Cabinets in a Corridor – Part 1

Q: It appears that the LSC allows up to 50 square feet of unprotected storage but also includes language that suggests it may need to be protected in accordance with 8.7 depending on the level of hazard. It is my experience that storage in a nurse station (even if combustible) is acceptable because it is located in a normally monitored and occupied area. But what about PPE or patient information storage in closed cabinets away from a nurse station? Would this decision be left to the AHJ?

A: In a scenario as you described, I believe it is all about the cabinet and doors. Is the cabinet mounted in such a way that it projects into the corridor by more than 4 inches? If so, that would be a problem. If the doors to the cabinet were to be left open, would the doors project into the corridor more than 4 inches? If so, that too would be a problem. As long as the square footage of the stored items is less than 50 square feet, I don’t see a problem. The cabinet door would not have to meet the requirements for corridor door (i.e. resist the passage of smoke, positive latching hardware, 1¾-inch thickness, solid bonded wood core) as long as the LS drawings delineated that the corridor wall ran behind the cabinet.

Illuminated Pumpkin – CORRECTION

On October 23, 2018, I posted a picture of this illuminated pumpkin and wrote that the extension cord could not be used since Article 400.8 (3) of NFPA 70-2011 says flexible cords could not be used as a substitute for fixed wiring. But just recently, a reader asked why this illuminated pumpkin would not qualify for Article 590.3(B) that permits extension cords on holiday decorations for up to 90-days.

After reviewing NFPA 70-2011, I discovered I was incorrect in my original posting and thanked the reader for bringing this to my attention. I then made changes to the original posting to ensure the correct code interpretation was stated.

To be sure, NFPA 70-2011, Article 590.3(B), says extension cords are permitted to be used for holiday decorations up to 90-days. But Article 590.2(A) does say all other requirements of the code would have to be met. implying the extension cord would have to be listed by a national listing agency (i.e. UL). Also, Article 590.2(B) says temporary wiring is acceptable if it is approved based on the conditions of use. So, you would not be able to abuse the concept of an extension cord used on holiday decorations.

This also means that individual organizations could have policies specific to their staff that limit or prohibit the use of extension cords on holiday decorations beyond what NFPA 70-2011 provides.

I apologize for this error, and appreciate the reader for bringing this to my attention.

Extension Cords

Q: Under CMS, is it possible to use a UL listed power cord (extension cord), permanently attached to the equipment assembly providing it meets the ampacity requirements? If yes, what UL listing? UL 1363 A and UL 60601-1 are only power strips and I’m looking for a single outlet configuration that meets the UL requirements.

A: No…. According to NFPA 70-2011, Article 400.8, flexible cords cannot be used as a substitute for fixed wiring.

Strange Observations – Wall Sconce Projection

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

Do you ever think about your corridor wall sconce light fixtures projecting more than 4-inches into the corridor…?

I do.

[Hey… AH: I made that change that you suggested.]

Fire Hose Valves

Q: We recently had our fire sprinkler inspection and was informed by the vendor that with the new 2012 LSC updates, every fire hose connection valve weather it is 1½ inch or 2½ inch needs to be tested and operated annually to verify they are in working order. We have had our fire hoses removed quite some time ago per recommendation from our local fire department. Are these fire hose valves (which are not used) still required to be tested?

A: Yes… but not as you say. First of all, removing the occupant use fire hoses does not mean the fire hose valves will not be used. The fire department will bring their own hoses in to hook up to your standpipe system. Secondly, the fire hose valves must be inspected quarterly, and the fire hose valves that are 2½ inches are required to be tested annually, and the fire hose valves that are 1½ inches are required to be tested once every 3-years.

Take a look at NFPA 25-2011, section 13.5.6.1 for quarterly inspections and section 13.5.6.2 for annual/3-year testing requirements. Just because you removed your occupant use fire-hoses does not relieve you of the responsibility of testing, inspecting and maintaining your fire hose valves. You have them – then you must maintain them.

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Door Frames

Q: I had an independent Life Safety inspection and during the inspection the inspector cited me for my 2-hour fire door frames not having a fire rating visible. I explained that we went to a fire rated continuous hinge on these doors that covered the labels. He said that that was not enough, he needed to see a label. Should I remove each hinge and take a picture of the fire rating labels?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

A: This topic has come up before, and I asked some AHJs about it since the answer is not found in the codes and standards.  The consensus was that the label should be documented with photos before the hinges are installed – close-up photos to show what is written on the label, and wider photos to show the location of the door.

I’m sure it’s a pain to get this documentation now, but I think that’s the only way to do it for a retrofit situation unless you want to have the doors relabeled.  For new doors and frames, the labels can be applied in another location – on the frame head, and for the doors – either on top or on the lock edge.

Patient Therapy Artwork: Decorations vs. Communication

Q: You once said this regarding bulletin board decorations:

If the bulletin board is decorated then yes; it is counted as decorations. But if the bulletin board is simply communication documents, then they are not decorations (even if they are combustible) and they are not counted in the wall surface calculations for decorations.

I would like to add a twist to this topic. We are a psychiatric hospital and the patients use a therapy activity for painting or drawing. They like to post their art work on the wall of the day-room with scotch tape. I interpret their art as a function of the hospital and as form of therapy and communication. I do not consider it decorations. Does this change your answer?

A: No. If I was surveying and saw what you described, I would still be inclined to consider the patient therapy artwork as decorations. Now, if you have documentation from medical and clinical experts in the form of a policy that confirms the patient therapy artwork is not decoration, but a clinical form of communication, I wound yield to those subject matter experts on this issue, and allow it to be communication.

But with the changes in the 2012 LSC on what they consider decorations, as long as you don’t exceed the 20% or 30% surface area of the walls and ceilings, I don’t think it will be a problem.

Strange Observations – Part 50

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

We already talked about this issue on ‘Strange Observations – Part 20’ posted April 5, 2018, but it’s worth revisiting.

You cannot have home-made components installed on the fire alarm system. The threaded rod is not UL listed for this purpose.

 

NOTE: I’ve received some skepticism on the validity of saying the door release equipment is part of the fire alarm system. I base my position on section 21.8 of NFPA 72-2010, which says the door release equipment is a function of the fire alarm system, and according to section 10.3, all equipment used in conformity with NFPA 72-2010 must be listed for the purpose for which it is used. If the manufacturer of the door release device obtained a UL listing for the threaded rod, then I stand corrected. But as far as I know, that has not happened.

 

 

Clean Waste Containers

Q: I have a question regarding recycling containers referenced in section 19.7.5.7.2 of the 2012 LSC. It outlines the requirements for clean recycling and patient records awaiting destruction.  Do the requirements for FM Approval (or equivalent) apply to containers less than 32 gallons or just for containers 32 to 96 gallons? The way the code reads I originally thought it was for any recycling container regardless of capacity but the way the code reads it has me thinking.

A: Section 19.7.5.7.2 of the 2012 LSC states containers used solely for clean recyclables do not have to be stored in a hazardous room, provided it meets all of the following:

  • Containers do not 96 gallon capacity, maximum
  • Containers that do exceed 96 gallon capacity must be stored in a hazardous room
  • If stored in a hazardous room, the capacity of the container is not limited
  • Containers must meet FM Approval 6921 requirements, or equal.

So, I would say the requirement for FM Approval 6921 applies to containers with capacities between 32 and 96 gallons. Because if the container is less than 32 gallons capacity, it is permitted to be stored outside of a hazardous room (think of your wastebasket in your office) and not meet the requirements of FM Approval 6921. But a container over 32 gallons capacity is not allowed to be stored outside of a hazardous room unless it meets the requirements of 19.7.5.7.2. And, all containers over 96 gallons capacity must be stored in a hazardous room regardless if they are FM Approval 6921 compliant.

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Fire Pins

Q: I have a concern regarding the use of fire pins in fire rated door leaves: Since the latching feature of these devices is not testable (that I’m aware of, anyway), and as these doors are prone to abuse and sometimes require adjustment for clearance issues and so forth, how do we ensure the alignment of the fire pin assembly when adjustments are made or even during normal expansion/contraction due to temperature/humidity changes?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

 A: You’re right – there’s no way to test the pin.  But the pin and the hole that it will project into (typically filled with a plastic cap) should be visible on the door edge so you can ensure that they’re aligned.  On most pins there is a fair amount of tolerance so the alignment doesn’t have to be perfect.  Since the pins operate only when there’s a fire, and only when the temperature reaches >1000 degrees in the vicinity of the door (approx. 450 degrees at the pin), only a very small percentage of the pins will ever be activated.  The pin doesn’t have much of an impact on life safety – by the time the pin projects, it’s mostly about compartmentalizing the building and protecting property.

New Forms on the ‘Tools’ Webpage

This is a special posting to let you know there are 6 new forms on the ‘Tools’ webpage for you to download for free:

  1. Advantages if the Building is Sprinklered – This form identifies all of the advantages that you can take  if your building is fully sprinklered.
  2. Building Tour by the Numbers – This form identifies many of the quantitative requirements for complying with the Life Safety Code.
  3. EC Document Review Form – This form identifies the documents you need to be compliant with The Joint Commission’s EC chapter.
  4. Fire Extinguisher Annual Maintenance Report – During the document review session, surveyors are often looking for documentation that identifies when the last 6-year inspection, or 12-year hydro test was conducted, and when the next one is due. This form helps you document that for each extinguisher.
  5. Cooking Hood Monthly Inspection – Did you know you are required to perform monthly inspections of the cooking hood fire suppression system? This form helps you document that.
  6. Sprinkler System Pressure Gauge Monthly inspection – All pressure gauges on the sprinkler system need to be inspected, and this form will track that for you.

Take a look at this re-defined webpage as there are over 35 forms and templates waiting for you to download… all at no cost.

Fire Watch Guidance

Q: We are looking for guidance now that the language of “If a fire watch is required, fire/smoke detection or alarm system outage” has become a point of conversation with our local and state Fire Marshals. We can’t seem to get a straightforward answer from them as to when exactly we need to implement a fire watch. For large projects, we will definitely be bringing in a contractor to install upright heads. Our question is related to the small, 1-2 day projects that may only have 1-2 heads without a ceiling barrier, making them non-compliant. Would this scenario, in your eyes, require a fire watch assuming no upright head installation? We struggle with the feasibility of both situations: implementing a continuous fire watch and also bringing in a contractor for just a couple of heads for one or two days.

A: Let’s take our guidance from section 9.6.1.6 of the 2012 Life Safety Code, which says where a required fire alarm system is out of service for more than 4 hours in a 24 hour period, then an approved fire watch must be conducted. Now, if we go to the Annex section A.9.6.1.6 it says the term ‘out of service’ is intended to imply a significant portion of the fire alarm system is not in operation, such as an entire initiating device circuit, signaling line circuit, or notification appliance circuit. It is not the intent to require a fire watch for a single non-operating device or appliance.

Now, I know that is for fire alarm systems and your question was specific towards sprinkler impairments, but the problem is beginning with the 2012 LSC, the LSC discontinued to have a standard on sprinkler system impairments, but in turn referenced NFPA 25-2011. So, we go to section 15.5.2 (4) through (6) for guidance. This section basically says whenever the sprinkler system is out of service for more than 10 hours in a 24 hour period, then you do a fire watch, contact the fire department, and notify the insurance carrier and the state AHJ. But in this case, the Annex section does not offer any explanatory information as what constitutes ‘out of service’ like the Annex section in the LSC does for fir alarm systems.

So, this means the AHJ gets to decide what ‘out of service’ means. I know that CMS and the accreditation organizations interpret it to mean a circuit or zone has to be out of service before a fire watch is required, and a single device impaired does not warrant a fire watch. But in your case, you’ve asked your state AHJ to explain their position and so far they have not.

I suggest you decide for yourself, since your AHJ refuses to make a decision. Write a policy that states a single device out of service does not warrant a fire watch, but rather a zone or circuit that is impaired does, and reference Annex section A.9.6.1.6 of the 2012 LSC as a guidance.

If the AHJ won’t help you by informing you what they expect, then you do the next best thing and decide for yourself based on referenced standards.

Strange Observations – Part 49

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

Sorry for another out-of-focus picture. I was still having difficulty adjusting to my new smart phone (I should have had my grand-daughter teach me how to use it).

Maximum corridor projections are limited to 4-inches, says CMS. This stairwell evacuation chair is mounted on the wall in the corridor… It had to be relocated.