Q: In healthcare, when calculating the 300 cubic feet of oxidizing gases like oxygen and nitrous oxide, do “air” tanks figure into the calculation?
A: Yes… According to 3.3.128 of NFPA 99-2012, an oxidizing gas is a gas that supports combustion. And, according to 11.1.1, the NFPA 99-2012 Health Care Facilities Code applies to all nonflammable medical gases. So, if the cylinders of compressed air are medical gases, then yes; they apply to the oxidizing gases rule.
Q: Are there any regular testing requirements for Generator Remote Shutdown Switches?
A: Yes… sort of. Section 8.4.1 of NFPA 110-2010 says generators, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
The term “appurtenant components” means accessory components, and the remote shutoff switch would be included in that. So, technically, you are required to inspect the remote shutoff switch weekly and exercise it when the generator is operating. You would not want to exercise this switch while the generator is under a load from the building, but rather during the ‘cool-down’ period after the test.
I have already seen a finding from a state agency that cited a facility for not testing the switch. It seems to be a ‘ticky-tack’ finding, but the surveyors are getting tougher because CMS is continuing to crack-down on Life Safety Code issues. But the bottom line… NFPA 110-2010 does require you to inspect it weekly and test it monthly.
Q: Where does “Homelike Environment” end and fire safety begin? We have a resident in our nursing home who likes to push-pin everything she makes in activities to her wall. On a recent Life/Safety visit, the surveyor noted that she had “too much stuff” on her walls and that it was a “fire hazard”. We are supposed to encourage “homelike” and “Individualized Care”, then we are told that we have to tell the resident that they cannot decorate their “home” as they desire. I know there has to be a balance, but the items do not impede entrance nor egress to the room and, while there are a lot of items, high and low, they are not on top of one another nor sticking out more than 3 or 4 inches from the wall. One might consider them to be “cluttered”, however, they are not on the floor. Also, he said that everything from pictures to wreaths to whatever has to be “flame retardant”. Are we to spray everything that a family brings in from home?
A: I am very empathetic to your problem as I understand that CMS state agencies want you to create a “home-like” environment for long-term care patients, but yet, you are required to comply with the 2012 edition of the Life Safety Code. However, there is some relief available to you on this subject. Since CMS adopted the 2012 edition of the Life Safety Code effective July 5, 2016, section 18.104.22.168 changes how decorations may be displayed in the patient’s room:
- Combustible decorations are permitted to be attached to walls, ceiling and non-fire rated doors as long as the decorations do not interfere with the operation of the doors
- Combustible decorations may not exceed 20 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is not fully protected by sprinklers
- Combustible decorations may not exceed 30 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is fully protected by sprinklers
- Combustible decorations may not exceed 50 percent of the wall, door and ceiling areas inside patient sleeping rooms having a capacity of no more than 4 patients, in a smoke compartment that is fully protected by sprinklers
When calculating the percentage of area of the walls covered by decorations, you calculate only the wall-sections that are used by the decorations. In other words, if the south-wall of the patient room is the only wall that has decorations pinned to it, then you only use the area of the south wall, and not the other three walls in the room.
I don’t know if the decorations covering the walls that the surveyor saw were within the above limitations, but I would think your organization could calculate the square footage of the decorations and ensure it stays within the limits.
Q: Is there presently a date in place in which existing Healthcare Occupancies (remaining portions or in their entirety) must be fully sprinklered?
A: Yes and no.
All existing high-rise hospitals must be fully protected with sprinklers by July 5, 2028. This was decided by CMS in their Final Rule to adopt the 2012 Life Safety Code.
For existing hospitals that are not high-rise (i.e. do not have an occupied floor higher than 75 feet above the lowest level used by a fire department) there is no requirement to become fully sprinklered unless their construction type requires it or there is renovation.
Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB). For quarterly fire drills, are we to have staff activate the building general fire alarm system for every drill? For the stand alone sites I do not see a problem with this, but for the others in MOBs we do not own where 90% of other tenants are business occupancies, cancer patients, rehab centers, etc. Are we not creating unnecessary stress by dumping the building four times a year, which is exactly what would happen if we pulled the pull station in a MOB? I reached out to the supervisor of the surveyor that cited us, but wanted to gain another perspective.
A: The surveyor was correct in citing you for not activating the fire alarm system during a fire drill. It is a key requirement that provides staff with knowledge and understanding what an actual fire alarm sounds and looks like.
I do see and understand your dilemma in those MOB’s where your organization is not the only entity in the building. But haven’t you discussed this issue with your landlord yet? There are ways to re-program the fire alarm occupant notification system (i.e. strobes, horns, chimes, etc.) to activate only in your area. Yes. It may cost some funds to do so, but that is part of the cost of doing business in a building that is shared with other entities.
Also, have you discussed the option of conducting building-wide fire drills with the other occupants? Since you’re an ASC you must do quarterly fire drills and the other entities may be business occupancies which only require annual fire drills. But if you scheduled the drills at a time when it is least likely to disrupt operations of everyone, then the other entities may be more accepting of your situation.
The bottom line: You must activate the fire alarm system when conducting a fire drill. Discuss this challenge with the other tenants and see if they are willing to accommodate you at various times (i.e. early in the day or late in the afternoon). If not, then invest in making the fire alarm system activate only in your area during a fire drill.
You do have options…
Hospital emergency operations plans can be overwhelming to produce and maintain. Not only can they be time-consuming to develop, but a challenge is to keep it user-friendly too. This resource must be simple to use to ensure its effectiveness when using it during a disaster.
Most healthcare institutions have limited resources and finances to put towards emergency preparedness plans; however, one disaster of significant impact could destroy your healthcare entity if you do not have the appropriate plans in place.
Here are a few suggestions to use to evaluate your emergency operations plans:
- Do you have the recommended emergency operations template for your facility that includes the CMS requirements for emergency preparedness?
- Do you have a current Hazardous Vulnerability Assessment (HVA) and is it reviewed/evaluated annually? Does it identify your top five risks based on your history and location?
- What does your communication plan entail and does it include downtime procedures?
- Do you have all of your response plans in an annex at the back of your emergency operations plan?
- Do you have designated Incident Command Staff that have received training (national recommendations) for their designated position? Do you have identified Incident Commanders?
- Is there a designated back up for your Incident Command Center if the primary location is compromised?
- Are you in compliance with the 96-hour sustainability requirement?
- How often do you open the Incident Command Center to ensure ease of use by the team members?
Next week, I will be sharing resources to aid in the development of emergency operations plans. In the meantime, if you would like more information regarding hospital emergency operations plans, please contact me at firstname.lastname@example.org.
Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that these staff sleeping rooms are required to have single-station smoke alarms since they are considered a different occupancy (Lodging & Rooming House) and must meet section 22.214.171.124.1 of the 2012 LSC. But can I use the hospital smoke detector system in lieu of installing a battery-operated smoke alarm in these rooms?
A: Yes… According to section 126.96.36.199 of the 2012 LSC, smoke detectors connected to the building’s NFPA 72-2010 approved fire alarm system are permitted instead of installing the battery-operated smoke alarms. However, section 188.8.131.52.1.4 does say these system smoke detectors must be arranged to function in the same manner as single-station or multiple-station smoke alarms. The typical building system smoke detectors are detectors only and do not provide any occupant notification.
But the single-station smoke alarms provide both functions: Detection and occupant notification. Therefore, on a technical standpoint, the basic fire alarm system smoke detectors are not enough and some sort of occupant notification system must be provided. Now, having said that, I do know that some accreditation organizations are simply accepting a smoke detector in the on-call sleeping room without the inclusion of an occupant notification device. But, I am aware that some state agencies surveying on behalf of CMS do enforce the letter of the code and will cite you if you do not have an occupant notification device in the room.
Q: Are gift shops stilled classified as hazardous areas if they have quantities of combustibles? I do not see the standard for gift shops to be classified as hazardous areas in the 2012 addition.
A: Nope. The 2012 edition dropped the requirement that gift shops have to be considered hazardous areas that was found in previous editions.
Since the combustible items that are in gift shops (i.e. greeting cards, clothes, stuffed animals, etc.) are on display rather than ‘in storage’ they are not required to comply with 184.108.40.206.5 of the 2012 LSC for hazardous areas. However, the storage room for gift shops still must comply with 220.127.116.11.5 for hazardous areas.
Q: For annual fire extinguisher inspection how long before and how long after do you have to re-tag?
A: NFPA 10-2010 section 18.104.22.168.1 says fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.
Depending on your accreditation organization, and your state agency surveying on behalf of CMS, an annual activity is required to be completed 12 months from the previous activity, during the 12th month. CMS is very adamant: If the requirement is annual, you cannot go more than 12 months between activities.
Q: What resources can hospitals use to manage workplace violence?
A: The law enforcement department in your community is a significant resource for healthcare in designing a united front in managing workplace violence. A strong and consistent relationship between the law enforcement leaders and the hospital leaders promotes safety for your institution and ensures a final process when violence occurs.
Here are some actions and tactics to consider in your program:
- Develop a direct communication plan between the hospital and law enforcement to troubleshoot emergencies. Have the leaders from law enforcement and the hospital meet regularly, including front-line staff. Record meeting notes and send them to the Environment of Care Committee for sharing and consistency.
- Consider including law enforcement in your security huddles.
- Develop a prior notification process with law enforcement that addresses incarcerated individuals or other persons in a “Not Free to Leave” status. This provides advance notice to the emergency department of a potential high-risk patient.
- If you have a hospital security department, consider making the security supervisor the point of contact for any officer coming to the hospital.
- A weapons policy that addresses managing a police officer’s weapon if they are injured and brought into the emergency department.
These are just a few of the actions that can be taken with your local law enforcement agency to improve the overall safety of your facility. Enlisting their assistance and creating a relationship is pivotal to a successful workplace violence program.
If you would like a copy of Carrie’s article, “Teaming Up with Law Enforcement in Healthcare,” please email email@example.com with “Carrie’s Article” in the subject line.
Q: We have a generator that doesn’t meet the 30% load for the monthly run so we have to do an annual run with the load at 50% for 30 min and 75% for 60 min for a 90-minute continuous run. Our contractor did the annual run but he ran it with 52% for 30 min, 75% for 30 min and 81% for 30 min, then he continued to run it for 2½ more hours dropping the percentages as he went for 4 continuous hours at not less than 30%. My question is does these meet the intent of the standards for both an annual and a 3-year load test?
A: According to section 22.214.171.124 of NFPA 110-2010, when the 3-year load test is combined with the annual load test, the first three hours shall be not less than 30-percent of the nameplate kW rating, and the remaining hour shall be not less than 75-percent of the nameplate kW rating.
I would say the test as you described could meet both the annual requirements and the 3-year test requirements, depending on how the test was administered. It is obvious that an external load bank would be required for the annual test since the building load did not meet the minimum 30%.
But section 126.96.36.199 of NFPA 110-2010 requires the 3-year test to begin with the building’s load through the ATS and only supplement the load with a load bank if the load cannot meet 30%. It is not at all that easy to combine an annual load test with a 3-year load test, because the 30% minimum load is not achieved through the building’s load.
The generator load testing requirements are minimum load settings, and it is permitted to exceed these minimums.
Q: How would I go about cleaning the dust off the sprinkler heads?
A: Use a portable vacuum cleaner. If the dirty heads are located in the kitchen, then you will need warm soapy water and a toothbrush. But you may want to leave that to a sprinkler contractor to do.
Q: We have chosen to install some extra battery egress lights in our hospital that are not required. One of these areas is our stairways. 100% of the lighting in our stairways is served by the hospital’s generators including the circuits that feed the egress lights. We installed the battery egress lights to help keep people calm and avoid falls during the ~5 second transition to generator power. Do we need to do 90-minute annual testing on battery lights served by generator power? We will continue the 30-second monthly testing, but the 90-minute testing is difficult as all lighting in the stairway must be turned off during testing. Also, these lights will never see a 90-minute outage. NFPA 101 2012 188.8.131.52 says an annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Since these are not required, I am hoping that these lights do not need the annual test.
A: Well, I’m sorry to say, but section 184.108.40.206 of the 2012 LSC says if you have an existing feature of life safety that is not required by the LSC but is obvious to the public then you must maintain it or remove it. I think we’d all agree that battery powered emergency lights would be obvious to the public. According to the NFPA standards, maintaining it includes the monthly 30-second test and the annual 90-minute test. You say the 90-minute test will be difficult since the normal power to the battery powered emergency lights are on the same circuit as the stairwell lighting.
Well, I see your point. You cannot turn off the circuit to the stairwell lighting for 90 minutes… that would be the wrong thing to do. I suggest you install a toggle switch on the battery powered emergency light fixture, preferably on top where it cannot be inadvertently turn off. This toggle switch will turn off the normal power to the battery powered emergency lights and you can perform the 90-minute test without interrupting normal power to the stairwell lights. So, you must test those battery powered lights, even if they are not required. Personally, I like your thinking… providing battery powered lights for the 5 seconds or so of darkness in the stairwell, even though you don’t have to.
Q: I’m a Facilities Director overseeing an existing 8-story (basement included) acute care hospital fully sprinklered. We wish to mechanically lock (no auto unlock feature) floors 2-7 (Floor one being the level of exit discharge) to prevent reentry from the stairwell side. I believe there used to be an exemption from the requirements of Chapter 7 of the 2000 LSC 101 for existing hospitals that are fully sprinklered; does that exemption still exist in the 2012 version? Can I lock all 6 floors and be code compliant?
A: Section 220.127.116.11.3 of the 2012 LSC says doors not located in a required means of egress shall be permitted to be subject to locking.
Section 18.104.22.168.9 says existing healthcare occupancies shall be exempt from re-entry provisions of 22.214.171.124.8. But Annex section A.126.96.36.199.9 says doors to the stairwell on the different levels should be arranged to open from the inside of the stairwell at not less than every third floor so it will be possible to leave the stairway if fire renders the lower part unusable.
Section 188.8.131.52.8 says every stairwell that serves more than four stories must have re-entry capabilities on every floor, but the doors could be locked with electronic locks that unlock (not unlatch) on a fire alarm signal. Section 184.108.40.206.8 continues with other exceptions and requirements, but section 220.127.116.11.3 says hospital are exempt from all of that.
So, based on the Annex section, you can lock the doors from re-entry from the stairwell side, but every third floor needs to be unlocked. So, come up with a plan so every third floor door is unlocked for re-entry.
Q: If an Emergency Department is greater than 7500 square feet but less than 10,000 square feet and is deemed to have “sleeping accommodations”, do the requirements of direct visual observation per 18.104.22.168.2.1(D)(1)(a) apply since only “sleeping accommodations” are provided and not a full “patient sleeping room”?
A: According to CMS, the answer is yes. They consider an Emergency Department that provides observation beds to be sleeping accommodations and must comply with healthcare occupancy sleeping suite requirements, and all that is required. They also consider the patient as ‘inpatients’, which seems to be contrary to the what the rest of the world believes.
See if you can do one of the following:
- Eliminate the ‘observation beds’
- Relocate those ‘observation beds’ to a regular inpatient unit
- Divide your ED up into multiple suites to get around the direct observation requirement for sleeping suites over 7500 square feet.