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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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Generator Batteries

BKeyes : January 21, 2016 12:00 am : Generators, Questions and Answers

Q: Recently I attended a meeting with our State Fire Marshall Department. One item which became a HOT topic of discussion was the monthly Specific gravity testing of the battery used to start up the generator. The Federal Regulation states that the cap should be unscrewed and then tested. Batteries are now sealed. The Fire Marshall’s response was that you peal off the sticker then pry the caps off. This triggers all kinds of issues, from a safety issue for employees to warrantees on the batteries. There are 3 battery monitoring procedures. 1. The annunciator for the generator monitors Low Battery and Low Charge. 2. Weekly monitoring of the 30 min test. 3. Monthly Load Testing I contend that this should be enough to support the monthly checking “Specific Gravity” checking. How do you see this to be?

A: What you’re referring to are newer style batteries that are sealed, and access to the electrolyte is not available, or necessary. But it really doesn’t matter what you contend or what I contend… it only matters what the State Fire Marshall will allow. It appears that they insist on specific gravity tests (i.e. electrolyte levels) so that is what you must do. You make a good case that opening a sealed battery is dangerous and voids the warranty of the battery. But NFPA 110-1999 Annex section A-6-3.6 says the specific gravity in the batteries must be recorded on a weekly basis.

However, section 1-4 of the same document does say that nothing in the document is intended to prevent the use of systems of equivalent or superior quality. You make a good point that the newer style sealed batteries are better than the older style that have caps and access to the electrolyte levels. One could argue that they are better than the older style. But this must be approved by the AHJ, which in this case is the fire marshal. Present a written plan to the fire marshal’s office and see if they will approve your plan to use sealed lead-acid batteries. Make sure it identifies the hardship, both financial and safety risk to staff, in using the older style batteries.

If they do not approve your plan, then I see no other choice that you have to purchase lead-acid batteries that has access to test the electrolyte levels as required by the AHJ. They are the authority and if you want their approval, then you have to do what they say. It is their prerogative to interpret the standards the way they see fit.

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Snow Removal

BKeyes : December 9, 2015 12:00 am : Questions and Answers, Snow Removal

Q: During the winter season how much time would a surveyor give us to remove all snow from the exit discharge leads out of the hospital? Since it could be snowing all day and overnight as well, and we only have so much time and man-power, what will a surveyor expect?

A: This is a great question. I have never seen anything in writing from an authority having jurisdiction (AHJ) as to how quickly they expect snow to be removed during and after a storm. It is my perception that they would not expect the snow to be removed continuously during a snow storm, but perhaps at least once during a storm and then as soon as the storm is over. But how soon after the storm is over? You get to decide since the AHJs do not state in writing what their expectations are. But it needs to be reasonable, and I would say we are talking about an hour or two after the storm is over. In other words, if you wait more than two hours to remove snow from the exit discharge, that may be considered too long by some AHJs.

Many hospitals do clear the exit discharge a couple of times during the storm and then do a final clearing after the storm is over. If you wait more than a couple of hours to do the final clearing, then safe egress from the facility may be considered to be impaired. It is all very subjective and up to the individual surveyor. If you are making a good effort during a storm and a surveyor happens to be present, I suspect he/she will be lenient and understand that you are doing everything possible. If they are not lenient, and you believe they are too restrictive in their interpretation, you can always call the AHJ central office and ask their standards interpretation staff for a ruling.

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Fire Alarm System Upgrade

BKeyes : November 13, 2015 12:00 am : Fire Alarm, Questions and Answers

Q: I am doing a renovation project in our hospital and the area of renovation is 50% of the total building area. Part of the renovation scope is a fire alarm system upgrade. Is there any code or standard requirement that the fire alarm devices in the remaining 50% of existing building should be upgraded also before it can be occupied? 

A: Your question involves the fire alarm system in the existing area of the building which is not being renovated, and asks if the fire alarm system in that remaining 50% of the existing building should be upgraded as well, before the building can be occupied.

First let me say that this is a question that does not have a direct answer, from either the Life Safety Code (2000 edition), or the NFPA 72 National Fire Alarm Code (1999 edition). When there is not a direct reference to a question in the codes or standards, then the authorities having jurisdiction (AHJ) must be consulted for their interpretation. This means you need to contact the AHJs who have authority over the design of your fire alarm system and ask them how they interpret the issue. A hospital typically has 5 or 6 different AHJs that should be consulted:

  • State health department or agency on public health
  • State fire marshal
  • Local fire department
  • Local building authority
  • Insurance company

Having said that, it appears to me that you may not have to replace the devices in the existing area of the building that is not under renovation. Section 1-2.3 of NFPA 72 (1999 edition) says this: “Unless otherwise noted, it is not intended that the provisions of this document be applied to facilities, equipment, structures, or installations that were existing or approved for construction or installation prior to the effective date of the document. EXCEPTION: Those cases where it is determined by the authority having jurisdiction that the existing situation involves a distinct hazard to life or property.”

So, as long as the existing devices are still in good working order and do not pose a hazard to life or property, it appears to me that you do not have to upgrade them in your project. However, as I said, it really doesn’t matter what I think: All that matters is what the AHJ say. So, please consult with them for direction.

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Fire Dampers in Rated Walls

BKeyes : November 6, 2015 12:00 am : Fire & Smoke Dampers, Questions and Answers

Q: Are fire dampers required in 1-hour fire rated walls if the facility is fully sprinkled? Also, we have a couple of inaccessible dampers and I was wondering if I needed to add them on the Statement of Conditions PFI list? 

A: According to NFPA 90A (1999 edition), 1-hour fire rated barriers do not require fire dampers in fully ducted HVAC systems, unless the 1-hour fire rated barrier is a vertical shaft. If the air duct is an air transfer opening (meaning it is not fully ducted) at the fire rated barrier, then the duct needs a fire damper where other openings are required to be protected as well. However, 2-hour fire rated barriers do require fire dampers in fully ducted HVAC systems. Being fully sprinklered, or not, has no bearing on the requirement whether fire dampers are required. It does have a bearing on whether or not smoke dampers are needed, though.

Inaccessible fire dampers are a life safety code deficiency, and must be addressed by the following:

  • The inaccessible fire dampers must be assessed for Interim Life Safety Measures (ILSM)
  • A decision must be made as to whether or not you will make the fire dampers accessible, and therefore be able to test them
  • If you cannot resolve the inaccessible fire dampers within 45 days of discovery, they must be placed on the PFI list of the Statement of Conditions.
  • If you decide you will not resolve the inaccessible fire dampers, then the projected completion date for the PFI may be set at 6-years. After 6 years, re-examine the inaccessible fire damper to determine if the environment has changed, and if they are still inaccessible, then close out the PFI, and open a new one for another 6-year cycle.

Joint Commission surveyors are very astute to identifying inaccessible fire dampers, and whether or not you placed them on the PFI list, and whether or not you assessed them for ILSMs. So, make sure you assess them for ILSMs, and place them on the PFI list.

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Obstructions to Fire Alarm Control Panel

BKeyes : October 30, 2015 12:00 am : Clearance, Fire Alarm, Questions and Answers

Q: Where in the Life Safety Code does it require clearance in front of a fire alarm control panel? I have a situation in our hospital where we want to put a stanchion near the panel, but I thought we had to maintain a certain amount of clearance. Can you point me to the exact standard? 

A: The requirement to maintain a certain amount of clearance in front of all electrical panels (which includes the fire alarm panel) is found in NFPA 70 National Electrical Code (NEC), section 110-26(a), which says: “Sufficient access and workings pace shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.” The actual distance required for clearance is found in Table 110-26(a) and is required to be 36 inches.

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Quarterly Testing and Inspection Challenges

BKeyes : October 23, 2015 12:00 am : Joint Commission, Questions and Answers, Testing

Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not always able to schedule us within the tight 20-day window each quarter that Joint Commission will now require. So by definition our schedule will now be in flux, depending on the completion date of the last inspection, rather than set on the same month each quarter. I realize they do not want people to schedule inspections in back to back months, which we do not do, but this seems like it will cause more instability than anything. 

A: I see your dilemma and understand the difficulty in the logistics of your situation. Scheduling a contractor to be onsite within the new 20-day window each quarter will be a challenge to large organizations like yours.

For the record, the Engineering department at the Joint Commission was not in favor of the requirement that quarterly testing and inspections to be performed 3 months from the previous test/inspection, plus or minus 10 days. But the power-that-be above them made that decision.

To answer your question: I do not know what other organizations are doing in regard to challenges with the new quarterly testing requirements. However, I think there is a way you can deal with this issue.

I suggest you contact the Standards Interpretation Group at the Joint Commission and discuss your options concerning the challenges in meeting the quarterly test/inspection window. Ask them if you can have some leeway that would allow you a wider window each quarter for the testing/inspection frequency other than the plus or minus 10 day window. My guess is they will allow it as long as you can demonstrate the hardship in meeting this requirement.

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Fire Damper Installation

BKeyes : October 19, 2015 12:00 am : Fire & Smoke Dampers, Questions and Answers

Q: Do you need a fire smoke damper at floor level in an open duct shaft? Or where the duct comes out through the shaft wall?

A: Section of the 2000 edition of the Life Safety Code requires compliance with section 9.2. Section 9.2.1 requires compliance with NFPA 90A Installation of Air Conditioning and Ventilation Systems, 1999 edition. If you have a copy of that standard, take a look at Figure A-3-3 in the appendix of the book, and there is a real nifty diagram that points out all of the possible locations where fire and smoke dampers would be required. But, to directly answer your questions, section 3-3.2 of NFPA 90A requires a fire damper at the floor level of any HVAC duct that penetrates a fire-rated floor if the duct is not enclosed within a fire rated shaft. But section 3-3.4.1 says an air duct that pass through floors of buildings that require the protection of vertical opening (such as a hospital would), must be enclosed with walls with 1-hour fire resistance rating if the shaft penetrates 3 or less stories, and 2-hour fire resistance rating if the shaft penetrates 4 or more stories. The exception to 3-3.4.1 says you do not need a fire rated shaft if the air duct passes through only one floor, or if the air duct passes through only one floor and an air-handling equipment penthouse floor, whereby the air duct would require a fire damper where the duct penetrates the floor. In reply to your second question… According to section 3-3.4.4, fire dampers are required in any opening into or out of a shaft required in 3-3.4.1, whether or not the shaft opening contains an air duct or is ductless. A fire damper is required, even if the shaft is only 1-hour fire rated. So, in conclusion, you do need fire dampers if the duct is not enclosed in a fire rated shaft and penetrates one floor (but only one floor), and you do need fire dampers where the duct exits a rated shaft.

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