Fire Drills

Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names. Do we only need to complete 1 fire drill per shift per quarter in EACH building or can we combine the 3 towers into one healthcare? They are breaking out each tower and conducting the required amount in each building, which seems overkill.

A: The intent of the Life Safety Code is to conduct fire drills once per shift per quarter in all healthcare occupancies per building. If you have more than one building on campus that contains healthcare occupancies, then you would have to conduct separate fire drills for each shift and each quarter in each building.

However, if the buildings that contain healthcare occupancies are contiguous (connected together) and there is no fire rated barrier serving as a separation barrier between the buildings, then you could do one fire drill per shift per quarter that would cover all the buildings.

A separation barrier would be a fire-rated barrier that is vertically aligned (meaning the barrier does not extend horizontally) from the lowest floor to the roof. The fire rating of the barrier could differ depending on the applicable codes and standards, but the NFPA 101 Life Safety Code would require at a minimum a 2-hour fire rating.

Nurse Call System

Q: My facility is upgrading from a hard-wired to a wireless nurse call system. Our safety and supply manager is concerned that call systems have to have a form of 2-way communication such that the nursing desk is able to speak to residents while in their room. Is this accurate?

A: The 2014 FGI Guidelines, section 2.1-8.3.7.2 does say each patient sleeping bed shall be provided with a patient call station equipped for two-way communication.

So, it appears your Safety/Supply person is correct.

Strange Observations – No ‘NO EXIT’ Sign

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

The door in the picture is to a courtyard where patients may go and enjoy the out-of-doors. The problem is, there is no ‘NO EXIT’ sign on the door, and in my opinion the door could be confused for an exit door.

The size and make-up of the ‘NO EXIT’ sign is very specific: The word “NO” must be 2-inches tall, and the word “EXIT” must be 1-inch tall. The word “NO” must be over the top of the word “EXIT”.

The reason the word “EXIT” is smaller than the word “NO” is the technical committee who wrote that portion of the Life Safety Code wanted people to read the word “NO” before they read the word “EXIT” while approaching the door.

Design Requirements for Clean Area

Q: What are the ventilation, air exchange and air pressure standards for an area in a very old basement that is being used to sanitize equipment in a hospital facility? There is a very small area that is used for cleaning and sanitizing with disinfectants that is right next to the clean storage of these equipment pieces after they are cleaned. Is there also a certain type of flooring that should be used to prevent spores from harboring in cracks in the tile? There is no separation from clean to dirty, passing through the clean area with soiled equipment to get to the sanitizing area. How can this be corrected? I want this area to be compliant and my staff safe.

A: For design requirements, you would be expected to comply with your state and local authorities, as well as the 2010 FGI Guidelines, as applicable. I cannot tell you what your state and local requirements are (they often follow the FGI Guidelines), but here is what the 2010 FGI Guidelines require for ventilation for new construction:

Clean workroom or clean holding: 

  • Positive air pressure;
  • 2 minimum outdoor air changes per hour (ach);
  • 4 minimum total ach;
  • No requirement to exhaust air to the outdoors;
  • No restrictions regarding air recirculated by means of room unit;
  • No restrictions on design humidity thresholds;
  • No restrictions on design temperature thresholds.

Soiled workroom or holding area:

  • Negative air pressure;
  • 2 minimum outdoor ach;
  • 10 minimum total ach;
  • All room air must be exhausted to the outdoors;
  • No recirculating the air by means of room units;
  • There are no design RH thresholds;
  • There are no design temperature thresholds.

Sterilizer equipment room:

  • Negative air pressure;
  • 10 minimum ach total, without any outdoor air requirements;
  • All room air must be exhausted to the outdoors;
  • No recirculating the air by means of room units;
  • There are no design RH thresholds;
  • There are no design temperature thresholds.

The flooring would have to be cleanable with seams that cannot trap dirt, such as welded seams on VCT. There are other products available that would work as well. You have a real problem having soiled equipment pass-through the clean area. These different areas have to be separated physically, otherwise you will not be able to meet the ventilation requirements above. Sounds like you need the assistance of a design professional. I suggest you start with an architect who has experience with healthcare facilities.

Medical Gas System PM

Q: In regards to medical gas system testing, our local AHJ uses NFPA 99-2015 edition. My corporate office has stated that there are no PM’s that have to be done. I feel this is not only incorrect but just not a safe practice. Our medical air compressor and vacuum system are placed in the high-risk category due to the impact to patients and their lives. Where does the NFPA 99 reference and give the codes for the testing and inspection frequencies of the equipment?

A: Section 5.1.14.2.1 of NFPA 99-2015 says health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Section 5.1.14.2.2.2 says scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

Annex section A.5.1.14.2.2.2 says in addition to the minimum inspection and testing in 5.1.14, facilities should consider annually inspecting equipment and procedures and correcting any deficiencies.

(Words in bold text my doing…)

So, section 5.1.14.2.1 says you must have a periodic maintenance program. Section A.5.1.14.2.2 says you should consider an annual program. The AHJ is correct in requiring you to perform an annual inspection of the medical gas system, since section 5.1.14.2.2. gives him that authority. Even if the AHJ did not require annual PMs, you would have had to conduct a risk assessment to determine the frequency of the PMs. Any deviations from an annual frequency would have to be explained in the risk assessment.

You should consider yourself lucky… CMS Appendix Q says failure to maintain any feature of life safety should result in an Immediate Jeopardy decision. If your surveyor did not consider this an Immediate Jeopardy situation, then you dodged a bullet.

ABHR Dispensers

Q: In a business occupancy building, can alcohol based hand-rub dispensers be placed over carpeted area with no sprinklers?

A: Maybe yes and maybe no… It all depends on which AHJ is looking at your business occupancy.

Section 19.3.2.6 (8) of the 2012 LSC requires ABHR dispensers that are mounted over carpets, to only be in sprinklered smoke compartments. But this only applies to healthcare occupancies, and section 21.3.2.6 has similar language for ambulatory healthcare occupancies. The problem is, there is nothing written in chapters 38 or 39 regarding the installation of ABHR dispensers in business occupancies.

Since nothing is written in the business occupancy chapters, one may think there are no limitations, and the ABHR dispensers may be placed wherever you want without regard to regulations. Some AHJs may agree, and allow the ABHR dispensers be installed over carpet in an unsprinklered area. But the AHJs with healthcare experience and knowledge probably will not, based on their understanding of chapters 19 and 21. And, this is not an incorrect process, since they know these regulations regarding ABHR dispensers and can apply them to a business occupancy based on safety-related issues. Section 4.6.1.2 supports this concept.

But please understand, section 8.7.3.2 of the 2012 LSC prohibits the handling and storage of flammable liquids where it would jeopardize egress. This means ABHR dispensers are not permitted in egress corridor. Chapter 18/19 and 20/21 specifically permit ABHR dispensers in corridor so that over-rides section 8.7.3.2. But the business occupancy chapters 38 and 39 do not have this language to over-ride 8.7.3.2, so that means ABHR dispensers are not permitted in egress corridor of business occupancies.

My advice is follow the same regulations for ABHR dispensers found in 19.3.2.6 for business occupancies, with the exception that ABHR dispensers are not permitted in egress corridors of business occupancies.

Happy Birthday…. to me

Well, no, it’s not my birthday, but 10-years ago today I published my first post on this website. In 10 short years, I have made over 1,150 postings, and answered gobs of questions in the process, some of them correctly.

So, in a way, it is the 10th birthday of the Keyes Life Safety website. I’ve enjoyed every minute and I hope we can go another 10-years.

Thanks for being a reader…

Sincerely,

Sprinkler Inventory List

Q: NFPA 13, 2010 edition, sections 6.2.9.7 & 6.2.9.7.1: Do I read this to mean every sprinkler in every room and hallway in a hospital should be on an itemized list?

A: Well… yes and no. If you are asking if every sprinkler in the facility needs to be on an inventory list that identifies the precise location of each sprinkler installed, then no, that is not the intent of NFPA 13-2010, section 6.2.9.7 (although, that’s a good inventory list to have).

But section 6.2.9.7 does require a list of sprinklers used (but not where they are installed) in the facility, that includes:

  • The sprinkler model number or identification number from the manufacturer;
  • A general description, such as upright or pendant; temperature rating; concealed; extended coverage; Quick-response; etc.
  • The quantity of each type to be sprinkler to be maintained as spares in the Spare Sprinkler Cabinet;
  • Issue or revision date of the list.

This information can be obtained from the “Contractor’s Material and Test Certificate” that was required to be submitted to the owner after the installation of the sprinkler system.

NFPA 13-2010, section 6.2.9 requires spare sprinklers to be maintained so there can be a quick replacement of any sprinkler that has operated or became damaged. You are required to maintain at least two spare sprinklers for each type of sprinkler installed in your facility, but never less than a combined total of six spare heads.

  • For a facility that has fewer than 300 total sprinklers, you are required to maintain a combined total of six spare sprinklers.
  • For a facility that has 300 to 1,000 total sprinklers, you are required to maintain a combined total of 12 spare sprinklers.
  • For a facility that has more than 1,000 sprinklers, you are required to maintain a combined total of 24 spare sprinklers.

So, for some hospitals that have more than 1,000 sprinklers, but only 4 different types of sprinklers are installed in the hospital, that would require them to maintain 6 spare sprinklers of each type. But understand, if the hospital has only two specialty sprinklers installed in the hospital (such as high temperature heads in the boiler room), then there is no requirement to stock 6 spare heads of that type. You may stock just the two heads. A wrench for installing each type of sprinkler is required, which mean if four different wrenches are required to install the four different styles of sprinklers, then that is what you need to maintain. Where dry sprinklers of different lengths are installed in the facility, then spare dry sprinklers are not required.

Strange Observations – Sprinkler in the Alcove

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

The good news is you have an alcove in the corridor where you can store linen carts. The bad news is a sprinkler head was installed in the alcove preventing you from storing linen carts.

In this photo, the top of the linen cart is too close to the sprinkler deflector. You must maintain at least 18-inches clearance underneath the sprinkler head.

I’m not an expert on sprinkler design, but I suspect they would not need a sprinkler head in the alcove, if another sprinkler head was in close proximity.

Stairwell Signage

Q: With the new 2012 Life Safety Code adoption, my question is around the stairwell signage and 7.2.2.5.4.1. Hospitals are confused whether they have to replace all their signs to meet this new code requirement, or if they are grandfathered-in, and not have to comply. From what I interpret from the code, this would be for new stairwells only… is this correct?

A: No… This applies to all new enclosed stairs serving three stories or more, and all existing enclosed stairs serving five stories or more. There is no ‘Grandfathering’ in the Life Safety Code. There are requirements for new construction (Chapter 18) and there are requirements for existing conditions (Chapter 19), but other than that, there is no ‘Grandfathering’.

When new editions of the Life Safety Code are adopted, facilities must comply with new requirements that apply to existing conditions. Just because the building was compliant with the Life Safety Code at the time of original construction, does not permit the building a ‘pass’ on meeting new requirements that apply to existing conditions.

 

Receptacle Adapters

Q: There seems to be some confusion on the use of multiplug outlet adaptors such as changing the receptacle from 2 outlet to 6 in our hospital. I have been told that they have to have a reset, while some have said they only need a surge protector. I cannot seem to find anything in the Life Safety Code. Do you have a comment on this?

A: Yes I do… NFPA 99-2012, section 10.2.4 discusses this to some detail:

  • Three-prong to two-prong adapters are not permitted
  • All adapters must be UL listed for their purpose

So, while this section seems to allow three-to-one receptacle adapters (or 2-to-6 adapters in your case), I would not be in a hurry to implement them. Most surveyors will cite an organization for using these three-to-one adapters because it implies there are not a sufficient number of receptacles in that area, and creates an unsafe environment. According to the NFPA 99-2012 Handbook, it says this about section 10.2.4:

“Any use of adapters or extension cords within healthcare facilities, while permitted subject to the conditions listed in 10.2.4.1 through 10.2.4.3, should be used with caution. The nature of this caution includes attention of the introduction of trip hazards for patients, staff, or visitors; the increased possibility of damage to cords that are lying on the floor; the ease with which grounding resistances or power cord ampacity can be exceeded; and the possibility of incorrect polarization.”

So, my advice is to NOT use these adapters for the reasons stated above. Take the time to increase the number of properly installed receptacles in that area.

Extension Cords

Q: Are there any life safety rules regarding the use of extension cords in the operating room?

A: According to NFPA 70-2011, Article 400.8 (1), extension cords are permitted as long as they are temporary and not used in lieu of fixed wiring such as a wall receptacle. From a safe environment perspective, the cord cannot present a trip hazard or any other safety-related hazard, and NFPA 99-2012, section 10.2.4.2 says extension cord adapters and fittings must be listed (i.e. UL listed) for the purpose that they serve.  Additionally, CMS K-Tag 920 says equipment that is connected to the extension cords should not over-load the current draw for the extension cord.

So, in a surgery room, an extension cord could be used for the temporary use of equipment, provided it meets all of the above requirements. But an extension cord cannot be used for equipment that is used over and over for multiple events, days, weeks, etc.

An extension cord is only permitted for temporary use, such as a housekeeper would use an extension cord for a vacuum cleaner, or a maintenance technician would use an extension cord for a power tool. Another example of a temporary use would be a temporary workstation set up for a vendor working for a day or two in your facility. But you cannot set up an extension cord in your office to operate your computer or printer because that would not be considered temporary. Similarly, you cannot set up an extension cord in a surgery room to power some medical equipment that is used for multiple cases, over and over. If the medical equipment is used only once, or used only once in a great while, then an extension cord would be permitted, provided it met all the other requirements.

Length of Emergency Pull Cord

Q: Can you reference the standard, code or any information from Joint Commission, CMS or any other regulatory organization on the length of the emergency pull cord in a patient used bathroom? Thanks

A: No… The end of the nurse call cords located 4-inches above the floor is an interpretation, not a standard. It is based on the FGI Guidelines, 2014 edition, section 2.1-8.3.7.3 which says a nurse call station shall be activated by a patient lying on the floor in each room containing a patient toilet. Accreditation organizations have used the so-called “4-inch rule” as an interpretation of the FGI Guidelines section 2.1-8.3.7.3.

Since there is no specific standard that identifies the maximum or minimum distance that the end of the call-cord can be from the floor, you can set your own policy, provided it is documented and approved by your respective committees. If your own policy said 6-inches would comply with FGI Guidelines 2.1-8.3.7.3, then the surveyors would have to accept that, since their agencies have not specified the distance between the floor and the end of the cord. But if you don’t have a policy on the distance between the floor and the end of the cord, then the surveyors will assess you based on their own interpretation, which for the most part, is 4-inches. However, if your policy said something that was entirely unreasonable, then the surveyors have the right to find you non-compliant.

I suggest you have a policy that identifies an acceptable range, say 3-inches to 6-inches, to allow a little fluctuation in the field. Get your respective Safety committee and Infection Control committee to approve that policy and then the surveyors cannot cite you for non-compliance unless you’re non-compliant with your own policy.

Strange Observations – Wall Mounted Signs

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

The discharge door for a stairwell opened out onto the 1st floor corridor, where egress was just down the corridor. (This is permitted by section 7.7.2 of the 2012 LSC, provided they met all of the other requirements).

As the picture indicates, when the stairwell door is fully opened, it sticks out into the corridor about half the width of the door. This can cause a momentary obstruction to people in the corridor when the door is open.

The facilities department thought it would be a good idea to warn people that the door may be a problem when open and created this sign on a swivel that warns people. To be sure, the sign does swing if anyone came into contact with it, but when it is in its normal position, it projected more than 4-inches into the corridor.

Even though the intentions for the sign were good, it does violate the maximum 4-inch corridor projection rule adopted by CMS, and therefore it was written up.

Alcoves

Q: Is there a limit to the size an alcove can be in a smoke compartment right off of the corridor? I understand equipment can be stored in alcoves but is there a definition of an alcove? I have a one hundred square foot room that was once required to be a remote nurse station, but the area is no longer used as a remote nurse station. There is no door to the room and the opening to the corridor is 6 feet wide. Am I allowed to store wheeled equipment (i.e. wheelchairs, patient lifts and crash carts) not in use in this area?

A: Crash carts are permitted to be left unattended in the required width of the corridor, but your question is valid for the other items. Generally speaking in healthcare occupancies, corridors must be separated from all other areas and rooms. But take a look at section 19.6.3.1 of the 2012 Life Safety Code. There are nine (9) exceptions to the LSC requirement that the corridor must be separated from the rest of the facility.

Depending on certain variables, such as sprinkler coverage, smoke detection, size of the open area, etc., you may be able to qualify for one or more of the exceptions. However, you cannot store any combustibles in this room that is open to the corridor. That means no bed storage (because mattresses are combustible) and no supply carts with combustible supplies can be stored in these rooms.

You will have patrol this area often to ensure it is maintained properly. But to answer your question, I have not seen any limitations on size of alcoves in corridors. And one of the exceptions to 19.3.6.1 says spaces unlimited in size may be open to the corridor if you meet all of the requirements.