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.

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.

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.

Alcohol Storage

Q: A question for you about alcohol storage. If we have over 5 gallons of alcohol, 70% isopropyl rubbing alcohol in a 1-hour rated room, is that acceptable?

A: It depends what type of containers the alcohol is stored in, the capacity of the containers, the size of the room, and the location of the room. Based on the assumption that the flash point of the alcohol is 53°F and the boiling point is 181°F, the alcohol would be considered a Class IB flammable liquid, according to NFPA 30-2012, section 4.3.1.

The maximum size container is identified in Table 9.4.3 as follows:

Glass                           1-quart

Metal (not a drum)      5.3 gal

Safety Can                  5.3 gal

Metal Drum                 119 gal

Rigid Plastic                Not Permitted

Polyethylene               5.3 gal

Fiber Drum                 Not Permitted

According to 9.5.1, the maximum volume stored in a safety cabinet is 120 gallons. According to 9.6.1, the maximum allowable quantities of Class IB flammable liquid is 120 gallons per control area, which is defined as a space in a building. This would be a designated space and nothing else would be permitted to be stored in this space.

According to 9.7.2, the maximum number of control areas for Class IB flammable liquids in a building is:

1st floor:                                   4

2nd floor:                                  3

3rd through 9th floor:             2

Above 9th floor:                       1

According to 9.3.6, storage of Class IB flammable liquids is not permitted in basements, which is defined as a level having ½ or more of its area below ground level. According to 9.9.1, the fire-resistant construction rating of the control area storing Class IB flammable liquids is:

  • 1-hour fire-rated if the control area is less than or equal to 150 square feet
  • 2-hour fire-rated if the control area is more than 150 square feet but not more than 500 square feet.
  • 4-hour fire-rated if the control area is more than 500 square feet.

So, the answer to your question is yes, 5-gallons of 70% isopropyl rubbing alcohol stored in a metal can, or a safety can, or a metal drum, or a polyethylene container in a 1-hour fire-rated control room (i.e. designated storage room), that is not over 150 square feet in size, would be acceptable, provided the room is not located below ground level.

Annual Eyewash Station Test

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.

Air Pressure Requirements

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.

Testing Elevator Fire-Fighters Service

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 9.4.6.2 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.

Heated Massaging Seat

Q: I work at an ICF facility. We have a person with arthritis and I was just asked if a heated pad massaging seat could be purchased for them. I know we can’t have heated blankets, personal heaters, etc. With this item having heat, I would assume it would probably not be approved either. Can I get your input??

A: There are no CMS codes or standards that would prohibit this type of device. Actually, there are no codes or standards that would prohibit electric heating blankets, but the perceived risk of danger usually disqualifies them from use.

There will be risks in using this heated, massaging seat that you need to address, such as:

  • Trip hazard with the electrical cord
  • Something heavy rolling on the electrical cord creating a pinch-point, thereby causing a short-circuit over time
  • The seat becoming too hot for the patient

If you address these risks in a risk assessment and mitigate them to the satisfaction of the surveyor, you should be fine.