Feb 24 2016

Strange Observations – Part 6

Category: BlogBKeyes @ 12:00 am
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Door with Conflicting SIgnage Web 2Continuing in a series of strange things that I have seen while consulting at hospitals….

This series of pictures is just plain sad… and wrong. The top picture shows a door in the path of egress with an ‘Exit’ sign over it. If you look closely, there is a magnetic lock on this door and there is a sign posted on the door as well. This door is in an exit access corridor and lead from one physician’s office area to another physician’s office area and for some reason was equipped with a magnetic lock. But the magnetic lock did not qualify for the exceptions to 19.2.2.2.4 of the 2000 LSC for delayed egress locks or access-control locks.

Take a look at the bottom picture… The picture is a close-up of the sign on the door. The sign says “This is not an exit…” but the ‘Exit’ sign over the door says “This is an exit”. That’s a conflict. To be sure, the door is an exit as this door was located in an exit access corridor and without the designated exit it would have been over a 100 foot dead-end corridor (which is not permitted). So, the exit is necessary.

But the conflicting signage is just wrong. Just because one physician’s office did not want people exiting into his area, you cannot lock the door and say the door is not an exit.

Close up of Door With Conflicting Signage Web 2I remember we tried to find out what actually releases the magnetic lock and the staff that I was with could not say. They said they were not sure if it released on a fire alarm and they checked with security and it did not release on any signal that security could transmit.

This is the type of deficiency that will lead to an Immediate Jeopardy decision and cause all sorts of headaches for a hospital.

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Feb 10 2016

Strange Observations – Part 4

Category: BlogBKeyes @ 12:00 am
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Deadbolt on Exit Door Web 2Continuing in a series of strange things that I have seen while consulting at hospitals….

This is a picture of a door to an exit stairwell. Note that there is a deadbolt lock on the door above the fire exit hardware. That is so not allowed, according to 19.2.2.2.4 of the 2000 LSC. You cannot lock a door in the path of egress that requires the use of a tool or a key. (There are some exceptions but this door does not qualify).

Also, the sign on the door indicates it is a delayed egress lock but it says the door can be opened in 30 seconds. Section 7.2.1.6.1 allows for a 30 second delay but only when it is approved by the authority having jurisdiction (AHJ).  Most national AHJs for hospitals do not approve of the 30 second delay so this is not permitted. (Some hospitals mistakenly believe that the local or state fire marshal is the only AHJ they need to ask permission, but they don’t realize that the accreditation organizations and CMS are AHJs as well.) If you want to utilize an exception in the LSC whereby it is permitted with the AHJ’s permission, then you need to have permission from all the AHJs who have authority over hospitals:

 

  • CMS (Federal agency who controls Medicare/Medicaid reimbursements)
  • Accreditation organization
  • State agency who license hospitals
  • State fire marshal
  • Local fire inspector
  • Insurance company

The likelihood of getting all of them to agree on an exception to the LSC is slim, if not impossible.

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Jan 04 2016

Sliding Glass Doors with Dead-Bolt Locks

Category: BlogBKeyes @ 12:00 am
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Q: In an existing hospital, exiting from the main lobby, there are two glass horizontal sliding doors. These door are exit doors and are capable of swinging on side hinges if pushed from the inside toward the outside. These doors have a thumb-turn dead bolt lock on them to secure the lobby after hours. Are these dead-bolts locks permitted in this application?

A: Doors in the path of egress cannot have more than one releasing action to operate the door. [See 7.2.1.5.4 of the 2000 edition of the Life Safety Code. Pushing or pulling the door is not considered a releasing action.] If the external exit door is not installed in a fire rated barrier (most Type I and Type II building are exempt from having external walls that are fire rated), then there is no requirement that the external exit door has to be a fire-rated door. If the exit door is fire-rated, then it must have a closer and fire rated hardware which allows the door to be positively latched. A dead-bolt lock on a fire-rated door which has positive latching hardware would not permitted, as it would then require two actions to operate the door (turn the dead-bolt thumb-turn device to unlock the door, and grab and turn the door handle to unlatch the door). However, if the doors that you mentioned are non-rated doors, and if they do not have positive latching hardware, then I could see that a dead-bolt device with a thumb-turn would be permitted. But it would only be permitted as long as there is no other device (i.e. door handle or crash-bar) needed to operate the door. The dead-bolt device would have to be mounted on the door no less than 34 inches above the floor and no more than 48 inches above the floor.

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Feb 26 2015

Expert Witness

Category: BlogBKeyes @ 5:00 am
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imagesXLH1EQVPI received a telephone call recently from a lawyer that asked me if I would be willing to serve as an expert witness in a pending litigation suit. The situation of the lawsuit is a patient who was admitted to the inpatient psychiatric unit of a hospital busted the protective cover over the fire alarm manual pull station, and activated the fire alarm system. The entrance doors to the psychiatric unit unlocked on the fire alarm, and the patient ran out, climbed to the roof of the facility and jumped off.

Now the family of the patient is suing the hospital and the fire alarm company who installed the interface between the door locks and the fire alarm system. The plaintiff’s lawyer is arguing that the interface should never have been installed and the doors should not have unlocked upon activation of the fire alarm system. I agree with the plaintiff’s lawyer, but the problem is, it was the defense’s lawyer who contacted me.

The two major codes and standards that apply in this situation are the NFPA 72 National Fire Alarm Code (1999 edition), and the NFPA 101 Life Safety Code (2000 edition). The Life Safety Code (LSC) allows clinical needs locks on doors in the path of egress, but only in healthcare occupancies (hospitals). They are not permitted in any other occupancy. These types of locks are permitted where the “clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times”. Clinical needs locks are permitted for Behavioral Health units, such as psychiatric and Alzheimer units, to prevent patients from leaving the unit unauthorized, and potentially harming themselves or others.  Clinical needs locks requires all staff who work on that unit (which includes physicians, nurses, aids, clerical, maintenance, foodservice, housekeeping, etc.) to have a key or device to unlock the door on their person at all times. [Code reference: 19.2.2.2.4, Exception No. 1, 2000 edition of the LSC].

But when it comes to connecting those clinical needs locks to the fire alarm system so they automatically unlock on a fire alarm activation, the codes are not so clear. Other permissible locks, such as delayed egress locks and access control locks, are required by code to be connected to the fire alarm system and automatically unlock the door whenever there is an alarm. However, there is no such similar language for clinical needs locks to unlock on an alarm. In addition, NFPA 72 section 3-9.7.1 and 3-9.7.2 says if you have a lock on an exit door it must be connected to the fire alarm system, and it must unlock the door on a fire alarm. However, the exception to 3-9.7.2 essentially says this is not required if an AHJ says so, or if another code says so. So, we go back to the Life Safety Code, and we see that delayed egress locks and access control locks are required to unlock on an alarm, but the section on clinical needs locks is very silent on the subject. When a code is silent on a subject that means it is open for interpretation. Therefore, section 3-9.7 of NFPA 72 does not apply to clinical needs locks in a hospital, because the interpretation Life Safety Code permits it. It is documented that psychiatric patients are astute enough to actuate a fire alarm to unlock the exit doors. Therefore, the code is available to be interpreted in such a way to not require clinical needs locks to unlock the doors in the path of egress on activation of the fire alarm system provided all staff carry a key to unlock the door in case of an emergency.

But who makes that interpretation? Usually the authorities having jurisdiction (AHJ) makes that interpretation. Section 4.6.1.1 of the 2000 LSC says the AHJ shall determine whether the provisions of the LSC are met. But when the AHJ does not issue an interpretation, then it is up to the individual organization’s to decide. As far as I know, there is no national AHJ for healthcare that has it written in their standards that clinical needs locks should not be connected to the fire alarm system. Therefore, the hospital needs to ask the question: Based on the potential risk to patient safety, is it best to connect the door locks on the psychiatric unit to the fire alarm system so they unlock upon activation of the fire alarm system?

I declined the offer to be an expert witness for the defense, and suggested they settle the lawsuit out of court.

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Oct 23 2014

Infant Abduction Locks

Category: BlogBKeyes @ 6:00 am
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Hospitals want to keep their nurseries, mother/baby units, and pediatric units secure, so they lock the doors. This causes a problem with the Life Safety Code because you can’t lock the doors in the path of egress in a hospital, other than three exceptions: 1) Clinical needs locks, which nurseries, mother/baby units, and pediatric units do not qualify; 2) Delayed egress locks; and 3) Access-control locks. Access-control locks really do not lock the door in the path of egress because a motion sensor will automatically unlock the door as a person approaches. So, in this situation the doors can only be locked using the delayed egress provision (found in section 7.2.1.6.1 of the 2000 Life Safety Code).

But hospitals want the infant security systems used on the babies. These systems have a bracelet that is attached to the baby, and some have bracelets to attach to the mother as well. If the bracelet gets too close to the exit door, an alarm will sound and the door will lock. The problem is, these infant security systems do not comply with any of the three exceptions for locking the doors in the path of egress, listed above. Even if the doors will unlock on a fire alarm the hospital says, that is still not enough to qualify for the any of the three exceptions.

But then the hospital says their accreditation organization approved this door locking arrangement. Why should it be considered non-compliant if the accreditor allows it?  Sorry… just because the accreditation organization says it is okay, still does not make it compliant with the requirements of the Life Safety Code. When the state agency who surveys on behalf of CMS takes a look at it, they will not be as benevolent as the accreditor, and they will cite it as a deficiency.

So, to be compliant with the Life Safety Code, when the doors lock because the bracelet gets too close to the door sensor, the doors should lock into a delayed egress mode (again… see section 7.2.1.6.1 in the 2000 Life Safety Code). Then it would be legal. But the 2012 LSC has made a change in this area and will allow locks on doors for the specialized protective measures for the safety of the occupants (see section 18/19.2.2.2.5.2 in the 2012 LSC). This will allow you to lock the doors without delayed egress, provided you meet the requirements listed in that section. CMS has already approved categorical waivers to allow hospitals to begin using this new section of the 2012 LSC before they adopt it.

Take a look at your locks that are used on the nurseries, pediatric, mother/baby units, and even the ICUs and the ERs. If they are not delayed egress, then take a look at the CMS categorical waivers and consider modifying the doors to meet those requirements.

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Feb 27 2014

Delayed Egress on Doors in Ambulatory Health Care Occupancies

Category: BlogBKeyes @ 6:00 am
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safeplace-ob-door-sm[1]

A friend of mine was working on a project involving ambulatory health care occupancy, and they wanted to use a delayed egress lock on an interior door.  The 2000 Life Safety Code (LSC) limits special locking arrangements to exterior doors in ambulatory health care occupancy, but the 2012 LSC does not include that limitation.  They wanted to know what I would recommend.

Well, they are correct: The 2012 edition of the LSC did away with the limitations of the special locking arrangements found in section 7.2.1.6 of the LSC. Section 20/21.2.2.2 of the 2012 edition of the LSC now permits delayed egress locks on any door in the path of egress, where the 2000 edition of the LSC limited them to the exterior door.

I assumed that the individual who asked me the question was bound by the 2000 edition of the LSC, such as a Joint Commission accredited organization, or perhaps a CMS provider for Medicare. My initial thought is the organization would have to comply with the conditions of the 2000 edition of the LSC, and cannot take advantage of the more lenient 2012 edition until such time that edition is adopted by CMS and/or Joint Commission.

However, CMS did issue a categorical waiver to healthcare organizations to allow them to use many of the provisions of the 2012 edition of the LSC now, before the 2012 edition is actually adopted (which may be at least another 12 months away). I reviewed the CMS S&C memo 13-58 once again, and while CMS did state in one of their opening paragraphs that they have the authority to grant waivers for ambulatory surgical centers, they failed to do so in the body of their memo. They have a categorical waiver on doors to allow healthcare occupancies to use the more liberal 2012 LSC position on delayed egress locks, but that categorical waiver only applies to healthcare occupancies, and not ambulatory surgical centers, assuming the ambulatory health care occupancy my friend was referring to was an ambulatory surgical center.

Therefore, I concluded that the organization should (or must) comply with the 2000 edition of the LSC and only install special locking arrangements on exterior doors. Once the 2012 edition of the LSC is adopted, they can then install delayed egress locks on interior doors.

I also mentioned that if the facility in question is only accredited by The Joint Commission, and does not receive any funds from CMS as a Medicare or Medicaid provider, then they could contact the Standards Interpretation Group (SIG) at Joint Commission and ask them if they would accept a Traditional Equivalency to allow them to use special locking arrangements on interior doors of their ambulatory care occupancy. (The telephone number for SIG is:  630-792-5900, select option 6.) My guess is they will, provided the organization meets all the requirements for a traditional equivalency.

If the facility in question actually is part of a larger organization that does have a CMS control number (CCN), then I advised my friend that they have no choice by to comply with the conditions of the 2000 edition of the LSC.

My friend replied asking if they could request a standard CMS waiver to allow the organization to install the delayed egress lock on an interior door now, before the 2012 edition of the LSC is adopted.

My reply was yes, there is always the possibility for a waiver, but CMS will not accept a waiver request unless it is in response to a survey deficiency. In other words, the waiver process is not valid until someone representing CMS cites a deficiency.

As a safety professional, I would never recommend or advise a client to knowingly violate the current edition of the LSC, even though we know that issue will be viewed differently in a more recent edition. There is always the chance that CMS may not adopt the 2012 LSC, although I would be very surprised if they did not.

However, any organization may do what they want, and often times they disregard the advice of a safety professional, and violate the LSC, taking the risk that they will not get caught. In this case, it is understandable as the presumption is the 2012 edition will be effective within the next 12 months or so, and they may feel they will not have any surveys or inspections before then.

So… in summary: The waiver process is not available to them since they have not been cited for non-compliance with the LSC. And, as a safety professional I cannot advise them to violate the LSC. What they do after that is their own business, and risk.

I have some clients who ignore my advice, preferring to ask other safety experts until they find someone who agrees with the answer they want. Hey… it’s their hospital, not mine. I always advise clients to follow the current rules, regulations, codes and standards, but if they decide otherwise, then that’s on them.

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May 02 2013

More on Dead-Bolt Locks

Category: BlogBKeyes @ 6:00 am
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Dead-bolt lock on door Web 2If you search my website on door locks, you will find a few entries concerning dead-bolt locks. For decades hospitals seem to have installed dead-bolt locks on any door they wanted, without any concern for compliance with the Life Safety Code. That’s all changing now, as surveyors and inspectors are becoming better educated on where dead-bolt locks may be used.

The picture to the left shows a dead-bolt lock on a corridor door that is separated from and is not part of the latch-set. It is mounted approximately 12 inches above the latch-set handle and in order to egress through this door, an individual would have to make two releasing motions: 1). unlock the dead-bolt, and 2). turn the latch-set handle. Those two actions make this dead-bolt installation non-compliant with section 7.2.1.5.4 of the 2000 edition of the LSC, which prohibits more than one releasing actions to operate the door.

Some people are quick to point out that dead-bolt locks installed as described above are approved for use on patient room doors in psychiatric units where ‘clinical needs’ locks are permitted. My reply would be, approved by who?  I am aware that Joint Commission has made an interpretation that permits their accredited organizations to have dead-bolt locks on psychiatric units, but that does not address the improper installation of them. Just because Joint Commission says you can have dead-bolt locks, does not mean you are permitted to install them incorrectly.

Hotel Door Latch & Lock Web 2The picture to the left shows a dead-bolt lock that is integrated (not separated) with the latch-set. This arrangement allows the retraction of the dead-bolt simply by turning the latch-set handle, and thereby complying with section 7.2.1.5.4 with a single releasing motion to operate the door. [NOTE: NFPA Healthcare Interpretations Task Force has ruled that pulling or pushing is not considered a motion to operate the door.]

This would be an excellent solution for those situations where you wanted to have a dead-bolt lock installed on a door in the path of egress. This concept of latch-set & dead-bolt lock combined could be obtained in anti-ligature arrangement, and be used in a psychiatric unit.

But there are situations where a traditional dead-bolt lock could be used on a door in the path of egress in a healthcare occupancy. Where? How about in areas where the corridor door is not required to latch?

There are multiple locations in a hospital where doors that open onto a corridor are not required to latch: bathrooms, toilet rooms, shower rooms, and sink rooms that do not contain any combustibles. Also, how about the exterior doors in a Type I or Type II building? Those doors aren’t required to be fire rated, so there is no requirement for exterior doors to latch, either. [Now, most hospitals want their exterior doors to latch even if they aren’t required to, in order to keep the weather and the riff-raff out, but in some rare situations such as the main entrance consisting of sliding glass doors, latching may not be desired.]

Dead-bolt lock on corridor door Web 2The picture to the left shows a door with a dead-bolt lock, but there is no other releasing device mounted on this door, such as a latch-set. While this door would not be permitted in many locations in a hospital corridor because it does not latch, it would be permitted on doors to rooms that are not required to latch, according to 19.3.6.3.1 (toilet rooms, bathrooms, shower rooms, and sink closet not containing combustibles). So a door in the path of egress with a dead-bolt lock and no latch-set on one of these limited rooms would still be compliant with section 7.2.1.5.4 because there is only one releasing action to operate the door: turning the thumb-screw to unlock the door.

Dead-bolt locks that are installed on corridor doors that are required to latch in such a way that they are separated from the latch-set, are just big red flags to surveyors and inspectors. If the door requires two releasing actions to operate the door, then that’s a violation, and they are easy to find. Check out your facility… it may be possible that you have a deficiency that you are not aware.

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Apr 18 2013

Door Locks in Healthcare Occupancies

Category: BlogBKeyes @ 6:00 am
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exit_mag_lock_hospital_10662932[1]Outside of the healthcare setting, locks on doors are utilized nearly everywhere we go, and we don’t give it much of a thought. But in the highly regulated industry of healthcare, we must be very vigilant and astute to what the codes and standards will and will not permit. Unfortunately, locks on doors that are in the path of egress are greatly misunderstood by hospitals, and therefore are widely abused.

 Ordinarily, you are not permitted to lock a door in the path of egress in a healthcare occupancy however, there are three exceptions:

  • Delayed egress locks
  • Access-control locks
  • Clinical needs locks

 Delayed Egress

Delayed egress locks are a lock when a person pushes on the horizontal crash bar of the locked door, a local buzzer will sound, and the door will automatically unlock within 15 seconds. This effectively allows a person to egress through the door, but just delays their egress, hence the name. The requirements for a delayed egress lock are:

  • Delayed egress locks are only permitted in buildings which are fully protected with smoke detectors or automatic sprinklers
  • The delayed egress locks must unlock upon activation of the sprinkler system or a heat detector or a smoke detector, and remain unlocked until manually reset. Notice that activation of a manual pull station is not required to unlock a delayed egress lock.
  • The delayed egress locks must unlock upon loss of power to the mechanism controlling the lock
  • Upon 3 seconds of activating the releasing device (horizontal crash bar) a local buzzer must actuate (to alert staff someone is attempting to exit), and within 15 seconds of activating the releasing device, the lock shall automatically unlock. The locks must reset manually, not automatically.
  • The code allows for the delayed egress lock to automatically unlock within 30 seconds if approved by the AHJ, but HFAP does not approve of this option.
  • A sign, in 1 inch letters, must be posted on the door which reads:

PUSH UNTIL ALARM SOUNDS

DOOR CAN BE OPENED IN 15 SECONDS

  • Only one delayed egress lock may be installed in the path of egress to the public way.

These types of locks are not uncommon in hospitals, but are not used very much. The most common deficiency observed with delayed egress locks is they are installed in a building that is not 100% protected with sprinklers or smoke detectors. [Code reference: 7.2.1.6.1, 2000 edition of the LSC]

 Access Control

Access Control locks are very common in hospitals, and most likely are misunderstood on their correct operation by the facilities staff.  An access control lock usually utilizes a magnetic lock (mag-lock) assembly, and is often integrated with the badge swipe reader to control access into a department. The requirements for an access control lock, are:

  • A motion senor must be mounted on the egress side of the door, that will detect a person approaching and will automatically unlock the door in the direction of egress
  • A loss of power to the device controlling power to the access control lock must unlock the doors in the direction of egress
  • A manual release device must be mounted within 5 feet of the door, and between 40 to 48 inches above the floor which, when depressed, will automatically unlock the door in the direction of egress, and must be identified with a  sign that reads:

PUSH TO EXIT

  • When depressed, the “Push to Exit” button must directly interrupt power to the lock, independent of the access control system electronics, and the doors must remain unlocked for a minimum of 30 seconds
  • Activation of the building sprinkler system or the building fire alarm system must unlock the door in the direction of egress

The most common deficiency with access control locks is the absence of the required motion sensor and/or the “Push to Exit’ button on the egress side of the door. When properly installed, access control locks are not a lock for people trying to get out of the building, but they serve as a lock on doors for people trying to get into the area controlled by the lock. [Code reference: 7.2.1.6.2, 2000 edition of the LSC]

 Clinical Needs

Clinical needs locks are only permitted in healthcare occupancies (hospitals). They are not permitted in any other occupancy. These types of locks are permitted where the “clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times”. Clinical needs locks are permitted for Behavioral Health units, such as psychiatric and Alzheimer units, to prevent patients from leaving the unit unauthorized, and potentially harming themselves or others.  Clinical needs locks requires all staff who work on that unit (which includes physicians, nurses, aids, clerical, maintenance, foodservice, housekeeping, etc.) to have a key or device to unlock the door on their person at all times. [Code reference: 19.2.2.2.4, Exception No. 1, 2000 edition of the LSC]

 Fire Alarm Connection

Delayed egress locks and access control locks are required by code to be connected to the fire alarm system and automatically unlock the door whenever there is an alarm. However, there is no such similar language for clinical needs locks to unlock on an alarm. In addition to the Life Safety Code, NFPA 72 National Fire Alarm Code, (1999 edition) section 3-9.7.1 and 3-9.7.2 says if you have a lock on an exit door it must be connected to the fire alarm system, and it must unlock the door on a fire alarm. HOWEVER, the exception to 3-9.7.2 essentially says this is not required if an AHJ says so, or if another code says so. So, we go back to the Life Safety Code, and we see that delayed egress locks and access control locks are required to unlock on an alarm, but the clinical needs locks is very silent on the subject. When a code is silent on a subject that means it permits it.  Therefore, section 3-9.7 does not apply to clinical needs locks in a hospital, because the Life Safety Code permits it. The code writers understand that psych patients are smart enough to actuate a fire alarm to unlock the exit doors. Therefore, they wrote the code in such a way to not require clinical needs locks to unlock the doors in the path of egress on activation of the fire alarm system PROVIDED all staff carry a key to unlock the door in case of an emergency. That is the trade-off: They will not require the locks to unlock on a fire alarm, as long as all staff can unlock the doors in the event of an emergency.

 Dead Bolt Locks

Generally speaking, dead bolt locks are not permitted on a door in the path of egress in a healthcare occupancy. The only exception would be a dead bolt lock which automatically retracts when the door handle is twisted but other than that, they are not allowed. The reason for this is the LSC only permits one releasing action to operate the door. So if a dead bolt lock is installed on a door in the path of egress and the lock is not part of the latch-set, then it would require two actions: one to unlock the dead bolt and another to turn the door handle, to operate the door. Please note that pulling or pushing is not considered one of the actions to operate the door. [Code reference: 7.2.1.5.4, 2000 edition of the LSC]

 

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Sep 06 2012

Testing Delayed Egress Hardware

Category: BlogBKeyes @ 5:00 am
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NOTE:  My good friend Lori Greene from Ingersoll Rand Security Technologies had this comment posted on her website /blog:  www.idighardware.com  last August 15th, addressing the testing requirements for delayed egress locks. I know some of you readers are already subscribers of Lori’s blog and probably have already read this comment. But I thought this was such a well-researched answer by Lori, that those individuals who are not yet regular readers of ‘I Dig Hardware’ might benefit from her knowledge. It is a very relevant subject to the healthcare setting, so with Lori’s permission, I am repeating her answer to the question: “What are the testing requirements for delayed egress locks?”   Brad Keyes

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Testing Delayed Egress Hardware- What are the Requirements?

( by Lori Greene)

The 2009 International Building Code (IBC) doesn’t include testing guidelines in section 1008.1.9.7 Delayed Egress Locks, but that makes sense because the IBC is used during construction and not for ongoing maintenance.  I checked the 2009 International Fire Code, and the section for delayed egress locks is exactly the same as the one in the IBC.  But since a delayed egress lock requires immediate release upon fire alarm, I thought I might find something in Chapter 9 of the IFC – Fire Protection Systems.  In the section on Testing, Inspection, and Maintenance (907.9), I found this statement:  “Testing. Testing shall be performed in accordance with the schedules in NFPA 72 or more frequently where required by the fire code official.”

NFPA 72 is the National Fire Alarm and Signaling Code.  There were some changes in the 2010 edition relative to this question, so I used that edition in my research.  According to NFPA 72-2010, “door unlocking” falls into the category of “emergency control functions”:  “Emergency control functions (i.e., fan control, smoke damper operation, elevator recall, elevator power shutdown, door holder release, shutter release, door unlocking, etc.) shall be tested by operating or simulating alarm signals. Testing frequency for emergency control functions shall be the same as the frequency required for the initiating device that activates the emergency control function.”  (Table 14.4.2.2).

Here’s some related information from Annex A – Explanatory Material:

Table 14.4.2.2, Item 23. Initiating devices configured to operate an emergency control function are required to be tested per the test methods listed in Table 14.4.2.2, Item 14 and the test frequencies listed in Table 14.4.5, Item 15. Whenever an emergency control function is observed to not operate properly during a test of an emergency control function initiating device, the problem should be reported to the building owner or designated representative. The failure of the emergency control function should be reported as a possible failure of the fire safety feature and not necessarily of the fire alarm system.

Here’s what NFPA 72-2010 says in the inspection/testing section about emergency control functions:

14.2.6 Interface Equipment and Emergency Control Functions.

14.2.6.1* Testing personnel shall be qualified and experienced in the arrangement and operation of interface equipment and emergency control functions.

14.2.6.2 Testing shall be accomplished in accordance with Table 14.4.2.2.

And finally, Table 14.4.5 says that emergency control functions must be tested annually, as well as upon acceptance/reacceptance.  So a delayed egress lock must be tested when it is installed, repaired, or replaced, and then annually after that.  Since NFPA 72 deals with fire alarm systems, the testing requirement is probably more related to whether the fire alarm unlocks the doors, but I think it makes sense to test the 15-second release at least annually too.  I don’t know of a specific requirement for testing that part of the delayed egress lock, other than the NFPA 101 – Life Safety Code requirement for certain egress doors to be inspected annually, depending on the occupancy type.  Local jurisdictions may require more frequent testing / inspection, and facilities may choose to increase the required frequency of testing and establish a specific process to ensure the safety of building occupants

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

From a healthcare facility point of view, I think Lori nailed the issue straight on top of the head. I agree 100% with what she said and would not have anything to add to your code search.

My experience tells me that currently, few Joint Commission surveyors or CMS inspectors actually request to see documentation on testing delayed egress locks, although it is clear the 1999 edition of NFPA 72 requires testing all interface devices connected to the fire alarm control panel. In order for a delayed egress to operate correctly, it must have an interface device between the delayed egress locks and the fire alarm control panel.

I believe surveyor and inspector awareness will improve when the CMS finally adopts the 2012 edition of the LSC, as the 2010 NFPA 72 explains the testing of emergency control functions much better.

Thank you Lori, for a well thought-out answer.      Brad Keyes

 

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Aug 16 2012

Application of Delayed Egress Locks and Access Control Locks

Category: BlogBKeyes @ 5:00 am
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I was recently asked to explain the difference between delayed egress (DE) locks and access controll (ACE) locks, and what are their applications.

The main difference between DE and ACE locks is, DE locks provide a measure of security in the path of egress, where ACE locks do not. The DE lock provides for a 15 second delay before the door will unlock, once the releasing device (crash bar) is activated. Although the Life Safety Code does say 30 seconds is permitted if the authority having jurisdiction allows it, don’t count on this. Even if your local and state authorities permit it, Joint Commission and CMS will not. Since Joint Commission and CMS are authorities having jurisdiction, then you would need their approval as well.

ACE locks automatically unlock in the path of egress when someone approaches the door,  and also by the actuation of the manual release button which is mounted within 5 feet of the door.

So, where would a hospital use a DE lock and where would they use an ACE lock, and why?

Delayed egress locks would be used where the security needs of the patients requires a certain level of delay in an unauthorized individual trying to flee the unit, such as a nursery, pediatrics, labor and delivery or mother-baby units. The 15 second delay can alert staff on the unit that someone is trying to leave the unit who should not be doing so.

Delayed egress locks would be used in a department that has highly sensitive materials, such as medical records, or accounts receivables, or even a large storage room with valuables where the attendant cannot monitor all of the exits. The 15 second delay can alert staff in the area that someone is trying to leave the unit (or room) who should not be doing so.

Delayed egress locks can be used in patient care areas where the patients are somewhat ambulatory but do not qualify for ‘clinical needs’ locks. (Clinical needs locks are permitted in psychiatric and Alzheimer’s units.) Areas such as emergency rooms, radiology, physical therapy, and even some acute care nursing units may use DE locks to discourage those patients who are able to get up and walk around on their own, from unauthorized leaving against medical advice (AMA).

NOTE: In order to qualify to use DE locks, the entire facility needs to be protected with automatic sprinklers, OR be protected with smoke detectors.

Access control locks are typically used where access into a unit or department is desired to be locked. Consider the situation where there is a single leaf entrance door in the corridor to a laboratory which swings into the lab when opened. Access into the lab is desired to be controlled so ACE locks are installed in conjunction with a card swipe reader. The function of the ACE lock would have the magnetic lock preventing unauthorized individuals from entering the lab, but authorized individuals could swipe their ID card on the reader, which would deactivate the mag-lock and the door would unlock and they could enter. Individuals who wanted to exit the lab would approach the door and the motion sensor would sense their presence and automatically deactivate the mag-lock and the door would unlock and they could egress the lab.

Access control locks are frequently misapplied and misused throughout the healthcare industry. Often times portions of ACE locks are installed on cross-corridor doors attempting to limit access into a certain area, and the organization fails to install the motion sensor and the ‘Push to Exit’ button on the wall. All they have is a card swipe reader to release the mag-lock. This is not permitted if the locks are installed on a door in the path of egress. Take a look at the ‘Exit’ signs. If the ‘Exit’ signs direct you through a door, then it is not permitted to be locked without the delayed egress locks or the access control locks.

These comments are based on sections 7.2.1.6.1 and 7.2.1.6.2 of the 2000 edition of the Life Safety Code. Please refer to these sections for further details on installation and operation requirements. Also, consult with your lcoal and state authorities for other requirements concerning DE and ACE locks.

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