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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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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Eyewash Stations in Labs

BKeyes : July 22, 2015 12:00 am : Eyewash Stations, Questions and Answers

Q: Does an eye wash station need to be mounted over a designated “clean sink” or can it be in any sink? Some of our Labs only have one sink, so that sink is considered to be a dirty sink. Can we have a swing-out eye wash station located above that sink?

A: The OSHA and ANSI standards do not directly address this issue. But Joint Commission, CMS, CAP and the other accreditors will definitely perceive this as a risk to the health and safety of the staff that may use the eye wash station. The risk must be assessed by you, and the mitigation activities to lessen the risk are really what you will be judged on. I suggest you discuss this with the Lab safety officer and the organization’s Infection Control practitioner, and see what they think. If you wouldn’t want to put your face down into the dirty sink then I’m sure you would not expect your staff to do so as well. Do a risk assessment, run it past the Lab safety officer and the IC practitioner, then run it past the Safety Committee and see what they say. If everyone is okay with it (including your accreditation organization), then you should be able to use it for the eye wash station, as long as the eye wash station is maintained and kept clean.

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Fire Drills at Offsite Blood Draw Locations

BKeyes : July 6, 2015 1:00 am : Business Occupancy, Fire Drills, Questions and Answers

Q: We were recently cited by a surveyor for not conducting annual fire drills at our offsite blood draw locations. I have reviewed the Life Safety Code for business occupancies and we have only 4 employees at these offsite locations, which is less than the 100-person threshold required by the LSC to conduct drills. These locations are rented inside commercial buildings. Do you think we have to conduct fire drills at these locations?

A: Yes I do, because your accreditation organization says you have to. I think the accreditation organization standard is very clear: “The hospital must conducts fire drills annually from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.”  The building you described sounds like a business occupancy, and the act of drawing blood from a patient is certainly ‘treatment’. So, they got you from two different angles. I would agree with the surveyor that a fire drill should have been conducted annually at the draw stations, regardless of their size or number of employees. This is an example where the accreditor’s standards over-ride the requirements of the Life Safety Code. It’s one disadvantage for the hospital having their own staff and quick draw station, rather than sub-contracting it out. The cost to manage the Environment of Care at these offsite locations is extensive, and probably wasn’t considered when the hospital opened them up. A fire drill is not an easy proposition at these types of small locations, situated within another building. The Life Safety Code requires the activation of the building’s fire alarm system whenever a fire drill is conducted. This would have to be coordinated with the building owner.

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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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