Q: For annual fire extinguisher inspection how long before and how long after do you have to re-tag?
A: NFPA 10-2010 section 220.127.116.11.1 says fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.
Depending on your accreditation organization, and your state agency surveying on behalf of CMS, an annual activity is required to be completed 12 months from the previous activity, during the 12th month. CMS is very adamant: If the requirement is annual, you cannot go more than 12 months between activities.
Q: What resources can hospitals use to manage workplace violence?
A: The law enforcement department in your community is a significant resource for healthcare in designing a united front in managing workplace violence. A strong and consistent relationship between the law enforcement leaders and the hospital leaders promotes safety for your institution and ensures a final process when violence occurs.
Here are some actions and tactics to consider in your program:
- Develop a direct communication plan between the hospital and law enforcement to troubleshoot emergencies. Have the leaders from law enforcement and the hospital meet regularly, including front-line staff. Record meeting notes and send them to the Environment of Care Committee for sharing and consistency.
- Consider including law enforcement in your security huddles.
- Develop a prior notification process with law enforcement that addresses incarcerated individuals or other persons in a “Not Free to Leave” status. This provides advance notice to the emergency department of a potential high-risk patient.
- If you have a hospital security department, consider making the security supervisor the point of contact for any officer coming to the hospital.
- A weapons policy that addresses managing a police officer’s weapon if they are injured and brought into the emergency department.
These are just a few of the actions that can be taken with your local law enforcement agency to improve the overall safety of your facility. Enlisting their assistance and creating a relationship is pivotal to a successful workplace violence program.
If you would like a copy of Carrie’s article, “Teaming Up with Law Enforcement in Healthcare,” please email email@example.com with “Carrie’s Article” in the subject line.
Q: We have a generator that doesn’t meet the 30% load for the monthly run so we have to do an annual run with the load at 50% for 30 min and 75% for 60 min for a 90-minute continuous run. Our contractor did the annual run but he ran it with 52% for 30 min, 75% for 30 min and 81% for 30 min, then he continued to run it for 2½ more hours dropping the percentages as he went for 4 continuous hours at not less than 30%. My question is does these meet the intent of the standards for both an annual and a 3-year load test?
A: According to section 18.104.22.168 of NFPA 110-2010, when the 3-year load test is combined with the annual load test, the first three hours shall be not less than 30-percent of the nameplate kW rating, and the remaining hour shall be not less than 75-percent of the nameplate kW rating.
I would say the test as you described could meet both the annual requirements and the 3-year test requirements, depending on how the test was administered. It is obvious that an external load bank would be required for the annual test since the building load did not meet the minimum 30%.
But section 22.214.171.124 of NFPA 110-2010 requires the 3-year test to begin with the building’s load through the ATS and only supplement the load with a load bank if the load cannot meet 30%. It is not at all that easy to combine an annual load test with a 3-year load test, because the 30% minimum load is not achieved through the building’s load.
The generator load testing requirements are minimum load settings, and it is permitted to exceed these minimums.
Q: How would I go about cleaning the dust off the sprinkler heads?
A: Use a portable vacuum cleaner. If the dirty heads are located in the kitchen, then you will need warm soapy water and a toothbrush. But you may want to leave that to a sprinkler contractor to do.
Q: We have chosen to install some extra battery egress lights in our hospital that are not required. One of these areas is our stairways. 100% of the lighting in our stairways is served by the hospital’s generators including the circuits that feed the egress lights. We installed the battery egress lights to help keep people calm and avoid falls during the ~5 second transition to generator power. Do we need to do 90-minute annual testing on battery lights served by generator power? We will continue the 30-second monthly testing, but the 90-minute testing is difficult as all lighting in the stairway must be turned off during testing. Also, these lights will never see a 90-minute outage. NFPA 101 2012 126.96.36.199 says an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Since these are not required, I am hoping that these lights do not need the annual test.
A: Well, I’m sorry to say, but section 188.8.131.52 of the 2012 LSC says if you have an existing feature of life safety that is not required by the LSC but is obvious to the public then you must maintain it or remove it. I think we’d all agree that battery powered emergency lights would be obvious to the public. According to the NFPA standards, maintaining it includes the monthly 30-second test and the annual 90-minute test. You say the 90-minute test will be difficult since the normal power to the battery powered emergency lights are on the same circuit as the stairwell lighting.
Well, I see your point. You cannot turn off the circuit to the stairwell lighting for 90 minutes… that would be the wrong thing to do. I suggest you install a toggle switch on the battery powered emergency light fixture, preferably on top where it cannot be inadvertently turn off. This toggle switch will turn off the normal power to the battery powered emergency lights and you can perform the 90-minute test without interrupting normal power to the stairwell lights. So, you must test those battery powered lights, even if they are not required. Personally, I like your thinking… providing battery powered lights for the 5 seconds or so of darkness in the stairwell, even though you don’t have to.
Q: I’m a Facilities Director overseeing an existing 8-story (basement included) acute care hospital fully sprinklered. We wish to mechanically lock (no auto unlock feature) floors 2-7 (Floor one being the level of exit discharge) to prevent reentry from the stairwell side. I believe there used to be an exemption from the requirements of Chapter 7 of the 2000 LSC 101 for existing hospitals that are fully sprinklered; does that exemption still exist in the 2012 version? Can I lock all 6 floors and be code compliant?
A: Section 184.108.40.206.3 of the 2012 LSC says doors not located in a required means of egress shall be permitted to be subject to locking.
Section 220.127.116.11.9 says existing healthcare occupancies shall be exempt from re-entry provisions of 18.104.22.168.8. But Annex section A.22.214.171.124.9 says doors to the stairwell on the different levels should be arranged to open from the inside of the stairwell at not less than every third floor so it will be possible to leave the stairway if fire renders the lower part unusable.
Section 126.96.36.199.8 says every stairwell that serves more than four stories must have re-entry capabilities on every floor, but the doors could be locked with electronic locks that unlock (not unlatch) on a fire alarm signal. Section 188.8.131.52.8 continues with other exceptions and requirements, but section 184.108.40.206.3 says hospital are exempt from all of that.
So, based on the Annex section, you can lock the doors from re-entry from the stairwell side, but every third floor needs to be unlocked. So, come up with a plan so every third floor door is unlocked for re-entry.
Q: If an Emergency Department is greater than 7500 square feet but less than 10,000 square feet and is deemed to have “sleeping accommodations”, do the requirements of direct visual observation per 220.127.116.11.2.1(D)(1)(a) apply since only “sleeping accommodations” are provided and not a full “patient sleeping room”?
A: According to CMS, the answer is yes. They consider an Emergency Department that provides observation beds to be sleeping accommodations and must comply with healthcare occupancy sleeping suite requirements, and all that is required. They also consider the patient as ‘inpatients’, which seems to be contrary to the what the rest of the world believes.
See if you can do one of the following:
- Eliminate the ‘observation beds’
- Relocate those ‘observation beds’ to a regular inpatient unit
- Divide your ED up into multiple suites to get around the direct observation requirement for sleeping suites over 7500 square feet.
Q: How do I decrease workplace violence incidents in the hospital where I work?
A: In my experience working within a healthcare setting, the best way to decrease workplace violence incidents is to have a workplace violence plan that is specific to your facility. This document must also be re-evaluated on a regular basis and be updated accordingly.
Developing a workplace violence plan can be daunting, but it’s critical to the health and safety of your employees. The key components to include in your plan are:
- You should perform a risk assessment of the facility you work in. Ask yourself, “What are the significant safety hazards that exist?”
- Utilize data collection tools to collect specific information on each incident to determine which solutions are necessary.
- Consider implementing safety and/or security teams that can manage the information and report to the administration on a regular frequency (monthly).
- Develop a user-friendly safety reporting process that all employees are required to fill out.
- Implement and stick to a zero-tolerance policy that supports all employees and empowers them to press charges on any acts of violence.
- Provide customer service training for all employees, as well as de-escalation training for those in high-impact areas. It’s also best to consider situational awareness training for employees too.
- Develop a controlled access plan for your facility and minimize the number of entrances for visitors and employees. This will allow you to better control who enters and exits your facility.
- Provide regular, hands-on, scenario-based training for your employees to teach them how to best manage workplace violence.
If you have additional questions about how to implement a workplace violence plan, please feel free to email Carrie at firstname.lastname@example.org.
Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?
A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage. I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency.
Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in either the corridor, or the room. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.
You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.
I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustibles stored in those patient rooms, you have a big problem. The room would have to comply with section 18.104.22.168 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.
Q: Someone just asked me a question and I haven’t thought about this one before. This AHJ is enforcing the IBC but I’m looking for an NFPA viewpoint and of course I thought of you. The IBC and the LSC both require corridor doors in a health care facility to latch. But what if those doors are horizontal sliding doors (manually-operated)? The IBC allows horizontal sliding doors if the space served by the door has an occupant load of 10 or less. The doors in question are not in suites. I don’t see anything that prevents the use of horizontal sliding doors, or anything that says these doors don’t need to latch, but why should they have to latch since they aren’t affected by pressure the same way a swinging door would be? It seems like latching hardware on horizontal sliding doors would be a pain for hospital staff. Have you ever run into this?
A: Yes… I see this issue a lot in hospitals. Many architects are mistaken when it comes to glass sliding doors. Perhaps they follow IBC and specify non-latching doors, but then they fail to comply with the 2012 Life Safety Code, which gets them (and the hospital) in hot water.
Section 22.214.171.124.10.2 discusses horizontal sliding doors that serve an occupant load of fewer than 10 people have to meet all of the requirements in the sub-headings 1 – 5. Sub-heading 5 says where corridor doors are required to latch, the doors are equipped with a latch or other mechanism that ensures the door will not rebound into a partially open position if forcefully closed.
So, the LSC is clear: Where corridor doors are required to latch, the horizontal sliding doors must also latch.
Yes… there are a lot of requirements in the LSC that are a pain to staff. But patient safety is a job that all have to work for, regardless how inconvenient it may be.
Q: If we put the fire alarm system in test by-pass but we are still monitoring the alarms so we can troubleshoot or test the system so we avoid nuisance FA activation do we need an ILSM (Fire watch)?
A: Well… How long do you have it in test mode? More than 4 hours? If so, then I can see where an ILSM assessment is required, but the assessment would identify that the fire alarm system is impaired since it is in test mode, but you have a Fire Watch in effect because you would have someone at the panel constantly until the panel is off test mode.
So… an ILSM assessment would be required after you reach the 4-hour mark, but the assessment should identify that you are doing a Fire Watch my posting a responsible individual at the panel.
Sounds like a paper documentation issue, as you are already doing the Fire Watch.
Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space that does not involve the use of a fire watch. We are looking at multiple sensor detectors, but the initial comment we received from our vendor is that they are sometimes triggered by dust. In your opinion, would changing the smoke detectors to heat detectors be an acceptable solution in a construction space? If the space has an active sprinkler system, in your opinion, would it be acceptable to simply remove these smoke heads? Any thoughts you can provide would be greatly appreciated.
A: Changing the smokes to heats is not an acceptable solution to prevent a fire watch, because heats do not sense the presence of smoke. But perhaps you are making this more difficult than it has to be. The code only requires a fire watch for required fire alarm devices that are impaired. Are the smoke detectors in the construction area required? If so, then you need to do the fire watch if you remove the detectors, or suffer through many false alarms.
But if they are not required devices, then you can remove the smoke detectors and not have to do a fire watch. Section 126.96.36.199 of the 2012 LSC specifically says a fire watch is for required fire alarm systems out of service.
One may be surprised to learn that in the typical hospital, there are very few locations that a smoke detector is required to be installed:
- In areas open to the corridor as described in section 188.8.131.52 of the 2012 LSC
- In areas containing fire alarm control panels (including NAC panels) that are not continuously occupied as described in 184.108.40.206.1 of the 2012 LSC
- Near doors that are held open that must close on a fire alarm activation as described in NFPA 72-2010, section 220.127.116.11.5.1
- Elevator recall for fire-fighter’s service as described in NFPA 72-2010, section 21.3
There are other situations where smoke detectors may be required, but those requirements are stipulated on optional design factors, such as on-call sleeping rooms, specialized protective measure locks, and equivalencies.
Therefore, if you have smoke detectors in an area that is under construction, and these smoke detectors are not required, then you may remove the detectors without having to perform a fire watch.
Q: Is there a code requirement for implementing an Interim Life Safety Measure (ILSM) for occupancies other than healthcare (i.e. business occupancies) if a life safety code deficiency has been identified?
A: Yes… ILSM (also known as Alternative Life Safety Measures) is found in chapter 4 of the 2012 Life Safety Code, specifically section 18.104.22.168 of the 2012 LSC. This describes the need to implement ALSMs when features of Life Safety are impaired. This chapter is part of the ‘core’ chapters and applies to all occupancy chapters, so that means it applies to business occupancies as well.
Most accreditation organizations should be enforcing this in offsite locations, such as business occupancies. Some surveyors fail to ask for this, but it is an enforceable requirement.
Q: I have a question regarding emergency generators and Level 1 classification. I’m at a sister hospital and they went through a State Surveyor and he asked for proof that the emergency generator was a Level 1 generator. The documentation indicates that it meets NFPA 110 but nowhere does it indicate that it is Level 1. Now the hospital was approved by the State in 2009 and been open since then. This has never come up in past 9 years. I’ve contacted the maker of the Generator for supplemental documentation. Is there another way to prove that the generator meets level 1 classification? We have patients on ventilators. Please provide me with some wisdom to address this issue with the surveyor
A: That surveyor is yanking your chain…. First of all, speaking in general terms, the use of the generator classifies whether it is a Level 1 or Level 2.
According to NFPA 110-2010, section 4.4.1 says Level 1 systems shall be installed where failure of the equipment to perform could result in loss of human life or serious injuries. Generators used in hospitals would be required to be Level 1. Section 4.4.2 says Level 2 systems shall be installed where failure of the EPSS to perform is less critical to human life and safety. There are different operational requirements based on whether the generator is classified as a Level 1 or Level 2.
A generator is a generator, and the manufacturer of that generator does not classify the use of that generator. It can say it qualifies for use as a Level 1 generator, but the actual use of the generator determines if it is a Level 1 or a Level 2.
Sounds like the surveyor is providing you a teachable moment by asking that question. He knew the answer before he asked.
Q: In the 2012 LSC concerning alcohol based hand rub (ABHR) dispensers in a hospital setting, is there a limit to the number of dispensers that can be in a patient sleeping room? We are wanting to have additional dispensers available in the room, such as 1 on the wall, one attached to the bed and one tabletop dispenser at the nurse workstation in the room. In the 2012 codes, would this number be allowed?
A: There is not a limit to the number of ABHR dispensers permitted in a patient room, but there is a limit to the quantity of ABHR product in dispensers per smoke compartment. You are limited to 10 gallons of ABHR product in dispensers per smoke compartment. If, for instance, each dispenser is 1 liter of product, then that means you can only have 37 dispensers per smoke compartment.
Now, the 2012 LSC does allow you to have one dispenser per room not contribute to the aggregate total of ABHR product in dispensers per smoke compartment, so if you have 12 patient rooms in the smoke compartment and one dispenser in each room, then that means you could increase the total ABHR dispensers from 37 to 49. And you must include in the aggregate total all pocket-sized dispensers and all table-top dispensers. This rule is not limited to just wall-mounted dispensers.