Q: According to Joint Commission standard EC.02.05.09 EP4 it is requiring this sign:
“Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” They are referencing NFPA 99 2012-220.127.116.11.1–18.104.22.168.7. Am I understanding correctly that if I have Oxygen, Medical Gas and Nitrous in the Medical Gas Storage Room that this is the correct sign I need?
A: I think you have this twisted a bit. Joint Commission’s standard EC.02.05.09, EP 4 (2018 CAMH) does not reference NFPA 99-2012 22.214.171.124.1 to 126.96.36.199.7. The EP 3 (located above EP 4) does, but EP 4 does not reference any NFPA standard or sub-section of NFPA 99.
So… where did Joint Commission get the information for EP 4? From NFPA 99-2012, section 188.8.131.52.8. But according to NFPA 99-2012, 184.108.40.206, sub-section 220.127.116.11.8 applies only to Central Supply Systems. This sign that 18.104.22.168.8 requires (Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening) is only required for Central Supply Systems, such as gas manifold rooms. It is not required on doors to storage rooms on units that contain less than 3,000 cubic feet of oxidizing gases.
Also, NFPA 99-2012, section 22.214.171.124.9 says locations containing Central Supply Systems or cylinders containing only oxygen or medical air shall have their doors labeled: “Medical Gases: NO Smoking or Open Flame”. Since this is a sub-section of 126.96.36.199, this requirement still only applies to Central Supply System locations, such as gas manifold rooms.
But the way Joint Commission’s EC.02.05.09, EP 4 is written, it does not really limit the signs to just Central Supply Systems….
My advice is to contact the accreditor for clarification.