Portable Fire Extinguishers

Q: In regards to fire extinguisher inspections… when the annual fire extinguisher maintenance is done, say in June, does the monthly fire extinguisher inspection still need to be completed?

A: Yes. According to NFPA 10-2010, there are distinctly different requirements for the annual maintenance and the monthly inspection. Typically, the annual maintenance does NOT include the actions required for monthly inspections, although there is no reason why the same person could not perform both duties during the annual maintenance process.

Annual Maintenance requires the following to be confirmed:

  • A thorough examination of the following:
    • Mechanical parts of all extinguishers
    • Physical appearance
    • Components of electrically monitored systems
    • Hoses on wheeled-type extinguishers completely uncoiled and examined for damage
  • Tamper seals on rechargeable extinguishers must be removed and replaced with new seals
  • For extinguishers that require a 12-year hydro-static test, once every 6-years the extinguisher must be emptied and subjected to an internal examination
  • A verification collar must be installed on the outside of the extinguisher, underneath the valve after an internal examination
  • CO2 hose assemblies must have a conductivity test

Monthly Inspection requires the following to be confirmed:

  • Location in designated place
  • No obstruction to access or visibility
  • Pressure gauge reading or indicator in the operable range or position
  • Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
  • Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
  • Indicator for non-rechargeable extinguishers using push-to-test pressure indicators

So, you can see an annual maintenance activity does not meet the requirement for a monthly inspection, but there should be no reason why the same person could not perform both duties.

Deactivating a Magnetic Lock

Q: When deactivating a magnetic lock but leaving it in place, what is the exact/excepted wording used noting that this magnetic lock is no longer in use?

A: What you are saying is not compliant with section 4.6.12.3 of the 2012 LSC which says existing life safety features obvious to the public, if not required by the LSC, shall be either maintained or removed.

If you want that maglock out of service, you must remove it since it is obvious to the public. 

 

Sprinklers in Lieu of Smoke Detectors

Q: We are seeking to reduce activation of smoke heads contained in our construction areas. In your opinion, if the construction area has existing sprinkler coverage or if new active sprinklers are installed in the construction area, would it be acceptable to remove the smoke heads in this space? In other words, are sprinklers a proper substitute for smoke heads?

A: No… sprinklers are never an acceptable substitute for smoke detectors, because sprinklers do not sense the presence of smoke. Conversely, smoke detectors are never an acceptable substitute for sprinklers because they do not extinguish a fire. However, if the smoke detectors are not required by code or regulation, then they can be removed without any alternative life safety measures applied.

According to 4.6.10.1 of the 2012 Life Safety Code, only deficiencies of required features of life safety necessitate alternative life safety measures (ALSM), also known as Interim Life Safety Measures (ILSM). However, be aware that not all surveyors will likely understand this and they may cite an organization for impaired smoke detectors even if the smoke detectors are not a required feature of life safety.

It is not uncommon for designers to over-install smoke detectors and place them in areas where they are not required. But if the smoke detectors are required, and you desire to remove them for construction purposes (not a bad idea) then you will have to assess them for ALSM and likely implement a fire watch, which can be very costly since it is now required to have a continuous fire watch. Replacing the smoke heads with heat detectors still does not change the result. If the smoke detectors are required then a heat detector is not an acceptable substitute.

Air Handler Unit

Q: Can we have a fan unit installed in a clean supply room? We have a room where an air handler unit is installed for cooling another equipment room. The unit is in the open and clean supplies are near it. Is this a violation of a code or standard?

A: Sounds like the room is now a mechanical room with clean supplies in it. As far as the Life Safety Code goes, and any referenced NFPA standards, I don’t see a problem. You must maintain 36-inches clearance around the equipment and have clear access to the unit. All electrical connections need to be enclosed (inside junction boxes, etc.).

If the clean supplies are combustible, then the room must be constructed to be a hazardous room. Check with your state and local AHJ to determine if they have any other requirements.

Hand Washing Sinks

Q: We have a relatively new Infection Control team.  They are performing rounds and having mock surveys with a nurse-consultant that cites issues from the 2014 FGI in areas that are much older.  The issue comes in when we are required to install new sinks (dirty, clean and a hand washing) in existing spaces.  We are a mixed hospital, some new that has to meet 2014 FGI due to new renovations.  What are your thoughts on the older areas that have not been renovated?  I am working with a design professional to see how he would design a space for the number of sinks and what reference he should use.  If it is simple and best practice to install them, I am all for it but some of the renovations come with a significant space or capital impact.  I am not sure if this is something you can help guide with or not.

A: According to Joint Commission’s standard EC.02.06.05, EP 1, the FGI Guidelines (2014 edition) is only used when planning for new, altered, or renovated spaces. Tell the nurse-consultant surveyor she is mistaken. She cannot apply a new guideline to an existing condition.

Now… if there was a requirement to have hand-washing sinks in the room at the time the room was designed or renovated, then she is correct and the sinks need to be installed. But if she plays that card, then she needs to provide evidence that there was a regulation (state, local, or otherwise) that required the sink at the time the room was designed and constructed.

Risk Assessments

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk level on the impact to patients/staff assuming the item being assessed would not be available or functional? We are performing a risk assessment on facility systems and medical equipment and are wondering what the standard is in the approach.

A: It sounds like you’re referring to the NFPA 99-2012 risk assessment for building system categories. If so, then the assessment is conducted with the assumption of the worst-case scenario, whereby the systems being evaluated fail and back-up systems (i.e. emergency power generators) fail as well. According to section A.4.1 of NFPA 99-2012, the category definitions apply to equipment operations and are not intended to consider intervention by caregivers or others. Also, the Introduction to Chapter 4 in the NFPA 99-2012 Handbook, the authors say:

“Each system must be evaluated for its impact on both the patients and the caregivers if the system should fail. Based on the worst-outcome scenario of a failure’s impact, the system is assigned a category. The chapter on that system the describes the requirements for the selected category.”

Be aware that the chairman of the Technical Committee who wrote this new chapter 4 for NFPA 99-2012 told me the intent was for the risk assessment to be on new equipment only, and existing equipment was exempted. However, chapter 4 of NFPA 99-2012 does not say that, and CMS is requiring all certified hospitals to have this risk assessment conducted on existing equipment as well as new. So, I recommend to my clients to do the assessment (it only takes a few minutes) on all existing and new equipment until such time CMS changes their minds.

Clearance in Front of Electrical Panels

Q: What is the clearance required in front of electrical distribution panels?

A: According to NFPA 70-2011, article 110.26, a minimum of 36 inches clearance is required in front of all electrical equipment, including controls and panels, extending from the floor to a height of 6 foot 6 inches or the height of the equipment whichever is higher. You must maintain clearance for the width of the equipment or 30 inches, whichever is greater, and all doors and panels must be able to be opened at least 90 degrees.

Business Occupancy Smoke Detectors

Q: What are the requirements for the use of smoke detectors in a business occupancy physician office that does not have an automatic sprinkler system? The fire marshal is telling me that this is not required, but I cannot find a specific clause in NFPA and want to confirm that statement.

A: The fire marshal is sort-of correct. Smoke detectors are not mandatory in a business occupancy, if the building already has manual pull stations. According to section 39.3.4.2 of the 2012 LSC, only one of the following means to initiate of the fire alarm system is required:

  • Manual pull stations
  • Smoke detectors
  • Sprinkler system water-flow

Of course, you can have more than one type to initiate the fire alarm system, but if you have manual pull stations, then smoke detectors are not required. But, if you don’t have manual pull stations or a sprinkler system, then smoke detectors would be required if the building requires a fire alarm system. Some smaller business occupancies do not require a fire alarm system. Check with your state and local authorities to see if they have other regulations concerning initiating devices.

Exit Enclosures

Q: I have been reading about stairwells and what the code addresses. I am interpreting that the AHJ’s are stringent of what can be placed in a stairwell. Is it permissible to install wireless access points (antenna) in the stairwell? We have no phone coverage in the stairwells because of the absence of these antennas. I believe without phone coverage creates a safety issue. If an emergency would arise in the stairwell we do not have access to contact anybody.

A: Well… section 7.1.3.2.1 (10)(b) of the 2012 LSC does say electrical conduits serving the exit enclosure are permitted to penetrate the exit enclosure, but the Annex section clarifies that the only electrical conduits permitted to penetrate the exit enclosure are those serving equipment permitted in the exit enclosure, such as security equipment, PA systems, and fire department emergency communication devices. Wireless access point antennas typically are not considered essential equipment in the stairwells and does not meet the intent of the list identified in the Annex section.

While you may get a local AHJ to approve such an installation, I think you will have trouble with national AHJs for accreditation. I suggest you install your antennas outside of the stairwell.

Lower Bottom Rods

Q: My department is assisting with a fire/smoke barrier door assessment. I have noticed that some of the ¾-hour corridor doors have had the lower bottom rods removed from the latching hardware with cups still visible in the floor. It is unclear why they were removed however the top latches still work and secure the door. There are small screw holes in the door as well where the hardware was removed. My thoughts are the door has been modified and no longer compliant. What are your thoughts?

 A: You are absolutely correct… By your description, the lower bottom rods were required when the door was installed, but have since been removed (They do get hit and bent by carts and are simply removed rather than replaced by poorly informed maintenance staff.) This door no longer meets the UL listing it received by the manufacturer when it was installed, and should be flagged as not passing an annual inspection.

Fire Alarm Testing Qualifications

Q: I have a question regarding testing and repair of fire alarm system in a hospital setting. Is a maintenance person who is employed by the hospital as an electrician but who has 10-years of on-the-job training qualified to swap out a bad smoke detector or smashed fire pull station? Is he allowed to test the notification and transmission equipment also? Just trying to make sure I am interpreting the NFPA standards correctly.

A: Only if that individual has met the requirements of NFPA 72-2010, section 10.4.3.1, which describes the certification(s) needed in order to provide service, testing or maintenance on the fire alarm system:

“Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of systems addressed within the scope of this Code. Qualified personnel shall include, but not be limited to, one or more of the following:

  • Personnel who are factory trained and certified for the specific type and brand of system being serviced;
  • Personnel who are certified by a nationally recognized certification organization acceptable to the authority having jurisdiction;
  • Personnel who are registered, licensed, or certified by a state or local authority to perform service on systems addressed within the scope of this Code;
  • Personnel who are employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of systems within the scope of this Code.”

Now, the Annex section A.10.4.3.1 of NFPA 72-2010 says it is not the intent to require personnel performing simple inspections or operational tests of initiating devices to require factory training or special certification, provided such personnel can demonstrate knowledge in these areas. While the Annex section is not part of the enforceable code, it is explanatory information from the Technical Committee on what they were thinking when the standards were written. Most AHJs follow the Annex section and enforce it as part of their own standards.

However, changing out smoke detectors and/or pull stations is not within the purview of what the Annex section is saying.  To directly answer your question: If your electrician does not have any of the certifications identified in section 10.4.3.1, then no, he is not permitted to replace detector and/or pull stations.

Warning Placards Above Class K Extinguishers

Q: We recently were cited for not having the placard placed on the wall above the K Fire Extinguisher, however, the “warning” on the front of the extinguisher is in red and it states: “WARNING” “IN CASE OF APPLIANCE FIRE, FIRST, ACTIVATE FIRE SUPPRESSION SYSTEM OR TURN OFF APPLIANCE TO REMOVE HEAT SOURCE”. The instructions on how to use the extinguisher is above that warning on the actual extinguisher. Does this meet the intent of the standard?

A: I don’t think so… While some surveyors and inspectors may accept this as meeting the intent of the standard, I’m not sure that it does. According to NFPA 10-2010, section 5.5.5.3, it says a placard shall be conspicuously placed near the Class K extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. A warning label on the extinguisher itself is not necessarily placed “near” the extinguisher. If the Technical Committee at NFPA wanted the sign on the extinguisher, they would have said that. Also, a warning label that is part of the fire extinguisher label is not necessarily considered to be “conspicuously” placed. People will not see the warning label on the extinguisher as easily as they will see a separate placard affixed to the wall above the extinguisher.

Also, the Meriam Webster definition of ‘Placard’ is: “A poster or sign for public display, either fixed to a wall or carried during a demonstration.” I don’t think a warning label on the extinguisher meets this definition. Also, section A.5.5.5.3 in the Annex says the placard should be 11 inches by 7 5/8 inches in size. That size sign is not typically possible on a Class K extinguisher. While the Annex section is not part of the enforceable section of the standard, it is considered to be explanatory material to assist the reader to understand the intentions of the Technical Committee who wrote the standards. I would conclude the Technical Committee wants a separate sign posted on the wall near the extinguisher.

I’m sure some surveyors may accept this warning label, but I would not. [Perhaps that is good that I’m not a surveyor anymore….?]

ABHR Dispensers in Business Occupancy Corridors

Q: Do you know of any other information on alcohol-based hand-rub (ABHR) dispensers not allowed in the egress corridors of business occupancies? I need more information than what you have already posted:

Please be aware that alcohol-based hand-rub (ABHR) dispensers are not permitted in the egress corridors of Business Occupancies. This is found in section 38/39.3.2.1 of the 2012 Life Safety Code which references section 8.7 of the same code. Section 8.7.3.2 states: “No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure…” Since corridors are used as paths of egress in business occupancies that means ABHR dispensers are not permitted in business occupancy corridors. Now, sections 18/19/20/21.3.2.6 of the 2012 Life Safety Code allows ABHR dispensers in corridors of healthcare occupancies and in ambulatory health care occupancies…. but not business occupancies.

A: Nope… that’s all there is. It is very clear that the Life Safety Code does not permit the storage or handling of flammable liquids in egress areas, based on section 8.7.3.2. However, the Life Safety Code makes specific exceptions for healthcare occupancies (i.e. hospitals, nursing homes, long term care centers, etc.) and ambulatory health care occupancies (ASC, physical therapy units) based on section 18/19. 3.2.6 and 20/21.3.2.6. The problem is, these exceptions do not apply to Business Occupancies and chapters 38/39 do not contain anything that would over-ride 8.7.3.2.

Sprinkler Inventory

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 6.2.9.7, 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.

Blanket Warmers

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.