Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?
A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage. I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency.
Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in either the corridor, or the room. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.
You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.
I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustibles stored in those patient rooms, you have a big problem. The room would have to comply with section 18.104.22.168 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.
Q: Someone just asked me a question and I haven’t thought about this one before. This AHJ is enforcing the IBC but I’m looking for an NFPA viewpoint and of course I thought of you. The IBC and the LSC both require corridor doors in a health care facility to latch. But what if those doors are horizontal sliding doors (manually-operated)? The IBC allows horizontal sliding doors if the space served by the door has an occupant load of 10 or less. The doors in question are not in suites. I don’t see anything that prevents the use of horizontal sliding doors, or anything that says these doors don’t need to latch, but why should they have to latch since they aren’t affected by pressure the same way a swinging door would be? It seems like latching hardware on horizontal sliding doors would be a pain for hospital staff. Have you ever run into this?
A: Yes… I see this issue a lot in hospitals. Many architects are mistaken when it comes to glass sliding doors. Perhaps they follow IBC and specify non-latching doors, but then they fail to comply with the 2012 Life Safety Code, which gets them (and the hospital) in hot water.
Section 22.214.171.124.10.2 discusses horizontal sliding doors that serve an occupant load of fewer than 10 people have to meet all of the requirements in the sub-headings 1 – 5. Sub-heading 5 says where corridor doors are required to latch, the doors are equipped with a latch or other mechanism that ensures the door will not rebound into a partially open position if forcefully closed.
So, the LSC is clear: Where corridor doors are required to latch, the horizontal sliding doors must also latch.
Yes… there are a lot of requirements in the LSC that are a pain to staff. But patient safety is a job that all have to work for, regardless how inconvenient it may be.
Q: If we put the fire alarm system in test by-pass but we are still monitoring the alarms so we can troubleshoot or test the system so we avoid nuisance FA activation do we need an ILSM (Fire watch)?
A: Well… How long do you have it in test mode? More than 4 hours? If so, then I can see where an ILSM assessment is required, but the assessment would identify that the fire alarm system is impaired since it is in test mode, but you have a Fire Watch in effect because you would have someone at the panel constantly until the panel is off test mode.
So… an ILSM assessment would be required after you reach the 4-hour mark, but the assessment should identify that you are doing a Fire Watch my posting a responsible individual at the panel.
Sounds like a paper documentation issue, as you are already doing the Fire Watch.
Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space that does not involve the use of a fire watch. We are looking at multiple sensor detectors, but the initial comment we received from our vendor is that they are sometimes triggered by dust. In your opinion, would changing the smoke detectors to heat detectors be an acceptable solution in a construction space? If the space has an active sprinkler system, in your opinion, would it be acceptable to simply remove these smoke heads? Any thoughts you can provide would be greatly appreciated.
A: Changing the smokes to heats is not an acceptable solution to prevent a fire watch, because heats do not sense the presence of smoke. But perhaps you are making this more difficult than it has to be. The code only requires a fire watch for required fire alarm devices that are impaired. Are the smoke detectors in the construction area required? If so, then you need to do the fire watch if you remove the detectors, or suffer through many false alarms.
But if they are not required devices, then you can remove the smoke detectors and not have to do a fire watch. Section 126.96.36.199 of the 2012 LSC specifically says a fire watch is for required fire alarm systems out of service.
One may be surprised to learn that in the typical hospital, there are very few locations that a smoke detector is required to be installed:
- In areas open to the corridor as described in section 188.8.131.52 of the 2012 LSC
- In areas containing fire alarm control panels (including NAC panels) that are not continuously occupied as described in 184.108.40.206.1 of the 2012 LSC
- Near doors that are held open that must close on a fire alarm activation as described in NFPA 72-2010, section 220.127.116.11.5.1
- Elevator recall for fire-fighter’s service as described in NFPA 72-2010, section 21.3
There are other situations where smoke detectors may be required, but those requirements are stipulated on optional design factors, such as on-call sleeping rooms, specialized protective measure locks, and equivalencies.
Therefore, if you have smoke detectors in an area that is under construction, and these smoke detectors are not required, then you may remove the detectors without having to perform a fire watch.
Q: Is there a code requirement for implementing an Interim Life Safety Measure (ILSM) for occupancies other than healthcare (i.e. business occupancies) if a life safety code deficiency has been identified?
A: Yes… ILSM (also known as Alternative Life Safety Measures) is found in chapter 4 of the 2012 Life Safety Code, specifically section 18.104.22.168 of the 2012 LSC. This describes the need to implement ALSMs when features of Life Safety are impaired. This chapter is part of the ‘core’ chapters and applies to all occupancy chapters, so that means it applies to business occupancies as well.
Most accreditation organizations should be enforcing this in offsite locations, such as business occupancies. Some surveyors fail to ask for this, but it is an enforceable requirement.
Q: I have a question regarding emergency generators and Level 1 classification. I’m at a sister hospital and they went through a State Surveyor and he asked for proof that the emergency generator was a Level 1 generator. The documentation indicates that it meets NFPA 110 but nowhere does it indicate that it is Level 1. Now the hospital was approved by the State in 2009 and been open since then. This has never come up in past 9 years. I’ve contacted the maker of the Generator for supplemental documentation. Is there another way to prove that the generator meets level 1 classification? We have patients on ventilators. Please provide me with some wisdom to address this issue with the surveyor
A: That surveyor is yanking your chain…. First of all, speaking in general terms, the use of the generator classifies whether it is a Level 1 or Level 2.
According to NFPA 110-2010, section 4.4.1 says Level 1 systems shall be installed where failure of the equipment to perform could result in loss of human life or serious injuries. Generators used in hospitals would be required to be Level 1. Section 4.4.2 says Level 2 systems shall be installed where failure of the EPSS to perform is less critical to human life and safety. There are different operational requirements based on whether the generator is classified as a Level 1 or Level 2.
A generator is a generator, and the manufacturer of that generator does not classify the use of that generator. It can say it qualifies for use as a Level 1 generator, but the actual use of the generator determines if it is a Level 1 or a Level 2.
Sounds like the surveyor is providing you a teachable moment by asking that question. He knew the answer before he asked.
Q: In the 2012 LSC concerning alcohol based hand rub (ABHR) dispensers in a hospital setting, is there a limit to the number of dispensers that can be in a patient sleeping room? We are wanting to have additional dispensers available in the room, such as 1 on the wall, one attached to the bed and one tabletop dispenser at the nurse workstation in the room. In the 2012 codes, would this number be allowed?
A: There is not a limit to the number of ABHR dispensers permitted in a patient room, but there is a limit to the quantity of ABHR product in dispensers per smoke compartment. You are limited to 10 gallons of ABHR product in dispensers per smoke compartment. If, for instance, each dispenser is 1 liter of product, then that means you can only have 37 dispensers per smoke compartment.
Now, the 2012 LSC does allow you to have one dispenser per room not contribute to the aggregate total of ABHR product in dispensers per smoke compartment, so if you have 12 patient rooms in the smoke compartment and one dispenser in each room, then that means you could increase the total ABHR dispensers from 37 to 49. And you must include in the aggregate total all pocket-sized dispensers and all table-top dispensers. This rule is not limited to just wall-mounted dispensers.
Q: My fire alarm installer tells me that NFPA 72 does not require strobe synchronization of two (only two) devices. The sync is required if there are more than two. I read NFPA 72 2010 22.214.171.124 (4) and it is not clear if he is correct. Can you comment on it, please?
A: The installer is technically correct in that, since 1996, all manufacturers’ strobe flash rates were lowered so that viewing two non-synched devices would not produce an overall flash rate considered to be dangerous. As far as code requirements, the NFPA 72-2010 requirement for strobe synchronization is actually found in Chapter 126.96.36.199.2 (for rooms) and 188.8.131.52.5 & 7 (corridors). If this question is being asked for a room, then the intent is to achieve a minimum light output. If achieving that output requires ‘…more than 2 visual appliances…’, then they must be synched. In a corridor, “when more than 2 visible notification devices are in any field of view, they shall flash in synchronization.” So technically, if just two strobes are in the overall field of view (including non-direct viewing), they don’t need to be synched to meet NFPA 72 requirements.
That’s in a vacuum. However, in the real world, these devices are generally on circuits that have additional visual devices that serve other areas where more than two devices are in the direct or non-direct field of view, or the circuit may need be expanded in the future where synchronization is required. Another important real world consideration is the expectation of the facility’s reviewing AHJ (CMS, State Agency, Joint Commission, etc.). Unless the strobes were installed prior to 1999, the expectation of every AHJ I’ve dealt with since that time is that every strobe in line of sight will be synched. If in response to a citation, the chief engineer of a healthcare facility wants to pull out the code book and cite specific code application of strobe synchronization to their reviewer, he may eventually win that battle (or not), but in doing so he may be opening the door to a more ‘letter of the code’ enforcement regarding other areas of concern.
NOTE: Gene Rowe from Affiliated Fire Systems provided the answer to this question.
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 184.108.40.206.7, whereby powered doors that comply with section 220.127.116.11 (sub-section 18.104.22.168.2(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 22.214.171.124.5. 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 126.96.36.199.6) 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 188.8.131.52 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 184.108.40.206.5.1 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.