Medical Gas System PM

Q: In regards to medical gas system testing, our local AHJ uses NFPA 99-2015 edition. My corporate office has stated that there are no PM’s that have to be done. I feel this is not only incorrect but just not a safe practice. Our medical air compressor and vacuum system are placed in the high-risk category due to the impact to patients and their lives. Where does the NFPA 99 reference and give the codes for the testing and inspection frequencies of the equipment?

A: Section of NFPA 99-2015 says health care facilities with installed medical gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed.

Section says scheduled inspections for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.

Annex section A. says in addition to the minimum inspection and testing in 5.1.14, facilities should consider annually inspecting equipment and procedures and correcting any deficiencies.

(Words in bold text my doing…)

So, section says you must have a periodic maintenance program. Section A. says you should consider an annual program. The AHJ is correct in requiring you to perform an annual inspection of the medical gas system, since section gives him that authority. Even if the AHJ did not require annual PMs, you would have had to conduct a risk assessment to determine the frequency of the PMs. Any deviations from an annual frequency would have to be explained in the risk assessment.

You should consider yourself lucky… CMS Appendix Q says failure to maintain any feature of life safety should result in an Immediate Jeopardy decision. If your surveyor did not consider this an Immediate Jeopardy situation, then you dodged a bullet.

Strange Observations – Oxygen Cylinder Storage

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

Yes… we are looking at oxygen cylinder storage issues again… Yuck.

The sad thing is, scenes like this are not that uncommon in my line of work as a consultant. That means it is not as strange as I would like it to be.

NFPA 99-2012, does require all compressed gas cylinders to be secured at all times. Presumably, those of you who are reading this realize this, and are as frustrated as I am when you find situations like this.

But put yourself in the position of the healthcare provider: Their number 1 priority is taking care of patients. Complying with Life Safety Codes, or other NFPA standards and regulations is not high on their list, and quite honestly, with everything they have to do, I’m okay with that. I’d rather they be concentrating on taking good care of me or my loved-one, rather than concentrating on making sure the corridor is not cluttered, or other basic LSC requirements.

So it is important for you to make compliance with the LSC as easy and simple as possible for those nurses, therapists, and technicians. That means, you need to do frequent rounding looking for basic violations as the one in the picture reveals. When you find these violations, you can do remedial training, but perhaps more importantly, make changes to eliminate the problem from happening again. In this case, obtain more storage racks so staff does not leave cylinders on the floor or unsecured.

Strange Observations – Oxygen Cylinder Storage

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

This room contained more than 300 cubic feet of compressed medical gases (but less than 3,000 cubic feet). And even though the picture does not show the whole room, what I wanted to capture is the fact that the oxygen cylinders in storage are not separated from combustibles by at least 20-feet, or 5-feet if the room is protected with sprinklers.

According to NFPA 99-2012, section you must store oxidizing gases at least 5-feet from combustibles if the room is sprinklered, or at least 20-feet if the room is not.

It is obvious in this picture that some sort of plastic items are stored right next to the oxygen cylinders. Another option is to store the oxidizing gas cylinders in a fire-rated storage cabinet, then you do not need to maintain the 5-feet or 20-feet clearance.

Partially Full Oxygen Cylinders

Q: My Facilities Director just attended a state association of healthcare facilities managers. He stated that the presenter said that for oxygen cylinder storage and segregation, if a cylinder is not completely empty it is considered full. This is 180 degrees from what we have always been told. At our hospital, we have always said that any cylinder that is has been opened is no longer considered full and must be stored with the empties. Have you heard anything to this effect?

A: This sounds like a surveyor preference issue, to me. In other words, this may be just the presenter’s opinion, or perhaps a CMS Regional Office’ opinion. NFPA 99-2012, section says “If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.” Well, a partial cylinder is not full, so in my way of thinking it cannot be stored with the full cylinders.

Actually, the presenter is not wrong when he says a partial cylinder should be stored with the ‘Full’ cylinders. Since NFPA 99 does not address partially full (or partially empty) cylinders, how they are stored is left to the AHJ to decide. If the presenter represented an AHJ, then he is within his right to say partial tanks cannot be stored with the empties. But taking this a step further, section says “Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner”.

This shows us the intent of the code is to prevent a non-full cylinder from being grabbed in an emergency. If partially-full cylinders are stored with full cylinders, then that goes against the intent. However, the intent of the code is not well-written on this particular issue and we are stuck with what is written, which does not prohibit an AHJ interpreting section to say partials cannot be stored with empties. I guess the best advice is to follow what Joint Commission is requesting… that there be three (3) separated storage areas; one each for full cylinders, partially full cylinders, and empty cylinders. That should solve the problem.

Strange Observations – Obstructed Zone Valve Box

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

If you look closely enough, you will notice a set of medical gas shutoff valves behind this cross-corridor door that is held open. Even though the door has a window (or vision panel, as NFPA calls it), and you can actually see the medical gas shutoff valves through the window, it is still a violation.

NFPA 99-2012, section says zone valve boxes shall be installed where they are visible and accessible at all times. Well, I think you could say the zone valve box in this picture is visible, but it certainly is not accessible as long as the door is held open.

Section speaks more directly to this issue: Zone valve boxes shall not be installed behind normally open or normally closed doors.

Curtains for Oxygen Storage

Q: Is there a code from NFPA or Joint Commission in regards to “cloth” curtains hanging in around/in front of oxygen cylinders. And if so would it make a difference if it is in an office setting vs hospital setting?

A: Yes… Both NFPA and Joint Commission prohibits the storage of oxygen cylinders within 20 feet of combustibles (or within 5 feet of combustibles if the room is protected with sprinklers, see NFPA 99-2012,, when the quantity of compressed gas stored is equal to or exceeds 300 cubic feet. It does not make a difference where the stored compressed oxygen is stored. NFPA 99 applies to all healthcare facilities.

Oxygen Tanks

Q: Can oxygen tanks be stored under a stretcher or on a wheelchair when no patient is present.?
Would this be considered in use?

A: Yes… As long as the wheelchair or gurney is designed to secure an oxygen cylinder, it may be placed there even when it is not in use. According to CMS S&C letter 07-10, oxygen cylinders secured in wheelchairs and gurneys are considered in use and not considered in storage, and do not have to be included when calculating the total amount of compressed gas stored per smoke compartment.

O2 Cylinder Storage

Q: Can full oxygen cylinders be stored in a hospital soiled utility room?

A: Yes… however, anything stored in a soiled utility room is considered soiled. That would require staff to clean the O2 cylinder before using it on a patient, and the likely hood of that happening every time is not very good.

Most surveyors will have a problem with full O2 cylinders stored in a soiled utility room because of that issue and would expect the hospital to have a policy or at least a written procedure on the proper cleaning of each cylinder before use.

It is best to not store full O2 cylinders in a soiled utility room. Now, empty O2 cylinders stored in a soiled utility room should not be a problem because they would not be used on patients.

Medical Gas Shutoff Valves

Q: As a hospital security assessor, I am concerned about the availability of hospital gases in Behavioral Health Units. It would be easy for a patient to pull the tab off the plastic covering on the window and tamper with the gases. Would it be permissible to install a clear locking door with hardened glass in place of the plastic panel and provide access to the locked box via scan card with the caveat that the door would automatically unlock open during a fire event?

A: One has to ask why would there be medical gases on a behavioral health unit? Do you treat acute-care patients there? However, if you have them there, then you need to deal with them.

Your question appears to address the medical gas shutoff valves, or zone valves as they are often called. According to NFPA 99-2012, section, zone valves have to be visible, accessible and readily operable from a standing position in the corridor. NFPA 99-2012 does not prohibit the use of special locking arrangements for access to the zone valves.

I think you have a legitimate concern, especially if you document this concern in a risk assessment. But I suggest you contact your authorities having jurisdiction, and ask them if it would be permitted. At a minimum, I suggest you ask:

  • Your accreditation organization
  • Your state agency in charge of hospital design and construction
  • Your local building authorities
  • Your state or local fire marshal

Door to Compressed Gas Storage Rooms

Q: I have an oxygen/med gas storage room that is attached to the hospital, and can only gain access to the room by way of the exterior of building. Does the room have to have a fire-rated door assembly?

A: Well… that depends. If the storage room contains 3,000 cubic feet or more of compressed medical gases, and the room is located indoors, then the room must be constructed with 1-hour fire-rated construction and the door to the room is required to be 1-hour fire rated if new construction, and 3/4-hour rated if existing conditions. (See of NFPA 99-2012).

However, the intent of is to separate the compressed gas storage room from the rest of the facility by requiring 1-hour fire rated barriers, and if the door opening to the storage room opens into the facility, one could easily understand why a fire-rated door is required. However, if the door to the storage room opens to the outdoors (i.e. receiving dock) then one could make a point that the door is not required to be fire-rated, because there is no separation between the storage room and the rest of the facility at that point.

But the problem is, NFPA 99-2012 section does not say that and does not appear to have any exception for a door to the storage room that opens to the outdoors. I think a rational, smart, understanding surveyor would agree with that point and not cite you for not having a fire-rated door that opens to the outdoors.

But will you always have a rational, smart, and understanding surveyor?