Q: We have just remodeled a suite and are planning on moving the chemo infusion department into it. There are 5 bays but total occupancy would never be more than 50. Are we required to have exit signs over both exits? Upon exiting the suite into the exit corridors there is less than 50 feet to exit to the outside of building.
A: Yes… You would need ‘Exit’ signs over the doors to the corridor. The reason is, section 184.108.40.206.1 of the 2012 Life Safety Code requires access to exits be marked with ‘Exit’ signs, unless they are readily apparent. In your situation, the doors to the corridors would not be readily apparent to the patients and visitors, although they may be to the employees who worked there.
Q: We are in the process of putting manual pull station covers on most if not all of our stations. Some of the stations are dual action. Will putting a cover on a dual action manual pull station convert it to a triple action? Is there a code which prevents this situation from being acceptable?
A: The installation of a protective cover over a double action manual station does constitute a triple action, but it’s not prohibited by code. Prior to 2013 edition of NFPA 72, this wasn’t expressly addressed. NFPA 72 (2010) Chapter 17.14.5 allows protective covers over manual stations, so long as they remain accessible. There’s nothing prohibiting a certain amount of ‘actions’; it just doesn’t mention it. However, it was addressed in the 2013 edition. NFPA 72 (2013) Chapter 17.14.7 states a protective cover may be placed over a single or double action manual station. The annex note explains that this does make it a triple action, but that it’s still code compliant. It should be noted that the 2012 Life Safety Code references the 2010 edition of NFAP 72, not the 2013 edition.
Q: In regards to oxygen cylinder storage, if the quantity of gas in storage is between 300 and 3000 cubic feet in a smoke compartment and the full cylinders are being stored in a fire-rated medical gas cabinet, the hospital was told that they do not need to be stored in a specially designated room. They were told the fire-rated cabinets act as a room themselves and they could place the cabinets anywhere in the smoke compartment. I don’t see it that way, and I believe that the cabinets only allow the cylinders to be stored without the need for separation from combustibles. Question is: What is permitted?
A: I believe you are correct. Section 11.3.2 of the NFPA 99-2012 says storage of non-flammable gases greater than 300 cubic feet but less than 3,000 cubic feet shall comply with the requirements of 220.127.116.11 through 18.104.22.168. Section 22.214.171.124 says storage locations shall be outdoors or within an enclosed interior space of noncombustible or limited combustible construction, with doors that can be secured against unauthorized entry. Section 126.96.36.199 says oxidizing gases cannot be stored with flammable gases, liquids or vapors.
188.8.131.52 says oxidizing gases must be separated from combustibles by one of the following:
- Minimum of 20 feet
- Minimum of 5 feet if the entire storage location is sprinklered
- Enclosed cabinet on noncombustible construction having a minimum fire protection rating of ½ hour.
So… there you have it. Those yellow “Fire Cabinets” are double-walled construction and really only rated for 30 minutes and they are commonly called “NFPA 30” cabinets. But they are permitted to be used in lieu of having to meet the 5 foot or 20 foot distance requirement inside a designated room that is constructed with noncombustible or limited combustible materials, and has a door that is lockable. Limited combustible materials are traditionally gypsum wall board that has a thin layer of paper on the surface.
But make no mistake about it… while the oxygen cylinders may be stored inside the metal cabinets, they still must be stored inside a designated room with a lockable door.
Q: We have some sprinkler piping that runs the length of the hall with multiple wires wrapped around the pipe. There is no way of removing the wiring from the pipe unless we perform some major sprinkler pipe removal and reinstallation. This has been identified in a mock survey and we need to come up with a plan of action. How do you recommend we deal with this?
A: Well… you really need to remove the cables and wires from the sprinkler pipe. If you don’t, then you are non-compliant with NFPA 25-2011, section 184.108.40.206.2.
However, here is one other possibility: Do a risk assessment; determine what risks there are to the sprinkler pipe that has cable surrounding it. (I suspect you will find there are no risks, or at least, minimal risks). If your risk assessment identifies any mitigating factors, then implement those mitigating factors. In other words, remove the cable from the sprinkler pipe the best that you can.
If you cannot remove all of the cable from the sprinkler pipe then I suggest you assess it for ILSMs and let it be. Wait for it to be cited during a survey, then submit a waiver request as part of your plan of correction. I suspect the accreditation organization would likely transfer the waiver request on to the respective CMS regional office and they would approve it, provided you demonstrated a significant hardship.
Q: I have an existing 3 story building in an urban environment with an exterior stair which discharges into an enclosed rear yard. The access to a public way is through an exit access passageway through the basement and up an enclosed stair to the street in front. This is very common in the city. The building is used as an ambulatory clinic (business occupancy) and the AHJ is not allowing the exterior stair to be considered an exit because of the necessity to pass back through the building. I cannot find this prohibition in the LSC but maybe there is some history on this?
A: Did you ask the inspector for a code reference? Usually, they are pretty good about sharing that information. But section 7.7.1 of the 2012 LSC would agree with the inspector and not allow the arrangement you describe. The exit discharge may discharge to an open court provided the open court provides occupants a safe access to the public way without re-entering the building. The NFPA LSC handbook on 7.7.1 discusses this in greater detail. I would say the inspector got it correct.
Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the sprinklers in the area for eight weeks. The construction is located on the lowest level and is unoccupied with no patient care in the area (but there’s patient care in the building). With the sprinklers out of service 24 hours a day, is a fire watch required? We also are looking at using 1 hour barriers and 3/4 hour doors during that time. Do the barriers change anything with a fire watch? Thank you
A: Can’t you re-install temporary sprinklers in this construction area for the duration of the project? You will need to turn the sprinkler lines upward to within 12 inches of the deck and install upright sprinklers. It is imperative that you have sprinkler protection, otherwise you will need to conduct a fire watch, continuously for the 8 weeks there are no sprinklers.
Yes… a fire watch is required because you have impaired sprinklers. It doesn’t matter where the impaired sprinklers are located… if you have impaired sprinklers, you must do a fire watch. NFPA 25-2011 section 15.5(4) says where the sprinkler system is out of service for more than 10 hours in a 24-hour period, you need to conduct a fire watch. CMS has said in their Final Rule to adopt the 2012 Life Safety Code published May 4, 2016, that a fire watch is conducted continuously, without interruption. The designated individual who performs no other function, continuously walks the impaired area looking for fire and the potential for a fire to occur, without leaving the area. This means the individual may not leave the impaired area to use the restroom, take a lunch break or any other function unless he is relieved by someone else.
This ‘continuous’ fire watch must be conducted for the duration that the sprinklers are impaired … 8 weeks. Can you afford to have that many FTEs designated to do nothing else but a fire watch for 8 weeks? I would believe it would be less expensive if you would turn up the sprinklers and install upright sprinkler heads in the construction area.
The fire watch does not affect the rated barrier, but the 1-hour fire rated barrier is required to separate the construction area from the occupied area if there are no sprinklers in the construction area.
Q: We are doing a fire extinguisher annual maintenance on a Hospital and find that there is a high volume of ABC dry powder units through the site and very few CO2 units. The question we are asking is this a problem? Are there regulations for a healthcare site to use other CO2 in certain areas?
A: The only regulation concerning fire extinguishers in healthcare is NFPA 10 (2010 edition). NFPA 10 requires that the classification of the fire extinguisher be matched with the classification of the potential fire. However, there are infection control issues to be concerned about and an ABC dry powder FE would not be a good selection for use in an operating room or a procedure room. There is no regulation that says you can’t use an ABC dry powder in an operating room or procedure room, but from a practical point of view… it doesn’t make sense. Some hospitals use CO2 FEs in operating rooms for flammable liquid fires on a patient, however CO2 may cause frostbite. Other hospitals rely on sterile water supply in the sterile field to extinguish flammable liquid fires on a patient, but do not rely on water-mist FEs for this purpose as the water in the water-mist FEs may contain bacteria.
An ABC dry powder FE may not be a good choice for critically sensitive equipment such as computer rooms. A risk assessment may reveal that a Halon or a FM-200 type extinguisher is more appropriate. In the Laboratory where there are flammable liquids in use, a CO2 extinguisher is the proper choice. Hospitals would be expected to have a documented risk assessment conducted, that determines what type of FE should be used in certain areas.
Q: Are recovery rooms and observation units considered sleeping suites or non-sleeping suites? What is the definition of what constitutes a sleeping suite?
A: Recovery rooms, surgical suites and pre-op suites would be considered “non-sleeping suites” because sleeping accommodations are not provided in these areas. The Life Safety Code uses the term “patient sleeping rooms”. If the suite includes patient sleeping rooms, then it is restricted to the requirements for sleeping suites. If the suite does not provide sleeping rooms, then it can be considered non-sleeping suites which have less restrictions.
An observation room can be a patient sleeping room, or it can be an exam room in an ER. Whether it is classified as a “patient sleeping room” depends on the hospital’s definition of an observation room. Remember: If it looks like a duck and quacks like a duck, then it pretty much is a duck. If the observation room looks like a patient sleeping room, then a surveyor can consider it a patient sleeping room even if you call it something else.
Q: What is the standard in hospitals regarding use of toasters or popcorn machines up in nursing units where patient care areas are located? Is there an issue or concern with use of these items in those areas?
A: This was not highly regulated, and some authorities got very uptight with this and did not permit such appliances to be used in patient care areas (and rightfully so… they produce a lot of heat, some smoke and vapor). But, section 220.127.116.11.2 on the 2012 LSC did address this type of equipment and says where residential cooking equipment is used for food warming or limited cooking, the equipment is not required to be protected in accordance with NFPA 96 and the presence of the equipment shall not require the area to be a hazardous area. This is a new section of the 2012 LSC and one that should allow residential toasters and popcorn makers and microwave ovens and coffee pots in break rooms.
Q: We have an underground tunnel that feeds and branches out three ways into three different hospitals. We are defining the tunnel as a business occupancy. There is a 2-hour barrier at all three doors leading into each perspective hospital. The tunnel does not have any sprinklers, fire alarm system or smoke detection. It does have a pull station at each hospital entry point. There are also exit signs at all three doors leading from the tunnel into the hospital as an exit. There are no stairways leading up and out from inside the tunnel. After hours there are badge swipes to gain entry into the hospital doors, but does have a 15 second delayed egress. There are no exit signs going from the hospital into the tunnel as a means of egress even though there is a 2-hour barrier, which I believe would turn into a dead end corridor. It’s hard to picture in your mind this scenario (imagine a Y) but do you believe we are compliant? I have not seen any codes related to specific tunnels.
A: You didn’t say how long the tunnels are. I like that you classified them as business occupancies, but without sprinklers, you are limited to 200 foot travel distance to get to an exit. So, if you’re standing in the middle of the tunnel (half-way between hospitals) do you have to travel more than 200 feet to get to an exit? If yes, then you have a problem. If no, then you’re okay on travel distance.
But the delayed egress locks are a problem. You cannot have delayed egress locks in a facility that is not fully protected with sprinklers or fully protected with smoke detectors. For your situation, it may be more cost effective to install smoke detectors in the tunnel to allow the use of delayed egress locks.
Other than that, it appears to me that you’re okay.