Battery Charging Room

Q: Are there any Life Safety Code requirements for a battery charging room, such as HVAC pressurization and air changes per hour (ACH) rates? These rooms are where I charge my EVS floor machines.

A: I guess it would depend on how the room is interpreted in regards to its function. According to the 2014 FGI Guidelines, which references the ASHRAE 170 table, a janitor’s closet must be negative, have 10 ACH, the air in the room must be exhausted to the outdoors, you cannot have a room HVAC that recirculates air, and there are no design requirements for humidity and temperature.

If the room is hazardous material storage (which sounds more like it), the room would have to meet the same requirements as listed above, with the added requirement that there is 2 ACH of outdoor air.

But those are for new construction. For existing conditions, you would have to comply with the FGI or AIA requirements in effect at the time of the design of the room.

 

Air Changes in the Morgue

Q: We are presently undergoing our 3-year licensure inspection by the Dept. of Health. One of the inspectors asked to see our air change records for the morgue. We have never completed air changes for the morgue. We use outside air and make sure the exhaust fan is working properly. So, should we be doing air change testing in the morgue? Also, do we need to do air change testing in all clean and soiled utility rooms in the hospital?

A: When your facility was designed and constructed, the HVAC system had to be designed to certain Air Changes per Hour (ACH). Depending when the facility was designed, the designer would use the AIA Guidelines (or as they are now called, the FGI Guidelines), or other state or local regulations as appropriate. You need to find out what those design ACH were at the time the facility was designed/constructed, or last renovated in that area.

It is important to understand that you do not have to meet the latest edition of FGI Guidelines; you just have to meet the edition at the time your facility was designed, or last renovated. It is important to also understand that you must comply with state and local regulations at all times.

So, let’s say the morgue was required to have 6 ACH at the time it was designed. You must maintain that 6 ACH for the life of the building, or until you renovate; then you would have to comply with new construction ACH for a morgue. The state inspector’s request is valid: How do you know you are maintaining 6 ACH if you don’t measure it from time to time? How often should you measure the ACH? The codes and standards do not say, so do a risk assessment and determine what is a valid number. Usually once per year is sufficient as long as you have historical data that shows the ACH rate was always in compliance.

You need to start measuring ACH rates in all areas where there was a design requirement for ACH.

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.

Sprinklers in Air Handlers

Q: Does a roof top air handler require sprinkler heads if it is unoccupied? We have large walk-in style air handlers on the roof of our hospital and they are not protected with automatic sprinklers.

A: Well… section 18.3.5.1 of the 2012 Life Safety Code requires buildings containing health care facilities to be protected throughout with automatic sprinklers. Initially, one could make the case that mechanical equipment sitting outside the building (although on top of the building) is not part of the building and therefore is not included in this requirement. Taking a look at NFPA 13 (2010 edition), I see sprinklers are required in elevator equipment rooms, and sprinklers are required in electrical rooms (with some exceptions). But these rooms are actually inside the building and would be required to be protected with sprinklers according to section 18.3.5.1 of the 2012 LSC.

So it depends: Is the roof-top air handler room considered outside the building, or is it considered part of the building? That’s going to be the deciding factor, and who makes this decision? The authority having jurisdiction (AHJ) does. Even though accreditation organizations like The Joint Commission, HFAP and DNV are AHJs, they typically leave the construction interpretations to the local and state AHJs. So, if your state or local AHJ has made the determination that the air handler on top of the hospital roof does not require sprinklers, that may be enough to convince the accreditation organizations.

Or it may not. You never know if the accreditation organizations will make a different interpretation while a surveyor is onsite. If you do not want to install sprinklers, then I suggest you get it in writing from your state and local AHJs that sprinklers are not required in the air handler, and keep that document on file. If an accreditation surveyor thinks you should have sprinklers, pull that document out and see if that stops them from writing a citation. However, if you start storing combustible items in the air handler (like cardboard boxes of clean filters) then that will likely prompt the surveyor to write a finding.

Clean Air Filters

Clean Air Filters in Mechanical Rooms

Clean air filters that are stored outside of the box, or a plastic bag, will often times be cited by surveyors under an infection control standard. The logic is dust and dirt will accumulate on the surface of the air filter and when inserted into the air handler, the dust and dirt may be blown downstream and into the patient care or staff areas. Therefore, the dusty clean filters presents an infection control problem by potentially re-distributing the dirt into a clean environment.

A simple solution to this problem is to always store your clean filters in the original shipping containers and never leave them out unprotected. If they do get separated from the box they came in, then place them in a clean plastic bag and seal the bag. Obviously, dirty filters should not be left in the mechanical rooms, as they need to be disposed of as soon as they are removed.

Questions that I get asked is it OK to store clean filters, in their original shipping boxes, in the mechanical room where they will eventually be used? Yes, boxes of clean filters may be stored in a mechanical room, provided:

  • The mechanical room itself does not house any fuel-fired equipment, such as gas furnaces, boilers, and gas water heaters
  • The mechanical room is constructed to meet Hazardous Room requirements, such as automatic sprinklers and 1-hour fire rated barriers for new construction, or automatic sprinkler or 1-hour fire rated barriers for existing construction.
  • There is no Joint Commission or CMS requirement to store the filters on pallets or shelves. Just make sure the boxes are not stored in a wet environment.