Sep 04 2014

Exit Sign Monthly Inspections

Category: BlogBKeyes @ 6:00 am

Access Control Locks WEb 2Why is it that hospital facility managers are often surprised when surveyors ask to see the documentation that their exit signs were inspected on a monthly basis? Probably because no one has ever asked to see that documentation before. If that is the case, then the facility manager appears to be preparing for a triennial survey based on the results of the previous survey, which is a dangerous strategy to follow.

Section 7.10.9 of the 2000 Life Safety Code requires exit signs to be inspected monthly to ensure that the sign is in fact illuminated. This inspection can be done when the exit sign is illuminated by normal power or emergency power, but is not required to be checked under both sources of power. The inspection is to ensure the sign is illuminated, and the lamps inside the sign are not burned out, or the circuit is not de-energized.

Some facility managers try to argue this requirement away by saying their exit signs are LED and therefore the lamps never burn out. Well, LED lamps do burn out, but it just takes forever to do it. Unfortunately, the 2000 LSC does not have an exception to NOT inspect exit signs for illumination if they are equipped with LED lamps.

Perhaps facility managers are surprised when surveyors ask to see the exit sign inspection documents because The Joint Commission does not have a specific standard or EP that addresses the issue. That does not mean a Joint Commission surveyor cannot ask to see that documentation, though. But Joint Commission is not the only authority that hospitals have to be concerned with. How about CMS; or their state health departments; or the local fire inspector; or their insurance company? Surveyors for those entities could very well ask to see that documentation.

If you are not already inspecting your exit signs on a monthly basis for illumination, then I suggest you get started. Develop a monthly PM work order that has your maintenance staff or security staff looking at each exit sign, and recording whether or not it passed or failed its inspection.

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Dec 06 2012

Stairwell Identification Signs

Category: BlogBKeyes @ 6:00 am

A question came up recently as to the proper mounting of the stairwell identification signs that are required in stairwells of a certain height. The  wall-mounted stair identification signs are supposed to be mounted within the enclosure on each landing in stairs serving five or more stories. The mounting height is ‘approximately’ 5 feet above the floor landing, according to section of the 2000 edition of the Life Safety Code. What does the word ‘approximately’ mean, in this situation? Is the 5 foot measured from the bottom, middle or top of the sign?

The NFPA 101 handbook (2000 edition) has a picture showing the 5 foot measurement is between the bottom of the sign and the floor. One could take this to mean the required 5 foot measurement is from the floor to the bottom of the sign, but that is not necessarily true. The handbook is just a commentary written by a NFPA staff individual, who is also a liaison between the Life Safety Code technical committees and the NFPA. While that person is very knowledgeable, it is still his (or her) opinion and is not considered part of the code.

The annex section of the Life Safety Code explains some of the rationale behind the decisions making up the code language. Unfortunately, the annex section for does not discuss the 5 foot mounting height, but does say the sign is intended not only for individuals evacuating the building, but also for the fire department responders to understand critical information about the building during an emergency. The annex section also says the information on the sign can be divided up into two signs to eliminate information over-load.

So, when the Life Safety Code is not specific or clear as to its meaning, the interpretation is left up to those entities that enforce the code in your facility. Those entities are called the authorities having jurisdiction (AHJ) and for healthcare organizations, the national AHJs are the Centers for Medicare & Medicaid Services (CMS), Joint Commission, Healthcare Facilities Accreditation Program (HFAP), and Det Norske Veritas Healthcare (DNV). As far as I know, none of the above AHJs have publicly stated where the 5 foot measurement has to be, therefore since the official code language says ‘approximate’, then the 5 foot distance can be interpreted to be to either the top, the center or the bottom of the sign. You will be safe with any of those measurements. Keep in mind that the requirement for stairwell identification signs is found in chapter 7 of the Life Safety Code, which makes the signs required in any building with 5 or more stories, not just healthcare occupancies.

Always check with your local and state AHJs to determine if they have a more restrictive interpretation.

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Sep 27 2012

Confusing and Conflicting Signage: Part 2

Category: BlogBKeyes @ 5:00 am

Last July 5 I posted an article on conflicting and confusing signage, in regards to hospitals and nursing homes. The posting dealt with situations where I had observed (and took pictures) of signs that I thought presented a confusing situation, such as an ‘Exit’ sign over a door, with another sign that said ‘No Exit’. The conclusion of that posting was the AHJs will most likely cite you for having confusing and conflicting signage.

Then I recieved a reply from Robert Welch from the State of Kentucky Office of Inspector General asking where in the Life Safety Code would ‘confusing and conflicting signage’ be cited. Knowing that there is not  a specific reference in the 2000 edition of the Life Safety Code that says “Thou shalt not have conflicting signs…”, I came up with the following explanation:

Section 4.1.1 of the 2000 edition of the Life Safety Code (LSC) states the goal of the LSC is to provide an environment that is reasonably safe from fire and similar emergencies, and section 4.1.2 states another goal is to provide for reasonably safe emergency crowd movement. Having conflicting signs concerning exiting seems to me to be contrary to this goal. Section 4.2.1 requires a structure to be maintained to protect occupants who are not intimate with the initial fire development. Also, requires the routes to the exits to be conspicuously indicated. Having conflicting signage in regards to exiting would not be obvious or easy to notice (i.e. conspicuous).

One could take this point further to section 18/ which discusses the concept of the LSC and how it pertains to healthcare occupancies. It says the occupants shall be protected from fire by appropriate arrangement of facilities, adequate staffing, and development of operating and maintenance procedures composed of [among other things] design and construction. If the path of egress has a sign that says ‘Exit’ and another sign that says ‘Authorized Use Only’ then that (to say the least) is a poor design of the structure.

CMS weighs in on this with their Condition of Participation (CoP) §482.41 which requires the hospital to be maintained to ensure safety. Citing a CoP out of compliance may be a bit much on one conflicting sign, so standard §482.41(a) may be more appropriate. Joint Commission would cite conflicting signage under EC.02.01.01, EP 1; or EC.02.06.01, EP 1.

When conflicting signage presents a perceived risk to the safety of the staff and patients, then that is an offense that should be cited. The bottom line: hospitals should know better. The conflicting signs that you saw in my post of July 5 should have been caught by the facilities staff long before I came along and took a picture of them. Shame on them for not having an adequate Life Safety program whereby someone walked around and discovered those problems.

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