NFPA 99 Signs on Doors to Central Supply Systems

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 2012-5.1.3.1.1–5.1.3.1.7. 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 5.1.3.1.1 to 5.1.3.1.7. 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 5.1.3.1.8. But according to NFPA 99-2012, 5.1.3.1, sub-section 5.1.3.1.8 applies only to Central Supply Systems. This sign that 5.1.3.1.8 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 5.1.3.1.9 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 5.1.3.1, 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.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.