By Brad Keyes….
Q: My question is in regards to alcohol-based hand rub (ABHR) dispensers in a recovery area in our Cath lab. Does an open bay in the recovery area count as a patient room and not in the overall count of dispensers in a smoke compartment?
A: No. Open bays for recovery do not count as individual rooms in regards to the count of ABHR dispenser locations. The reason why is, those bays are located in one room, not in separate rooms. According to section 184.108.40.206.1 of the 2012 LSC, areas used for patient treatment or sleeping have to be separated from the corridor. So, they are either in a large room, or a suite (which is a large room as well). They cannot be open to the corridor, and if they are, you have other problems.
Q: What is the most common deficiency that you cite during a Life Safety Code survey?
A: Improper inspection, maintenance, and testing of the building features that protect occupants from smoke and fire seem to be the area I tend to cite the most. The focus in ambulatory surgery centers (ASCs) has changed from evacuation of patients to shelter-in-place. Staff is trained to move patients and themselves to safety behind barrier walls that are designed to limit the transfer of fire and smoke.
The following features are often neglected:
- Fire and smoke dampers – Many times, ASC staff have no idea if the facility even has fire and smoke dampers. Since the dampers are usually located above the ceiling tiles, they are often forgotten. Dampers are required to be inspected and tested one (1) year after inspection and every four (4) years after that. I have found that ASCs that are maintained by hospital maintenance staff often only conduct the testing every six (6) years, as required for a hospital, instead of every four (4) as required for ASCs. I am often asked who inspects and tests fire dampers. I usually suggest that the original HVAC contractor be contacted first for guidance. If they can’t help, I suggest that they contact other ASCs or the hospital to find out who they need to conduct the work.
- Barrier walls – Once above the ceiling tiles, barrier walls are often forgotten. Regardless of the type of barrier wall, the wall needs to be inspected and maintained to ensure that it is compliant with the standard. There shouldn’t be any open holes. Penetrations should be properly sealed. Walls should be properly constructed for their type. I often suggest that at least annually ASCs should have someone, with knowledge of the standards, inspect the barrier walls for deficiencies. Deficiencies should be repaired by trained individuals.
- Rated fire doors – Rated fire door assemblies are required by NFPA 80 edition 2010 to be annually tested and inspected. Usually, the doors are not inspected, or the inspection does not meet the standard. Besides deficiencies related to door inspections, the next prevalent deficiency is fire doors being propped open.
By Brad Keyes…
Q: Are smoke detectors required in individual hospital patient rooms, and what are the exemptions to not have a detector in individual rooms?
A: There is no Life Safety Code or NFPA 72-2010 requirement to have smoke detectors in hospital patient sleeping rooms or treatment areas. There may be other standards or regulations that could require them, so check with your state and local authorities.
Typically, the only areas that are required to have smoke detectors in a hospital are:
- Elevator lobbies and elevator mechanical rooms
- Near doors that are held-open by magnets
- In the same room with fire alarm control panels that are not constantly supervised
- In areas open to the corridor that are not constantly supervised
- Inside locked areas that use the Specialized Protective Measure locking arrangement identified by 220.127.116.11.5.2
- Patient sleeping suites that do not provide direct supervision
- Smoke compartments containing patient sleeping suites over 5,000 square feet but not exceeding 7,500 square feet and are not equipped with Quick Response (QR) sprinklers
- Patient sleeping suites over 7,500 square feet but not exceeding 10,000 square feet
Additionally, smoke detectors may be required in patient sleeping rooms if an Equivalency was submitted and approved.
By Brad Keyes…
Q: I need you to settle an argument for us, and your answer will settle this situation for all. We have a fire door to a hazardous room, that has lockers behind it when you open the door. The lockers will not allow the door to open fully. Since this door is not in the means of egress, is this situation allowable?
A: All doors are in the means of egress as long as you can physically be inside the room. Once you’re in the room, the door is now in the path of egress to get to the outdoors. Section 18.104.22.168.1 of the 2012 Life Safety Code says all doors in the means of egress shall be capable of swinging from any position to the full required width of the opening. So, the door must swing open to at least 90 degrees. I would say your situation is not permitted and the lockers should be relocated to allow the door to open fully.
By Brad Keyes…
Q: What is the allowed distance a non-sprinkled stick-built building can be located beside a hospital?
A: Your question encompasses a couple of different issues. When you say “stick-built” building, I think of wood frame construction, which is Construction Type V (000) in accordance with the Life Safety Code and NFPA 220. Construction Type V (000) is not permitted in healthcare occupancies unless the hospital is only one story and is fully sprinklered. So, let’s assume your hospital is more than one story and is at least Construction Type II (222), which is non-combustible construction with beams, columns, joists and floors fire rated at 2-hours. If you have an adjoining wood-frame building with Construction Type V (000), then it must be separated from the healthcare occupancy with a 2-hour fire rated barrier. However, there is a caveat with this requirement. If the wood-frame construction building is separated by a minimum of 10 feet and is not-connected to the building containing the healthcare occupancy, then a 2-hour fire rated barrier is not required. This 10-foot gap would act as a fire barrier is one building were to catch on fire. This 10-foot gap is an interpretation based on section 22.214.171.124.2.1 that requires 10-feet of the horizontal exterior of the building wall to be fire-rated where unprotected exterior walls of a stairwell connect to the building at an angle less-than 180 degrees.
By Brad Keyes…
Q: Housekeeping products like germicidal, glass cleaner, air freshener are stored in a locked metal box on housekeeping cart. All of our stock of these and other products are stored in two large locked metal lockers. They are not fire rated cabinets. The surveyor said aerosols all have to be stored in fire rated cabinets. While they are in use while on housekeeping carts, they will have to be checked in and out daily from a fire cabinet.
The surveyor did not cite a tag or code for this he just told us we had to do it. I have searched and so much is left to interpretation I am confused on what to do. With all the changes occurring and more to come with state regulations and inspections I would like to be prepared.
A: It is safe to say that there is no NFPA standard, no CMS standard, and no accreditation standard that specifically says aerosol cans must be stored in a fire rated cabinet. However, if access to these aerosol products by unauthorized individuals is a safety risk (i.e. can children get into them) then it may be perceived as an unsafe environment and the surveyor would have a legitimate concern about them.
I suggest you go back to the surveyor and ask them why they believe the aerosol products have to be stored in a fire-rated cabinet. Ask for a specific code, standard, or regulation that they are using to make this recommendation.
Otherwise… it’s not a code violation, but a surveyor’s preference.
By Brad Keyes…
Q: In regards to corridor width, section 126.96.36.199 of the 2012 LSC discusses that a corridor has to be at least 48-inches outside of a sleeping room in clear width. Does that mean that you only need to worry about situations where your corridor projection will reduce the hallway to less than 48 inches? Is clear width from wall to wall, or from projection to wall? When I had asked our Accreditation Organization for guidance on this issue they stated that we did not need to worry about a projection so long as the corridor still maintained 8 feet from the projection to the other wall. I don’t see that that stated anywhere in my copy of the LSC. Is this true?
A: No… it is not true. Let’s put to rest the erroneous comment that you do not need to worry about a corridor projection so long as the corridor still maintained 8 feet from the projection to the other wall. This is absolutely false. A projection into the corridor is not affected by how much distance to the other wall remains. If someone wants to cling to that statement, then ask them to identify where in the Life Safety Code it permits it (they won’t find it).
According to the CMS Final Rule to adopt the 2012 Life Safety Code that was published May 4, 2016, all CMS-certified healthcare providers cannot have a wall-mounted projection of more than 4 inches. This is measured from 27-inches above the floor to 80-inches above the floor according to the ANSI standard A117.1-2009, section 307.2, which is referenced in the ADA standard. But this also allows for wall-mounted items (i.e. clocks, signs, monitors) to extend more than 4-inches into the corridor as long as they are at least 80-inches above the floor.
This is true no matter how wide your corridor currently is, although some exceptions apply for areas open to the corridor like lobbies and waiting areas.
By Brad Keyes…
Q: How do I perform the elevator recall test?
A: If you have never performed an elevator recall test, I suggest you have your elevator maintenance company show you how it is done the first time, then you can continue to do it on a monthly test. But, in lieu of that, here is how a monthly elevator recall test is performed:
- Take a copy of the elevator recall key, insert it in the corridor keyed switch on the level best used by the responding fire department, and turn it to the “Test” position. This key should be available from the elevator service company.
- This will recall all the elevators in that bank to the floor that you are on. The elevator will ‘recall’ to that floor and open the doors. The controls inside the elevator will not respond to normal touch and the elevator car will sit there waiting for someone to take control. The elevators will be “out of service” during this test, so plan on doing this test when it will least impact your operations.
- Remove the key from the recall corridor switch (leave the switch still in the “Test” position) and enter one of the elevator cars. Take the key and insert it in the keyed switched labeled “Fire Fighter Service” and turn it to the “Test” position (It should say “Test”, but if not, turn the switch anyway). Now you have manual control on the elevator buttons inside the car.
- Push a button to another floor, holding it until the doors closed. The elevator will travel to that floor, but the doors will not open. If you push the “Door Open” button, then the doors will open, and stay that way until another floor button is pressed.
- While in the elevator car, test the function of the emergency telephone in the car.
- Return the elevator car to the recall floor and test any other cars in that bank. Remove the key and go back to the corridor switch and return the switch to the normal setting.
That is a monthly recall test, which must be done each month to all elevators. You may find that the fire alarm system will become alerted during this test and before the elevators return to normal service you may have to reset the fire alarm system. But check with your state and local AHJs before conducting this test for the first time… There are some states that will only allow certified elevator technicians to perform this test.
By Brad Keyes…
Q: My facility is installing perforated ceiling tiles because it looks “modern” and does not look like the old healthcare setting. With the perforation in the ceiling tiles, does this mean I have to install sprinklers and fire alarm smoke detectors above and below the ceiling since the dropped ceiling is no longer a smoke-resistant barrier? I believe I have to also take the smoke compartment barrier walls to the deck… is that correct?
A: First of all, do you need smoke detectors in the area where the new ceiling tiles are being installed? If yes, then we need to address this issue, but the NFPA codes and standards do not require that many smoke detectors in a hospital. Unless you are employing Specialized Protective Measure locks (see section 188.8.131.52.5.2 of the 2012 Life Safety Code), or have specific requirements from a state or local authority that exceed what NFPA requires, smoke detectors are only mandatory in the following locations of a hospital:
- In areas open to the corridor that are not directly supervised by a person (see section 184.108.40.206 of the 2012 LSC)
- Near doors that are held open by devices that release on a fire alarm activation (see section 220.127.116.11.5.1 of NFPA 72-2010)
- In elevator lobbies and elevator equipment rooms (see section 18.104.22.168 of the 2012 LSC)
- In rooms where fire alarm panels (including NAC panels and off-premises monitoring transmission equipment) are located without direct supervision by a person (see section 22.214.171.124.1 of the 2012 LSC)
You may want to revisit why the smoke detectors are there in the first place. Check with your state and local authorities to see if they have requirements for smoke detectors to be there.
But assuming you do want to maintain the smoke detection level in this area where the new ceiling tiles are located, NFPA 72-2010 does address this issue. Let’s look at section 126.96.36.199.3 which discusses the requirements for an open grid ceiling. It says smoke detectors are not required below an open grid ceiling if the openings in the ceiling are ¼-inch or larger in the least dimension, and the openings constitute at least 70% of the surface area of the ceiling. So, what this means, smoke detectors are not required above the ceiling if the openings are less than ¼-inch and the accumulative area of the openings is 30% of the total surface area of the ceiling. But this section only applies if smoke detectors are required in the general area where these new ceiling tiles are being installed. But keep in mind, if you install smoke detectors where they are not required, they still must be installed in compliance with NFPA 72-2010.
Here are the requirements found in NFPA 13-2010, at section 8.15.13 for an approved open-grid ceiling. Open-grid ceiling must be installed below the sprinklers where all of the following apply:
- The openings of the open-grid ceiling must be at least ¼ inch or larger in the least dimension.
- The thickness or the depth of the material does not exceed the least dimension of the opening.
- The openings must constitute 70 percent of the area of the ceiling material.
If your ceiling tile openings are less than ¼-inch and the openings in the ceiling tile equal less than 70% of the ceiling area, then I conclude sprinklers would not be required above the ceiling.
There is one issue you need to be aware of… Most surveyors will cite you for having gaps in ceiling tiles greater than 1/8-inch as that would allow heat and smoke to filter up through the ceiling and would cause the sprinklers or smoke detectors to delay activation. Make sure these ceiling tiles do not have openings greater than 1/8-inch.
Smoke compartment barrier walls always have to extend from the floor to the deck above regardless whether or not the ceiling tiles have openings in them.
Last week, I shared a brief checklist for evaluating your hospital emergency operations plan and now, I’m here to share a couple of free resources with you to aid in this process.
U.S. Department of Health & Human Services ASPR TRACIE
This website, which is free to join, is a great national resource for templates and more. They also have a feature section titled “Beyond the Response: Experiences from the Field” which details organizations’ responses to emergencies.
California Emergency Medical Services Authority (EMSA)
This website provides multiple tools and templates to assist you with the emergency preparedness process. You can find editable Word documents that cover topics such as active shooter, infectious disease, missing persons, utility failure, and more.
If you would like more information regarding hospital emergency operations plans, please contact me at firstname.lastname@example.org.
Q: In healthcare, when calculating the 300 cubic feet of oxidizing gases like oxygen and nitrous oxide, do “air” tanks figure into the calculation?
A: Yes… According to 3.3.128 of NFPA 99-2012, an oxidizing gas is a gas that supports combustion. And, according to 11.1.1, the NFPA 99-2012 Health Care Facilities Code applies to all nonflammable medical gases. So, if the cylinders of compressed air are medical gases, then yes; they apply to the oxidizing gases rule.
Q: Are there any regular testing requirements for Generator Remote Shutdown Switches?
A: Yes… sort of. Section 8.4.1 of NFPA 110-2010 says generators, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
The term “appurtenant components” means accessory components, and the remote shutoff switch would be included in that. So, technically, you are required to inspect the remote shutoff switch weekly and exercise it when the generator is operating. You would not want to exercise this switch while the generator is under a load from the building, but rather during the ‘cool-down’ period after the test.
I have already seen a finding from a state agency that cited a facility for not testing the switch. It seems to be a ‘ticky-tack’ finding, but the surveyors are getting tougher because CMS is continuing to crack-down on Life Safety Code issues. But the bottom line… NFPA 110-2010 does require you to inspect it weekly and test it monthly.
Q: Where does “Homelike Environment” end and fire safety begin? We have a resident in our nursing home who likes to push-pin everything she makes in activities to her wall. On a recent Life/Safety visit, the surveyor noted that she had “too much stuff” on her walls and that it was a “fire hazard”. We are supposed to encourage “homelike” and “Individualized Care”, then we are told that we have to tell the resident that they cannot decorate their “home” as they desire. I know there has to be a balance, but the items do not impede entrance nor egress to the room and, while there are a lot of items, high and low, they are not on top of one another nor sticking out more than 3 or 4 inches from the wall. One might consider them to be “cluttered”, however, they are not on the floor. Also, he said that everything from pictures to wreaths to whatever has to be “flame retardant”. Are we to spray everything that a family brings in from home?
A: I am very empathetic to your problem as I understand that CMS state agencies want you to create a “home-like” environment for long-term care patients, but yet, you are required to comply with the 2012 edition of the Life Safety Code. However, there is some relief available to you on this subject. Since CMS adopted the 2012 edition of the Life Safety Code effective July 5, 2016, section 188.8.131.52 changes how decorations may be displayed in the patient’s room:
- Combustible decorations are permitted to be attached to walls, ceiling and non-fire rated doors as long as the decorations do not interfere with the operation of the doors
- Combustible decorations may not exceed 20 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is not fully protected by sprinklers
- Combustible decorations may not exceed 30 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is fully protected by sprinklers
- Combustible decorations may not exceed 50 percent of the wall, door and ceiling areas inside patient sleeping rooms having a capacity of no more than 4 patients, in a smoke compartment that is fully protected by sprinklers
When calculating the percentage of area of the walls covered by decorations, you calculate only the wall-sections that are used by the decorations. In other words, if the south-wall of the patient room is the only wall that has decorations pinned to it, then you only use the area of the south wall, and not the other three walls in the room.
I don’t know if the decorations covering the walls that the surveyor saw were within the above limitations, but I would think your organization could calculate the square footage of the decorations and ensure it stays within the limits.
Q: Is there presently a date in place in which existing Healthcare Occupancies (remaining portions or in their entirety) must be fully sprinklered?
A: Yes and no.
All existing high-rise hospitals must be fully protected with sprinklers by July 5, 2028. This was decided by CMS in their Final Rule to adopt the 2012 Life Safety Code.
For existing hospitals that are not high-rise (i.e. do not have an occupied floor higher than 75 feet above the lowest level used by a fire department) there is no requirement to become fully sprinklered unless their construction type requires it or there is renovation.
Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB). For quarterly fire drills, are we to have staff activate the building general fire alarm system for every drill? For the stand alone sites I do not see a problem with this, but for the others in MOBs we do not own where 90% of other tenants are business occupancies, cancer patients, rehab centers, etc. Are we not creating unnecessary stress by dumping the building four times a year, which is exactly what would happen if we pulled the pull station in a MOB? I reached out to the supervisor of the surveyor that cited us, but wanted to gain another perspective.
A: The surveyor was correct in citing you for not activating the fire alarm system during a fire drill. It is a key requirement that provides staff with knowledge and understanding what an actual fire alarm sounds and looks like.
I do see and understand your dilemma in those MOB’s where your organization is not the only entity in the building. But haven’t you discussed this issue with your landlord yet? There are ways to re-program the fire alarm occupant notification system (i.e. strobes, horns, chimes, etc.) to activate only in your area. Yes. It may cost some funds to do so, but that is part of the cost of doing business in a building that is shared with other entities.
Also, have you discussed the option of conducting building-wide fire drills with the other occupants? Since you’re an ASC you must do quarterly fire drills and the other entities may be business occupancies which only require annual fire drills. But if you scheduled the drills at a time when it is least likely to disrupt operations of everyone, then the other entities may be more accepting of your situation.
The bottom line: You must activate the fire alarm system when conducting a fire drill. Discuss this challenge with the other tenants and see if they are willing to accommodate you at various times (i.e. early in the day or late in the afternoon). If not, then invest in making the fire alarm system activate only in your area during a fire drill.
You do have options…