Clean Linen Stored in a Corridor

Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and carts of clean linen are being stored on one side of the breezeway for more than 30 minutes, would this be allowed as long as the width is maintained at 8ft or greater?

A: Let’s re-think this situation… You have a breezeway, and you want to store clean linen in this breezeway? Do you see anything wrong with this picture…?

Talk with your Infection Control people. It does not make sense to me to store clean linen in a breezeway. Clean linen must be stored in a clean environment, such as a designated storage room for clean linen. A breezeway is not a clean environment and is not a suitable place to store clean linen.

But… if you’re asking about storing items in the corridor and if it is okay with the Life Safety Code, the answer is…. It depends.

You may store non-combustible items in the corridor as long as the required width of the corridor remains clear. You indicate the required width of the corridor is 8-feet… is that because inpatients would be using this corridor?

However, you cannot store combustible items in the corridor even if they do not obstruct the required width of the corridor. Clean linen is combustible, so therefore, to answer your question: No, you cannot store clean linen in the corridor.

Strange Observations – Smoke Detectors

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

According to NFPA 72-2012, Annex A.17.7.4.1 smoke detectors should not be located in direct airflow, or any closer than 36-inches from an air diffuser. This would include return-air diffusers, exhaust-air diffusers, as well as supply-air diffusers.

While the Annex section is not part of the enforceable code, it is explanatory information provided to give the reader direction on how the Technical Committee viewed certain standards. Any authority having jurisdiction (AHJ) may use this Annex information in determining compliance with the standard, and most AHJs do. Therefore, the 36-inch rule is widely enforced in all surveys.

But some smoke detectors have UL listings for use in high-velocity airflow areas and are recommended by the manufacturer to be mounted close to air-diffusers. This would lead one to believe they would be permitted within close proximity to an air-diffuser, such as the one in the picture indicates. But I have read reports where surveyors still cite the organization for installing the special high-velocity smoke detectors too close to air-diffusers because of the perception that the airflow would prevent ambient smoke from being detected by the smoke detector.

Rather than fighting this battle with over-zealous surveyors, it is best to just make sure all smoke (and heat) detectors are at least 36-inches from all air-diffusers.

Ambulatory Healthcare Occupancy Fire Drills

Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? The ambulatory healthcare occupancy has a 24hr ED and also has some departments that have three shifts, ie: EVS, Security and Medical Imaging.

A: According to section 21.7.1.6 of the 2012 Life Safety Code, fire drills are to be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and the emergency action required under varied conditions. So, the answer is once per shift per quarter.

Fire Pump Phase Reversal

Q: On our fire pump, we monitor the “Fire Pump Run” and “Fire Pump Loss of Power” on our supervisor points, but the fire pump control panel has a point which could be monitored for “Phase Reversal”. My question is, are we required to monitor “Phase Reversal” as a supervisory point?

A: That answer depends on the version of NFPA 20 “Standard for the Installation of Stationary Pumps for Fire Protection” that was enforced when the pump was installed or renovated (upgraded).

According to NFPA 20-2010, section 10.4.7, where the fire pump room is not constantly attended, audible or visual signals powered by a source not exceeding 125 volts must be provided at a point of constant attendance, for each of the following points:

  • Pump running
  • Loss of power
  • Phase reversal
  • Connected to EM power

According to NFPA 72-2010, section 23.8.5.9, the building fire alarm system is to be used for fire pump monitoring.

There was a time when NFPA only required the points for “Pump running” and “Loss of power” to be monitored, so you may not have to connect “Phase reversal” to the building fire alarm system. According to section 1.4.1 of NFPA 72-2010, the NFPA 72 code/standard is not retroactive to existing equipment.

When was this fire pump controller installed? I checked the 1999 edition of NFPA 20, and that edition required all four points to be monitored. If the controller was installed or updated since March 11, 2003 (the date CMS adopted the 2000 Life Safety Code) then I would say “Phase reversal” is required to be monitored.

Fire-Rated Doors in Fire-Rated Barriers?

Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read in NFPA 101 that they do not….

A: Where do you read that…? I would like to know what you’re reading to be able to provide you with a better answer.

Generally speaking, where you have a fire-rated barrier, you usually need to have fire-rated doors in openings in the fire-rated barriers. But there are some exceptions:

  • Fire-rated barriers that separate an atrium from the rest of the facility are not required to have fire-rated doors.
  • Corridor walls in existing healthcare occupancies located in a smoke compartment that is not fully sprinklered, are required to be 30-minute fire-rated and the corridor doors are permitted to be non-fire-rated, but must limit the passage of smoke.
  • Some building codes that require fire-rated corridor walls do not require fire-rated doors in the openings. But this is not a LSC issue.
  • Smoke barriers that separate smoke compartments are required to be rated (1-hour for new construction) but doors in smoke barriers are not required to be fire-rated.

 

Strange Observations – Oxygen Cylinder Storage

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

This room contained more than 300 cubic feet of compressed medical gases (but less than 3,000 cubic feet). And even though the picture does not show the whole room, what I wanted to capture is the fact that the oxygen cylinders in storage are not separated from combustibles by at least 20-feet, or 5-feet if the room is protected with sprinklers.

According to NFPA 99-2012, section 11.3.2.3 you must store oxidizing gases at least 5-feet from combustibles if the room is sprinklered, or at least 20-feet if the room is not.

It is obvious in this picture that some sort of plastic items are stored right next to the oxygen cylinders. Another option is to store the oxidizing gas cylinders in a fire-rated storage cabinet, then you do not need to maintain the 5-feet or 20-feet clearance.

Partially Full Oxygen Cylinders

Q: My Facilities Director just attended a state association of healthcare facilities managers. He stated that the presenter said that for oxygen cylinder storage and segregation, if a cylinder is not completely empty it is considered full. This is 180 degrees from what we have always been told. At our hospital, we have always said that any cylinder that is has been opened is no longer considered full and must be stored with the empties. Have you heard anything to this effect?

A: This sounds like a surveyor preference issue, to me. In other words, this may be just the presenter’s opinion, or perhaps a CMS Regional Office’ opinion. NFPA 99-2012, section 11.6.5.2 says “If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.” Well, a partial cylinder is not full, so in my way of thinking it cannot be stored with the full cylinders.

Actually, the presenter is not wrong when he says a partial cylinder should be stored with the ‘Full’ cylinders. Since NFPA 99 does not address partially full (or partially empty) cylinders, how they are stored is left to the AHJ to decide. If the presenter represented an AHJ, then he is within his right to say partial tanks cannot be stored with the empties. But taking this a step further, section 11.6.5.3 says “Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner”.

This shows us the intent of the code is to prevent a non-full cylinder from being grabbed in an emergency. If partially-full cylinders are stored with full cylinders, then that goes against the intent. However, the intent of the code is not well-written on this particular issue and we are stuck with what is written, which does not prohibit an AHJ interpreting section 11.6.5.2 to say partials cannot be stored with empties. I guess the best advice is to follow what Joint Commission is requesting… that there be three (3) separated storage areas; one each for full cylinders, partially full cylinders, and empty cylinders. That should solve the problem.

Frequency Between Fire Pump Tests

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

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

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

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

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

Fire Extinguishers in an ASC

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

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

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

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

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

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

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

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

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

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

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

Strange Observations – Obstructed Zone Valve Box

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

If you look closely enough, you will notice a set of medical gas shutoff valves behind this cross-corridor door that is held open. Even though the door has a window (or vision panel, as NFPA calls it), and you can actually see the medical gas shutoff valves through the window, it is still a violation.

NFPA 99-2012, section 5.1.4.8.4 says zone valve boxes shall be installed where they are visible and accessible at all times. Well, I think you could say the zone valve box in this picture is visible, but it certainly is not accessible as long as the door is held open.

Section 5.1.4.8.5 speaks more directly to this issue: Zone valve boxes shall not be installed behind normally open or normally closed doors.

Curtains for Oxygen Storage

Q: Is there a code from NFPA or Joint Commission in regards to “cloth” curtains hanging in around/in front of oxygen cylinders. And if so would it make a difference if it is in an office setting vs hospital setting?

A: Yes… Both NFPA and Joint Commission prohibits the storage of oxygen cylinders within 20 feet of combustibles (or within 5 feet of combustibles if the room is protected with sprinklers, see NFPA 99-2012, 11.3.2.3), when the quantity of compressed gas stored is equal to or exceeds 300 cubic feet. It does not make a difference where the stored compressed oxygen is stored. NFPA 99 applies to all healthcare facilities.

Fire-Proofing Structural Steel

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

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

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

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

Contiguous Facilities

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

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

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

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

Coded Words for Fire

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

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

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

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

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

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

Strange Observations – Aisle Width

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

This is an equipment room. It appears to be a water room of some sort as I see a water tank and some water filters. I also see boxes and ‘stuff’ blocking access into and out of this room.

The problem with this situation is the room does not have a clear aisle width. Even though this is an equipment room, you still must maintain a clear aisle width of at least 28-inches for existing conditions, and 36-inches for new construction.

Remember: The exit-access is not limited to the corridor. Every room has an exit-access, and the appropriate aisle width must be maintained in those areas. Section 7.3.4.1.1 and 7.3.4.1.2 of the 2012 Life Safety Code provides the standards that regulate the aisle width.