Equivalencies for Exit Enclosures

Q: We have a hospital with a number of exit enclosures. These passageways have a large number of unrelated utilities running above the ceiling. Modification will not only be very expensive, but very difficult. Can we use NFPA 101A FSES equivalencies for alternate compliance?

A: Section 7.1.3.2.1 (10)(h) of the 2012 LSC does say “Existing penetrations protected in accordance with 8.3.5” as an exception regarding utility penetrations into an exit enclosure, so the undesirable utility penetrations in the exit enclosures may be acceptable if you can prove they are ‘existing’ conditions. According to CMS, anything designed or constructed prior to July 5, 2016 is considered existing conditions as far as the 2012 Life Safety Code goes, but not all other authorities agree with this concept entirely. Ever since the 1988 edition and all of the subsequent editions of the LSC, it has said that penetrations of ductwork, conduit, pipes, etc., that do not serve the exit enclosure are prohibited.

Many authorities having jurisdiction enforce this to present day…. Meaning if the utility was installed in 1992 in the exit enclosure but does not serve the exit enclosure, then it still can be cited today because it was not installed correctly ‘back then’. But the 1985 edition does not say that. So, any utility installed in an exit enclosure that does not serve the exit enclosure before the 1988 edition was adopted would be considered ‘existing’ and since it wasn’t prohibited when it was installed, it would be permitted to remain, provided it met the requirements of 8.3.5. For CMS, they were on the 1985 edition until March 11, 2003.

But Joint Commission had been adopting the new editions of the LSC shortly after they were published. So, they were on the 1991 edition back in 1992, which is as far as my memory goes. It’s all a crap-shoot…. Some surveyors will recognize the July 5, 2016 date as the only threshold between new and existing and will allow the existing utilities in the exit enclosure, and then some surveyors will be more scrutinizing and try to determine when the utilities were installed. But to answer your question, if you get cited, you could always go for an equivalency (NFPA 101A FSES) as part of your Plan of Correction, but you would have to prove a significant hardship in complying with the LSC.

One can assume it will be costly to install a 2-hour fire-rated ceiling in the exit enclosure to cover-up the utilities, but the CMS Regional Office is the entity to make the decision to approve the FSES equivalency or not, and you need to convince them whether or not it is a significant hardship. CMS does not accept equivalencies unless the deficiency is first cited, so you will have to wait to get cited by your accreditor or state agency surveying on behalf of CMS. And don’t forget to conduct an assessment for ILSMs now of the deficiency… most authorities will expect you to do so. But equivalencies are only valid until the next triennial survey, so it would be best to make long-range plans to resolve the issue, rather than continuously presenting equivalency requests.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

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. Certificate of Attendance 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!

Exclusively presented by:

Life Safety Drawings

Q: I just got done with a triennial accreditation survey at one of my facilities and the engineer surveyor requested LSC drawings for all buildings that support patients, not just the in-patient buildings. The support buildings are business occupancy and patients do not sleep in these areas, they only go to these building for program. We are surveyed under Behavioral Health. History has it we have never had to provide LSC drawings for non-inpatient buildings. Have you ever heard of the drawings being requested for all buildings?

A: Oh, sure. This is a common, if not a normal practice. Ask yourself this question: How can you adequately maintain the rated barriers in your offsite business occupancies if you don’t have LS drawings showing their location? How can you demonstrate to the surveyor that your travel distances are within limits? How can you demonstrate to the surveyor that your hazardous areas are properly maintained if you (or he) does not know where they are?

LS drawings are important for all the buildings you maintain… not just the hospital. This finding should not be a deal-breaker with the accreditor… meaning, you may receive a citation (or you may not), but if you do, it will not be a Condition Level Finding. Bully for the LS surveyor for asking to see those LS drawings.

Tamper-Proof Screws in Psychiatric Unit

Q: Do all of the screw heads in a psych ward need to be tamper proof?

A: There is no specific code or standard that addresses screw heads in a psych unit, but CMS and the accreditation organizations have a standard that requires you to provide a safe environment for your patients and staff. Therefore, having a screw head in a psych unit that is not the tamper-proof style would likely be a citation by a surveyor because the environment is not considered safe by their point-of-view.

Strange Observations – Signs on Fire-Rated Doors

Continuing in a series of strange things that I have seen while consulting at hospitals…

Doors to medical gas storage rooms are required to be fire-rated.

Fire-rated doors cannot have signs applied that cover more than 5% of the total surface of the door.

A sign that does not exceed 5% surface of the fire-rated door is approximately 8.5″ x 11″. This door has signs that exceed the 5% surface amount.

Also, the signs cannot be attached to the door using screws or nails, but must use adhesive.

Home-Made Bumpers on Doors

Q: We have metal “bumpers” (for lack of a better term) that were fabricated onsite at our hospital, that are used to keep carts and beds for damaging the doors. These bumpers are installed on fire-rated door assemblies and protrude out past the push pad of the horizontal crash bar on the door. Are these bumpers allowed?

A: No… According to NFPA 80- 2010, section 4.6.1, all devices mounted to a fire-rated door assembly must be listed by an independent laboratory (i.e. UL, Intertek, FM Approval) for use on a fire-rated door assembly. Home-made devices are not permitted. Also, the bumpers may stick out more than the maximum 7 inches allowed by section 7.2.1.4.3.1 of the 2012 LSC, when the door is fully opened.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

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. Certificate of Attendance 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!

Exclusively presented by:

Spark-Ignited Generators

Q: I have two questions regarding spark-ignited emergency power generators:

  1. What maintenance tests are required for natural or propane Generators?
  2. Are load bank test required for Natural gas or Propane gas powered generators.

A: Monthly tests, but since they are spark-ignited generators they do not have to meet a particular load. They just have to operate with the available EPSS load for a minimum of 30 minutes or until the water temperature and oil pressure have stabilized. (See section 8.4.2.4 of NFPA 110-2010).

No, spark-ignited generators are not required to have an annual load bank tests. An annual load bank test is required when diesel powered generators cannot meet the minimum load of 30% of the nameplate rating (in kW) during each monthly load test. Spark-ignited generators are exempt from having to meet this requirement.

A 3-year 4-hour load test is required for all generators, including spark-ignited generators. But you are not permitted to use a load bank on spark-ignited generators. The 3-year 4-hour load test must operate using the load from the ATS. For spark-ignited generators, the load is permitted to be the available load. (See section 8.4.9.5.3 of the NFPA 110-2010.) Load banks are not permitted for the 3-year 4-hour load test for spark-ignited generator.

Temperature Range

Q: I work in the Central Processing department and yesterday they upped the temperature to 72 – 73 degrees in decontam and the clean side. I always thought it had to be a lot cooler than 72. Did this change recently?

A: According to the 2014 FGI Guidelines, the design temperature in Central Supply decontamination rooms is from 72° F to 78° F. This is the same design temperature range that was called for in the 2010 edition of the FGI Guidelines, but is a change from the 2006 edition which called for a range between 68° F to 73° F.

Now, design temperatures are just that… a target to aim for. There is no reason why you cannot have set-points on thermostats that are outside of the design temperature range provided the reason is documented in either a policy or a risk assessment.

Strange Observations – Adjunct Corridor Width

Continuing in a series of strange things that I have seen while consulting at hospitals…

These portable X-ray units were double-parked in the adjunct corridor to the radiology control room.

The adjunct corridor is required to have 44-inches clear width, which is not present between thee two units.

 

Negative Air-Pressure

Q: I’m butting heads with our Infection Control group regarding holes in construction barriers. They have started requiring the contractors to make the construction sites negative air-pressure, which is fine, if they have access to the outside of the building. If there isn’t any way to vent to the outside they want to install filters in the construction barrier so they can exhaust filtered air into the corridors. Our construction sites are fully sprinkled so we are not required to have fire barriers but I can’t find anywhere in the code that it says they can put holes in the corridor walls to exhaust air through. I’m telling them that if they put holes in the barrier I might as well hang beaded curtains because we don’t have a smoke separation anymore. What do you think?

A: I guess it depends on the level of construction, demolition or renovation. I like the idea of poking a hole in the corridor wall and exhausting through a HEPA filter into the corridor to create a negative air pressure in the construction area. That is a common process where there is no access to the outdoors. I don’t see a problem with this… just make your ILSM assessments for a corridor that no longer resists the passage of smoke and keep that exhaust fan w/HEPA filter running 24/7. Don’t let them turn it off.  Sometimes, IC people don’t like the airflow into the corridor because it stirs up the air in the corridor. But if your IC people are okay with this, then that would be considered best practice. I think you’re over-reacting… The Infection Control people are correct on this one.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

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. Certificate of Attendance 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!

Exclusively presented by:

Cabinets in a Corridor – Part 2

Q: Is there a codified requirement for doors in a cabinet mounted in a hospital egress corridor? We have worked on projects when a nurse server; i.e., pass through cabinet, was required by the local AHJ to have positive latching on the cabinet door in order to protect the sanctity of the egress corridor. But when it is just a typical cabinet (non-pass through), is there a danger to the egress corridor if the cabinet doors do not have positive latching?

A: The only code requirements that I can think of are corridor obstruction and projection. A nurse server that has an open pass-through to the patient room from the corridor is required to have a door that meets the requirements of 19.3.6.3 of the 2012 LSC for corridor doors, such as positive latching, 1¾-inch thick solid-bonded wood core, and resisting the passage of smoke, because it needs to separate the corridor from the patient room. I think a typical cabinet that does not have a pass-though would not have to have a door that is positive latching because positive latching is only required when the door is separating a corridor from a room. If there is no pass-through, then there is no need for a positive latching door.

Christmas Garland

Q: We are a fully sprinkled hospital. Is it permissible to hang Christmas garland from the ceiling, as long as we stay away from sprinkler heads and abide by the 30% rule? Does the garland need to be fire-retardant?

A: According to section 19.7.5.6 (4) of the 2012 Life Safety Code, combustible decorations such as photographs, paintings, and other art are permitted as long as they are attached directly to the walls, ceiling, and non-fire-rated doors provided the following is complied with:

  • Decorations on non-fire-rated doors not interfere with the operation of any required latching of the door;
  • Decorations do not exceed 20% of the wall, ceiling and door areas inside any room or space of a smoke compartment that is not protected with sprinklers;
  • Decorations do not exceed 30% of the wall, ceiling and door areas inside any room or space of a smoke compartment that is protected with sprinklers;
  • Decorations do not exceed 50% of the wall, ceiling and door areas inside patient sleeping rooms having a capacity not exceeding four persons in a smoke compartment that is protected with sprinklers;

According to the Annex section A.19.7.5.6 (4):

  • The percentage of decorations should be measured against the area of any wall or ceiling where the decorations are located, and not the aggregate total of all walls, ceilings, and doors;
  • The decorations must be located such that they do not interfere with the operation of any doors, sprinkler, smoke detector, or any other life safety equipment;
  • The term “Other art” might include hanging objects or three-dimensional items.

While the Annex section of the Life Safety Code is not considered to be part of the requirements of the enforceable code, it is considered explanatory material intended for informational purposes only. It provides guidance to the readers of the LSC on what the reasoning was by the Technical Committee when that section of the code was written. Most authorities having jurisdiction (AHJ) follow what the Annex says but they are not under any obligation to do so.

So, let’s break this down into steps:

  1. Garland is not the same as a photograph or a painting, but may likely comply with the definition of ‘Other art’ as explained in the Annex.
  2. Some surveyors may believe that garland that is suspended from the ceiling and allowed to ‘droop’ may be considered to not be attached directly to the ceiling as section 19.7.5.6 (4) requires.
  3. Non-fire-retardant garland attached directly to the ceiling appears to be permitted based on what the Annex says, provided it does not take up more than 30% of the ceiling space from which it is attached.
  4. The garland cannot interfere with the sprinklers so you would have to comply with section 8.6.5.1.2 and 8.6.5.2.1.3 of NFPA 13-2010 for ceiling mounted obstructions. Quite honestly, this will be pretty difficult to meet with hanging garland in a corridor.

The problem with all of this is not every surveyor will agree that garland qualifies as ‘Other art’. You can show them what the Annex says, but remember that they are not under any obligation to comply with what the Annex says. Most AHJs do, but you may get a rouge surveyor who simply does not agree and will cite it if they observe it. And, as stated above, it is very challenging to suspend something like garland from the ceiling in a corridor and not interfere with the sprinklers. Make sure you follow NFPA 13-2010 carefully.

All in all, it would be easier to not permit it in your facility.