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 11.6.5.2 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 11.6.5.3 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 11.6.5.2 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.

Frequency Between Fire Pump Tests

Q: How long is a grace period for the annual fire pump test to be past due?

A: Well, technically, there is no grace period. Either you are compliant or you are not. But most AHJs usually have their way of determining time when it involves frequencies for testing and inspection.

One AHJ may be “by the NFPA book” and when the NFPA code or standard says annually, that means it needs to be done within 12-months of the previous annual test. CMS typically does not allow for more than 12-months for an annual test. In other words, there is no “12-months plus 30-days” for CMS.

But accreditation organizations (AO) seem to have a slightly different interpretation of time. Where NFPA says annually, one AO could mean 12 months from the previous test, plus or minus 30 days. But, as mentioned, CMS does not like the “plus” side of the equation, meaning they don’t mind if you do your flow-test before 12 months has pass from the last test, but they don’t care for one day beyond 12 months. So, state agencies surveying on behalf of CMS would likely cite an organization if the test is one or more days beyond 12 months from the last test, but many accreditation organizations would allow up to 30-days past the 12-month date.

This is one area where NFPA has not clearly defined how they interpret the different time periods for testing or inspection. They purposefully leave this open for the AHJ to decide, but the problem is, hospitals typically have 5 or 6 different AHJs who inspect them for compliance with the Life Safety Code. Chances are, you will never get all 5 or 6 AHJs to agree on what it means. It’s a crap-shoot sometimes. You don’t know how one particular AHJ will respond until they are onsite and write a citation. So, the hospital has to follow the most restrictive interpretation.

Fire Extinguishers in an ASC

Q: We have a 1400 square foot ambulatory surgical center (ASC). In the plans there are only 5 Fire Extinguishers throughout the facility. I looked at 2012 Life Safety Code and the referenced NFPA 10-2010 but still not sure. What are the locations and how many fire extinguishers should be in this 3 operating room 1400 square foot ASC?

A: The placement of portable fire extinguishers is determined on the length of travel distance to get to a fire extinguisher…. It is not determined by the total square footage of the facility. According to NFPA 10-2010, the maximum travel distance to get to a fire extinguisher is dependent on the classification of the fire extinguisher, the capacity of the fire extinguisher, and the potential level of hazard from the fire.

Class A fire extinguishers are for normal combustibles, such as paper, wood, plastic and linens. The maximum travel distance to get to a Class A extinguisher is 75 feet for all capacities of Class A extinguishers, and all potential levels of hazard from the fire. That means you need a Class A extinguisher within 75 feet of all paper, wood, plastic and/or linen. Since paper, wood, plastic and linen are nearly everywhere in a healthcare facility, you will need a Class A fire extinguisher within 75 feet of everywhere inside the facility.

Class B fire extinguishers are for flammable liquids, such as alcohol, alcohol-based hand-rub (ABHR) solution, and xylene. The maximum travel distance to get to a Class B extinguisher is either 30 feet or 50 feet, depending on the capacity of the Class B fire extinguisher, and the level of hazard of the potential flammable liquid fire. The capacity of a Class B extinguisher is pre-determined by the manufacturer, and is identified on the extinguisher label. Usually, it is determined by the ability of the extinguisher to extinguish a fire, so the quantity of the product in the extinguisher is a factor. According to Table 6.3.1.1 of NFPA 10-2010, where the level of the potential hazard is low, a 5-B extinguisher is only permitted a 30-foot travel distance, but a 10-B extinguisher is permitted a 50-foot travel distance. Similarly, if the level of potential hazard is moderate, then a 10-B extinguisher is permitted a 30-foot travel distance, and a 20-B extinguisher is permitted a 50-foot travel distance.

Class C fire extinguishers are for electrical fires. An electrical fire is started by electricity, but the actual substance that burns is either Class A (normal combustibles) or Class B (flammable liquids). Therefore, where potential electrical fires are expected, then a Class C extinguisher is needed, based on the maximum travel distance to get to the extinguisher on either Class A or Class B standards.

Class D fire extinguishers are for combustible metals such as magnesium, zirconium, and potassium, which a typical healthcare facility does not have. Therefore, Class D extinguishers are not required if you do not have any of the combustible metals.

Class K extinguishers are for fires from cooking appliances that involve combustible cooking media (vegetable or animal oils and fats). These are found in kitchens and the maximum travel distance to get to a Class K extinguisher is 30 feet.

The determination of the level of hazard for a Class B potential fire is subjective and could vary depending on the surveyor and authority having jurisdiction (AHJ). For a healthcare facility, a low level of hazard would be areas where individual (or low quantities) of ABHR dispensers or bottles are located, and low levels of alcohol or xylene are located. A potential hazard of flammable liquids is moderate where larger quantities of flammable liquids are stored. But be careful: Based on the information in NFPA 10-2010, you would need Class B extinguishers with a 10-B rating with a maximum travel distance of 50 feet to cover potential fires from ABHR dispensers. This is often overlooked by designers when they are placing portable fire extinguishers in new facilities. Instead of the usual 75 maximum travel distance to get to a Class A extinguisher, you will need to place the Class B extinguishers with a maximum 50-foot travel distance to cover potential fires from ABHR dispensers.

There are fire extinguishers that have the rating to fight Class A, Class B, and Class C fires all in one extinguisher. These are typically ABC dry powder extinguishers, but there are other media types, such as clean agent extinguishers that can achieve an ABC rating. But dry powder extinguishers are not desirable in operating rooms where the possibility of infection is high if the dry powder extinguisher is activated. Therefore, many healthcare facilities rely on water-mist Class A:C extinguishers and a carbon dioxide (CO2) Class B inside the operating room. But you would have to make sure the water-mist extinguishers are charged with distilled water and nitrogen to prevent the growth of pathogens.

Other healthcare facilities do not use water-mist extinguishers in the operating room and rely on the sterile water in a bowl in the sterile field to extinguish any Class A fires that may occur. They then find Class B:C extinguishers to cover Class B and Class C potential fires. Keep in mind, there is no requirement that portable fire extinguishers have to be located inside each operating room. The fire extinguishers just have to be located within the maximum travel distance permitted for each classification of extinguisher, capacity of the extinguisher, and the level of hazard for the potential fire. But be careful: Some operating rooms are rather large, and it might be more than 30 feet to travel from the far corner of the operating room, to the Class B extinguisher in the hallway.

Class K extinguishers are required in kitchens, and the maximum travel distance to get to a Class K extinguisher is 30 feet. A placard needs to be installed above the Class K extinguisher that informs the staff to activate the kitchen hood suppression system first, before using the Class K extinguisher.

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 5.1.4.8.4 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 5.1.4.8.5 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, 11.3.2.3), 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.

Fire-Proofing Structural Steel

Q: Since our last survey we were introduced to an epoxy based intumescent fire proofing product to repair damaged areas of vermiculite fireproofing on our structural steel that had bare areas from years of wear. Two weeks-ago we had a “mock” survey by my corporate representative and while he seemed to like the application process, he is not sure that we could pass our survey when the real surveyors come. He suggested that we think about having it repaired with the vermiculite product. What do you think? Any help would be greatly appreciated.

A: This issue is not clearly understood among the different AHJs, let alone their surveyors. I can say that many surveyors would not know what they are looking at if you had mixed fire-proofing products on the same piece of structural steel.

But, to be sure, your representative who conducted the mock survey is correct: You cannot mix and match different types of fire-proofing material to repair missing fire-proofing on structural members of your building. While you will not find a specific code or standard that says this, it is an interpretation of the UL listings for fire-proofing structural members of the building. Simply stated; There is no UL listing that allows you to mix different UL listed products to form a contiguous fire-proofing protection on the structural member. If there is, I have not seen or heard about it.

So, heed the advice from your mock surveyor and only put back the same type of fire-proofing material that was originally applied. Sounds to me, that your mock surveyor should be a real surveyor for CMS or one of the accreditation organizations. He seems to know what he is looking at.

Contiguous Facilities

Q: If an inpatient in a hospital (healthcare occupancy) is taken into a building that is not a healthcare occupancy for say CT or MRI, does this building have to then meet the requirements in the Life Safety Code for a healthcare occupancy?

A: According to section 19.1.3.4.2 of the 2012 LSC, it says ambulatory care facilities, medical clinics, and similar facilities that are contiguous to healthcare occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. This is new for the 2012 LSC and was not found in the 2000 edition, so not everyone may be aware of this.

But the kicker is “inpatients who are capable of self-preservation”. The inpatient really does need to be capable of taking action for their own self-preservation without the assistance of others.

All healthcare occupancy inpatients, even if it is just one inpatient, that are brought into a contiguous facility that is not a healthcare occupancy for diagnostic or treatment purposes must be capable of self-preservation. Otherwise, it is not permitted.

Coded Words for Fire

Q: Our EP manager was discussing removing the code words like Code pink for a missing infant to missing child and the conversation about code red for fire came up. Someone in the conversation said there is a NFPA code requirement that “Code Red” must be in code form instead of saying “Fire”. I have not heard of this and haven not search yet. I wondered what your take is on this. Our FA system is programmed for voice that states “Code Red” and then the location.

A: Well… that ‘someone’ is actually correct… sort of.

Section 19.7.1.7 of the 2012 Life Safety Code actually does say “When drills are conducted between 9:00 pm and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms.” So this section of the LSC does reference a code-word should be used to identify fire, such as ‘Code Red’.

But that requirement for a coded word for fire is only found in section 19.7.1.7 and is limited to a fire drill conducted without audible alarms between 9:00 pm and 6:00 am. Therefore, since the Life Safety Code does not prohibit it, the conclusion is you would be permitted to say ‘Fire’ instead of ‘Code Red’ when the fire alarm system is activated.

But is that in your best interest to do so? I am aware that there is a trend across the country to eliminate coded words for certain emergency announcements. Many coded words (i.e. ‘Code Pink’) are not used universally in all hospitals, and since healthcare staff is rather transient, the movement is to have announcements identify the actual emergency rather than using coded words. But the original intent in using ‘Code Red’ is to alert staff of a fire condition, yet not alarm visitors and patients un-necessarily, thereby causing a panic.

If it were my hospital, I would be an advocate to allow ‘Code Red’ to remain, but eliminating other coded words should be considered.

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.

Generator and ATS Testing

Q: I am new in my position and I would like to know what the weekly generator inspection consists of? I also would like to know what the monthly generator inspection and transfer switch testing consist of?

A: Some of this depends on your accreditation organization. Not all AOs survey generators the same way. So I will provide you with what the Life Safety Code requires, with the understanding you need to check with your AO to determine if they have additional requirements. The following information is derived from NFPA 110-2010, which says the routine maintenance and operation testing program must be based on the manufacturer’s recommendations and instruction manuals (section 8.1.1):

Weekly Inspections:

  • Inspection per manufacturer’s recommendation
  • Storage batteries, including electrolyte levels or battery voltage, used in conjunction with systems must be inspected weekly and maintained in accordance with the manufacturer’s specifications. (8.3.7)
  • Emergency Power Supply Systems (EPSS), including all appurtenant components, must be inspected weekly. (8.4.1)

Monthly Inspections:

  • Maintenance of lead-acid batteries must include the testing and recording of electrolyte specific gravity, Battery conductance testing is permitted in lieu of the testing of specific gravity when applicable or warranted. (8.3.7.1)
  • Emergency Power Supply Systems (EPSS), including all appurtenant components, must be exercised under load at least monthly. (8.4.1)
  • Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods (8.4.2):
    • Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
    • Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
  • Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours (8.4.2.3).
  • Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized (8.4.2.4).

Annual Test:

  • A fuel quality test must be performed annually in accordance with ASTM D 975 Standard Specification for Diesel Fuel Oils.

3-Year Testing:

  • Level 1 EPSS shall be tested at least once within every 36 months (8.4.9)
  • Level 1 EPSS shall be tested continuously for the duration of its assigned class (8.4.9.1).
  • Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours (8.4.9.2).
  • The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested (8.4.9.3).

Automatic Transfer Switches:

  • Transfer switches shall be operated monthly (8.4.6).
  • The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position (8.4.6.1).

Circuit Breakers:

  • EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the “off” position (8.4.7).
  • Circuit breakers rated in excess of 600 volts for Level 1 system usage shall be exercised every 6 months and shall be tested under simulated overload conditions every 2 years (8.4.7.1).
  • The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

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.

Smoke Detectors in Patient Restrooms

Q: Can I provide a smoke detector in an existing hospital patient restroom? The smoke detector was recommended by the hospital safety committee to avoid smoking in these rooms. Our patient restrooms have bathtubs but no showers. Some restrooms are protected by sprinkler systems and some are not. Some restrooms are provided with heat detectors, but of course, they do not activate during patient smoking. Even though the safety committee recommended changing to a smoke detector, I am afraid of false alarms from the high humidity a restroom can generate.

A: While the Life Safety Code and NFPA 72-2010 do not require smoke detectors to be installed in patient bathrooms, designers usually do not place them there for fear of nuisance alarms. But experience shows a smoke detector in a bathroom that has a toilet and a bathtub is not the same risk that a smoke detector located in a bathroom with a shower has. The shower will atomize water droplets to form high concentrations of water vapor and will more likely cause nuisance alarms. The bathtub and toilet would not raise the relative humidity much at all.

Try it and see how it works for you.

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.