Gaps in Ceilings

Q: I am looking for the 1/8-inch gap reference for ceiling tiles. If the ceiling has broken tiles, or misaligned tiles, or gaps greater than 1/8-inch caused by anything (such as data cables temporarily run up through the ceiling), then I see that the surveyors will cite this. Is that actually written in the NFPA codes and standards anywhere? Is the 1/8-inch gap rule “real”? Does it use the 1/8-inch measurement anywhere? If so, where? If not, where does it come from?

A: No, there is no direct statement in the LSC that says gaps greater than 1/8-inch are prohibited, but ceilings containing smoke detectors and sprinklers must form a continuous membrane and any sizable gap in this membrane would allow smoke and heat to rise above the ceiling which would delay the activation of the detector or sprinkler, thereby causing an impairment.

Since the size of the gap must be quantifiable, and NFPA does not say how big the gap has to be before it is a problem, authorities having jurisdiction have ‘borrowed’ the 1/8-inch gap concept from NFPA 80 regarding the gap between a fire door and the frame. Authorities having jurisdiction are permitted to do this as section 4.6.1.1 of the 2012 Life Safety Code says the authority shall determine whether the provisions of the LSC are met. This means, when the Life Safety Code is not clear on a subject, the authorities have to make interpretations in order to determine compliance.

False Alarm Fire Drills

Q: Can accidental fire alarm activations, such as burnt popcorn, be counted toward a quarterly fire drill requirement if documentation of staff response is received in regard to said accidental activation?

A: I would think so. A long as you evaluated the staff’s response; the building’s response; and the fire alarm system’s response, I would believe a false alarm activation of the fire alarm system could be considered the same as a fire drill.

Fire Drills in the Behavioral Health Unit

Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: For fire drills in the main hospital, I am sure it would be best to separate these activities from the Behavioral Health unit. And I am sure we would need to be notified on our panel if an event happened on the unit. Am I on the right track? Is there any code that speaks to this? In addition, what would be your suggestions in regard to stairwell egress in the case of an alarm on the Behavioral Health unit. Delayed egress? Clinical needs locks?

 A: Okay… so there is a lot to cover here. As I understand your question, you will soon be opening a behavioral health unit in an existing acute-care hospital. You say you are partnering with another organization… does this mean the behavioral health unit is a separate entity (i.e. does it have a separate CMS certification number) from the acute-care hospital?

 If the behavioral health unit is a separate entity, then you must conduct separate fire drills (once per shift per quarter) in the behavioral health unit as compared to the rest of the acute-care hospital. If the behavioral health unit is not a separate entity, then you are not required to conduct separate fire drills from the rest of the acute-care hospital. So, you need to verify if the behavioral health unit will be a separate entity from the acute-care hospital.  

The fire alarm control system is a system for the entire building, even if there are separate entities inside the building. If a fire alarm originated on the behavioral health unit, you most definitely need to know about it in the acute-care hospital, and vice-versa.

The behavioral health unit would likely qualify for clinical needs locks as described in 18.2.2.2.5.1 of the 2012 LSC. These locks are not required to automatically unlock on activation of the fire alarm system. You can do that if you want, but there is no requirement to do so. Actually, you really don’t want the locks on the doors in the behavioral health unit to automatically unlock on a fire alarm, because patients will soon figure that out and will loiter around the locked egress doors and jump at the chance to elope whenever a fire alarm actuates. I do not suggest delayed egress locks, but rather clinical needs locks as long as you qualify for them.  

Aerosol Can Storage

Q: Our nursing home just completed a state survey and while we were not cited we were “warned” that all aerosols are to be put into fireproof cabinet. The metal cabinets and toolboxes we have them in currently are not adequate. We use metal toolboxes on housekeeping carts to store one can of each cleaning product we use. The surveyor said these would have be logged in and out daily from fireproof cabinet. Is this an actual NFPA requirement?

A: This is not a Life Safety Code requirement. I’m always suspicious when I hear a surveyor ‘warns’ a facility about an alleged issue rather than actually cite them. In this day and age of the CMS dominant mantra of “If you see it, cite it” mentally, I have to question why didn’t the surveyor actually cite it. One reason could be that it is not a violation of any code or regulation, but it is a surveyor preference. Perhaps the surveyor is using his/her authority to cajole the facility into doing something that is actually not required. Would the facility be safer if all aerosols are stored in a fire-rated cabinet? Perhaps, but if it is not a requirement then the ends have to justify the means.

You didn’t say what was in the aerosol cans; are the contents flammable? According to NFPA 30-2012 flammable liquids are permitted to be stored in their original containers up to 1-gallon in size, and you do not need special containment (i.e. fire-rated cabinet) until the aggregate total of the stored product (per smoke compartment) reaches 5 gallons. To me, aerosol cans placed on a housekeeper’s cart would not be considered in storage – they would be considered in use. However, there are other aspects to consider: Are the cans of aerosol products on the housekeeper’s cart safe from unauthorized individuals (i.e. children, dementia patients)? If not, then that may be a valid reason to place them inside a storage container.

I’m not telling you to NOT follow the surveyor’s advice, but I am saying the warning is not based on Life Safety Code or other NFPA requirements. Perhaps it is based on state or local regulations. If you haven’t already done so, ask him/her to cite the code or standard that requires the storage requirements. If there is an actual code or standard that requires it, then we learned something. But if there is not an actual code or standard that requires it, then the surveyor will back down and admit it is a recommendation or preference.

GFCI Receptacles

Q: Where can I find the requirements for ground-fault circuit interrupters (GFCI) protection in the dietary/kitchen area of a nursing home? I thought it was 6′ within a water source. But when I look in the 2011 NEC it does not say that. The way I read it, it is everywhere in the kitchen/dietary that is 110v. What is your thought, and where can I find the clarification?

A: According to NFPA 70-2011, section 210.8, says:

All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(A)(1) through (8) shall have ground-fault circuit interrupter protection for personnel.

(6) Kitchens— where the receptacles are installed to serve the countertop surfaces

(7) Sinks — located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink

Section 210.8 does apply to healthcare facilities so NFPA 70-2011 does require GFCI receptacles in kitchens in healthcare facilities.

Surveyors will often use section 210.8 in assessing GFCI compliance in healthcare occupancies.

Illumination of the Egress

Q: Is there a standard on lighting of offices and exam room in the ambulatory or clinics?

A: The Life Safety Code is primarily concerned about egressing the facility under emergency conditions, and only has illumination requirements for emergency egress situations. Section 7.8.1.3 of the 2012 Life Safety Code says the floors and other walking surfaces within exits, and designated stairs, aisles, ramps, escalators, passageways, and exit discharges to be illuminated to 10 ft-candles for new conditions, and 1 ft-candle for existing conditions. Assembly occupancies are permitted to have 0.2 ft-candles of illumination. This applies to clinics and ambulatory healthcare occupancies. Please check with your state and local authorities to determine if they have more restrictive requirements.

ILSM Fire Drills

Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I should be doing 2 per quarter each on different shifts. My facilities guy says 2 per month. Who is correct? I think we are giving our employees alarm fatigue.

A: Fire drills must be conducted as follows for healthcare occupancies (i.e. hospitals) and ambulatory health care occupancies (i.e. ASC):

  • Regular fire drills must be conducted once per shift per quarter, with start times staggered by 2-hours on fire drills conducted on the same shift but on consecutive quarters;
  • ILSM fire drills must be conducted once per shift per quarter in areas affected by the impairment requiring the ILSM fire drill. This drill is in addition to the regular fire drill.

The ILSM fire drill must evaluate each departments response that is affected by the impairment that requires the ILSM fire drill. This may mean you will have more than one ILSM fire drill per shift per quarter.

It appears you are on the right track with 2 fire drills per shift per quarter while the construction is underway. I’m not sure where the facility guy is coming from with the 2 drills per month requirement.

Oxygen Therapy and Beauty Salons

Q: I am curious if you know of any regulations that deal specifically with LTC residents with oxygen supply and beauty salons. We have a salon in house, and the beautician comes twice a week and I have a sign up that says no oxygen allowed in salon. Do you know of any specific regulations that relate to the use of oxygen in a salon?

A: After reviewing sections 10.5.4.1 and 11.5.1.1.4 of NFPA 99-2012, I believe oxygen therapy would not be permitted to be administered around hot appliances. While beauty salon heating devices such as hair dryers and curling irons typically do not get much attention from surveyors, NFPA 99-2012 does prohibit the administration of oxygen therapy around hot appliances… and hair dryers and curling irons are hot appliances. I would recommend that you not allow the use of O2 therapy equipment in a beauty salon.

Courtyard

Q: Are there any life safety requirements concerning courtyards? We have an outdoor courtyard, surrounded on all sides by our building, with one door entering and exiting the area. As of now, the door remains locked with “Not An Exit” sign posted on it. Our management team would like to open the area to our visitors and came to me for LS concerns. From my perspective, we would need to look at Life Safety issues involving entering the area and look at adding an ‘Exit’ sign, inside the courtyard above the door that goes back into the hospital. Is there anything else that could pose a concern?

A: Beside the ‘Exit’ sign over the door from the courtyard, the courtyard would have to have constant illumination and the door from the courtyard to the indoors must be unlocked all the time.  The walking surface in the courtyard must be level with no abrupt changes in elevation greater than ¼ inch. Also, the “Not An Exit” sign is incorrect; the sign must read “NO EXIT” with the word “NO” 2 inches tall and the word “EXIT” 1 inch tall.

Large Trash Containers

Q: I have a question about the limits on the size of trash containers in healthcare facilities, including ambulatory healthcare facilities. Consider larger collection bins, that are housed in one-hour rated soiled utility rooms, and are then moved close to the loading dock area, an area which is separated from the rest of the facility with 2-hour occupancy separations and is indicated “Business” occupancy although it is the sub-basement of a hospital building. These are staged in a hallway of this business area while awaiting emptying, cleaning and return to the soiled utility rooms. NFPA 101 2012 Chapter 38/39.7.6 would seem to permit this. What do you think?

A: You are correct… As long as the large tubs are located in business occupancies, there is no Life Safety Code requirement that requires them to be stored in a 1-hour hazardous room. That is strictly a healthcare occupancy (see 19.7.5.7.1 of the 2012 LSC) and an ambulatory healthcare occupancy (see 20.7.5.5.1 of the 2012 LSC) requirement.