Strange Observations – Aisle Width

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

This is an equipment room. It appears to be a water room of some sort as I see a water tank and some water filters. I also see boxes and ‘stuff’ blocking access into and out of this room.

The problem with this situation is the room does not have a clear aisle width. Even though this is an equipment room, you still must maintain a clear aisle width of at least 28-inches for existing conditions, and 36-inches for new construction.

Remember: The exit-access is not limited to the corridor. Every room has an exit-access, and the appropriate aisle width must be maintained in those areas. Section 7.3.4.1.1 and 7.3.4.1.2 of the 2012 Life Safety Code provides the standards that regulate the aisle width.

Last Day to Register for… Compliance One Presents Keyes Life Safety Boot Camp

TODAY IS THE LAST DAY TO REGISTER!

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel.

NOTE: CEUs will be awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Presented by:

Fire Drills

Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift?

A: Yes. According to section 19.7.1.4 of the 2012 Life Safety Code, fire drills in healthcare occupancies must include the transmission of a fire alarm signal and simulation of emergency fire conditions. The Annex explains that the purpose of the drill is to test and evaluate the efficiency, knowledge, and response of the healthcare personnel in implementing the emergency fire response plan. The purpose is to not excite or disturb the patients, so doors to patient rooms should be closed. Between the hours of 9pm and 6am, you still must activate the fire alarm system during a drill, but you have the option to silence any audible notification devices.

Strange Observations – Exit Enclosure

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

This is not corridor, but rather an exit enclosure to a stairwell. There was a construction project in progress and to achieve a negative air pressure in the project area, the contractor cut a hole (twice) in the 2-hour fire-rated barrier for the exit enclosure to run the temporary flex duct to the exhaust fan.

Section 7.1.3.2.1 (10) of the 2012 LSC does not allow penetrations into and through an exit enclosure for this purpose, even on a temporary basis.

If you’re asking what the hospital should have done if this was their only option to create negative air for the project, I would say they could have set-up a HEPA filter negative air machine inside the project area, and discharge the air from the HEPA blower to an adjacent corridor. Not the best solution, but one that is far better than making penetrations into the exit enclosure.

There is also the issue of headroom which must be at least 7-foot 6-inches, according to section 7.1.5.1.

Door Lever Hardware

Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not “hook” passing clothing, straps, purses during emergency evacuations? I swear I remember this for healthcare occupancies from somewhere, but can no longer find it in the Life Safety Code.

A: No, the 2012 Life Safety Code does not require a return on door lever handles to prevent hooking clothing during egress. But my good friend Lori Greene (www.idighardware.com) tells me the return is only required by the California Referenced Standards Code, which says: Levers.  The lever of lever-actuated levers or locks shall be curved with a return to within 1/2″ of the face of the door to prevent catching on the clothing of persons during egress. Since this is not a requirement of the NFPA or ICC codes or standards, it would only apply in California.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel.

NOTE: CEUs will be awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by:

Closet Doors

Q: Are closet doors located inside a corridor considered corridor doors and do they have to meet life and safety codes referring to corridor doors?

A: It depends…. What does your Life Safety drawings say?

Section 19.3.6.3 of the 2012 LSC requires doors in the corridor to be positive latching. If the closet door is in the corridor wall then it must be positive latching. However, there may be a possibility that the corridor wall could run behind the closet, provided the back of the closet wall meets the requirements of 19.3.6.2 for construction of corridor walls.

But your Life Safety drawings need to specifically identify that the corridor wall runs behind the closet. If they do not, then the surveyor has no choice but to hold your closet doors compliant to 19.3.6.3 for positive latching corridor doors.

Strange Observations – Picture Hanging Device

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

Apparently, sidewall sprinkler heads can also be used to hang pictures…. NOT.

[That was sarcasm…]

I admit I did not take this picture, but it was contributed to this effort by Tim Niemer… Thanks Tim.

Non-Compliant Construction Type Above a Healthcare Occupancy

Q: I have an interesting one for you. We have an architect propose a construction type of Type V (111) for a 3-story building with the first-floor being Healthcare occupancy (a nursing home) and the upper 2 floors being Residential Board and Care occupancy (assisted living). There is a 2-hour floor ceiling assembly separating the nursing home and assisted living.

It is interesting to me because I am not aware that the LSC has ever allowed this in the past, but it appears to be allowed by the 2012 LSC in accordance with 18.1.3.5. The 2012 LSC Handbook also gives a good description. What I am worried about is CMS and accreditation surveys. This is against everything that has been engrained in our brains and it could be a major issue. Have you seen this or heard of this before?

A: Yes… this is a very interesting case. I cannot recall that I’ve seen this before, mainly because the 2000 LSC did not allow this arrangement. It was not until the 2009 edition of the LSC that this was clearly permitted. And I agree, the Handbook for the 2012 LSC explains this very well. I recall a conversation that I had with a representative from NFPA years ago on this very subject and he assured me it was not permitted (we were under the 2000 LSC at the time). So, I agree with you… It goes against what we’ve been taught. But times change, don’t they!

Unless you have other regulations preventing this arrangement, I would say that the NFPA codes and standards would permit it, but please check with your state and local authorities to see if they have any problems with it. I would not be too concerned about a nursing home being cited by a CMS surveyor or an accreditation surveyor since they follow NFPA rather rigidly (or are supposed to), and since the 2012 LSC does permit it, the nursing home may make the case that it is permitted if the surveyor is considering citing them.

Personally, I think it is poor insight by the healthcare organization to do this, as they will never be able to expand their healthcare occupancy beyond the 1st floor, and maintaining that 2-hour fire-rated barrier is a special challenge for anyone, let alone a typical maintenance staff of a nursing home that is often under-manned, and not trained well on technical issues. I suspect over a period of time the 2-hour fire-rated horizontal barrier will be compromised and not maintained properly due to a lack of understanding.

 

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by: