Q: We are a life safety service company that provides consultation services for multiple hospitals. We had a hospital go through a survey recently, and the surveyor wrote them up for not having an inventory of sprinkler heads. Would you know where we could find this requirement for this inventory?
A: The surveyor may be looking at NFPA 13-2010, section 126.96.36.199, which does require the facility to have a spare sprinkler list, which is based on the different types of sprinklers in your facility and the quantity of those sprinklers. While this is not the same as saying an inventory of the sprinkler heads is required, you do need to know the types and quantities of sprinklers in your facility.
Or the surveyor may be looking at NFPA 25-2011 section 5.2.1, which requires an annual inspection of all the sprinkler heads. Usually, the hospital will contract this out to a sprinkler contractor and often the report simply says “All sprinkler heads inspected”, or something like that. The problem is, how does the hospital know that the contractor actually inspected every sprinkler head in the hospital? Did the contractor enter every room, every closet, every office, every OR, every equipment room, etc. in the facility? Without a detailed inventory or documentation (such as drawings of sprinklered areas) showing the heads were inspected in the respective areas, what assurance does the hospital (and the surveyor) have that every head was inspected?
But to be sure, there is no direct NFPA standard that says “Thou shalt inventory every sprinkler”, but it is well within the right of the authorities to request documentation that assures how the facility documented the spare sprinkler list and that the contractor inspected every head.
Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the same as having a space heater?
A: No… Portable space heaters are regulated by section 19.7.8 of the 2012 LSC. Blanket warmers are not regulated by the LSC.
However, blanket warmers are unofficially regulated by the accreditation organization and by CMS. While there are not specific standards that address blanket warmers, surveyors will expect the hospital to regulate their blanket warmers via their own policies. The hospital is expected to have a policy that sets the maximum temperature that the blankets may be. Usually, the maximum temp is set at 130 degrees F. Anything over that will likely be scrutinized by a surveyor.
Blanket warmers are considered medical equipment and must be included in the medical equipment inventory, and they must be maintained in accordance with the manufacturer’s recommendations.
Q: I can find a lot of information about portable fire extinguishers but nowhere can I find what size is required for use in a hospital. Can you point me in the right direction? We specified 2.5 lbs. and 5 lbs. and no one can tell me what is correct.
A: Section 188.8.131.52 of the 2012 Life Safety Code says portable fire extinguishers must be selected, installed, inspected, and maintained in accordance with NFPA 10. NFPA 10-2010, section 5.1 says the selection of fire extinguishers for a given situation shall be determined by the applicable requirements of Sections 5.2 through 5.6 and the following factors:
- Type of fire most likely to occur
- Size of fire most likely to occur
- Hazards in the area where the fire is most likely to occur
- Energized electrical equipment in the vicinity of the fire
- Ambient temperature conditions
- Other factors
So, you must first determine the classification of the potential fire (Class A, Class B, Class C, or Class K) and then place an appropriate fire extinguisher nearby. How far away from the potential fire is determined on the capacity of the fire extinguisher and the hazard of the potential fire.
For example, Table 184.108.40.206 identifies the fire extinguisher size and placement for Class A hazards. The hazards are listed as Light, Ordinary, and Extra and the selection of the capacity of the fire extinguisher is dependent on the level of hazard and the area served by the extinguisher. For a fire extinguisher that has a capacity of 2-A, the maximum floor area of light hazard (most areas of hospitals are light hazard, other than Laboratories, Pharmacies, Central Storage, Boiler rooms, etc.), it can serve up to 6,000 square feet (3,000 sq. ft. for each unit of ‘A’… 2-A = 6,000 sq. ft.), and the maximum travel distance to get to a Class A extinguisher is 75 feet.
But be careful… as the level of hazard goes up, the area served by the same size extinguisher goes down. Even though they may have the same travel distance to get to an extinguisher (75 feet), the total area served by the extinguisher is reduced. Similarly, Class B, Class C, and Class K have their design limitations as well. You will note that the travel distance for a Class B extinguisher is either 30 feet or 50 feet, depending on the level of hazard and the capacity of the extinguisher. Also, all Class K extinguisher have a maximum travel distance of 30 feet.
Q: Is there a requirement to test eyewash stations annually? We do a weekly test for various items but are we required to conduct an annual test as well?
A: Yes… ANSI Z358.1-2014 section 5.5.5 says all eyewashes shall be inspected annually to assure conformance with Section 5.4 requirements of this standard.
Section 5.4 says once a year, it is the owner’s responsibility to ensure that eyewashes shall:
- Be assembled and installed in accordance with the manufacturer’s instructions, including flushing fluid delivery requirements.
- Be in accessible locations that require no more than 10 seconds to reach. The eyewash shall be located on the same level as the hazard and the path of travel shall be free of obstructions that may inhibit its immediate use.
- Be located in an area identified with a highly visible sign positioned so the sign shall be visible within the area served by the eyewash. The area around the eyewash shall be well-lit.
- Be arranged such that the flushing fluid flow pattern as described in Section 5.1.8 is not less than 33 inches and no greater than 53 inches from the surface on which the user stands and 6 inches minimum from the wall or the nearest obstruction.
- Be connected to a supply of flushing fluid per the manufacturer’s installation instructions to produce the required spray pattern for a minimum period of 15 minutes. Where the possibility of freezing conditions exists, the eyewash shall be protected from freezing or freeze-protected equipment shall be installed. If shut off valves are installed in the supply line for maintenance purposes, provisions shall be made to prevent unauthorized shut off.
- Deliver tepid flushing fluid. In circumstances where chemical reaction is accelerated by flushing fluid temperature, a facilities safety/health advisor should be consulted for the optimum temperature for each application.
- When the plumbed eyewash is installed, its performance shall be verified in accordance with the following procedures:
- With the unit correctly connected to the flushing fluid source and the valve(s) closed, visually check the piping connections for leaks.
- Open the valve to the full open position. The valve shall remain open without requiring further use of the operator’s hands.
- With the valve in the fully open position, make sure that both eyes will be washed simultaneously at a velocity low enough to be non-injurious to the user.
- Using the flowmeter or other means, determine that the rate of flow is at least 0.4 gpm.
- Using a temperature gauge or other means, determine that the flushing fluid is tepid.
- When the self-contained eyewash is installed, its installation shall be verified in accordance with manufacturer’s instructions.
Q: We have a complete gut renovation project that consist of two buildings (Admin. Bldg. & Lab Bldg.). The buildings are connected in all three levels and will be unoccupied. Both buildings are connected on the first level only to the adjacent occupied building. A one-hour barrier will be built to separate the occupied building from the construction areas. Is a fire watch required once the sprinklers system and fire alarm system is demolished?
A: According to section 220.127.116.11, whenever a required fire alarm system is out of service for 4 or more hours in a 24-hour period, you are required to do the following:
- The AHJ must be notified. Don’t forget to notify your state AHJ, your insurance company AHJ, as well as your local AHJ. There is no need to notify your accreditation AHJ.
- The building must be evacuated, or an approved fire watch must be conducted. An approved fire watch consists of a designated, trained individual who has no other responsibilities, continuously patrols the entire area affected by the outage looking for signs of fire and potential situations where fire could start, and has the ability to communicate to call the local fire responders in case of fire. This individual cannot leave the impaired area until the fire watch is discontinued or is relieved by another designated, trained individual.
So, you are saying these buildings will be unoccupied, so it appears you do not have to conduct a fire watch for the impaired fire alarm system, provided you have a 2-hour fire-rated barrier separating the unoccupied building and the occupied building. But let’s look at NFPA 25-2011, section 15.5.2 which says this about sprinkler impairments: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
- The extent and expected duration of the impairment have been determined;
- The areas or buildings involved have been inspected and the increased risks determined;
- Recommendations have been submitted to management or the property owner or designated representative;
- Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for: A) Evacuation of the building or portion of the building affected by the system out of service; B) An approved fire watch, which must be the same as the approved fire watch described above; C) Establishment of a temporary water supply; D) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire;
- The fire department has been notified;
- The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified;
- The supervisors in the areas to be affected have been notified;
- A tag impairment system has been implemented;
- All necessary tools and materials have been assembled on the impairment site.
So, again since you have an unoccupied building, it appears to me that you do not have to conduct a fire watch for an impaired sprinkler system, provided you have a 2-hour fire-rated barrier separating the unoccupied building and the occupied building. Item #4 above clearly states a fire watch is not required if you have evacuated the building.
Q: This question concerns isolation room negative pressure parameters. Our ICU isolation rooms have two sensors for air pressure; one located inside the room and the other located outside the room, of course. Could you tell me what the maximum and minimum negative pressure standard is supposed to be? Is there even such a standard? The CDC website says that if a room is negative then it’s fine. That seems too ambiguous for me. I’d like to see something more specific if possible. I want to be sure that our negative pressure monitors are configured correctly.
A: The ASHRAE standard 170-2013, which is incorporated into the 2014 FGI Guidelines, calls for 0.01 inches of water column (wc) of air pressure, when the air pressure relationship to surrounding areas is required to be positive or negative. This number is referenced in many sections inside ASHRAE 170-2013, such as: 7.2.1(e), 7.2.1(f), 7.2.2(a), 7.4.1, 7.5.1(c), 7.5.2(a). This seems to be the standard value for positive/negative air pressure. But I suggest you check with your state and local authorities to determine if they have additional requirements.
Q: In regards to portable fire extinguishers, I have a fully sprinkled building but my room that my hot water heaters are in are on the outside of the building. My furthest hot water room is more than 75 feet from the closet fire extinguisher. I looked in the Life Safety Code and have not found any reference on this. Do I need to place a fire extinguisher in this room?
A: Yes, you do… Section 18.104.22.168 of the 2012 LSC requires compliance with NFPA 10. According to chapter 6 of NFPA 10-2010, the installation of portable fire extinguishers is based on the classification of the extinguisher, the capacity of the extinguisher, and the level of hazard the extinguisher is expected to address.
For Class A extinguishers, the maximum travel distance to an extinguisher is 75 feet. For Class B extinguishers, the maximum travel distance is either 30 feet or 50 feet, depending on the capacity of the extinguisher and the expected level of hazard. For Class C extinguishers, the fire is started by electrical current, but the material that burns is either a Class A material or a Class B material, so you space the extinguishers on the class A or Class B requirements. For a Class K extinguisher, the maximum travel distance is 30 feet.
You need to install an extinguisher to be within the maximum travel distance limits.
Q: We have multiple hospitals that we provide fire-safety testing services to. With the new requirement for testing elevator fire-fighters emergency operations, we all have a different opinion about what needs to be done. I believe we need to test Phase I and Phase II. Some people believe its only Phase I and some believe its only Phase II that need to be tested. I even have one hospital that believes it’s only the emergency phone that needs to be tested. What is your opinion on this?
A: Well…. The hospital that believes only the phones need to be tested are not among the enlightened. They need to get a new understanding.
Section 22.214.171.124 of the 2012 Life Safety Code says all elevators equipped with firefighters’ emergency operations in accordance with section 9.4.3 (which references ASME A17.1 Safety Code for Elevators) shall be subject to a monthly operation with a written record. ASME A17.1 is the industry standard for Phase I and Phase II operations. Phase I is typically the recall portion, and Phase II is the in-cab operation of the fire fighters’ service. So, I would say both Phase I and Phase II must be operated monthly. Now, if the elevators are only equipped with Phase I, then of course you can’t test Phase II operations.
Q: Is it a requirement to keep access to the medical gas alarm panel clear in a similar manner that access to medical gas shutoff valves must remain clear? These alarm panels seem to always be mounted in a crowded area.
A: I don’t think so. I do not see any language in NFPA 99-2012 that requires any clearance around area alarm panels or even master alarm panels. But check with your accreditation organization, and your state and local authorities to see if they have more restrictive requirements.
Q: Do business occupancy buildings with soiled utility rooms have to be one-hour fire-rated or just sprinkled if the building falls under a hospital license and will be inspected by State and CMS surveys?
A: It depends…. Is the soiled utility room used for general storage? In business occupancies, soiled utility rooms are not considered outright to be a hazardous area like they are in healthcare occupancies. However, many soiled utility rooms are also general storage rooms, and section 38/126.96.36.199 of the 2012 Life Safety Code specifically says general storage rooms are considered hazardous areas and must be maintained in accordance with section 8.7. Section 188.8.131.52 says the room needs to be either 1-hour fire rated or protected with sprinklers.
Whether or not the business occupancy falls under the hospital license is not a factor, regardless who inspects the building. The LSC is clear: If used for general storage, then the room is either sprinklered or 1-hour fire rated. If the room is not used for general storage, then there is no requirement. This is based on its occupancy; not its license.
Q: Do hospital grade receptacles need to be tested yearly in an ambulatory setting?
A: Section 184.108.40.206 of NFPA 99-2012 says hospital-grade receptacle testing shall be performed after initial installation, replacement, or servicing of the device. It also says additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
This means hospital-grade receptacles must be tested at intervals determined by the healthcare organization, based on ‘documented performance data’. This could be data provided by the manufacturer, or it could be data compiled by the healthcare organization itself. You could base the frequency on testing hospital grade receptacles in patient care rooms on the history of known failures of the receptacles. Whatever frequency you decide, make sure you document the process that you used to decide this frequency.
The important thing to realize is, hospital grade receptacles are NOT exempt from testing. To be sure, non-hospital grade receptacles must be tested annually, if they are located near patient bed areas, and near deep sedation or where general anesthesia is administered.
Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required single path of egress? (All options have 4 locked doors in the path.)
A: The 2012 Life Safety Code does not address any restrictions on how many doors in the path of egress may be equipped with Clinical Needs locks. Therefore, if the LSC does not prohibit it, then it is permitted.
However, not all AHJs permit it. For example; I am told that the IBC prohibits more than one Clinical Need lock in the path of egress (or, at least they used to). When I worked at the hospital, I tried to get the state to allow two locked doors in the path of egress from the Psychiatric unit but they would not allow it.
But in my travels, I have seen multiple doors in the path of egress equipped with Clinical Needs locks where permitted in various states around the country. The most common use of multiple Clinical Needs locks create a ‘Sally Port’ or ‘airlock’ that allows one locked door to open but the other locked door must be closed. This is an added security to prevent anyone from eloping.
So, the LSC does not prohibit it, but the IBC and some AHJs do.
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.
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.220.127.116.11 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.
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.