Jun 01 2018

NFPA 99 Signs on Doors to Central Supply Systems

Category: BlogBKeyes @ 12:00 am

Q: According to Joint Commission standard EC.02.05.09 EP4 it is requiring this sign:
“Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” They are referencing NFPA 99 2012-– Am I understanding correctly that if I have Oxygen, Medical Gas and Nitrous in the Medical Gas Storage Room that this is the correct sign I need?

A: I think you have this twisted a bit. Joint Commission’s standard EC.02.05.09, EP 4 (2018 CAMH) does not reference NFPA 99-2012 to The EP 3 (located above EP 4) does, but EP 4 does not reference any NFPA standard or sub-section of NFPA 99.

So… where did Joint Commission get the information for EP 4? From NFPA 99-2012, section But according to NFPA 99-2012,, sub-section applies only to Central Supply Systems. This sign that requires (Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening) is only required for Central Supply Systems, such as gas manifold rooms. It is not required on doors to storage rooms on units that contain less than 3,000 cubic feet of oxidizing gases.

Also, NFPA 99-2012, section says locations containing Central Supply Systems or cylinders containing only oxygen or medical air shall have their doors labeled: “Medical Gases: NO Smoking or Open Flame”. Since this is a sub-section of, this requirement still only applies to Central Supply System locations, such as gas manifold rooms.

But the way Joint Commission’s EC.02.05.09, EP 4 is written, it does not really limit the signs to just Central Supply Systems….

My advice is to contact the accreditor for clarification.

Tags: ,

Mar 19 2015

Stairwell Signage

Category: BlogBKeyes @ 1:00 am

In Case of Fire Web 2If you were a bit surprised by the wording of the sign to the left… You’re not alone. I had to do a double-take when I first saw it, as it certainly got my attention.

The sign is a marketing strategy by the Stairwell Signage Solutions company in Palm Beach Gardens, Florida, and is re-printed here with permission. The sign is an ominous warning to facility managers that their existing stairwell signage may not be compliant with the new 2012 Life Safety Code.

When the new 2012 LSC is adopted facilities will have to comply with the following requirements, found in section


  • New enclosed stairwells serving three or more stories and existing enclosed stairwells serving five or more stories must have stairwell identification signs (previously, the 2000 LSC only required stairwells serving five or more stories to have stairwell identification signs);
  • The stairwell must be provided with identification signs inside the enclosure at each floor landing;
  • The signage must indicate the floor level;
  • The signage must indicate the terminus of the top and the bottom of the stairwell;
  • The signage must indicate the stairwell name (identification);
  • The signage must indicate the floor level of, and the direction to, the exit discharge;
  • The signage must be located inside the enclosure approximately 60 inches above the floor landing in a position that is visible when the door is open or closed;
  • The signage must be continuously illuminated with emergency power back-up capability (this was not previously required);
  • The floor level designation must be tactile in accordance with ICC/ANSI A117.1 (this was not previously required);
  • The signage must be painted or stenciled on the wall or on a separate sign securely attached to the wall (this was not previously required);
  • The name of the stairwell must be located at the top of the sign in minimum 1 inch tall lettering (this was not previously required);
  • Stairwells that do not provide roof access must read ‘NO ROOF ACCESS’ underneath the name of the stairwell in 1 inch tall lettering (this was not previously required);
  • The floor level number must be located in the middle of the sign in 5 inch tall numbers (this was not previously required);
  • The identification of the lower and upper terminus of the stairwell must be located at the bottom of the sign in 1 inch tall lettering (this was not previously required).

The phrase ‘this was not previously required’ is referring to the 2000 LSC. If you would like to contact Stairwell Signage Solutions, contact Stephen Salzberg, at imagemaven@aol.com.


Tags: , ,

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.

Tags: , ,

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.

Tags: , ,

Jul 05 2012

Confusing and Conflicting Signage

Category: BlogBKeyes @ 5:00 am

Just like a policy or a management plan, CMS, Joint Commission, HFAP and DNV surveyors will hold you accountable to what your signage is telling you. If a sign is posted informing you of something to do (or not to do), and if  a surveyor finds a contrary action, then you are open for a citation. If multiple signs contradict each other, then you have a confusing situation and still susceptible to findings. Let’s take a look at some signs that create problems and challenges…

This hand-written sign informs occupants that this is not an exit, while the ‘Exit’ sign says it is… Which is it? This photo was taken in a construction project. It appears that the contractor wanted to shut-down this exit for construction purposes, but he was reluctant to cover up the ‘Exit’ sign. Apparently, he did not understand that it is permissible to cover up an ‘Exit’ sign as long as you implement appropriate ILSM procedures.







 The sign on the door says ‘Authorized Personnel Only – Do Not Enter’ which implies “Don’t Go In Here”, but the ‘Exit’ sign says this is the way to the exit. Confusing… which will get them in trouble with a surveyor.







 The sign on the wall says ‘Surgical Suite- Do Not Enter’ but the ‘Exit’ sign points out that this is the way to exit the building. Although you don’t want unauthorized individuals waltzing into a surgical suite, you can’t tell them on one hand “This is the way to get out of the building” and then say on the other hand “Hey! Don’t You Come in Here!” You can’t have it both ways. Perhaps a better sign on the wall could have been “Surgical Suite – Emergency Exit Only”.





This is a classic. I use it a lot during my seminars on not what to do. Again, you have the ‘Exit’ sign saying “This is the way out of the building” and then you slap another sign on the door that essentially says “No, this is not the way out of the building”.  This stairwell that the ‘Exit’ sign points to did not qualify as a ‘required exit’. It had a problem with the discharge out of the stairwell on the level of exit discharge, and the hospital did not believe that it complied with the LSC. I think it did qualify for an exception in the LSC, but the hospital wanted to discontinue using it as a ‘required exit’. Anyway, until I saw this signage arrangement, the hospital thought they had to have the ‘Exit’ sign over all stairwells, regardless whether or not they were required or legal, and then they wanted to post a sign indicating that the stairwell really wasn’t legal, so they would only make it a ‘communicating stairwell’ between floors. You can’t have it both ways. (They found out they did not need this stairwell for required exiting so they removed the ‘Exit’ sign. Right Mike?)

 First they wanted you to use the ‘Other’ door, then they decided they wanted you to use ‘This’ door. Then someone parked a gurney in front of the door effectively telling everyone “Don’t use any door”. Placing a gurney or other object in front of a door, effectively blocking access to and from the room is a huge NO-NO.






This is not a shelf? Sure it is…. Staff was ignoring a sign which was posted by someone else. Surveyors won’t like this type of disregard. This may be a good example of never using ‘home-made’ signs, and only use indelible signs. It might cut down on the blatant disregard by staff.








I was looking for the generic “In Case of Fire, Use Stairs” sign for an article I was writing, and I found this on the Internet. Silly…






 She’s the Director of HIM, but who’s the director of HER?

Sounds like a ‘Get Smart’ episode.







 And last but not least, this sign is from my good friend Lori Greene. She had it on her blog (www.idighardware.com) just this past week. I can fully understand how mistakes happen, but I wonder how long that sign was in place before anyone found out it was wrong? Take a look at the lower edge of the sign… it looks a bit worn, indicating it’s been there a while. (For those that may not know what the problem is, the sign was supposed to read: PUSH UNTIL ALARM SOUNDS- DOOR CAN BE OPENED IN 15 SECONDS)


The lesson learned from all of these signs, is they cannot conflict with other signs, and they must be obeyed.


Feb 03 2012

Stairwell Signage

Category: Life Safety Code UpdateBKeyes @ 6:00 am

Remember the rush we all made in the last 10 years or so to install stairwell identification signs inside our stairwells? Well, with the adoption of the new 2012 Life Safety Code, many hospitals may have to take down the signs that they put up and replace them with new signs.

The sign to the left is an example of a stairwell identification sign that we had to install in stairwells serving 5 or more stories. It identified all the correct parameters:

1). The name of the stairwell

2). The floor level

3). The top and bottom terminus

4). The direction to the exit

5). The level of the exit


This sign will no longer meet the requirements of when the 2012 edition of the Life Safety Code is adopted.


With the adoption of the new 2012 edition of the Life Safety Code, hospitals will have to replace all of those signs with new ones similar to the second picture below, and in addition to the requirements above, the new signs must have the have the following additional parameters:

1). The sign needs to be illuminated by a reliable light source (the stairwell illumination light should be sufficient for this requirement)

2). The floor level designation needs to be tactile in accordance with ADA requirements

3). The sign may be painted or stenciled on the wall, or if a separate sign, it needs to be fastened to the wall

4). The stairwell identification lettering is required to be at the top of the sign, in minimum 1 inch tall letters

5). Stairwells that do not provide roof access must have the words ‘NO ROOF ACCESS’ and must be located underneath the stairwell identification lettering in minimum 1 inch tall lettering

6). The floor level number must be in the middle of the sign, and be a minimum 5 inches tall. Mezzanine levels must have the letter ‘M’ (or other appropriate identification letter) preceding the floor number, and basements must have the the letter ‘B’ (or other appropriate identification letter) preceding the floor level number

7). Identification of the lower and upper terminus of the stairwell must be located at the bottom of the sign and in minimum 1 inch tall letters and/or numbers.

There is no indication yet from any of the Accreditation Organizations (Joint Commission, HFAP and DNV) or the CMS that the old stairwell signs will be exempt from having to be replaced.

Also, when the new 2012 edition of the Life Safety Code is adopted, all new stairwells serving 3 or more stories are required to have stairwell identification signs.