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Lower Bottom Rods

BKeyes : January 19, 2017 12:00 am : Doors, Hardware, Questions and Answers

Q: I am a consultant and I am surveying a system where the bottom strike rod and the floor receiver have been removed.  I think this “field” modification may void the UL rating.  Is there a reference for clarification on this?

A: You’re not going to find a section in any NFPA code or standard that says “There must be a lower bottom rod on fire rated doors”. But, nonetheless, they are required when the manufacturer says they are required. The manufacturer of fire rated door assemblies have to have them listed by on independent testing laboratory, such as UL or ETL (Intertek). The manufacturer submits their fire door assembly for testing and if it passes the test, then the testing laboratory will list it as meeting the required standards based on the total assembly, including the hardware.

For decades certain types of cross-corridor fire rated door assemblies were designed with surface mounted hardware that included the lower bottom rod for latching. And for decades, hospital employees hit that lower bottom rod with carts and instead of repairing the rod, the poorly-informed maintenance staff would just remove the rod. Along comes better-informed surveyors who identifies that this is not correct and cites the hospitals.

Recently, some door manufacturers are actually designing cross-corridor fire-rated doors with surface hardware that eliminates the lower bottom rod all-together. This design was tested and listed by the testing laboratories. Some of these designs have employed devices what are commonly called ‘fire-pins’ in the lower part of the door that releases a pin from one door leaf to the other door leaf to ‘lock’ it in place when the ambient temperature at the floor approached 500 degrees (or so).

As you come across fire-rated doors that have surface mounted hardware but no lower bottom rods, I suggest you do the following:

  • Check the horizontal crash bar hardware and confirm if there is an opening on the underside of housing for a lower bottom rod. If not, then check the independent testing laboratory label on the horizontal crash bar assembly to confirm that it is listed for use as fire-rated hardware.
  • If there is an opening on the underside of the housing, then check to see if there is a fire-pin installed on one of the door leafs.
  • If there is no fire-pin installed, then ask the organization to provide you with documentation that the door assembly as presented meets the requirements for the UL (or ETL) listing. If they can provide that information, then review it and determine that the remaining hardware is installed as designed.
  • If they cannot provide that information, then cite them for non-compliant modifications to a fire-rated doors assembly.
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Fire Door Maintenance

BKeyes : January 18, 2017 12:00 am : Fire Doors, Questions and Answers

Q: If a door is a fire-rated door is it required to be maintained as a rated door in compliance with NFPA 80, regardless if its location doesn’t require a rated door? I was told by a facilities employee that there isn’t any information that he can find that states this. Really my fight with him is simple that a fire rated door regardless of location and function needs to meet the standards at all times i.e. door closer, holes in door and frame etc.

A: According to the 2012 Life Safety Code, section, openings required to have a fire protection rating must meet the requirements of NFPA 80. So, based on this passage, if the fire door is installed in a non-rated barrier, one could assume that testing the fire doors would not be required.

But one would be wrong. According to section of the 2012 LSC, doors must be in compliance with section 7.2.1 of the same code. Section says fire rated doors assemblies must be inspected and tested in accordance with NFPA 80. This section does not differentiate whether the door is in a fire-rated barrier or not. Therefore, all fire rated doors must be inspected and tested (and maintained) in accordance with NFPA 80.

The requirements of the occupancy chapter always over-rule the requirements of a core chapter when the two chapters conflict. So, in this case, section has precedence over section, and requires all fire rated door assemblies, regardless if the door is installed in a fire-rated barrier or not, to be tested and inspected in accordance with NFPA 80.

You win… your friend loses… Start planning on testing all of the fire doors and have your first test completed by July 5, 2017.

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Too Many Extra Fire Drills

BKeyes : January 16, 2017 12:00 am : Fire Drills, Questions and Answers

Q: We have a building adjacent to our main hospital (separated by a two hour fire wall) that is a mixed occupancy.  There are three stairwells that serve this building, but one has been taken out of service for emergency egress due to a large construction project outside. I have been conducting two fire drills per shift per quarter in this particular building for almost two years now and I fear I have fire drilled our employees in that building to the point that they have become desensitized to the fire alarms.  It’s my understanding that the fire drill frequency can be specified in our ILSM policy.  Here’s my thought – I’d like to state in our ILSM policy that any project lasting longer than a year will no longer require additional fire drills.  That is; a whole year’s worth of additional drills is plenty and more drills can actually have a negative impact instead of a helpful one for our fire response efforts.

A: I think your thought process is valid and sound. Conducting too many fire drills does in fact desensitize one to an actual event. Since the accreditation organizations do not specify exactly what your ILSM policy must say, then I agree that you can reduce the number of ‘additional’ drills based on the length of time that the deficiency exists.

However, the accreditation organization will be somewhat suspicious of this action so you need to be prepared. Do a risk assessment identifying the pros and cons of doing additional fire drills for an extended period of time. Have the risk assessment draw a conclusion. Present this risk assessment to the Safety Committee and ask them to review and approve it. Make sure you get the committee’s response into the minutes. If challenged by a surveyor about doing less than the traditional amount of fire drills for ILSMs, then present the risk assessment and a copy of the Safety Committee’s minutes as evidenced of a thoughtful and considerate decision. The surveyor may accept your position and he/she may not. It’s a crap shoot.

On another point… is the stairwell that has been removed from service a ‘required’ means of egress? If there is a chance you can get your architect to deem the affected stairwell is not a required means of egress, then you can declare the stairwell is no longer a required means of egress and ILSM would not be needed. That means since the stairwell is not a required means of egress then blocking off the discharge is not a Life Safety Code deficiency. If you go that route, make sure you get a decision in writing by the architect and run that through your Safety Committee.

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Fire Alarm Systems

BKeyes : January 12, 2017 12:00 am : Fire Alarm, Questions and Answers

Q: Our hospital has an outpatient clinic attached via a hallway and connected to the hospital directly. When I am in the out-patient clinic you cannot hear the fire alarms going off in the hospital. Do the systems need to communicate? They are currently on 2 different systems.

A: No… the two systems are not required to communicate with each other unless the expectation is for staff at one location is to respond to fire alarms in the other location. However, it may be practical for the alarm to communicate in each other’s building, in some fashion. There may be key individuals (i.e. engineering staff, management staff, and executives) who may be in one location and if the alarm is activated in the other location, they should know about it. But this can also be accomplished using two-way radios or pagers.

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Fire Alarm Audible Devices in Physician Sleep Rooms

BKeyes : January 11, 2017 12:00 am : Fire Alarm, Questions and Answers

Q: We have audible notification devices for the fire alarm system installed in our physician sleep rooms. We have a physician requesting the one in his area be removed. Are we permitted to remove the audible devices or do we have to have them?

A: Well…. I would certainly remove any audible alarm notification devices from a physician sleeping room, but there are some surveyors who are sticklers for them. Here is the reason why:

A physician sleeping room on a patient unit would be considered a mixed occupancy as the physician sleeping room would have to meet chapter 29 Existing Hotels & Dormitories. Section of the 2012 Life Safety Code requires an approved single-station smoke alarm in every sleeping room. A smoke alarm is different than the typical smoke detector in the hospital. The smoke alarm is required to have an audible device when the smoke alarm is activated it will alert the individual in the room. So, technically, the audible device is required and some surveyors actually require it.

However, since the sleeping room is in a hospital, most accreditation organizations allow a hospital smoke detector to be installed in the sleeping room in lieu of a smoke alarm since there is staff on duty that would wake any sleeping physicians in the event of a fire. But, not all surveyors and AHJs see it that way and actually require the smoke alarms with audible devices to be installed.

But perhaps the saving grace for you is the smoke alarm in the physician sleeping room is not required to be connected to the building fire alarm system (a smoke detector would be, but not a smoke alarm) so you don’t have to have a building audible notification device in the sleeping room which would activate everytime the fire alarm system is activated. Just have a single-station smoke alarm that has an audible signal installed, which will only activates if the a fire develops in the sleeping room.

By the way, section and requires a fire-rated door to that room if the corridor is not sprinklered, and the door needs a closer.

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Electric Blanket in Nursing Home

BKeyes : January 10, 2017 12:00 am : Electric Blankets, Questions and Answers

Q: My mother suffers from a syndrome which causes her feet to turn white and feel extremely icy. She is not allowed to use an electric blanket which allows her to sleep since moving to a nursing facility. Can the doctor write a prescription to supersede the rule?

A: I’m sorry to hear about your mother… If you go to my website and type in “Electric blanket” in the search engine, you will get this response which I wrote 2 years ago:

Q: Are electric blankets permitted to be used by patients in long term care facilities? I cannot find any references to electric blankets in any NFPA codes or standard.

A: Technically, you are correct: There is no specific NFPA code or standard that prohibits the use of electric blankets in healthcare. However, there are significant risks to the patient and staff if you do use them, and before you allow the use of electric blankets, you need to conduct a risk assessment. At a minimum, the risk assessment needs to address to following issues:

  • Could the heat generated from the blanket cause epidermal damage to the patient?
  • Could the electrical portion of the blanket become damaged due to abuse or spillage, and cause harm to the patient?
  • Could the electrical cord become damaged (frayed) by other wheeled equipment rolling on top of the cord?
  • Could the electrical cord become a tripping hazard to the patient or staff?
  • Could the patient accidentally set the temperature control too high and cause damage to their body?
  • How will the electric blankets be maintained and inspected, and who will perform this task?

Another issue that you need to address… Why do you want to use electric blankets? Is the patient room too cool for the patient’s comfort level? There are minimum temperature levels that the organization must meet. If a surveyor observes the use of electric blankets, they have the right to investigate to determine if you did a risk assessment that addresses all of the above issues, and more. They have the right to review your risk assessment and they have the right to disagree with the conclusions in the risk assessment. In other words, no matter how you justify their use, a surveyor can still cite you for an unsafe environment for using electric blankets if they want.

My advice: Stay away from electric blankets, and do not allow them. They become more problems than they are worth. Check with your state and local authorities to determine if they have regulations that would prohibit their use.

To answer your question directly… no, a physician doe snot have the power to write an order that supersedes the Life Safety Code, or any other regulatory requirement. However, healthcare organizations may take Interim Life Safety Measures (ILSM) when situations require the non-compliance of a code or standard.

While electric blankets are not prohibited from use in healthcare organizations, they do present a certain level of risk. If administration wants to re-evaluate that risk and take special precautions to accommodate your mother, that would be permitted.

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Bronchoscopy Procedures

BKeyes : January 9, 2017 12:00 am : Bronchoscopy, Questions and Answers

Q: Could you clarify whether bronchoscopy procedures should be performed in a negative pressure room or positive pressure? It’s seems as though many folks are doing them bedside and using emergent need as a justification to do so. I seem to recall that the AIA guidelines to indicate a negative pressure room.

A: Here is how the FGI Guidelines call ventilation requirements for Bronchoscopy:

2014 FGI:                   negative           12 ach

2010 FGI:                   negative           12 ach

2006 FGI/AIA:           negative           12 ach

2001 AIA:                   negative           12 ach

1996-97 AIA:             negative           12 ach

So… it is obvious bronchoscopy needs to be done in a room that is negative and has 12 air changes per hour. The typical patient room does not have that level of ventilation.

While FGI Guidelines are in fact guidelines and not standards or regulations, authorities such as accreditation organizations and state departments of health can adopt them as a requirement. Some accreditation organizations may permit a bronchoscopy outside of a properly ventilated room if it was a true emergency, but what constitutes an emergency? That’s beyond my capabilities and perhaps yours. Ultimately, that decision will be reviewed and assessed by the accreditation organization. They will judge if the emergency procedure is just or not.

I recently attended a conference where a representative from the Joint Commission engineering department stated that Joint Commission will allow bedside bronchoscopies provided the organization has a written, documented policy permitting them, and the organization has conducted a risk assessment to determine that the patient is TB free. The risk assessment would have to be documented as well.

Make sure your Infection Control practitioner is part of the discussion to determine proper utilization of the procedure. I would also suggest you contact your state agency who surveys you on behalf of CMS and ask if they would permit an emergency bronchoscopy procedure outside of a properly ventilated room.

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Alcohol Based Hand-Rub (ABHR) Dispensers

BKeyes : January 5, 2017 12:00 am : Alcohol Based Hand-Rub Dispensers, Questions and Answers

Q: In the 2012 edition of the Life Safety Code, section (9) states dispensers of ABHR are permitted to be installed directly over carpeted floors in fully sprinkled smoke compartments. My question is: Does said dispenser need to have the catch pan installed under it? My second question is: If said dispenser is installed on a pedestal (also called cough stations) and has a catch type pan or area under the dispenser, is it acceptable to place the pedestal in a carpeted floor that is not sprinkled?

A: No on both accounts. There is no provision in the Life Safety Code for catch-pans as part of the ABHR dispenser for a qualification for use in a carpeted area, in a non-sprinklered smoke compartment. While it kind-of makes sense, unfortunately there is no provision that allows ABHR dispensers with catch-pans to be installed in a carpeted areas that are not protected with sprinklers.

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Cables Strapped to Conduit and LIM Testing

BKeyes : December 30, 2016 12:00 am : Conduit, Line Isolation Monitors, Questions and Answers

Q: Can fiber optic and low voltage cables be attached or strapped to conduit? Also, what certification is needed for individuals who perform the annual line isolation monitor (LIM) tests in operating rooms?

A: No, cables and wires are not permitted to be strapped to conduit, unless the cables or wires control the circuit inside the conduit. This is a huge problem in many hospitals as many facilities did not adhere to article 300-11(B) of the 2011 NFPA 70 National Electric Code requirement for many years.

To answer your second question, I reviewed article 517-160 of NFPA 70-2011, on Isolated Power Systems for healthcare, and I did not see anything that required any level of training, certification or licensure for individuals conducting tests on LIM.

I also examined NFPA 99 Health Care Facilities Code, 2012 edition, and according to sections and, LIM must be tested after installation, then monthly; or every 12 months if the LIM is equipped with automated self-test and self-calibration capabilities. Nowhere in this document does it discuss the requirements for the individual performing this test.

Perhaps there may be another code or standard that specifies the requirements for testing, but I did not find it. I suggest you ask your state or local AHJs to see if they have any requirements that must be adhered to.

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A Reader Speaks Out…

BKeyes : September 3, 2016 12:00 am : Power Strips, Questions and Answers

A reader has an objection to one of the answers I provided in yesterday’s blog concerning Power Strips…


In the Sept. 2, 2016 article on Power Strips the following Q & A appeared.

Question: Can IT electronic health record equipment use an RPT within the patient care vicinity?

Answer: No. “Patient-care-related electrical equipment” is defined as electrical equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity. IT electronic health record equipment does not meet this definition. Since it is non-patient care related electrical equipment, it is not permitted to be connected to a power strip in the patient care vicinity.

I had asked George Mills from The Joint Commission at the 2015 ASHE Convention if bedside IT electronic health record equipment met the definition of ““Patient-care-related electrical equipment”. He said it did. I agree with this since these units are being used to do things such as display x-rays and act as a gate keeping prior to a patient being given medication. I feel that this equipment is an integral and direct component in patient care. The ability to adjust the workstation permanently mounted next to the bed depends on the wires from the various components (monitor, CPU, barcode reader) being plugged into an RPT and the single wire from the RPT being routed through the workstation and out to a wall outlet.

My question is: Has TJC or CMS placed anything in writing that states that these devices do or do not meet the definition of patient care equipment?


A: No… TJC and CMS has not placed anything in writing that’ states these devices do or do not meet the definition of patient care equipment. But, you make a good point.

By your description, the traditional electronic health record equipment is now serving as “monitoring” equipment for patient care. You and George have changed the traditional use of the equipment from just storing and retrieving healthcare records, to a patient care related use. This meets the definition of patient care related electrical equipment and would then be permitted to be used in the patient care vicinity.

I suggest you perform a risk assessment and get that documented so a surveyor in the future will not cite you for that. Because, from the traditional use of the equipment, it does not appear to meet the definition of patient care related electrical equipment.


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