Q: I read recently that Joint Commission allows a door with a power operator to not have to positively latch as long as it has 5-lbs. of force keeping it closed. I thought CMS already said that the 5-pound existing door exemption that’s in the Life Safety Code does not apply to CMS facilities. Is the change that they are now allowing the 5-pound exemption on doors with automatic operators and not requiring positive latching on restroom doors? Is it common for an automatic door manufacturer to be unable to provide positive latching?
A: I was not aware that there were any door manufacturers that could not provide positive latching hardware on power-operated doors. Apparently, the Joint Commission is aware of at least one manufacturer and made this exception to their standard. But the 2012 LSC does permit this action under 188.8.131.52.7, whereby powered doors that comply with section 184.108.40.206 (sub-section 220.127.116.11.2(5) requires powered doors to latch upon activation of the fire alarm system) are considered compliant provided the door is equipped with a means to keep the door closed that is acceptable to the AHJ, and is capable of keeping the door closed with 5-lbs. of force. But just because Joint Commission permits this (i.e. it is acceptable to them), it does not mean it is acceptable to all other AHJs. Hospitals will be taking a certain risk if they choose to go this route because it may pass a Joint Commission survey but fail a state agency survey.
You are correct in that CMS does not permit the option of a device with 5-lbs. of force to keep an existing corridor door closed, as described under 18.104.22.168.5. They have prohibited this for a few years and communicated that via informal emails to the accreditors, but did not release that information to the public as far as I know.
Certain corridor doors do not require positive latching (i.e. toilet-room doors, shower-room doors, janitor’s closets that do not store combustibles… see 22.214.171.124.6) and therefore they are permitted to have roller latches if they want. CMS and the accreditors are okay with that, although I’m not sure all surveyors fully understand that concept.
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 126.96.36.199 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.
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.
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 188.8.131.52.5.1 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.
Q: I was having a discussion regarding toaster ovens use in healthcare and the frequency of fires was a factor for not favoring them. We have a few on campus and my research finds nothing in our policies or elsewhere specifically banning them from use. I see the requirements in the LSC regarding residential vs. commercial equipment requirements but no equipment is listed along these lines as not allowed. Can you share your knowledge on this subject?
A: Toaster ovens are not prohibited… but they are considered a perceived risk by many (if not most) authorities because they can be set to 450 degrees and they will not automatically shut-off, and potentially set something on fire. Therefore, you need to decide if you want to permit them in your facility. If so, conduct a risk assessment that identifies mitigating actions to reduce the perceived risk of these devices. If not, then remove them from the building.
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.
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.
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 184.108.40.206 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.
Q: In the standards manual from our accreditation organization it states that every 12 months the critical access hospital either performs a functional test of battery powered lights on the inventory required for egress for a duration of 1½-hours or replaces the batteries and tests 10% of all batteries and records the results. Do we need a written inventory of these lights? If so, can these lights be labeled on a drawing? Or do these need to be listed out in a spreadsheet?
A: First of all…. be careful which edition of the standards you are reading. That accreditation organization changed their standard on this issue in 2018 and eliminated the option of replacing the batteries annually, and only testing 10% of them. The requirement since January 1, 2018 is you must conduct the annual 90-minute test on all of the batteries.
But to answer your question…. Yes… the battery powered emergency lights do need to be listed on an inventory in order to be sure all of them were tested. You need to list them on a spread-sheet that identifies them by location and/or asset-tracking number, so you can demonstrate that your tested each device and whether or not it passed or failed.
To help your staff located the devices quicker, you should consider listing them on drawings so each location can be tracked.
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.
Q: My question involves childproof outlets in healthcare. Where are they required and where in the code does it discuss not using snap-in covers?
A: According to NFPA 70-2011, Article 517.18(C), tamper-resistant receptacles are required in pediatric locations of health care facilities (i.e. hospitals, physician offices, therapy areas, etc.) including patient rooms, bathrooms, playrooms, activity rooms, and patient care areas of designated pediatric locations. As an option, the receptacle may use a listed tamper-resistant cover. The listing would have to be from an independent testing laboratory, such as UL, ETL, or the like. In essence, wherever an unattended child could be, you would have to have tamper-resistant receptacles.
Q: Is it required to keep electrical panels locked even if they are behind doors that are restricted by card-access readers? Does it depend on which AHJ is inspecting it?
A: According to NFPA 99-2012, section 220.127.116.11.1.3 (A), circuit breaker panels to Category 1 and Category 2 rooms must be secured against unauthorized access. If you can justify that only authorized individuals with approved badge readers can access the panels, then you should not have to lock the individual panels.
But section 1.3.2 of NFPA 99-2012 also says that construction and equipment requirements shall be applied only to new construction and new equipment. That means in existing conditions, relocating your circuit breaker panels to locked rooms is not a requirement.
This is one good reason to conduct the NFPA 99 Risk Assessment to determine what your Category ratings are for your electrical equipment and where they are located.
All AHJs should enforce this the same way… but we know that is not likely to happen.
Q: Please clarify if electrical closets and /or electrical rooms can be accessible to anyone. The NFPA70 National Electrical Code seems to require warning signs limiting access to authorized personnel only.
A: For many years there has not been any specific standard that says access to electrical control panels has to be restricted to authorized individuals only. But with the new NFPA 99-2012, section 18.104.22.168.1.3 now says access to over-current protective devices (i.e. circuit breakers) serving Category 1 or Category 2 rooms is restricted to authorized individuals only. This standard actually only applies to new construction.
But be aware that for many years accreditation organization have cited healthcare facilities for not securing their circuit breaker panels from unauthorized access, and they base this on their “Safe Environment” standard, or as some people call it the ‘General Duty’ clause.
So, it has been enforced for years by accreditation organizations, and by some state agencies, while there has not been an actual standard that required securing the panels. So, I would suggest you do secure all electrical rooms from unauthorized access.
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 22.214.171.124.4 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.
Q: What would be the appropriate standard for a daisy chain?
A: I’m not entirely sure of what you are asking…. But when you say “What would be the appropriate standard for a daisy chain” I’m assuming you are referring to an extension cord (or power strip) plugged into another extension cord (or power strip). The Code trail that would prohibit that, is:
2012 Life Safety Code, section 126.96.36.199 requires compliance with section 9.1 for utilities. Section 9.1.2 requires compliance with NFPA 70-2011 on all issues of electrical wiring and equipment. NFPA 70-2011, Article 400.8 (1) says: “…flexible cords and cables shall not be used …as a substitute for the fixed wiring of a structure”. So NFPA 70-2011, Article 400.8 (1) prohibits daisy chains, because the first extension cord (or power strip) is now acting as a substitute for the fixed wiring of a structure.
Also, NFPA 70-2011, Article 400.7 (B) says each flexible cords shall be equipped with an attachment plug and shall be energized from a receptacle outlet. That also prohibits a flexible cord (i.e. extension cord or power strip) from being plugged into another flexible cord.