirements of NFPA 72 apply, and you would have to perform the quarterly testing as long as you have the equipment. However, if the offsite facility is not accredited or certified, then you would have to look at any local or state requirements to see what they expect for testing and inspections.

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Fire Drills with the Local Fire Department

BKeyes : June 22, 2015 1:00 am : Fire Drills, Questions and Answers

Q: I am new to this position and I am working on updating my management plan on fire safety. Currently it states “The fire department’s Fire Prevention Bureau will conduct at least two fire drills annually”. Is it a requirement to have the local fire department participate in two of our fire drills, annually?

A: No, it is not. The accreditation organizations and CMS do not have standards that require the local fire department to participate in the healthcare organization fire drills. The Life Safety Code and the other NFPA standards do not as well. It may be possible that there is a local or state regulation that requires the involvement of the local fire department in your drills, but there is no accreditation or certification requirement to do so. However, having the local fire department present during fire drills can be a good thing as it creates positive interaction with them. You can never have too much good will with the local fire inspector and his department. But if it is not required, and it becomes a burden to continue to involve them, take it to your Safety Committee and discuss the issue with them. Ask them if it is okay to stop including the local fire department, and see what they think.

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Fire Extinguisher Signage

BKeyes : June 15, 2015 1:00 am : Fire Extinguishers, Questions and Answers, Signs

Q: I have a question regarding fire extinguishers. We have our extinguishers located in cabinets that are flush with the wall. Is it required to have signage above the extinguisher?

A: No, it is not. The 2000 Life Safety Code requires you to be in compliance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, and section 1-6.12 of NFPA 10 requires fire extinguishers that are mounted inside a cabinet or wall recesses, must be marked conspicuously. A sign mounted on the wall above the fire extinguisher cabinet is certainly a conspicuous marking, but it is not the only marking that meets the requirements of 1-6.12. A red dot on the floor or on the ceiling is also a conspicuous marking as well. If the fire extinguisher cabinet is lettered with the words “Fire Extinguisher”, then that qualifies as a conspicuous marking. If the authority having jurisdiction does not believe that lettering on the outside of the cabinet that says “Fire Extinguisher”  meets the requirements of 1-6.12, then you need to negotiate with them and try to get them to understand that it does meet the requirements of NFPA 10. Otherwise, you need to comply with what the AHJ interprets.

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Wireless Nurse Call System

BKeyes : June 8, 2015 1:00 am : Nurse Call Systems, Questions and Answers

Q: We are looking at the difference between a “wired” and “wireless” nurse call system in our healthcare facility addition. Our current health center has a “wired” call system however our I.T. department wants us to go with a “wireless” system. I could see where it will only take one bad incident with a wireless system and the authorities will say that everyone must have a wired system or have one as a back-up. What is your thought on this subject?

A: My experience with the national accreditation organizations is they are all for new technology. While none of them have standards or interpretations that directly address the use of wireless technology (that I am aware of), I believe they would be in favor of it. However, if there is a perceived risk in using wireless technology then that risk must be assessed through a risk assessment and appropriate mitigation activities implemented. The bottom line is this: You get to decide the level of mitigation activities for a wireless nurse call system. If you decide having a hard-wired system in place as a back-up system is appropriate, then that is what you do. Other possibilities include a manual bell system, or post additional aids or runners in the corridors listening for a call until the wireless system is up and running again.

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Eyewash Stations in Kitchens

BKeyes : June 1, 2015 1:00 am : Eyewash Stations, Kitchens, Questions and Answers

Q: Are we required to have an eyewash station inside a kitchen?

A: Maybe yes and maybe no…. It all depends on whether or not there are caustic or corrosive materials that could be splashed into the eye. The organization needs to do a risk assessment of the hazardous materials in and around the kitchen to see if there are any chemicals/ materials that are considered caustic and/or corrosive, and whether or not they can be splashed into the eye when used according to the manufacturer’s recommendations. I’ll say from my experience, there probably are not many such materials in a kitchen, as that would seem to be a bit risky to have hazardous materials where food is being prepared. But you may very well find such materials in a janitor’s closet nearby, or in the dishroom. If you do have caustic or corrosive materials, the eyewash station must be located no more than 10 seconds of travel away from where the materials are used or stored. All of these requirements are found in the ANSI Z358.1 standard, available through an on-line search.

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Door to Medical Gas Storage Room

BKeyes : May 25, 2015 1:00 am : Doors, Medical Gas, Questions and Answers, Storage

Q: I have an existing medical gas storage room in an outpatient surgery center that was constructed with 1-hour barriers and ¾ hour fire rated door. A surveyor cited me because he says the door has to be constructed of non-combustible or limited combustible materials. The door that is installed is a high pressure decorative laminate with a bonded agri-fiber core with a 45 minute fire resistance rating. I maintain that doors are exempted from the noncombustible/limited-combustible provision. Who’s correct?

A: One scenario that the surveyor may hold you accountable to is medical gas systems in ambulatory care occupancies are regulated by the Life Safety Code, and not by NFPA 99. The Life Safety Code (2000 edition) would look at medical gas room as a hazardous room, and for ambulatory care occupancies, a hazardous room compares their level of hazard to their surrounding area. The section that regulates hazards in ambulatory care occupancies is section 20/21.3.2 which refers you to 38/39.3.2, which in turn refers you to section 8.4. Section 8.4 essentially says any area with a higher level of hazard than the surrounding area needs to be protected with fire protection sprinklers, or 1-hour fire rated barriers. Section requires a 1-hour fire rated barrier to have at least a ¾ hour fire rated door as long as the fire barrier is not used as a vertical opening (such as a rated shaft) or an exit enclosure (such as a stairwell). Hopefully, you don’t have the med gas room in a stairwell, so a properly labeled ¾ hour rated doors is acceptable, and in this scenario I would say the surveyor is mistaken. However, if the surveyor requires that you comply with NFPA 99 in regards to medical gas systems, then that is an entirely different situation. Section 4- (a) 11 (a) of the 1999 edition of NFPA 99 requires doors to be constructed of non-combustible or limited combustible materials. If the 45-minute fire rated door that you have is laminated with limited combustible materials, then it would not be compliant with NFPA 99 (1999 edition), and I would say the surveyor is correct. Section 3.3.118 in the Life Safety Code defines what limited combustible materials are. I suggest you contact the manufacturer of the door and ask them to produce documentation whether or not the door meets the heat values stipulated in section 3.3.118, that may qualify the door as being constructed with limited combustible materials. Now, on another point of view, if the surveyor requires you to comply with NFPA 99, 2005 edition, the door to this room still has to be constructed from non-combustible or limited combustible materials, but it is no longer permitted to be ¾ hour fire rated, but must be 1-hour fire rated, according to section The 2012 edition of NFPA 99 has the same requirement.

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Evacuation Route Maps

BKeyes : May 18, 2015 1:00 am : Evacuation, Maps, Questions and Answers

Q: Are evacuation route drawings required to be posted at nurse stations or anywhere else per Joint Commission or CMS requirements?

A: No. There is no Joint Commission standard or requirement and there is no CMS standard or requirement for evacuation route plans to be posted on units or in corridors. Although, having them in strategic locations are valuable teaching aids during routine fire drills. This is one of those great surveyor myths that seems to have been started decades ago by an misinterpretation by an official from CMS (or as it was called back then, HCFA). You may want to check with your local and state authorities to see if they have any requirements on this issue.

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Compressed Flammable Gas

BKeyes : May 11, 2015 1:00 am : Cooking Appliances, Flammable Liquids, Gas Cylinders, Questions and Answers

Q: Can we store compressed butane gas cylinders used for food-warming and heating in the kitchen or do they require special storage?

 A: NFPA 30 requires all flammable gases and liquids exceeding 1 gallon (aggregate total) must be stored in a proper fire rated cabinet, or in a hazardous room with 1-hour fire rated barriers. You are not allowed to store mixed substances, such as combustibles with flammable liquids and gasses. For quantities less than 1 gallon, they must be stored in their original container, or in a special safety can. Joint Commission does have a standard (EC.02.01.01) whereby they could cite you for having any flammable liquid or gas stored outside a fire rated cabinet regardless of the quantity.  

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Staff On-Call Sleeping Rooms

BKeyes : May 4, 2015 1:00 am : On-Call Sleeping Rooms, Questions and Answers

Q: Does the Life Safety Code require hospital staff sleeping rooms have smoke detection inside the room and door closers installed? We have an on-call sleeping room for physicians in our Labor & Delivery unit and a consultant said we need smoke detectors and a closer on the door.

A: The answer is yes, the Life Safety Code (2000 edition), does require it. Section says where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards must comply with the most restrictive life safety requirements of the occupancies involved. This means where there is a dominate occupancy (such as healthcare occupancy in the Labor & Delivery unit) that also has a small portion of a different occupancy (such as the staff on-call sleeping room which is actually hotels and dormitories occupancy) and these two occupancies are not separated by a 2-hour fire rated barrier, then this means the two occupancies are mixed, and the most restrictive requirements of both occupancies apply. As you indicated, hotel and dormitory occupancy does require single station smoke alarm and a closure on corridor doors to sleeping room (see sections and However, there is an exception to section which says where incidental to another occupancy, buildings used as follows shall be permitted to be considered part of the predominant occupancy and subject to the provisions of the Code that apply to the predominant occupancy:

  1. a) Mercantile, business, industrial, or storage use;
  2. b) Nonresidential use with an occupant load fewer than that established by Section 6.1 for the occupancy threshold.

This exception is allowing small incidental use of one occupancy to not have to comply with the requirements of that particular occupancy, and instead may comply with the requirements of the predominant occupancy, which in your case would be healthcare occupancy. There is only one catch, though. The phrase ‘incidental’ is ambiguous and is not defined. Therefore, the authority having jurisdiction (AHJ) gets to answer the question: What does incidental mean? I do not know what state and city you are located in, so I do not know who your AHJs are, but it’s a sure bet you have 5 or 6 AHJs who enforce the Life Safety Code, and it is likely that not all of them would make this interpretation the same way:

  • Joint Commission (or one of the other accreditation organizations)
  • CMS
  • State fire marshal
  • State public health
  • Local fire inspector
  • Insurance company

Since you have so many AHJs who have the right to interpret the phrase ‘incidental’, my advice is to take a very conservative approach and do not consider the exception, and go with installing a single station smoke alarm and a closure on the door to the corridor for the sleep room. By the way, most of the AHJs accept the fact that a smoke detector connected to the building fire alarm system in a hospital is equivalent to a single station smoke alarm, so you may be okay by just installing a smoke detector, rather than a single station smoke alarm. That’s your call.

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Helium Tank/ ABHR Dispenser Location

BKeyes : April 27, 2015 6:00 am : Alcohol Based Hand-Rub Dispensers, Gift Shops, Helium, Questions and Answers

Q: Can we have a helium tank if secured properly in gift shop? And what are requirements for hand sanitizer locations- location to switches or outlets?

A: Provided the tank is secured properly, and there is less than 300 cubic feet of compressed gas total in the Gift Shop, you may have a helium tank in the shop. The typical ‘H’ tank (which is approximately 9 inches in diameter and about 55 inches tall) contains 250 cubic feet, so 1 ‘H’ tank properly secured in the gift shop would be permissible (but only one tank). Joint Commission has changed their requirements to allow the Alcohol Based Hand Rub (ABHR) dispensers to be mounted no less than 1 inch side-to-side to an electrical outlet or an electrical switch. However, CMS is still on the definition of no less than 6 inches center-to-center between an ABHR dispenser and an electrical outlet or switch. Once the new 2012 edition of the Life Safety Code is adopted, then CMS will be on the same page as Joint Commission

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