Hand Washing Sinks

Q: We have a relatively new Infection Control team.  They are performing rounds and having mock surveys with a nurse-consultant that cites issues from the 2014 FGI in areas that are much older.  The issue comes in when we are required to install new sinks (dirty, clean and a hand washing) in existing spaces.  We are a mixed hospital, some new that has to meet 2014 FGI due to new renovations.  What are your thoughts on the older areas that have not been renovated?  I am working with a design professional to see how he would design a space for the number of sinks and what reference he should use.  If it is simple and best practice to install them, I am all for it but some of the renovations come with a significant space or capital impact.  I am not sure if this is something you can help guide with or not.

A: According to Joint Commission’s standard EC.02.06.05, EP 1, the FGI Guidelines (2014 edition) is only used when planning for new, altered, or renovated spaces. Tell the nurse-consultant surveyor she is mistaken. She cannot apply a new guideline to an existing condition.

Now… if there was a requirement to have hand-washing sinks in the room at the time the room was designed or renovated, then she is correct and the sinks need to be installed. But if she plays that card, then she needs to provide evidence that there was a regulation (state, local, or otherwise) that required the sink at the time the room was designed and constructed.

Risk Assessments

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk level on the impact to patients/staff assuming the item being assessed would not be available or functional? We are performing a risk assessment on facility systems and medical equipment and are wondering what the standard is in the approach.

A: It sounds like you’re referring to the NFPA 99-2012 risk assessment for building system categories. If so, then the assessment is conducted with the assumption of the worst-case scenario, whereby the systems being evaluated fail and back-up systems (i.e. emergency power generators) fail as well. According to section A.4.1 of NFPA 99-2012, the category definitions apply to equipment operations and are not intended to consider intervention by caregivers or others. Also, the Introduction to Chapter 4 in the NFPA 99-2012 Handbook, the authors say:

“Each system must be evaluated for its impact on both the patients and the caregivers if the system should fail. Based on the worst-outcome scenario of a failure’s impact, the system is assigned a category. The chapter on that system the describes the requirements for the selected category.”

Be aware that the chairman of the Technical Committee who wrote this new chapter 4 for NFPA 99-2012 told me the intent was for the risk assessment to be on new equipment only, and existing equipment was exempted. However, chapter 4 of NFPA 99-2012 does not say that, and CMS is requiring all certified hospitals to have this risk assessment conducted on existing equipment as well as new. So, I recommend to my clients to do the assessment (it only takes a few minutes) on all existing and new equipment until such time CMS changes their minds.

Clearance in Front of Electrical Panels

Q: What is the clearance required in front of electrical distribution panels?

A: According to NFPA 70-2011, article 110.26, a minimum of 36 inches clearance is required in front of all electrical equipment, including controls and panels, extending from the floor to a height of 6 foot 6 inches or the height of the equipment whichever is higher. You must maintain clearance for the width of the equipment or 30 inches, whichever is greater, and all doors and panels must be able to be opened at least 90 degrees.

Business Occupancy Smoke Detectors

Q: What are the requirements for the use of smoke detectors in a business occupancy physician office that does not have an automatic sprinkler system? The fire marshal is telling me that this is not required, but I cannot find a specific clause in NFPA and want to confirm that statement.

A: The fire marshal is sort-of correct. Smoke detectors are not mandatory in a business occupancy, if the building already has manual pull stations. According to section 39.3.4.2 of the 2012 LSC, only one of the following means to initiate of the fire alarm system is required:

  • Manual pull stations
  • Smoke detectors
  • Sprinkler system water-flow

Of course, you can have more than one type to initiate the fire alarm system, but if you have manual pull stations, then smoke detectors are not required. But, if you don’t have manual pull stations or a sprinkler system, then smoke detectors would be required if the building requires a fire alarm system. Some smaller business occupancies do not require a fire alarm system. Check with your state and local authorities to see if they have other regulations concerning initiating devices.

Exit Enclosures

Q: I have been reading about stairwells and what the code addresses. I am interpreting that the AHJ’s are stringent of what can be placed in a stairwell. Is it permissible to install wireless access points (antenna) in the stairwell? We have no phone coverage in the stairwells because of the absence of these antennas. I believe without phone coverage creates a safety issue. If an emergency would arise in the stairwell we do not have access to contact anybody.

A: Well… section 7.1.3.2.1 (10)(b) of the 2012 LSC does say electrical conduits serving the exit enclosure are permitted to penetrate the exit enclosure, but the Annex section clarifies that the only electrical conduits permitted to penetrate the exit enclosure are those serving equipment permitted in the exit enclosure, such as security equipment, PA systems, and fire department emergency communication devices. Wireless access point antennas typically are not considered essential equipment in the stairwells and does not meet the intent of the list identified in the Annex section.

While you may get a local AHJ to approve such an installation, I think you will have trouble with national AHJs for accreditation. I suggest you install your antennas outside of the stairwell.

Lower Bottom Rods

Q: My department is assisting with a fire/smoke barrier door assessment. I have noticed that some of the ¾-hour corridor doors have had the lower bottom rods removed from the latching hardware with cups still visible in the floor. It is unclear why they were removed however the top latches still work and secure the door. There are small screw holes in the door as well where the hardware was removed. My thoughts are the door has been modified and no longer compliant. What are your thoughts?

 A: You are absolutely correct… By your description, the lower bottom rods were required when the door was installed, but have since been removed (They do get hit and bent by carts and are simply removed rather than replaced by poorly informed maintenance staff.) This door no longer meets the UL listing it received by the manufacturer when it was installed, and should be flagged as not passing an annual inspection.

Fire Alarm Testing Qualifications

Q: I have a question regarding testing and repair of fire alarm system in a hospital setting. Is a maintenance person who is employed by the hospital as an electrician but who has 10-years of on-the-job training qualified to swap out a bad smoke detector or smashed fire pull station? Is he allowed to test the notification and transmission equipment also? Just trying to make sure I am interpreting the NFPA standards correctly.

A: Only if that individual has met the requirements of NFPA 72-2010, section 10.4.3.1, which describes the certification(s) needed in order to provide service, testing or maintenance on the fire alarm system:

“Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of systems addressed within the scope of this Code. Qualified personnel shall include, but not be limited to, one or more of the following:

  • Personnel who are factory trained and certified for the specific type and brand of system being serviced;
  • Personnel who are certified by a nationally recognized certification organization acceptable to the authority having jurisdiction;
  • Personnel who are registered, licensed, or certified by a state or local authority to perform service on systems addressed within the scope of this Code;
  • Personnel who are employed and qualified by an organization listed by a nationally recognized testing laboratory for the servicing of systems within the scope of this Code.”

Now, the Annex section A.10.4.3.1 of NFPA 72-2010 says it is not the intent to require personnel performing simple inspections or operational tests of initiating devices to require factory training or special certification, provided such personnel can demonstrate knowledge in these areas. While the Annex section is not part of the enforceable code, it is explanatory information from the Technical Committee on what they were thinking when the standards were written. Most AHJs follow the Annex section and enforce it as part of their own standards.

However, changing out smoke detectors and/or pull stations is not within the purview of what the Annex section is saying.  To directly answer your question: If your electrician does not have any of the certifications identified in section 10.4.3.1, then no, he is not permitted to replace detector and/or pull stations.

Warning Placards Above Class K Extinguishers

Q: We recently were cited for not having the placard placed on the wall above the K Fire Extinguisher, however, the “warning” on the front of the extinguisher is in red and it states: “WARNING” “IN CASE OF APPLIANCE FIRE, FIRST, ACTIVATE FIRE SUPPRESSION SYSTEM OR TURN OFF APPLIANCE TO REMOVE HEAT SOURCE”. The instructions on how to use the extinguisher is above that warning on the actual extinguisher. Does this meet the intent of the standard?

A: I don’t think so… While some surveyors and inspectors may accept this as meeting the intent of the standard, I’m not sure that it does. According to NFPA 10-2010, section 5.5.5.3, it says a placard shall be conspicuously placed near the Class K extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. A warning label on the extinguisher itself is not necessarily placed “near” the extinguisher. If the Technical Committee at NFPA wanted the sign on the extinguisher, they would have said that. Also, a warning label that is part of the fire extinguisher label is not necessarily considered to be “conspicuously” placed. People will not see the warning label on the extinguisher as easily as they will see a separate placard affixed to the wall above the extinguisher.

Also, the Meriam Webster definition of ‘Placard’ is: “A poster or sign for public display, either fixed to a wall or carried during a demonstration.” I don’t think a warning label on the extinguisher meets this definition. Also, section A.5.5.5.3 in the Annex says the placard should be 11 inches by 7 5/8 inches in size. That size sign is not typically possible on a Class K extinguisher. While the Annex section is not part of the enforceable section of the standard, it is considered to be explanatory material to assist the reader to understand the intentions of the Technical Committee who wrote the standards. I would conclude the Technical Committee wants a separate sign posted on the wall near the extinguisher.

I’m sure some surveyors may accept this warning label, but I would not. [Perhaps that is good that I’m not a surveyor anymore….?]

ABHR Dispensers in Business Occupancy Corridors

Q: Do you know of any other information on alcohol-based hand-rub (ABHR) dispensers not allowed in the egress corridors of business occupancies? I need more information than what you have already posted:

Please be aware that alcohol-based hand-rub (ABHR) dispensers are not permitted in the egress corridors of Business Occupancies. This is found in section 38/39.3.2.1 of the 2012 Life Safety Code which references section 8.7 of the same code. Section 8.7.3.2 states: “No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure…” Since corridors are used as paths of egress in business occupancies that means ABHR dispensers are not permitted in business occupancy corridors. Now, sections 18/19/20/21.3.2.6 of the 2012 Life Safety Code allows ABHR dispensers in corridors of healthcare occupancies and in ambulatory health care occupancies…. but not business occupancies.

A: Nope… that’s all there is. It is very clear that the Life Safety Code does not permit the storage or handling of flammable liquids in egress areas, based on section 8.7.3.2. However, the Life Safety Code makes specific exceptions for healthcare occupancies (i.e. hospitals, nursing homes, long term care centers, etc.) and ambulatory health care occupancies (ASC, physical therapy units) based on section 18/19. 3.2.6 and 20/21.3.2.6. The problem is, these exceptions do not apply to Business Occupancies and chapters 38/39 do not contain anything that would over-ride 8.7.3.2.

Sprinkler Inventory

Q: We are a life safety service company that provides consultation services for multiple hospitals. We had a hospital go through a survey recently, and the surveyor wrote them up for not having an inventory of sprinkler heads. Would you know where we could find this requirement for this inventory?

A: The surveyor may be looking at NFPA 13-2010, section 6.2.9.7, which does require the facility to have a spare sprinkler list, which is based on the different types of sprinklers in your facility and the quantity of those sprinklers. While this is not the same as saying an inventory of the sprinkler heads is required, you do need to know the types and quantities of sprinklers in your facility.

Or the surveyor may be looking at NFPA 25-2011 section 5.2.1, which requires an annual inspection of all the sprinkler heads. Usually, the hospital will contract this out to a sprinkler contractor and often the report simply says “All sprinkler heads inspected”, or something like that. The problem is, how does the hospital know that the contractor actually inspected every sprinkler head in the hospital? Did the contractor enter every room, every closet, every office, every OR, every equipment room, etc. in the facility? Without a detailed inventory or documentation (such as drawings of sprinklered areas) showing the heads were inspected in the respective areas, what assurance does the hospital (and the surveyor) have that every head was inspected?

But to be sure, there is no direct NFPA standard that says “Thou shalt inventory every sprinkler”, but it is well within the right of the authorities to request documentation that assures how the facility documented the spare sprinkler list and that the contractor inspected every head.

Blanket Warmers

Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the same as having a space heater?

A: No… Portable space heaters are regulated by section 19.7.8 of the 2012 LSC. Blanket warmers are not regulated by the LSC.

However, blanket warmers are unofficially regulated by the accreditation organization and by CMS. While there are not specific standards that address blanket warmers, surveyors will expect the hospital to regulate their blanket warmers via their own policies. The hospital is expected to have a policy that sets the maximum temperature that the blankets may be. Usually, the maximum temp is set at 130 degrees F. Anything over that will likely be scrutinized by a surveyor.

Blanket warmers are considered medical equipment and must be included in the medical equipment inventory, and they must be maintained in accordance with the manufacturer’s recommendations.

Sizing Fire Extinguishers

Q: I can find a lot of information about portable fire extinguishers but nowhere can I find what size is required for use in a hospital. Can you point me in the right direction? We specified 2.5 lbs. and 5 lbs. and no one can tell me what is correct.

A: Section 9.7.4.1 of the 2012 Life Safety Code says portable fire extinguishers must be selected, installed, inspected, and maintained in accordance with NFPA 10. NFPA 10-2010, section 5.1 says the selection of fire extinguishers for a given situation shall be determined by the applicable requirements of Sections 5.2 through 5.6 and the following factors:

  1. Type of fire most likely to occur
  2. Size of fire most likely to occur
  3. Hazards in the area where the fire is most likely to occur
  4. Energized electrical equipment in the vicinity of the fire
  5. Ambient temperature conditions
  6. Other factors

So, you must first determine the classification of the potential fire (Class A, Class B, Class C, or Class K) and then place an appropriate fire extinguisher nearby. How far away from the potential fire is determined on the capacity of the fire extinguisher and the hazard of the potential fire.

For example, Table 6.2.1.1 identifies the fire extinguisher size and placement for Class A hazards. The hazards are listed as Light, Ordinary, and Extra and the selection of the capacity of the fire extinguisher is dependent on the level of hazard and the area served by the extinguisher. For a fire extinguisher that has a capacity of 2-A, the maximum floor area of light hazard (most areas of hospitals are light hazard, other than Laboratories, Pharmacies, Central Storage, Boiler rooms, etc.), it can serve up to 6,000 square feet (3,000 sq. ft. for each unit of ‘A’… 2-A = 6,000 sq. ft.), and the maximum travel distance to get to a Class A extinguisher is 75 feet.

But be careful… as the level of hazard goes up, the area served by the same size extinguisher goes down. Even though they may have the same travel distance to get to an extinguisher (75 feet), the total area served by the extinguisher is reduced. Similarly, Class B, Class C, and Class K have their design limitations as well. You will note that the travel distance for a Class B extinguisher is either 30 feet or 50 feet, depending on the level of hazard and the capacity of the extinguisher. Also, all Class K extinguisher have a maximum travel distance of 30 feet.

Annual Eyewash Station Test

Q: Is there a requirement to test eyewash stations annually? We do a weekly test for various items but are we required to conduct an annual test as well?

A: Yes… ANSI Z358.1-2014 section 5.5.5 says all eyewashes shall be inspected annually to assure conformance with Section 5.4 requirements of this standard.

Section 5.4 says once a year, it is the owner’s responsibility to ensure that eyewashes shall:

  • Be assembled and installed in accordance with the manufacturer’s instructions, including flushing fluid delivery requirements.
  • Be in accessible locations that require no more than 10 seconds to reach. The eyewash shall be located on the same level as the hazard and the path of travel shall be free of obstructions that may inhibit its immediate use.
  • Be located in an area identified with a highly visible sign positioned so the sign shall be visible within the area served by the eyewash. The area around the eyewash shall be well-lit.
  • Be arranged such that the flushing fluid flow pattern as described in Section 5.1.8 is not less than 33 inches and no greater than 53 inches from the surface on which the user stands and 6 inches minimum from the wall or the nearest obstruction.
  • Be connected to a supply of flushing fluid per the manufacturer’s installation instructions to produce the required spray pattern for a minimum period of 15 minutes. Where the possibility of freezing conditions exists, the eyewash shall be protected from freezing or freeze-protected equipment shall be installed. If shut off valves are installed in the supply line for maintenance purposes, provisions shall be made to prevent unauthorized shut off.
  • Deliver tepid flushing fluid. In circumstances where chemical reaction is accelerated by flushing fluid temperature, a facilities safety/health advisor should be consulted for the optimum temperature for each application.
  • When the plumbed eyewash is installed, its performance shall be verified in accordance with the following procedures:
    • With the unit correctly connected to the flushing fluid source and the valve(s) closed, visually check the piping connections for leaks.
    • Open the valve to the full open position. The valve shall remain open without requiring further use of the operator’s hands.
    • With the valve in the fully open position, make sure that both eyes will be washed simultaneously at a velocity low enough to be non-injurious to the user.
    • Using the flowmeter or other means, determine that the rate of flow is at least 0.4 gpm.
    • Using a temperature gauge or other means, determine that the flushing fluid is tepid.
  • When the self-contained eyewash is installed, its installation shall be verified in accordance with manufacturer’s instructions.

Is a Fire Watch Necessary?

Q: We have a complete gut renovation project that consist of two buildings (Admin. Bldg. & Lab Bldg.). The buildings are connected in all three levels and will be unoccupied. Both buildings are connected on the first level only to the adjacent occupied building. A one-hour barrier will be built to separate the occupied building from the construction areas. Is a fire watch required once the sprinklers system and fire alarm system is demolished?

A: According to section 9.6.1.6, whenever a required fire alarm system is out of service for 4 or more hours in a 24-hour period, you are required to do the following:

  • The AHJ must be notified. Don’t forget to notify your state AHJ, your insurance company AHJ, as well as your local AHJ. There is no need to notify your accreditation AHJ.
  • The building must be evacuated, or an approved fire watch must be conducted. An approved fire watch consists of a designated, trained individual who has no other responsibilities, continuously patrols the entire area affected by the outage looking for signs of fire and potential situations where fire could start, and has the ability to communicate to call the local fire responders in case of fire. This individual cannot leave the impaired area until the fire watch is discontinued or is relieved by another designated, trained individual.

So, you are saying these buildings will be unoccupied, so it appears you do not have to conduct a fire watch for the impaired fire alarm system, provided you have a 2-hour fire-rated barrier separating the unoccupied building and the occupied building. But let’s look at NFPA 25-2011, section 15.5.2 which says this about sprinkler impairments: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:

  1. The extent and expected duration of the impairment have been determined;
  2. The areas or buildings involved have been inspected and the increased risks determined;
  3. Recommendations have been submitted to management or the property owner or designated representative;
  4. Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for: A) Evacuation of the building or portion of the building affected by the system out of service; B) An approved fire watch, which must be the same as the approved fire watch described above; C) Establishment of a temporary water supply; D) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire;
  5. The fire department has been notified;
  6. The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified;
  7. The supervisors in the areas to be affected have been notified;
  8. A tag impairment system has been implemented;
  9. All necessary tools and materials have been assembled on the impairment site.

So, again since you have an unoccupied building, it appears to me that you do not have to conduct a fire watch for an impaired sprinkler system, provided you have a 2-hour fire-rated barrier separating the unoccupied building and the occupied building. Item #4 above clearly states a fire watch is not required if you have evacuated the building.

Air Pressure Requirements

Q: This question concerns isolation room negative pressure parameters. Our ICU isolation rooms have two sensors for air pressure; one located inside the room and the other located outside the room, of course. Could you tell me what the maximum and minimum negative pressure standard is supposed to be? Is there even such a standard? The CDC website says that if a room is negative then it’s fine. That seems too ambiguous for me. I’d like to see something more specific if possible. I want to be sure that our negative pressure monitors are configured correctly.

A: The ASHRAE standard 170-2013, which is incorporated into the 2014 FGI Guidelines, calls for 0.01 inches of water column (wc) of air pressure, when the air pressure relationship to surrounding areas is required to be positive or negative. This number is referenced in many sections inside ASHRAE 170-2013, such as: 7.2.1(e), 7.2.1(f), 7.2.2(a), 7.4.1, 7.5.1(c), 7.5.2(a). This seems to be the standard value for positive/negative air pressure. But I suggest you check with your state and local authorities to determine if they have additional requirements.