Linen Chute

By Brad Keyes…

Q: I have a 3-story linen chute in our facility. The chute is enclosed within a 1-hour shaft from the 1st floor deck through the roof of the facility. In the basement level of the facility, the chute is not enclosed above the laid-in ceiling tiles and the walls to the discharge room also terminate just above the laid-in ceiling tiles. In addition, the chute door is held open by a magnetic device which releases upon activation of the fire alarm system. Should the chute be enclosed above the ceiling tiles in the discharge room? If the chute door is held open with the magnet device, should the discharge room walls extend to the deck above to rate the room for a continuation of the linen chute? We currently have a 60-minute door with a closer installed on the discharge room as well.

A: The scenario that you describe concerning the linen chute discharge room requires a little thought, and the answer depends on a couple of issues.

  1. Is the facility classified as a healthcare occupancy (hospital, nursing home, etc.)?
  2. What year was the facility with the linen chute constructed? We need to determine if ‘new construction’ requirements or ‘existing construction’ requirements are enforced.
  3. Is the linen chute protected with automatic sprinklers?

Now, I will make some assumptions here… I envision your facility to be a hospital, built many years ago and chapter 19 “Existing Healthcare Occupancy” requirements apply. I will also assume your linen chute is sprinklered. The questions that you raise involves the linen chute which is unprotected above the ceiling in the basement discharge room. You ask if the linen chute needs to be enclosed from the ceiling level to the deck above. I would say it does NOT need to be enclosed, PROVIDED the shaft that the linen chute is in is sealed at the deck level in the basement discharge room. That seal needs to be 1-hour fire rated, not just sealed with sheet metal. There is a provision in the Life Safety Code that allows the shaft to be unsealed and open to the basement discharge room, provided the discharge room is protected with barriers that are constructed to the same fire rating as the shaft. But that is not the case in your scenario, as you said the basement discharge room walls terminate at the ceiling. I am puzzled though by your comments that the door to the basement linen chute discharge room is 1-hour fire rated. Why is there a fire rated door in a wall that is not fire rated? Wouldn’t be the first time a fire rated door was installed where it was not needed. So, based on your description I would say the linen chute is fine not being enclosed above the ceiling provided the shaft itself is tightly sealed with 1-hour fire rated construction where the chute pokes through the deck and into the basement discharge room. But your room is a problem since it is not a 1-hour fire rated room. The magnetic hold-open device on the linen chute discharge door is fine, provided it actually closes and latches upon a fire alarm activation. I have seen many of these types of held-open doors that do not close due to too much trash or linen piling up into the room or cart. Take a look at this at various times of the day and different days of the week and make sure staff is keeping this chute door open and clear. You will need a smoke detector inside the room that released the magnet when it senses smoke. Another bit of advice… even though you didn’t ask for it. The linen chute discharge door is a fire rated door, and as such, it cannot be repaired in the field, other than to replace approved fire rated door hardware. In other words, you are not permitted to weld the door when it becomes cracked and you are not permitted to replace the latching hardware with non-fire rated hardware.  All you can do is purchase a new fire rated chute door assembly and install that.

Smoke Detectors

By Brad Keyes…

Q: Are smoke detectors required in individual hospital patient rooms, and what are the exemptions to not have a detector in individual rooms?

A: There is no Life Safety Code or NFPA 72-2010 requirement to have smoke detectors in hospital patient sleeping rooms or treatment areas. There may be other standards or regulations that could require them, so check with your state and local authorities.

Typically, the only areas that are required to have smoke detectors in a hospital are:

  • Elevator lobbies and elevator mechanical rooms
  • Near doors that are held-open by magnets
  • In the same room with fire alarm control panels that are not constantly supervised
  • In areas open to the corridor that are not constantly supervised
  • Inside locked areas that use the Specialized Protective Measure locking arrangement identified by 19.2.2.2.5.2
  • Patient sleeping suites that do not provide direct supervision
  • Smoke compartments containing patient sleeping suites over 5,000 square feet but not exceeding 7,500 square feet and are not equipped with Quick Response (QR) sprinklers
  • Patient sleeping suites over 7,500 square feet but not exceeding 10,000 square feet

Additionally, smoke detectors may be required in patient sleeping rooms if an Equivalency was submitted and approved.

Aerosol Can Storage

By Brad Keyes…

Q: Housekeeping products like germicidal, glass cleaner, air freshener are stored in a locked metal box on housekeeping cart. All of our stock of these and other products are stored in two large locked metal lockers. They are not fire rated cabinets. The surveyor said aerosols all have to be stored in fire rated cabinets. While they are in use while on housekeeping carts, they will have to be checked in and out daily from a fire cabinet.

The surveyor did not cite a tag or code for this he just told us we had to do it. I have searched and so much is left to interpretation I am confused on what to do. With all the changes occurring and more to come with state regulations and inspections I would like to be prepared.

A: It is safe to say that there is no NFPA standard, no CMS standard, and no accreditation standard that specifically says aerosol cans must be stored in a fire rated cabinet. However, if access to these aerosol products by unauthorized individuals is a safety risk (i.e. can children get into them) then it may be perceived as an unsafe environment and the surveyor would have a legitimate concern about them.

I suggest you go back to the surveyor and ask them why they believe the aerosol products have to be stored in a fire-rated cabinet. Ask for a specific code, standard, or regulation that they are using to make this recommendation.

Otherwise… it’s not a code violation, but a surveyor’s preference.

Elevator Recall Test

By Brad Keyes…

Q: How do I perform the elevator recall test?

 A: If you have never performed an elevator recall test, I suggest you have your elevator maintenance company show you how it is done the first time, then you can continue to do it on a monthly test. But, in lieu of that, here is how a monthly elevator recall test is performed:

  1. Take a copy of the elevator recall key, insert it in the corridor keyed switch on the level best used by the responding fire department, and turn it to the “Test” position. This key should be available from the elevator service company.
  2. This will recall all the elevators in that bank to the floor that you are on. The elevator will ‘recall’ to that floor and open the doors. The controls inside the elevator will not respond to normal touch and the elevator car will sit there waiting for someone to take control. The elevators will be “out of service” during this test, so plan on doing this test when it will least impact your operations.
  3. Remove the key from the recall corridor switch (leave the switch still in the “Test” position) and enter one of the elevator cars. Take the key and insert it in the keyed switched labeled “Fire Fighter Service” and turn it to the “Test” position (It should say “Test”, but if not, turn the switch anyway). Now you have manual control on the elevator buttons inside the car.
  4. Push a button to another floor, holding it until the doors closed. The elevator will travel to that floor, but the doors will not open. If you push the “Door Open” button, then the doors will open, and stay that way until another floor button is pressed.
  5. While in the elevator car, test the function of the emergency telephone in the car.
  6. Return the elevator car to the recall floor and test any other cars in that bank. Remove the key and go back to the corridor switch and return the switch to the normal setting.

That is a monthly recall test, which must be done each month to all elevators. You may find that the fire alarm system will become alerted during this test and before the elevators return to normal service you may have to reset the fire alarm system. But check with your state and local AHJs before conducting this test for the first time… There are some states that will only allow certified elevator technicians to perform this test.

Perforated Ceiling Tiles

By Brad Keyes…

Q: My facility is installing perforated ceiling tiles because it looks “modern” and does not look like the old healthcare setting. With the perforation in the ceiling tiles, does this mean I have to install sprinklers and fire alarm smoke detectors above and below the ceiling since the dropped ceiling is no longer a smoke-resistant barrier? I believe I have to also take the smoke compartment barrier walls to the deck… is that correct?

A: First of all, do you need smoke detectors in the area where the new ceiling tiles are being installed? If yes, then we need to address this issue, but the NFPA codes and standards do not require that many smoke detectors in a hospital. Unless you are employing Specialized Protective Measure locks (see section 19.2.2.2.5.2 of the 2012 Life Safety Code), or have specific requirements from a state or local authority that exceed what NFPA requires, smoke detectors are only mandatory in the following locations of a hospital:

  • In areas open to the corridor that are not directly supervised by a person (see section 19.3.6.1 of the 2012 LSC)
  • Near doors that are held open by devices that release on a fire alarm activation (see section 17.7.5.6.5.1 of NFPA 72-2010)
  • In elevator lobbies and elevator equipment rooms (see section 9.4.3.2 of the 2012 LSC)
  • In rooms where fire alarm panels (including NAC panels and off-premises monitoring transmission equipment) are located without direct supervision by a person (see section 9.6.1.8.1 of the 2012 LSC)

You may want to revisit why the smoke detectors are there in the first place. Check with your state and local authorities to see if they have requirements for smoke detectors to be there.

But assuming you do want to maintain the smoke detection level in this area where the new ceiling tiles are located, NFPA 72-2010 does address this issue. Let’s look at section 17.5.3.1.3 which discusses the requirements for an open grid ceiling. It says smoke detectors are not required below an open grid ceiling if the openings in the ceiling are ¼-inch or larger in the least dimension, and the openings constitute at least 70% of the surface area of the ceiling. So, what this means, smoke detectors are not required above the ceiling if the openings are less than ¼-inch and the accumulative area of the openings is 30% of the total surface area of the ceiling. But this section only applies if smoke detectors are required in the general area where these new ceiling tiles are being installed. But keep in mind, if you install smoke detectors where they are not required, they still must be installed in compliance with NFPA 72-2010.

Here are the requirements found in NFPA 13-2010, at section 8.15.13 for an approved open-grid ceiling. Open-grid ceiling must be installed below the sprinklers where all of the following apply:

  1. The openings of the open-grid ceiling must be at least ¼ inch or larger in the least dimension.
  2. The thickness or the depth of the material does not exceed the least dimension of the opening.
  3. The openings must constitute 70 percent of the area of the ceiling material.

If your ceiling tile openings are less than ¼-inch and the openings in the ceiling tile equal less than 70% of the ceiling area, then I conclude sprinklers would not be required above the ceiling.

There is one issue you need to be aware of… Most surveyors will cite you for having gaps in ceiling tiles greater than 1/8-inch as that would allow heat and smoke to filter up through the ceiling and would cause the sprinklers or smoke detectors to delay activation. Make sure these ceiling tiles do not have openings greater than 1/8-inch.

Smoke compartment barrier walls always have to extend from the floor to the deck above regardless whether or not the ceiling tiles have openings in them.

Resources for Developing an Emergency Operations Plan

Last week, I shared a brief checklist for evaluating your hospital emergency operations plan and now, I’m here to share a couple of free resources with you to aid in this process.

U.S. Department of Health & Human Services ASPR TRACIE
This website, which is free to join, is a great national resource for templates and more. They also have a feature section titled “Beyond the Response: Experiences from the Field” which details organizations’ responses to emergencies.

California Emergency Medical Services Authority (EMSA)
This website provides multiple tools and templates to assist you with the emergency preparedness process. You can find editable Word documents that cover topics such as active shooter, infectious disease, missing persons, utility failure, and more.

If you would like more information regarding hospital emergency operations plans, please contact me at carrie.kotecki@complianceonegroup.com.

Teaming with Law Enforcement in Healthcare

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:

  1. 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.
  2. Consider including law enforcement in your security huddles.
  3. 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.
  4. If you have a hospital security department, consider making the security supervisor the point of contact for any officer coming to the hospital.
  5. 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 info@complianceonegroup.com with “Carrie’s Article” in the subject line.

Direct Visual Observation Required in Emergency Department

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 19.2.5.7.2.1(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.

Workplace Violence

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:

  1. You should perform a risk assessment of the facility you work in. Ask yourself, “What are the significant safety hazards that exist?”
  2. Utilize data collection tools to collect specific information on each incident to determine which solutions are necessary.
  3. Consider implementing safety and/or security teams that can manage the information and report to the administration on a regular frequency (monthly).
  4. Develop a user-friendly safety reporting process that all employees are required to fill out.
  5. Implement and stick to a zero-tolerance policy that supports all employees and empowers them to press charges on any acts of violence.
  6. 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.
  7. 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.
  8. 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 carrie.kotecki@complianceonegroup.com.

Corridor Doors

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 43.7.1.2 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.