Q: We are presently undergoing our 3-year licensure inspection by the Dept. of Health. One of the inspectors asked to see our air change records for the morgue. We have never completed air changes for the morgue. We use outside air and make sure the exhaust fan is working properly. So, should we be doing air change testing in the morgue? Also, do we need to do air change testing in all clean and soiled utility rooms in the hospital?
A: When your facility was designed and constructed, the HVAC system had to be designed to certain Air Changes per Hour (ACH). Depending when the facility was designed, the designer would use the AIA Guidelines (or as they are now called, the FGI Guidelines), or other state or local regulations as appropriate. You need to find out what those design ACH were at the time the facility was designed/constructed, or last renovated in that area.
It is important to understand that you do not have to meet the latest edition of FGI Guidelines; you just have to meet the edition at the time your facility was designed, or last renovated. It is important to also understand that you must comply with state and local regulations at all times.
So, let’s say the morgue was required to have 6 ACH at the time it was designed. You must maintain that 6 ACH for the life of the building, or until you renovate; then you would have to comply with new construction ACH for a morgue. The state inspector’s request is valid: How do you know you are maintaining 6 ACH if you don’t measure it from time to time? How often should you measure the ACH? The codes and standards do not say, so do a risk assessment and determine what is a valid number. Usually once per year is sufficient as long as you have historical data that shows the ACH rate was always in compliance.
You need to start measuring ACH rates in all areas where there was a design requirement for ACH.
Q: How does one handle a “Soiled Utility” room in an Ambulatory Healthcare Occupancy? If it is a small storage room without large volumes of flammable liquids, but perhaps containing soiled linens, are there any special fire protection features that need to be included?
A: Soiled utility rooms in ASCs are treated differently than they are in hospitals and healthcare occupancies. Where chapters 18 and 19 specifically identify soiled utility rooms as hazardous areas for healthcare occupancies, chapters 20 and 21 do not for ambulatory healthcare occupancies.
But chapters 20 and 21 refer to chapters 38 and 39 for “Protection from Hazards” and it does identify ‘storage rooms’ as a hazardous area and must comply with section 8.7. Section 184.108.40.206 requires the hazardous room (i.e. soiled utility room in ASC) to be protected in one of the following two ways:
- Enclosing the room with 1-hour fire rated barriers, that would include a ¾ hour fire rated door assembly that is self-closing and positive latching, or:
- Protect the room with sprinklers.
That’s what you need to do.
Q: Nursing staff has a tendency to stuff patient rooms that are not used as often with extra beds, furniture etc. Building does not have sprinklers on these patient floors so the concern is fuel load in a nonrated room. Is there a particular code I can cite to discourage this behavior?
A: Yes… Section 4.6.7 in the 2012 LSC says when you have a change in use (that’s what is happening… the patient room is not being used as a patient room anymore, but now is used as a storage room with combustible supplies), you need to comply with chapter 43. Section 220.127.116.11 (2) says when existing healthcare occupancies are fully protected throughout with automatic sprinklers, when you have a change is use in a room that does not exceed 250 square feet, the result is the room does not have to meet new construction requirements but is permitted to meet existing conditions for hazardous rooms. This is significant as the room where the extra beds and furniture are placed would not have to meet the more restrictive new construction requirements for adding sprinklers and making the walls become 1-hour fire rated barriers, with a ¾ hour fire rated door assembly. The room would only have to be sprinklered and the walls and doors made to resist the passage of smoke and the door be self-closing. But this is only permitted if the entire building is protected with sprinklers, and you say it is not. Therefore, you have no choice; you must reconstruct the former patient room to be 1-hour fire rated with a ¾ hour fire rated door assembly and install sprinklers in the room. This could cost you $10,000 – $20,000 per room depending on the current arrangement of the facility. This is an example of staff changing the use of a room or area without checking with facilities to see if it is permitted. Your best bet would be to complete the sprinkler installation in your building.
Q: Do you have to have smoke detectors in emergency electrical rooms or electrical rooms?
A: In a hospital? Only if you have an FSES equivalency that requires it, or the room is located inside an area under Specialized Protective Measure locks as described in section 18.104.22.168.5.2 of the 2012 LSC. Otherwise, there are no NFPA codes or standards that require it. But check with your state and local authorities to see if they have regulations that require it.
Often times smoke detectors are placed in locations based on designer preference.
Q: Section 19.3.7 of the 2012 LSC discusses smoke compartments in facilities that have greater than 30 sleeping beds per floor or building. If your facility is under 30 beds, but greater than 22,500 square feet, are smoke compartments required? Or can they be removed on the life safety plans?
A: No… They cannot be removed, because section 22.214.171.124 of the 2012 LSC says existing life safety features shall not be removed or reduced where such feature is a requirement for new construction. According to section 126.96.36.199 of the 2012 LSC, new construction requires it so you must maintain it for the life of the building.
Q: A question came up concerning NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never had an assessment done in the past but it is my understanding that it became a requirement in 2016. The CMS has established compliance requirements (K Tag) for risk assessment and its completion. Who would be the qualified personnel to perform this procedure and create a formal and documented risk assessment?
A: According to members of the Technical Committee who wrote the new Chapter 4 in NFPA 99-2012, the original intent was the risk assessment only applies to new construction. However, the way chapter 4 is written, it is not clear that the risk assessment is only applicable to new construction. CMS has instructed their state agencies who survey on their behalf to require all hospitals to have completed their NFPA 99 risk assessment for new as well as existing construction. Therefore, hospitals must conduct the risk assessment for new and existing conditions. These assessments are not difficult to do and only take a few minutes. There is no requirement to make a room-by-room assessment, but the intent is to assess the risk of the entire system if it were to fail and there were no back-up systems. It would stand to reason that most hospital systems would be Category 1 or Category 2. Anyone may conduct the assessment but would have to have knowledge of the risk assessment process and knowledge of the facility.
Q: Do we need to post the temperature ranges on the outside of our blanket and fluid warmers?
A: Well… no, I don’t believe you do. But the expectation is everyone using the blanket warmers will know what the maximum and minimum temperature settings are. This needs to be established and approved via policies, and staff needs to know the acceptable ranges.
So, one of the better ways of reminding staff what the acceptable ranges are is posting the temps on the warmer itself. It may not be a requirement and you don’t have to do it, but it may be considered ‘best practice’ to post the temps on the cabinets as a reminder.
Q: We have operating rooms with two doors, one that is adjoining to the sterile corridor and one to the common corridor in the Surgery department. We monitor the common corridor continuously through our building automation system (BAS). We do not monitor the sterile corridor. Is there a requirement to monitor the sterile corridor continuously or daily?
A: The standards on monitoring and logging are weak on ventilation requirements and not well defined in many cases. But the expectation is your organization will be monitoring and logging certain environmental parameters regarding operating rooms, such as:
- Air-pressure relationship to surrounding areas;
- Humidity levels;
- Temperature levels
For new construction, CMS and the accreditation organizations recommend compliance with industry standards such as FGI Guidelines, AORN, CDC, and the like when other state or local regulations are silent. For existing conditions, most accreditation organizations have standards that require you to maintain ‘appropriate’ pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity, based on the edition of the design standards used at the time of design… if you know when that was, and what document was used for the design.
Many organizations don’t have that information available to them. When that is not known, most surveyors will lean on what is currently required for temperature, humidity, and air-pressure relationships. The FGI Guidelines require a positive air-pressure relationship to surrounding areas for operating rooms. That would include all areas, including the sterile OR corridor. I believe CMS and the accreditation organizations would expect you to monitor the air-pressure relationship between the operating room and all other areas, including the sterile corridor. There is no requirement to monitor this on a continuous basis, but should be conducted prior to every case.
I have often been told by ambulatory surgery center staff during surveys that the Life Safety Code surveyor is the person that they fear the most.
Keeping up with the requirements can be a daunting task, but I have found that it isn’t the deep-down obscure requirements that trip up facilities; it is often the easy stuff that is missed by the staff and easily found by a surveyor. These are the deficiencies that start popping up over time and are ignored – soon they become commonplace. Sometimes they are even on a routine environment of care (EOC) check form, but those forms can become time-consuming and things may get marked as being compliant but actually were not even checked.
Here are a few of the deficiencies that I often find that are easily avoidable:
Medical gas cylinders that are not secured from falling. We all know they have to be secured, but this is still a common deficiency. This is often blamed on the medical gas delivery person. Probably the best time to check the cylinders in the medical gas room is right after a gas delivery.
Fire-rated doors that are being propped open with just about anything other than a proper hold-open device that is connected to the fire alarm system. If the door needs to be open on a regular basis, then it is probably best to install a hold-open device instead of being cited by a surveyor or the fire marshal.
Fire-rated doors that do not latch because someone has put tape or other items over the latching system so the door can just be pushed open.
Access to manual fire alarm pull stations that are visually and/or physically blocked. For some reason, potted plants like to grow in front of pull stations. Chairs also like to grow there. Keep in mind that access to these pull stations needs to be unobstructed.
Access to fire extinguishers that are visually and/or physically blocked. This is the same as the manual pull stations. Occupants need to know that it is there and need to be able to get to it.
Equipment and other items blocking clear access in ASC corridors or reducing the clear width to less than 44 inches. As ASCs get busy, it is easy for clutter to build up in the corridors and egress paths. Staff should be educated on the importance of keeping the paths clear.
Electrical circuit breaker panels that are blocked and do not have a clear working area of at least 36 inches in front of them. This is usually seen inside the electrical rooms, but it does happen throughout some facilities.
This list is just a small sampling of the simple things that fall through the cracks and results in citations for ASCs. Education is often the first step to combat this on-going issue; however, if the issues persist, persistent on-going surveillance may be needed. There is nothing more irritating than being cited for simple deficiencies that are easy to prevent.
By Brad Keyes…
Q: I have a storage question for you that relates to storing beds and other hospital equipment in our mechanical rooms. Is this allowed or would I be cited for storing things in the mechanical room?
A: To be sure, mechanical rooms are designed to house mechanical equipment, and storage should not obstruct access to the mechanical equipment. According to the 2012 edition of the LSC, storage in mechanical rooms is not prohibited, but there are some exceptions and there are some requirements that you must meet. If the mechanical room opens onto an exit enclosure, section 188.8.131.52.1 (9)(c) of the 2012 LSC now permits existing openings from mechanical spaces to exit enclosures to remain provided the door assembly is properly fire-rated; the mechanical space is not used for fuel-fire equipment; the space contains no storage of combustible materials; and the building is protected throughout by sprinklers. So, if that describes your situation, then storage of combustible materials such as beds (i.e. mattresses), and boxes of supplies would NOT be permitted. But where the mechanical room does not open onto an exit enclosure the items stored in the mechanical room must be orderly and neat. Storage cannot obstruct access to electrical panels, fire extinguishers, and fire alarm pull stations, and storage must be clear of all sprinklers located on a horizontal plane 18 inches below the sprinkler deflector. If the items stored in the mechanical room are combustible (cardboard boxes, paper or plastic wrapping, linens, etc.) then the mechanical room must meet normal hazardous room requirements. If the room is new (meaning if the room has been designated for storage on or after July 5, 2016) or was designed to meet new construction requirements, then it must be protected with automatic sprinklers and the walls constructed from the floor to the deck above with 1-hour fire rating, with a ¾ hour fire rated, self-closing, positive latching door. Be careful with this as new construction hazardous rooms were required to be 1-hour fire rated as far back as the 1967 edition of the LSC. If the room is considered existing (meaning the room was designated as storage before July 5, 2016 and there have not been any major renovations since), then it must be protected with automatic sprinklers with walls that are smoke resistant and extend from the floor to the ceiling, and protected with a 1 ¾ inch solid bonded wood core door that is smoke resistant and self-closing and positive latching, or if not sprinklered, then the room is required to be protected with 1-hour fire rated barriers. However, please check with your state and local authorities as they may have other codes or standards that may prohibit storage in a mechanical room.
Q: I just would like to confirm: When you say a 4-inch projection is allowed into the corridor is that for one side of the corridor or is that for a total of both sides cannot exceed 4-inch?
A: I would say that is for each individual side of a corridor. So, each side of the corridor is allowed a 4-inch projection. The reason I say that is the limit on a projection into the corridor is to prevent a sight-impaired person from running into an object while egressing. Since most corridors are wider that the largest human, the 4-inch restriction is based on individual sides of the corridor.
Even though section 184.108.40.206(2) of the 2012 Life Safety Code permits a 6-inch projection into the corridor, CMS explained in their Final Rule to adopt the 2012 Life Safety Code (published May 6, 2016) that they will require all healthcare facilities who receive Medicare/Medicaid reimbursements to comply with the ADA restriction of a 4-inch maximum projection. The ADA refers to the ANSI standard A117.1-2009, section 307.2 that limits a 4-inch projection from 27-inches above the floor to 80-inches above the floor.
Q: Our Emergency Operations team does regulatory rounding every 2 weeks in a different unit or clinic. Our department is responsible for Life Safety. Recently, we did some rounding in our Cancer Center which is an outpatient service in a business occupancy building that is attached to the hospital. The Cancer Center building is 3 stories high and the hospital is 6 stories. There is a large open lobby with a stair and elevator between the two buildings. The cancer center has a 30-minute smoke wall that runs through the middle of it per the life safety drawings. One of the questions on our rounding sheet is “Do all the smoke barrier walls go to the deck?”. I discovered that there is a large gap in the smoke wall above a set of double doors. As a group we have discussed this and there are conflicting opinions. One opinion is the walls have to go to the deck regardless. The other opinion is they do not since we have a dropped ceiling grid which also acts as a smoke barrier. Is there a right answer?
A: Boy… You’ve got a lot going on there. First of all, when was this facility constructed? New construction smoke barriers have been required to be 1-hour rated for decades. You may have a problem calling these barriers 30-minute rated. Secondly, all smoke barriers (i.e. barriers that separate two or more smoke compartments) have to be continuous from outside wall to outside wall and from floor to deck above. Section 220.127.116.11 does allow for smoke barriers to stop at interstitial spaces, provided the underside of the interstitial space provides the same rating and smoke resistance as the smoke barrier. A suspended grid and tile ceiling does NOT meet that parameter.
What your fellow employees may be thinking about is a smoke partition… not a smoke barrier. A smoke partition is a non-rated wall that resists the passage of smoke and is found in corridor walls and non-rated hazardous rooms. Those smoke partitions are permitted to terminate at the ceiling provided the ceiling also resists the passage of smoke. While NFPA does recognize that a suspended grid and tile ceiling may resist the passage of smoke, the IBC does not.
From what you are describing… it appears to me that the smoke barrier must go to the deck. Write up an ILSM assessment and get that barrier scheduled for repair. Next, is there a fire-barrier of 1-hour construction meeting the requirements of 8.6.7 separating the cancer center from the atrium and another 1-hour barrier separating the hospital from the atrium? Finally, is there a 2-hour fire-rated barrier separating the cancer center business occupancy from the healthcare occupancy?
Q: What is one of the main reasons that ambulatory surgery centers (ASCs) get cited for deficiencies in relation to testing, inspection, and maintenance activities for Life Safety equipment?
A: I have found that ASCs often make the mistake of assuming that outside vendors for the inspection, testing, and maintenance of the ASC’s medical gas, back-up generator, fire alarm, and fire sprinkler systems are adhering to the required NFPA standards. When educating ASC staff on the deficiencies that I find, they often ask, “Well, shouldn’t the vendor know what is required by NFPA?” That’s a great question, but does the vendor know that your facility has to follow the NFPA standards? Not every one of their clients does. The vendor usually knows exactly what is required by the standards, but they will only perform the tasks that are spelled out in the service contract that they have with the ASC or building management.
One of the main issues is that the ASC staff does not know what is required by the NFPA standards. The best way to solve the problem is through education; taking the time to review the standards and getting to know the requirements is very beneficial for anyone who is responsible for making sure that the ASC’s utilities are properly maintained. A basic internet search for testing, inspection, and maintenance requirements for the specific utility systems leads to many resources. Even contact with the vendor can be enlightening. It is also a good time to make sure that the vendor is aware of standards the ASC has to follow and if the vendor has a good grasp on what is required by those standards.
Another issue is that ASC staff does not really review the contracts to make sure that all required elements of the standards are covered. If it is not in the contract, it probably doesn’t get done. Over the years, as ASC personnel change and new individuals are responsible for the care of the ASC utilities, they often assume that whoever approved the service contracts in the past actually read them and made sure that the contracts included all the required tasks. Requirements also change over the years and the changes need to be reflected in the contract; therefore, service contracts should be reviewed periodically and they should especially be reviewed when they have reached their end and a new contract is going to be signed.
Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that opens to the corridor, and each has a 3’0″ door in the rear of the OR that opens into a central sterile core. The OR walls other than the corridor side are not labeled as a fire/smoke barrier on the life safety drawings. The main OR entrance door that opens into the corridor has a door closer, is rated, and has latching hardware. My question is: The 3′ 0″ doors opening into the sterile core have closers but do they have to be fitted with latching hardware?
A: Does the Life Safety drawings identify the sterile core area and the operating room together as a suite-of-rooms? What does the life safety drawings say about the sterile core area? Is it classified as a suite? If so, then the door could be fine without a latching door between the OR and the sterile core area, because it is all one suite. However, if the life safety drawings clearly identify the internal walls of the sterile core area as corridor walls, then the door between the OR and the sterile core area would have to latch. Remember: All corridor doors must latch.
There is another issue here… Most sterile core areas that I have seen qualify as an hazardous area, due to the many combustible items stored in the room. If the walls surrounding the sterile core area are 1-hour fire-rated, then the door itself would have to be 3/4-hour fire-rated (see 18.104.22.168 of the 2012 LSC), and it would have to be self-closing and positive latching. If the walls surrounding the sterile core area are smoke partitions and the sterile core area is protected with sprinklers, then the door is not required to be fire-rated, but it must be self-closing (see 22.214.171.124.3) and positive latching (see 126.96.36.199.2, which references 188.8.131.52 which references 184.108.40.206.10).
Based on the information you provided, it is probable that the door between the OR and the sterile core area would have to positively latch.
Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have different interpretations of 220.127.116.11.1.2.
A: No. Corridor entrance doors to suites must latch. Section 18.104.22.168.5 requires all corridor doors to latch. CMS does not allow the exception for a device that holds the door closed with 5 lbs. of force.
Since a suite is nothing more than a large room with smaller rooms inside, the barrier that separates the suite from the corridor must meet the conditions for corridor walls, which means the door must latch. The provision in 22.214.171.124.1.2 (2) is written to allow existing suites to have smoke resistant walls when fire-rated barriers are required by the corridor walls.