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Sprinkler Escutcheon Plates

BKeyes : May 2, 2016 12:00 am : Questions and Answers, Sprinklers

Q: Why does the escutcheon plate on a sprinkler need to be required when the ceiling is not rated and the corridor walls extend to the deck? If a basement can have sprinklers and no ceilings why are the sprinklers on the floors above required to have these plates when the ceiling is not rated?

A: The escutcheon plates are required on sprinkler heads which are mounted in ceilings to fill the gap between the head and the ceiling. Many times a sprinkler installer will use a hole saw larger than necessary to make the opening for a sprinkler head. Any gap over 1/8 inch must be sealed, so the escutcheon plate serves as a gap sealer and as an attractive trim plate. Without sealing this gap, heat and smoke will rise up above the ceiling and activation of the sprinkler head (and smoke detector, if so equipped) will be delayed. They are very important, and an easy deficiency for a surveyor to find.

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Entrance Door to Mechanical Room

BKeyes : April 25, 2016 12:00 am : Mechanical Rooms, Questions and Answers

Q: We have an old dark room that was converted into an air handler room. What’s the requirement for a door to this room?

A: It all depends where this former dark room is located. First of all, what is the occupancy designation for the building or area where this air handler is located? If it is business occupancy and the air handler does not include a gas-fired furnace, then it is very likely that no door is actually required to this room. However, if the building or area is designated as a healthcare occupancy, then it depends whether or not the room opens up onto a corridor. In healthcare occupancies, all corridors must be separated by walls and doors from all other areas. Now, there are some exceptions to this requirement, but an air handler room will not qualify for any of these exceptions. If the former dark room/air handler room does not open onto a corridor, but opens onto another room, then it is likely that a door would not be required, provided the air handler room does not contain anything to make it a hazardous room, such as fuel-fired equipment, or storage of combustibles of flammables. If the air handler room somehow qualifies as a hazardous room (see sections of the 2000 edition of the LSC) then the room will need to be protected with automatic sprinklers, and the walls will be required to be 1-hour fire rated, and the doors will be required to be ¾-hour rated, self-closing and positive latching. All of that would be required even if the room does not open onto the corridor. If the air handler room is not considered to be a hazardous area, and the room opens onto a corridor, then the door is only required to resist the passage of smoke, or if the corridor is located in a non-sprinklered smoke compartment then a substantial door such as 1¾ inch thick, solid-bonded, wood-core door, or be of such construction to resist fire for at least 20 minutes. Notice it did not say the door had to be 20-minute fire rated. That is a common misunderstanding.

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Weekly Fire Pump Testing

BKeyes : April 18, 2016 12:00 am : Fire Pump, Questions and Answers, Testing

Q: The Joint Commission standard for weekly testing of the fire pump only requires us to record the test date of the inspection. We were cited for not recording the suction and discharge pressures. Is this a requirement?

A: Yes, recording the suction and discharge pressures, along with the amount of time required to start the weekly test (by lowering the water pressure) are required documentation for each weekly fire pump test. Even though these requirements are not specifically identified in the EC standards, they are identified in the NFPA 25 (1998 edition) which is referenced by the Joint Commission standards.

Get a copy and read the NFPA 25 (1998 edition) as it has a lot of testing requirements of the sprinkler system which are not identified in the Joint Commission standards, but are required.

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Required Exit from OR

BKeyes : April 11, 2016 12:00 am : Egress, Questions and Answers

Q: Can a sterile supply corridor that feeds the back of Surgical OR’s have a corridor of less than 8′ if the patient access is from the front of the OR? This front patient access provides the required exit access for inpatients to two exits.

A: Maybe. It all depends on whether or not the sterile supply corridor that feeds the back of the Surgical ORs could in any way be considered a path of egress for the inpatients receiving treatment in the OR. Is this path marked with ‘Exit’ signs? That is usually a dead-giveaway since it marks the path of egress through the sterile corridor as a means of egress for the occupants of the ORs. But, that is not the only indication. Even if the path is not marked with an ‘Exit’ sign, it could still be considered a required path of egress from the ORs. You mentioned that the front patient access provides the required exit access for inpatients to two exits. If that is true (and I have no reason to doubt you), then that may possibly make the sterile corridor to NOT be a required means of egress, and then it would not have to comply with section (2000 edition) for 8 foot corridor widths for new construction. For existing construction, section says 4 foot width is required, but if the corridor is already constructed to a width greater than 4 feet, then you must maintain to corridor to 8 feet of width if you make any alterations or renovations. Parking equipment in a corridor would be considered an alteration.

Before you make any changes to your facility, you need to discuss this issue with the architect who designed the egress routes from the ORs, if that person is still available. It is important that any change in function be reviewed by the proper individuals, which may also include your local or state authorities.

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Fire Alarm Test Report

BKeyes : April 4, 2016 12:00 am : Fire Alarm, Questions and Answers, Testing

Q: Does NFPA 72-1999 edition specifically state that annual fire system inspection documentation include an itemized inventory of each system device as passed or fail? Does a report stating that (i.e. 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed) satisfy the requirement?

A: Specifically? I would say it does, but if you want to see the words: “Every annual fire alarm system documentation must include an itemized inventory of each device as passed or failed” … you will not find those words in NFPA 72, 1999 edition.

What it does say is this: Section 7-5.2.2 requires documentation of the fire alarm test to comply with all the applicable information found in Figure 7-5.2.2. On page 3 (of 4) of figure 7-5.2.2, the documentation required by NFPA 72 includes:

    • Location of the device
    • Serial number of device
    • Device type
    • Visual check
    • Functional test
    • Factory setting
    • Measured setting
    • Pass of Fail

In addition to that requirement for annual testing, section 7- requires all components affected by a change to the system to be 100% tested. This is in regards to a change to the system, like the addition of an initiating device all the devices on the circuit for the new device must be tested.

So, I would say NFPA 72 (1999 edition) does specifically require the documentation of whether or not each device passed or failed its test. Also, it is now an interpretation by many of the national AHJs for healthcare organizations that each test report has this information documented. The logic for this requirement is solid; how does the facility manager know that the fire alarm testing technician actually tested each and every device in their building, if you do not know where they are, and document the results of each test?

A report stating that 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed their inspection would NOT satisfy the reporting requirement, as I understand it. There needs to be an inventory list showing each device location and whether or not it passed or failed its test.


It makes good sense.


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Illumination of the Means of Egress

BKeyes : March 28, 2016 12:00 am : Exit Signs, Questions and Answers

Q: My question is in regards to illumination of the means of egress, specifically, illumination provided outside the building to a public way. I was told by a consultant that the only means of egress requiring illumination are the “designated” egress paths. We were cited for no illumination for the exit path to the public way, and it was not marked by Exit signs. Is emergency lighting required for illumination outside the building?

A: I agree that only the portions that are designated as the path of egress on the exit discharge are required to be illuminated. The exit discharge becomes a ‘designated path of egress’ when the exit from the building discharges onto the walkway outside the building. I have seen many paths outside the building that are confusing and unsure which path to follow to the public way. In those situations, outdoor ‘Exit’ signs need to mark the path of egress, even though it is outside.  Section of the 2000 edition of the LSC clearly states that the exit discharge only includes ‘designated’ stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. If you were cited for not having illumination on an outside sidewalk that lead to a dumpster or other such area that does not serve as a means of egress, then I would say that was an incorrect finding and should be appealed. However, if the finding was for lack of illumination for an outside walkway that does serve as a means of egress from an exit of the building, then that would seem to be a correct finding.

Your question: “Is emergency lighting required for illumination outside the building?” depends on what type of building it is. If the building is healthcare occupancy or ambulatory care occupancy, then yes, emergency lighting is required. According to section (and for ambulatory care) of the 2000 edition of the LSC, emergency lighting must be provided according to section 7.9. Section 7.9.1 says the exit discharge is included in this emergency lighting requirement. You are permitted to utilize battery back-up lighting (as long as it meets the requirements), or generator power for the emergency lighting. Most hospitals use generator power for their emergency lighting since they already have the generator. Battery back-up emergency lights take much more maintenance in monthly and annual testing.

If the building is a business occupancy, then section states emergency lighting is only required in a building that has two or more stories above the level of exit discharge; in a building that is subject to an occupant load of 100 or more persons, above or below the level of exit discharge; or in a building that is subject to 1000 or more total occupants.

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Fire Dampers in the Pneumatic Tube System?

BKeyes : February 12, 2016 12:00 am : Fire & Smoke Dampers, Questions and Answers

Q: Our pneumatic tube vendor is telling our Engineering folks that they have to install dampers inside the system everywhere that a pneumatic tube run penetrates a fire wall or floor. I’ve never heard of this, have you?

A: I don’t see that as a requirement with the NFPA codes and standards. My first thought is for you to just ask this vendor on what code or standard he is making that claim. It is possible that a local or state authority made this a requirement at a previous project and he is just being over-zealous in wanting to make sure the job is done right, as he understands it.

Here is a code search that may shed more light on this subject. (All references are to the 2000 Life Safety Code.) Section says openings in fire barriers for air-handling ductwork or air movement shall be protected in accordance with section 9.2.1. Section 9.2.1 requires compliance with NFPA 90A which is the standard that requires the installation of fire dampers in various locations of fire rated barriers. Since only requires openings in fire barriers for air-handling ductwork or air movement purposes to comply with NFPA 90A, then there is no requirement for a pneumatic tube to have fire dampers because it is not used to move air through fire rated barriers; it is used to move carriers through fire walls, by using differences in air pressure. It would be similar to a large electrical conduit.

Make the vendor shown you the standard that he says requires dampers. Then see if it applies to your situation.

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Non-ANSI Approved Eyewash Stations

BKeyes : February 5, 2016 12:00 am : Eyewash Stations, Questions and Answers

Q: Is it better to have an eye wash station that doesn’t comply with ANSI standards or to remove eyewash stations from ambulatory clinics setting which may contradict Joint Commission standards on safety in the workplace?

A: To be sure, it is not a violation of a CMS, Joint Commission, or an OSHA standard to have an eye wash station that does not meet the requirements of ANSI Z358.1-2014 guidelines in areas where there are no caustic or hazardous chemicals. However, if there is a need for an eyewash station due to caustic or hazardous chemicals being used, then OSHA has issued interpretive letters that states their inspectors will use the ANSI Z358.1-2014 standard to determine compliance. [Joint Commission and most state agencies that survey on behalf of CMS will follow likewise.] This means an eyewash station that is non-compliant with ANSI Z358.1-2014 in an area where an eyewash station is required (such as a laboratory, or an Environmental Services work room) will likely be cited because the organization has not provided adequate emergency response equipment for the safety of their employees.

I have seen hospitals place eyewash stations that are non-compliant with ANSI Z358.1-2014 on faucets in every nurse station just because they thought it was a ‘good idea’; not because they were needed. Was that a violation? I don’t think so because there is usually not a chance of splashing caustic or hazardous chemicals in the eyes at the nurse stations. But, it is a red flag for surveyors and inspectors. If they observe an eyewash station that is non-compliant with ANSI Z358.1-2014 standard, they will start snooping around to see why it is there. If they find any caustic or hazardous chemicals used in the area that could be splashed into the eyes, then it is likely they will cite the organization for not having an ANSI Z358.1-2014 approved eyewash station.

I often see the hand-held squeeze bottles of sterile water mounted on the wall in certain area. I always ask the hospital why are they there. In some cases, caustic and hazardous chemicals were a splash concern and the hospital did not want to spend the $1,000 (or so) to install a ANSI Z358-1-2014 approved plumbed eyewash station, so they bought the cheaper bottles instead. That is a serious issue and likely would be cited by a surveyor. However, I have also seen the hand-held bottles placed in areas where there was no hazard, and the hospital just wanted them there for a ‘first-aid’ device. There is no standard or guideline that prevents that arrangement, but again, it is a red flag to a surveyor to start snooping around to see why the bottles are there in the first place. Also, the water in the bottles are typically only good for 2 years, and the hospital must be diligent in replacing the bottles before the water expires.

To directly answer your question: I think the hand-held bottles and the eyewash stations that are non-compliant with ANSI Z358.1-2014 in locations where there is no potential of caustic or hazardous chemicals to be splashed in the eyes is a potential source of problems during a survey, and I recommend to my clients to remove them, even though technically, they are permitted. It is a matter of opinion, and I always like to remove red-flags from the hospital before surveyors walk through. However, to not provide ANSI Z358.1-2014 approved eyewash stations where caustic or hazardous chemicals could be a potential splash problem, is definitely a safety hazard and would most likely be cited by a surveyor or an inspector. It is far better to spend the extra funds to either install the approved eyewash stations, or relocate the function and process to an area where there already is an approved eyewash station.

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Infection Control in a Trauma Room

BKeyes : January 29, 2016 12:00 am : Infection Control, Questions and Answers

Q: I know it is inappropriate to place a flushing hopper sink in a trauma room between the hand washing sink and clean storage cabinets but I can’t find the standards to back me up. The hospital did not involve Infection Control during this planning phase and I need assistance.

A: My first look is to the Guidelines for Design and Construction of Health Care Facilities, written by the Facilities Guidelines Institute (FGI), 2010 edition. Section 2.1-2.6.10 says soiled workrooms or soiled holding rooms shall be separate from and have no direct connection with clean workrooms or clean supply rooms. It is obvious that a flushing hopper sink and a separate hand washing station are part of a “Soiled Workroom” as defined in 2.1-, and as such is required to be located in a soiled utility room and separated from clean supplies.

Table 7-1 “Design Parameters” in the same book requires soiled workrooms to have a negative air pressure in the room compared to its surrounding area, and clean workrooms are required to have a positive air pressure in the room compared to its surrounding area. That is physically impossible if the soiled and the clean are in the same room.  Also, a soiled workroom must have 2 ½ times the amount of air changes per hour than the clean workrooms.

It does not make sense to have a trauma room in a room that is defined as a soiled workroom. A room with a hopper sink is by definition a soiled workroom. According to Table 7-1, the air pressure in a soiled workroom must be negative, but the air pressure in a trauma room is required to be positive. Again, how can that be if the two rooms are together? The answer is, it can’t. The two rooms have to be separate.

Take this information to the project manager and explain the logic that differentiates their design. If they do not listen and do not change the design, then escalate this issue to a higher authority (your M.D. in charge of Infection Control; or the COO; or the CEO) and explain to them that CMS, Joint Commission, and any other accreditation organization will enforce the FGI guidelines for new construction and the arrangement you describe will be cited and the hospital will be required to resolve this at a later date. Better to resolve it now, while it is still being designed/built, than doing so a couple of years from now.

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Standpipe Tests

BKeyes : January 22, 2016 12:00 am : Questions and Answers, Standpipe Flow Tests

Q: Is it mandatory that we perform a “Standpipe Hydrostatic and Flow Test” every 5 years?  We do not have a dry system.  Our system is full of water and has pressure on it at all times.  Our sprinkler installer stated (basically argued) that he could understand the need for it if we had a dry system, but we don’t.  So, I just need clarification, please.

A: You are describing two different tests for the standpipe system: A hydrostatic test and a flow-test. NFPA 25 (1998 edition) section 3-3.1.1 requires a flow-test be conducted once every 5 years on all standpipes. You must flow water at the hydraulically most remote location, which is usually the roof. The flow must be measured (in gallons per minute, or GPM) to determine if the flow is equal to the requirements when the standpipe was first installed. If the flow requirements at the time the standpipe was installed are not known, then the flow must equal 500 GPM.

Hydrostatic tests are required on all dry standpipes and dry portions of wet standpipes once every 5 years according to 3-3.2.1. The system must be pumped up with water pressure to 200 psi, or 50 psi over the maximum operating pressure where the maximum operating pressure is over 150 psi, for a minimum of 2-hours.

Conducting a hydrostatic test on a dry standpipe system is very cumbersome and at times, difficult. This is due to the lack of water in the standpipe system. Contractors must transport water to the dry standpipe and then pump it up to 200 psi, using a water pump. What NFPA did in subsequent editions of NFPA 25, is to allow air pressure testing on dry standpipe systems in lieu of hydrostatic pressure testing. But, Joint Commission and CMS are not on that newer edition of NFPA 25, and therefore this more convenient system of testing a dry standpipe is not available for hospitals today.

Even if you obtained special permission from Joint Commission to use air pressure testing in lieu of hydrostatic testing, it would not be acceptable to CMS. You must follow the most restrictive requirements of your authorities.

To answer your question directly… Yes you need to conduct a flow-test once every 5 years on your wet standpipe systems.

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