Q: Are there any Life Safety Code requirements for a battery charging room, such as HVAC pressurization and air changes per hour (ACH) rates? These rooms are where I charge my EVS floor machines.
A: I guess it would depend on how the room is interpreted in regards to its function. According to the 2014 FGI Guidelines, which references the ASHRAE 170 table, a janitor’s closet must be negative, have 10 ACH, the air in the room must be exhausted to the outdoors, you cannot have a room HVAC that recirculates air, and there are no design requirements for humidity and temperature.
If the room is hazardous material storage (which sounds more like it), the room would have to meet the same requirements as listed above, with the added requirement that there is 2 ACH of outdoor air.
But those are for new construction. For existing conditions, you would have to comply with the FGI or AIA requirements in effect at the time of the design of the room.
Q: As the world faces this pandemic, can fire drill requirements be suspended or replaced with staff education type in-services?
A: Fire drills are a mandatory requirement that is regulated by the federal government through the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation standards. At this time, there has been no communication from CMS to suspend any of the Life Safety Code requirements, including fire drills, during this COVID-19 crisis.
If (or when) CMS issues a formal communication announcing any suspension to their standards, that will be reported by my website, as well as by many other informational services, and your accreditation organization.
So, no – fire drill requirements cannot be suspended at this time.
Q: We have a Geri-Psych unit and the stairwells are locked on that unit. Back in 2009, you surveyed our facility and wrote in your findings, “The housekeeper person on the Geri-Psych unit does not have a key on her person to unlock the exit doors.” This is a battle that we are continually fighting. We need some ammunition! Can you please provide me with the code that would require them to have keys on their person (since common sense isn’t so common around here)?
A: Look at section 22.214.171.124.5.1 of the 2012 LSC. It says staff can readily unlock the doors at all times. Housekeepers, maintenance, food service, physicians, nurses, therapists, etc., are all ‘staff’, and each one working inside the locked unit needs to be able to unlock the doors. Therefore, each staff member must have a key or device to unlock the doors on their person.
Q: A California Life Safety Code surveyor enforcing the 2012 edition of the LSC asked for a map of all of the smoke and fire dampers in the building (skilled nursing home) and threatened a deficiency if one could not be produced. I have been searching for the 2012 LSC and cannot find any such reference to this specific requirement. I have not heard of this before. Can you shed any light on this matter?
A: Yes, I can understand the surveyor’s request, although threatening you with a citation seems a bit much.
The surveyor’s position is: How can you effectively maintain all of your fire/smoke dampers if you do not know where they are located? Having them documented on a drawing is logical in that you can then properly maintain the dampers. Without having them documented on a drawing, the chance is great that you would miss one or more dampers and they would not be tested.
But, to be sure, there is no standard that requires you to have drawings showing the locations of all fire/smoke dampers. But if you provide a test report that says you tested 25 dampers, how do you know where these 25 dampers are located, and you don’t have more than 25, and you got them all tested? I can see the surveyor could cite you with a finding that would read something like this: “The organization failed to provide evidence that all fire and smoke dampers were properly tested.”
But I don’t approve of surveyors making threats… that is just unprofessional.
Q: My hospital is preparing for COVID-19. I’m at odds with the clinicians who believe that the pandemic is a special situation, meaning that Life Safety Code can go by the wayside in order to be prepared to receive and care for contagious patients. For instance, clinicians have decided to move waiting chairs into corridors to provide what is considered “social distancing.” Another example is the plan to place plastic sheeting barriers in corridors so that the hospital can be split into a clean and dirty zone. What would be your recommendation for these situations? Can the Life Safety Code be ignored for emergency situations?
A: Yes, but only when the Emergency Response Plan is activated. You still must maintain a level of safety for staff, visitors, and patients, but that level of safety is a moving target when there is a disaster to accommodate. Having plastic sheeting in an exit access corridor is certainly a violation of the Life Safety Code, but it may very well be necessary when there is a disaster. This is a judgment call and one that should be addressed in the Emergency Response Plan and approved by the person in charge of the disaster response team, not the physicians.
You will not find this written in any standard that I am aware of, but is based on years of experience working with Centers for Medicare & Medicaid Services (CMS) and The Joint Commission.
Q: What are the rules for fire extinguishers in elevator mechanical rooms? Is it good enough to have the extinguisher outside the room in the hallway?
A: Yes… Based on NFPA codes and standards, there is no requirement to have an extinguisher inside the mechanical room, as long as there is an extinguisher within the maximum travel distance for the classification of the extinguisher and the capacity of the extinguisher. It is permitted to have an extinguisher outside of the elevator mechanical room.
Q: I was reviewing the various regulatory requirements and came across the need for weekly visual inspections of the generators. At one campus, we have changed the batteries to the gel type. On the other campus, we still have wet cell type. Yes, we have a hydrometer and, within the weekly PM work order, it does state to check them. But we don’t really use a form to capture that information. We called our contractor who provides the generator service and asked them to quote on gel batteries. They state that the manufacturer does not recommend sealed batteries because they can’t be manually maintained and because generator batteries are constantly in a state of being charged, the water could dry out and the batteries can explode. They also state that gel batteries for our particular engines will lose 200 to 300 cranking amps. I saw your question/answer section on generator batteries and wondered, now that the Accreditation Organizations (AO) have adopted NFPA 101 2012 version if there are any formal decisions on the use of gel/sealed batteries?
A: There is no formal decision or interpretation from any national AHJ (that I know of) that prohibits maintenance-free batteries, or gel-type batteries, for generators. However, there are standards that say you must follow the manufacturer’s recommendations regarding plant equipment maintenance and operations (see CMS CFR §482.41(d)(2), and your AO’s standards.
So, in your case, it appears the manufacturer of your generator says do not use maintenance-free batteries. So, CMS and your AO could cite you for not following your manufacturer’s recommendations. By the way, the requirement to test the generator battery electrolyte level is monthly, not weekly according to NFPA 110-2010, section 126.96.36.199. But you still must document the monthly reading.
According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud financial losses are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300 billion1.
Beginning in the mid-1990s, many healthcare providers were encouraged to develop and implement compliance plans. While many hospitals and large healthcare systems followed this guidance, many ambulatory surgery centers did not. As a result, those centers may unknowingly be at risk.
But the good news is that it’s never too late to implement a compliance plan. It doesn’t have to be expensive or time-consuming; in fact, there are simple and inexpensive steps that facilities can take to promote compliance and develop strategies2 that will keep your organization safe in the long run.
Choose who will develop the plan.
There are to options for establishing your plan: you can hire a consultant, like Compliance One Group, to develop it for you or you can prepare one yourself. The latter may be appropriate for smaller ASCs that have tighter operating budgets. If you choose to develop the plan yourself, you then have a couple of options: buying a ready-made, off-the-shelf product or starting from scratch. While a pre-developed plan may seem like a good idea at the time, keep in mind that your plan needs to be customized for your facility. Filling in the blanks of an off-the-shelf product will not be effective.
Perform a facility audit.
When it comes to audits, there are two that should be conducted: a standards and procedures audit to assess how well you are complying with regulatory requirements and a claims submission audit to examine the claims development and submission process from patient intake through to submission and payment of claims.
However, these audits are not one-and-done; ASCs should re-audit annually to measure the success of the plan.
Write the plan.
Once you have performed your audits and have a thorough understanding of what your problem areas are, you can begin establishing your compliance plan.
A standard compliance plan includes:
- Overview of applicable federal and state laws
- Duties and responsibilities of the Chief Compliance Officer
- Acknowledgment form, signed by each owner and employee
- Code of Conduct, applicable to owners, board members, and employees
- Corporate compliance checklist
- HIPAA compliance plan
If you would like to discuss how our team can assist you with effective compliance planning, leave me a message by clicking here.
Q: Is it allowed to disable a corridor door’s closer by removing the arm in order to keep it open while working inside of the office in a healthcare facility? I know that propping the door open with a wedge is not an option; I was just wondering that if these doors were required to have closers on them due to being a corridor door.
A: No… it would not be acceptable to disengage the function of the closer, even if it is was not required by a code or standard. Section 188.8.131.52 of the 2012 LSC says existing features of life safety obvious to the public if not required by a code or standard, must be maintained or removed. Now, there are exceptions. When you say ‘working in the office’, if you meant there was a construction project or a repair job in progress, then yes, you can disengage the closer in order to accommodate the work in progress. In a situation like that, you would assess it for Alternative Life Safety Measures according to section 184.108.40.206 (some AHJs call this Interim Life Safety Measures or ILSMs). But if you mean the person whose office it is wants the closer disabled so they don’t have to deal with a door that closes automatically, then the answer would be no, it is not permitted. If the closer is not required on the door by the Life Safety Code, then I suggest you ask your state and local authorities to determine if you may remove the closer.
Q: Our hospital recently purchased a few lactation pods like they have in airports. I can’t help wondering if they need to have fire alarm notification devices and sprinklers. Has this been issue with any accreditation surveyors yet?
A: I can’t say that I’ve given this subject much thought. I am not aware that any surveyors have cited this issue so far.
It would be my thinking that a Lactation Pod would be similar to the concept of a clothes closet as described in section 220.127.116.11 of the 2012 LSC whereas sprinklers would not be required. But there is a maximum area allowed under that section of 6 square feet, and I don’t know if the Lactation Pod is under 6 square feet.
I did contact CMS and asked them if they would require sprinklers in these pods and they replied in an informal communication and said they agreed that the lactation pods would be considered comparable to a portable wardrobe unit and would not require sprinklers to be installed in the pod.
Q: Can E-cylinders be stored in a closet where people hang their jackets even if they are in an acceptable storage cart?
A: Yes… up to a certain number of ‘E’ cylinders. Storage of compressed medical gases up to 300 cubic feet in accumulative quantity per smoke compartment is unregulated, other than the requirement in section 18.104.22.168 (11) of NFPA 99-2012 to properly secure the cylinders and to not store them in such a way that they obstruct the required egress. But once the accumulative total of stored gases exceeds 300 cubic feet per smoke compartment, then section 11.3.2 of NFPA 99-2012 regulates how they are stored:
- Must be in a designated room constructed with non-combustible or limited combustible materials
- Must have a door that can be secured against unauthorized entry
- Oxidizing gases cannot be stored with any flammable gas, liquid or vapor
- Oxidizing gases must be separated from combustibles by 20 feet, or 5 feet if the room is sprinklered, or enclosed in fire-rated cabinets
An ‘E’ cylinder (which is 25.5 inches tall and 4.3 inches in diameter) contains 24 cubic feet of gas when full, so that means you could have up to 12 ‘E’ cylinders in a single smoke compartment before you would have to comply with section 11.3.2 for storage.
Q: We are building a new ER and an area of the existing building had to have some work done so that the new ER could connect to the old building. The existing ceiling was a “hard” ceiling and the existing sprinklers were hung below the ceiling. We now have a drop ceiling and the sprinklers are installed with the pipe above and the heads below the drop ceiling. The sprinkler installer is hanging the pipe where it touches duct, electrical conduit and is hung from the trusses. My question is, is this non-compliant?
A: It depends on the size of pipe and where it is supported from. Generally speaking, sprinkler piping may only be connected to the building structure, such as beams, trusses and decks. But there are some exceptions. Section 22.214.171.124 of NFPA 13-2010 says sprinkler piping must be supported independently of the ceiling sheathing, but they do allow sprinkler pipe up to 1½-inch or smaller diameter pipe to be supported from ceilings of hollow tile or metal lath and plaster. But this excludes acoustical tile ceilings, and gypsum board ceilings. Section 126.96.36.199.1 says unless the requirements of 188.8.131.52.3 apply (which allows special hangers for flexible piping), sprinkler piping shall be substantially supported from the building structure, which must support the added load of the waterfilled pipe plus a minimum of 250 lb. applied at the point of hanging. Section 184.108.40.206.3 discusses Flexible Sprinkler Hose Fittings, and says listed flexible sprinkler hose fittings and their anchoring components intended for use in installations connecting the sprinkler system piping to sprinklers shall be installed in accordance with the requirements of the listing, including any installation instructions. This allows the special hangers for flexible piping to connect to the grid of acoustical tile ceilings. Section 220.127.116.11 on Metal Decks, says branch line hangers attached to metal deck shall be permitted only for the support of pipe 1 inch or smaller in size, by drilling or punching the vertical portion of the metal deck and using through bolts. Section 18.104.22.168 says where sprinkler piping is installed below ductwork, the piping shall be supported from the building structure or from the ductwork supports, provided such supports are capable of handling both the load of the ductwork and the load of the pipe, the water inside the pipe and an additional 250 lbs. Remember, section 22.214.171.124 says sprinkler piping or hangers shall not be used to support non-system components. Take a look at the sprinkler system design drawings… often the sprinkler designer will specify where sprinkler piping is required to be supported. See if the installing contractor is following what has already been designed and approved. But, NFPA 13-2010, chapter 9 on hangers should take precedent over whatever the designer specifies.
Q: With regards to a fire watch, the code is specific about requiring one in an occupied building when a fire alarm system or suppression system is out of service for a prescribed period of time. This makes sense for head end shutdowns and other scenarios where entire buildings or significant portions of buildings are impacted. My question is what if you are only taking part of a “system” down? Meaning a small renovation that impairs 3 heads in a room because the ceiling grid and tile are removed for greater than 10 hours. This is not a “system”, only a part of one. Where does an AHJ draw the line? Is it possible that our ILSM and Fire Impairment Policy could allow for a certain number of heads, certain square footage or percentage of a smoke compartment to be impaired without the fire watch requirement (given that other ILSMs are in place)?
A: While the interpretation is not written down as to how many impaired sprinkler heads constitute a system, it is generally understood more than 2. While that number may fluctuate between surveyors, it would be fair to say all of the sprinkler heads inside one room that are impaired would require a fire watch. The logic is, if a fire started in the room, there is no fire suppression device to extinguish the fire if all the heads were impaired. Does not matter if the room only has 3 sprinkler heads.
To be sure, you should obtain a decision directly from your accreditation organization. But even then, the CMS state agency may not agree with what your AO says. It is best to be conservative and conduct the Fire Watch as long as the sprinkler heads are impaired. Besides, how long does it take to install upright heads within 12 inches of the deck in this room?
Q: Am I allowed to have a suite inside an area designated as an Ambulatory Occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated?
A: Yes… you are permitted to have a suite in an ambulatory health care occupancy. Look at section 20/126.96.36.199 which permits suites in AHCO, but any suite over 2,500 square feet must have two remotely located doors from the suite. No… Suite boundary walls are not necessarily required to be 1-hour fire-rated. They are required to be equal to the fire-resistive rating of the corridor walls. For new construction, corridor walls would be a minimum of 1-hour fire rated barriers, unless one of the following exists:
- Where exits are available from an open floor area
- Within a space occupied by a single tenant
- Within buildings that are fully protected with automatic sprinklers
For existing construction, there are no requirements for corridor walls, so therefore there are no requirements for suite boundary walls.