Lower Bottom Rod Latching

Q: My question is regarding a 2-hour fire-rated wall that is separating our physical therapy department and the main hospital. In between the two is a long glass hallway with a dual egress 90-minute fire-rated door. The doors are top latching. I have had an environment of care consultant say that the door has to be top and bottom latching. Their reasoning is because it separates two occupancies. But both occupancies are owned by the hospital, and are not separate entities. Does the dual egress door have to be top and bottom latching?

A: Maybe yes and maybe no… The requirement for a lower bottom rod is dependent on the door assembly manufacturer’s UL listing when they had the door tested. It is not a NFPA standard that all doors have to have a lower bottom rod, but rather it is driven by the manufacturer’s hardware listing from UL.

I have not seen the door assembly but your consultant has. If there is evidence that the lower bottom rod on the fire-rated door assembly was originally installed and now it has been removed, then yes you need to re-install it and have a top and bottom latching connection. This is not uncommon after a few years when the lower bottom rod becomes damaged, and the hospital maintenance just removes it since it latches at the top. If that is the situation for you, then that would be a non-compliant situation.

In some cases, the door manufacturer provides a ‘Fire Pin’ in lieu of the lower bottom rod, which is spring-activated to shoot a pin horizontally from one leaf to the other to hold the door closed during a fire. These ‘Fire Pins’ do not operate until the temperature at the floor reaches 450°F or thereabouts, so there is no chance of the pin activating prior to anyone wanting to use the doors.

Then I’ve been told there are a few door manufacturer’s that have passed the UL testing whereby they are only required to have a latching device at the top of the door, and not at the bottom of the door. I’ve never seen one, but I’ve been told they are out there.

I suggest you contact the distributer of the door in question and ask them what hardware is required in order to maintain the fire-rating from UL. Then maintain that documentation for future reference during a survey.

Manual Shutdown Switch

Q: We got a hit on our life safety inspection because we were told the manual shutdown switch be detached from the generator. The deficiency report says “The manual shutdown switch should be located external to the waterproof enclosure of the generator and should be appropriately identified.” The manual shut off switches of our generators are on the outside of the waterproof enclosure but they are on the outside of the generator but on the side of it. Just getting some clarification before calling an electrician to put a switch away from generator.

A: The surveyor got it right… the manual shut-down switch must not be connected to the generator containment structure. According to section A.5.6.5.6 of NFPA 110-2010, the manual shut-down switch must be mounted exterior of the weatherproof container for the generator. This was discussed in great length at a recent HITF annual meeting and the conclusion was the same; the manual switch must be mounted separate from the container housing the generator.

Sprinkler Obstructions

Q: My question is in regard to NFPA 13 sprinkler obstruction compliance…We want to install some surveillance monitors in our security office along a wall. How much vertical clear space is required between the monitors to the ceiling, if the monitors will be 30 inches away, horizontally from the sprinkler head?

A: Those monitors may extend vertically up to the ceiling as long as they are not directly underneath a sprinkler head, and they are attached to the wall. You said they were 30 inches away horizontally from the sprinklers, so you should be okay.

The Annex section A.8.6.6 of NFPA 13-2010 says the following:

“The 18 in. (457 mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 8.6.6, 8.7.6, 8.8.6, and Section 8.9. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (457 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (457 mm) below the ceiling sprinkler deflectors.”

While the monitor may not be shelves, the concept is the same.

Annual Alarm Transmission Test

Q: Is the alarm transmission verification test generally performed by a fire alarm testing company on every device during an annual test/inspection? I also thought that this was a quarterly requirement. I would verify receipt and timing of transmission with the central station once a quarter during fire drills. Do I have this confused with another standard?

A: No… NFPA changed the standard on you. Under the 1999 edition of NFPA 72, which the 2000 LSC referenced, the requirement was quarterly to test your off-premises monitoring transmission equipment. But with the 2012 LSC, it now references the 2010 edition of NFPA 72 which changed it to be an annual requirement.

But do not make the mistake of just testing the alarm transmission to the central station monitoring agency. This needs to be tested to the fire responder’s location, be it the 9-1-1 center or the local fire department. Many hospitals make the mistake of testing the alarm transmission to just the central station monitoring your fire alarm panel, but the interpretation by CMS and many of the accreditation organizations is you need to confirm that the local fire department received the alarm signal. This can be accomplished during a routine fire drill whereby you do not notify the central station monitoring company but you do notify the local fire department that a drill will be conducted, and tell them to not respond. After you complete the fire drill, contact the fire department to confirm they received the call from the central station monitoring company, and to return to normal response mode.

This test is conducted annually on a general alarm… not on every device that you test.

Fire Pins

Q: I had a company put in the fire plugs on the doors to replace the lower bottom rods. Was this okay? They say that the plugs have a thermal-pin that will secure the door in case there was a fire.

A: You must be referring to fire pins… I cannot say if this is okay or not. That is up to the manufacturer of the fire doors. You are not allowed to modify a fire-rated door assembly other than what the manufacturer permits. If you haven’t already done so, contact the manufacturer of the door and ask them if fire pins are permitted to be installed in their door in lieu of the lower bottom rod after the door is installed.

The manufacturer achieves a listing from an independent testing laboratory for the fire-rating of their door assembly. If you modify that door assembly beyond what was tested and listed by the testing laboratory, then you have violated the listing of the door and the entire door assembly would need to be replaced.

Delayed Egress Locks

Q: Lately, due to many different construction projects within this hospital, contractors install crash bars (aka panic bars) on doors that have locks for security reasons. The doors do lead to alternate evacuation exits/stairs. The crash bars release the locks in 15 seconds and I have been told that signs notifying people of this is required on the doors. Where is the code for this requirement? One location is an entrance directly into an outpatient care service directly off the public elevator lobby. At two newer locations on another floor, employees are to use their ID badge for access but in one location the sensor is not readily seen. In this location employees frequently open the door via the crash bar setting off the alarm requiring someone to go there to reset the alarm. The message contractors are putting on the doors read: PUSH UNTIL ALARM SOUNDS / DOOR CAN BE OPENED IN 15 SECONDS. The message gives people permission as well as instruction of how to enter a secured area. Where is this code requiring the sign and does it specify the message?

A: Yes… The answer to your question is: Section 7.2.1.6.1 of the 2012 Life Safety Code.

What you have on these doors are called “Delayed Egress Locks”, and the sign that reads “PUSH UNTIL ALARM SOUNDS – DOOR CAN BE OPENED IN 15 SECONDS” is a requirement. If you don’t have these signs, you can be cited by an inspector or surveyor.

Also, as an FYI… you are not allowed to use delayed egress locks on doors in the required path of egress unless the facility is fully smoke detected or fully sprinklered. So, check with your staff to determine if your building is fully sprinklered. In all my 40+  years in this business, I have never seen a fully smoke-detected hospital.

Keep in mind, delayed egress locks are not designed to secure an area. They are designed to allow access through the door on a delayed basis. If the door is located in the required path of egress, then you cannot secure the door, unless it meets one of the exceptions provided in section 19.2.2.2.4.

Heated Massaging Seat

Q: I work at an ICF facility. We have a person with arthritis and I was just asked if a heated pad massaging seat could be purchased for them. I know we can’t have heated blankets, personal heaters, etc. With this item having heat, I would assume it would probably not be approved either. Can I get your input??

A: There are no CMS codes or standards that would prohibit this type of device. Actually, there are no codes or standards that would prohibit electric heating blankets, but the perceived risk of danger usually disqualifies them from use.

There will be risks in using this heated, massaging seat that you need to address, such as:

  • Trip hazard with the electrical cord
  • Something heavy rolling on the electrical cord creating a pinch-point, thereby causing a short-circuit over time
  • The seat becoming too hot for the patient

If you address these risks in a risk assessment and mitigate them to the satisfaction of the surveyor, you should be fine.

Emergency Management

Q: Regarding the new CMS rule on emergency preparedness, are they telling us that we must have full heating and cooling support for the entire hospital during a power outage up to and including adding more generators?

A: No… I don’t believe it is. Section 482.15 (b)(1)(ii)(A) says, “The hospital must develop and implement emergency preparedness policies and procedures … that must address temperatures to protect patient health and safety”. This does not say or mean that you need to add equipment to maintain temperatures (other than what the Life Safety code and NFPA 99 requires). It’s saying you must have a policy and a procedure that must address temperatures to protect the health and safety of patients.

So, your policies must reflect a plan on how you are going to accomplish this. If you lose fuel for the heating appliances, then what is your back-up plan? If you lose normal power and then emergency power, what is your back-up plan? Ultimately, your plan should recognize that you must evacuate the building if you can no longer maintain safe temperatures for your patients and staff.

Magnetic Locks

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director?

A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (i.e. relays, control modules) be tested once per year. Since the magnetic locks in access-control and delayed egress locks are connected to the fire alarm system via an interface relay, then the magnetic lock needs to be tested once per year to ensure it disconnects during a fire alarm signal. This test is required to be conducted by someone who is certified in accordance with NFPA 72.

If you are CMS certified or accredited by any of the major accreditation organizations then you would be expected to comply with the manufacturer’s recommendations on preventive maintenance. Most manufacturers of magnetic locks requires periodic maintenance to ensure they are functioning correctly.

Temporary Emergency Power Generators

Q: We are going to have temporary generators onsite for two months that we will use during our construction project to replace the main power distribution gear for our bed tower, installing new substation and distribution gear. During the time we will have 10 shutdowns from 4 hours to 12 hours at a time. We will be on the regular emergency power generators and ATS’s normally and only on the temporary units for the shutdowns. This affects normal critical and life safety circuits. Do we have to do monthly generator, and ATS transfers on the temporary units or would the shut downs count for testing? And for annunciation, we are planning to have the generators manned anytime they are in operation with no other temporary remote annunciation. Is this permissible?

A: These are all good questions, and I can provide you with answers on how I would approach this, but ultimately you need to talk with your state, local, and accreditation AHJs in order to get their opinions. Their opinions count and mine does not.

But since you asked, the accreditation organizations already allow an actual emergency event when the generators operate to count as one of the monthly load tests, provided the emergency event meets all of the requirements for a monthly load test. Therefore, I do not see any difference if the temporary generators operate or the regular emergency generators operate during an emergency event. So, I would say you still need to conduct monthly load tests on the generators (normal and temporary units), but an emergency event can count as one of the monthly load tests if it meets all of the requirements for a monthly load test.

I would think an ILSM on the annunciation issue should be sufficient, rather than running a temporary annunciation panel.

Strange Observations – Sprinkler Pipe Supported From Ductwork

Continuing in a series of strange things that I have seen while consulting at hospitals…

This is another picture of sprinkler pipe supported from HVAC ductwork, similar to last week’s Strange Observations.

I include it here to emphasize that sprinkler pipe cannot be supported from anything except the building structure itself.

I suspect I see this problem in 75% of the hospital where I consult… but then, I’m looking for it.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.

Probe Cleaning Room

Q: We have two small processing rooms in a hospital where they clean and reprocess vaginal probes, using the chemical RESERT. Should these rooms be held to the same standard as an Endoscope cleaning room (negative pressure, 10 ACH and exhausted directly to the outdoors, per FGI Guidelines)?

A: I would think so… The Life Safety Code does not comment on this, so it ends up being an issue that the Infection Control people should be consulted. Also, since it is a design issue, please check with your state and local authorities to see if they have a comment.

Portable Space Heaters

Q: Could you please clear up a concern related to section 19.7.8 of the 2012 Life Safety Code, that addresses Portable Space-Heating Devices? Section 19.7.8 (1) states such devices are used only in non-sleeping staff and employee areas. Does this mean that the approved space heaters are allowed at nurse stations or offices that are located in the same smoke compartment as patient care rooms?

A: It really depends on the AHJ’s interpretation of the term “non-sleeping staff and employee areas”. I know Joint Commission interprets this to mean approved space heaters cannot be used in any smoke compartment that contains patient sleeping or treatment activities. Other AHJ’s may not be as definitive, and leave it up to the surveyor to decide.

Personally, I suggest you go with Joint Commission interpretation (see LS.02.01.70, EP 8) as that seems to me to be the more restrictive. You should be safe with most other AHJs if you follow that interpretation.

Handrails

Q: According to the 2012 Life Safety Code, section 7.2.2.3.5, the distance between a handrail and adjoining wall should be 2¼-inches. Does this apply to just spaces in which NFPA requires handrails such as stair and ramps, or does it apply to corridors where a handrail is not specifically required by NFPA? If so, then in areas where NFPA does not require a handrail, but one is installed such as in a corridor, can the distance between the handrail and the wall just have to comply with ADA and the building code, which is 1½-inches?

A: Section 7.2.2.4.4.5 of the 2012 LSC does require new installation of handrails on stairs and ramps to be at least 2¼ inches from the wall. Since section 7.2.2.4.5 is a sub-section of 7.2.2 “Stairs”, this 2¼ inch requirement is limited to just stairs and ramps. It does not apply to handrails on corridors.

I do not see any restrictions on clearance between a handrail and the wall in corridors, other than the CMS limitation of 4-inches maximum projection into the corridor.

Strange Observations – Sprinkler Pipe Suspended From Ductwork

Continuing in a series of strange things that I have seen while consulting at hospitals…

Some organizations fail to install sprinklers underneath the ductwork that is 48-inches wide or wider. This facility did not forget, but the sprinkler-fitter who installed this pipe for the sprinkler head attached it to the ductwork, which is not permitted.

The sprinkler pipe can only be suspended from the building itself (i.e. structural beams, joists, etc.), and not from anything else.

There is one exception to that rule… Sprinkler pipe may be suspended from a hanger that also supports ductwork, provided the hanger is designed to support the weight of the duct, the pipe, the water in the pipe, and an additional 250 lbs. (see NFPA 13-2010, 9.2.1.5). If you ever see sprinkler pipe suspended from the same hanger that supports ductwork, ask the installer to provide documentation that the hanger can support that weight.