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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Fire Extinguisher Bar-Code Labels

BKeyes : October 20, 2014 6:00 am : Fire Extinguishers, Questions and Answers

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.

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Ambulatory Surgical Center Mixed Occupancies

BKeyes : October 13, 2014 6:00 am : Ambulatory Care Occupancy, Occupancies, Questions and Answers

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/ 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.

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Use of Fans

BKeyes : October 6, 2014 6:00 am : Portable Fans, Questions and Answers

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. 

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Patient Owned Equipment

BKeyes : September 29, 2014 6:00 am : Appliances, Patient, Questions and Answers

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- 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.

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Hospital Owned Appliances

BKeyes : September 22, 2014 6:00 am : Appliances, Consumer, Questions and Answers

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-, 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.

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Equipment Room Storage

BKeyes : September 15, 2014 6:00 am : Mechanical Rooms, Questions and Answers, Storage

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 for new construction and 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

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Door Locks

BKeyes : September 8, 2014 6:00 am : Door Locks, Questions and Answers

Q: We have been asked to install a lock on a door in the path of egress through an office. For security reasons they would like to lock the doors to and from this area. We are thinking of using an electric strike fail safe connected to fire alarm on both doors. This is not in a patient care area, and the doors would only be used by staff.

A: In a hospital, there are only three permissible methods to lock a door in the path of egress: 1) Delayed egress; 2) Access-control; and 3) Clinical needs. Let’s eliminate clinical needs right off the bat, as that refers to a behavioral health unit or an Alzheimer’s unit. Delayed egress may be a possibility, but the hospital needs to be fully sprinklered or fully smoke detected, and you cannot have more than one delayed egress lock in the path of egress to the public way. Delayed egress does not provide true security for the doors, just a 15 second delay which if activated can be very annoying to the staff. I don’t see this as a suitable arrangement.  The more logical approach is the access-control locks, which allows you to provide security to prevent unauthorized individuals from entering the space, but it does not prevent anyone from exiting the space. Section of the 2000 edition of the Life Safety Code describes the requirements for access-controlled egress:

  • A sensor must be installed on the egress side of the door to detect an occupant approaching the door and automatically unlock the door. This sensor must also be wired where a loss of power to the sensor unlocks the door.
  • A loss of power to the access-control system must unlock the door.
  • A manual release ‘Push to Exit’ button must be installed on the egress side of the door, 40 – 48 inches above the floor, and within 5 feet of the door. The manual release button must be labeled with a sign that reads ‘Push to Exit’. When operated, the manual release button must directly interrupt power to the lock independent of the access-control system, and the door must remain unlocked for a minimum of 30 seconds.
  • Activation of the building’s fire alarm system and/or sprinkler system must unlock the door, and remain unlocked until the fire alarm system has been manually reset.

Access-control locks do not provide any security in the path of egress. In your question, you stated that the door in question is in the path of egress. If that is truly the case, then there is no way you can legally lock this door. I would advise the hospital to re-configure their walls and path of egress to allow the office space they desire without locking a door in the path of egress. Another issue to consider: Is the door in question required to latch? If so, then access-control locks cannot be used in lieu of latching. Even though the door may be locked by a mag-lock, it still needs to latch (if required). The phrase “fail safe” means different things to different people. Typically, for locksmiths ‘fail safe’ means when power is removed, the locks remain locked, but for fire safety people the phrase ‘fail safe’ means the lock remains unlocked.

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Storage in Electrical Rooms

BKeyes : September 1, 2014 6:00 am : Electrical Rooms, Questions and Answers, Storage

Q: Can cardboard boxes be stored in an electrical room that is over 50 square feet, fully sprinklered, and has only dry transformers under 112 1/2 kVA?

 A: Yes, only if the room qualifies as a hazardous room under sections or of the 2000 edition of the Life Safety Code, depending if the room is considered new construction or existing conditions. With the exception of NFPA 1 (2012 edition) NFPA codes and standards do not prevent storage in electrical rooms as long as it does not obstruct access to the electrical equipment. Since NFPA 1 is NOT a referenced standard by the Life Safety Code, the restrictions found in that standard does not apply.  You must maintain at least 36 inches clearance in front of all electrical panels, and at least 30 inches clearance to the side of electrical panels. Now, other authorities having jurisdiction may have their own rules and interpretation, so I would suggest you check with your accreditation organization, state and local authorities to see if they have any issues with that.

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O2 Cylinders in Ambulatory Surgical Centers

BKeyes : August 25, 2014 6:00 am : Ambulatory Care Occupancy, Oxygen Cylinders, Questions and Answers

Q: Since the Life Safety Code addresses ambulatory surgery centers in chapters 20-21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage of compressed gas cylinders?

 A: According to the CMS S&C-07-10 memo dated January 12, 2007, Ambulatory Surgical Centers (ASC) are included in the scope of that interpretation memo and ASC are required to abide by the 2005 edition of NFPA 99, section 9.4.3. This allows them the same advantage as hospitals with no storage requirements for 300 cubic feet and less of non-flammable compressed gas per smoke compartment. For storage of non-flammable compressed gas over 300 cubic feet and less than 3,000 cubic feet per smoke compartment, the ASC needs to comply with Chapter 13 of NFPA 99, section 13-3.8 which refers back chapter 8. Section 8- provides the requirements for storage of non-flammable compressed gas in quantities less than 3,000 cubic feet, which do not include 1-hour fire rated barriers. However, since the CMS S&C memo grants a special dispensation for ASC to follow the 2005 edition of NFPA 99, for 300 cubic feet and less of compressed gas, then they are the same as hospitals in regards to storage of compressed gas. According to the CMS S&C memo, cylinders in use are not to be counted as cylinders in storage. Therefore, they are not included in the calculation of cubic feet of compressed gas when considering storage requirements.  NFPA 99 requires full compressed gas cylinders to be segregated when stored with empty compressed gas cylinders.

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Special Fire Extinguisher Placard

BKeyes : August 18, 2014 6:00 am : Fire Extinguishers, Kitchens, Questions and Answers

Q: Do we have to have a special placard on our fire extinguishers in our kitchen, alerting people to activate the cooking hood fire suppression system first, before using the fire extinguishers? We received a citation from a surveyor on this issue.

 A:  The answer is yes, but I admit I was not aware of this requirement until recently. A hospital-client of mine was cited by their state surveyor for not having a placard near the Class K fire extinguishers informing the staff not to use the fire extinguisher until the cooking hood fire suppression system had been activated. I had never heard of this, so I contacted the surveyor at the state agency and asked what code or standard required this. He said it was in NFPA 96 (1998 edition), and sure enough, there it was in section 7-2.1.1: “A placard identifying the use of the extinguisher as a secondary means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.” Now, the standard says ‘each portable fire extinguisher in the cooking area’, but the state surveyor cited just the Class K extinguishers. I learned something new that day, so I considered it a successful day. If you don’t have those placards near all of your extinguishers in the cooking areas of your establishment, then I suggest you consider them, before you get cited.


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