Q: We have operating rooms with two doors, one that is adjoining to the sterile corridor and one to the common corridor in the Surgery department. We monitor the common corridor continuously through our building automation system (BAS). We do not monitor the sterile corridor. Is there a requirement to monitor the sterile corridor continuously or daily?
A: The standards on monitoring and logging are weak on ventilation requirements and not well defined in many cases. But the expectation is your organization will be monitoring and logging certain environmental parameters regarding operating rooms, such as:
- Air-pressure relationship to surrounding areas;
- Humidity levels;
- Temperature levels
For new construction, CMS and the accreditation organizations recommend compliance with industry standards such as FGI Guidelines, AORN, CDC, and the like when other state or local regulations are silent. For existing conditions, most accreditation organizations have standards that require you to maintain ‘appropriate’ pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity, based on the edition of the design standards used at the time of design… if you know when that was, and what document was used for the design.
Many organizations don’t have that information available to them. When that is not known, most surveyors will lean on what is currently required for temperature, humidity, and air-pressure relationships. The FGI Guidelines require a positive air-pressure relationship to surrounding areas for operating rooms. That would include all areas, including the sterile OR corridor. I believe CMS and the accreditation organizations would expect you to monitor the air-pressure relationship between the operating room and all other areas, including the sterile corridor. There is no requirement to monitor this on a continuous basis, but should be conducted prior to every case.
I have often been told by ambulatory surgery center staff during surveys that the Life Safety Code surveyor is the person that they fear the most.
Keeping up with the requirements can be a daunting task, but I have found that it isn’t the deep-down obscure requirements that trip up facilities; it is often the easy stuff that is missed by the staff and easily found by a surveyor. These are the deficiencies that start popping up over time and are ignored – soon they become commonplace. Sometimes they are even on a routine environment of care (EOC) check form, but those forms can become time-consuming and things may get marked as being compliant but actually were not even checked.
Here are a few of the deficiencies that I often find that are easily avoidable:
Medical gas cylinders that are not secured from falling. We all know they have to be secured, but this is still a common deficiency. This is often blamed on the medical gas delivery person. Probably the best time to check the cylinders in the medical gas room is right after a gas delivery.
Fire-rated doors that are being propped open with just about anything other than a proper hold-open device that is connected to the fire alarm system. If the door needs to be open on a regular basis, then it is probably best to install a hold-open device instead of being cited by a surveyor or the fire marshal.
Fire-rated doors that do not latch because someone has put tape or other items over the latching system so the door can just be pushed open.
Access to manual fire alarm pull stations that are visually and/or physically blocked. For some reason, potted plants like to grow in front of pull stations. Chairs also like to grow there. Keep in mind that access to these pull stations needs to be unobstructed.
Access to fire extinguishers that are visually and/or physically blocked. This is the same as the manual pull stations. Occupants need to know that it is there and need to be able to get to it.
Equipment and other items blocking clear access in ASC corridors or reducing the clear width to less than 44 inches. As ASCs get busy, it is easy for clutter to build up in the corridors and egress paths. Staff should be educated on the importance of keeping the paths clear.
Electrical circuit breaker panels that are blocked and do not have a clear working area of at least 36 inches in front of them. This is usually seen inside the electrical rooms, but it does happen throughout some facilities.
This list is just a small sampling of the simple things that fall through the cracks and results in citations for ASCs. Education is often the first step to combat this on-going issue; however, if the issues persist, persistent on-going surveillance may be needed. There is nothing more irritating than being cited for simple deficiencies that are easy to prevent.
By Brad Keyes…
Q: I have a storage question for you that relates to storing beds and other hospital equipment in our mechanical rooms. Is this allowed or would I be cited for storing things in the mechanical room?
A: To be sure, mechanical rooms are designed to house mechanical equipment, and storage should not obstruct access to the mechanical equipment. According to the 2012 edition of the LSC, storage in mechanical rooms is not prohibited, but there are some exceptions and there are some requirements that you must meet. If the mechanical room opens onto an exit enclosure, section 220.127.116.11.1 (9)(c) of the 2012 LSC now permits existing openings from mechanical spaces to exit enclosures to remain provided the door assembly is properly fire-rated; the mechanical space is not used for fuel-fire equipment; the space contains no storage of combustible materials; and the building is protected throughout by sprinklers. So, if that describes your situation, then storage of combustible materials such as beds (i.e. mattresses), and boxes of supplies would NOT be permitted. But where the mechanical room does not open onto an exit enclosure the items stored in the mechanical room must be orderly and neat. Storage cannot obstruct access to electrical panels, fire extinguishers, and fire alarm pull stations, and storage must be clear of all sprinklers located on a horizontal plane 18 inches below the sprinkler deflector. If the items stored in the mechanical room are combustible (cardboard boxes, paper or plastic wrapping, linens, etc.) then the mechanical room must meet normal hazardous room requirements. If the room is new (meaning if the room has been designated for storage on or after July 5, 2016) or was designed to meet new construction requirements, then it must be protected with automatic sprinklers and the walls constructed from the floor to the deck above with 1-hour fire rating, with a ¾ hour fire rated, self-closing, positive latching door. Be careful with this as new construction hazardous rooms were required to be 1-hour fire rated as far back as the 1967 edition of the LSC. If the room is considered existing (meaning the room was designated as storage before July 5, 2016 and there have not been any major renovations since), then it must be protected with automatic sprinklers with walls that are smoke resistant and extend from the floor to the ceiling, and protected with a 1 ¾ inch solid bonded wood core door that is smoke resistant and self-closing and positive latching, or if not sprinklered, then the room is required to be protected with 1-hour fire rated barriers. However, please check with your state and local authorities as they may have other codes or standards that may prohibit storage in a mechanical room.
Q: I just would like to confirm: When you say a 4-inch projection is allowed into the corridor is that for one side of the corridor or is that for a total of both sides cannot exceed 4-inch?
A: I would say that is for each individual side of a corridor. So, each side of the corridor is allowed a 4-inch projection. The reason I say that is the limit on a projection into the corridor is to prevent a sight-impaired person from running into an object while egressing. Since most corridors are wider that the largest human, the 4-inch restriction is based on individual sides of the corridor.
Even though section 18.104.22.168(2) of the 2012 Life Safety Code permits a 6-inch projection into the corridor, CMS explained in their Final Rule to adopt the 2012 Life Safety Code (published May 6, 2016) that they will require all healthcare facilities who receive Medicare/Medicaid reimbursements to comply with the ADA restriction of a 4-inch maximum projection. The ADA refers to the ANSI standard A117.1-2009, section 307.2 that limits a 4-inch projection from 27-inches above the floor to 80-inches above the floor.
Q: Our Emergency Operations team does regulatory rounding every 2 weeks in a different unit or clinic. Our department is responsible for Life Safety. Recently, we did some rounding in our Cancer Center which is an outpatient service in a business occupancy building that is attached to the hospital. The Cancer Center building is 3 stories high and the hospital is 6 stories. There is a large open lobby with a stair and elevator between the two buildings. The cancer center has a 30-minute smoke wall that runs through the middle of it per the life safety drawings. One of the questions on our rounding sheet is “Do all the smoke barrier walls go to the deck?”. I discovered that there is a large gap in the smoke wall above a set of double doors. As a group we have discussed this and there are conflicting opinions. One opinion is the walls have to go to the deck regardless. The other opinion is they do not since we have a dropped ceiling grid which also acts as a smoke barrier. Is there a right answer?
A: Boy… You’ve got a lot going on there. First of all, when was this facility constructed? New construction smoke barriers have been required to be 1-hour rated for decades. You may have a problem calling these barriers 30-minute rated. Secondly, all smoke barriers (i.e. barriers that separate two or more smoke compartments) have to be continuous from outside wall to outside wall and from floor to deck above. Section 22.214.171.124 does allow for smoke barriers to stop at interstitial spaces, provided the underside of the interstitial space provides the same rating and smoke resistance as the smoke barrier. A suspended grid and tile ceiling does NOT meet that parameter.
What your fellow employees may be thinking about is a smoke partition… not a smoke barrier. A smoke partition is a non-rated wall that resists the passage of smoke and is found in corridor walls and non-rated hazardous rooms. Those smoke partitions are permitted to terminate at the ceiling provided the ceiling also resists the passage of smoke. While NFPA does recognize that a suspended grid and tile ceiling may resist the passage of smoke, the IBC does not.
From what you are describing… it appears to me that the smoke barrier must go to the deck. Write up an ILSM assessment and get that barrier scheduled for repair. Next, is there a fire-barrier of 1-hour construction meeting the requirements of 8.6.7 separating the cancer center from the atrium and another 1-hour barrier separating the hospital from the atrium? Finally, is there a 2-hour fire-rated barrier separating the cancer center business occupancy from the healthcare occupancy?
Q: What is one of the main reasons that ambulatory surgery centers (ASCs) get cited for deficiencies in relation to testing, inspection, and maintenance activities for Life Safety equipment?
A: I have found that ASCs often make the mistake of assuming that outside vendors for the inspection, testing, and maintenance of the ASC’s medical gas, back-up generator, fire alarm, and fire sprinkler systems are adhering to the required NFPA standards. When educating ASC staff on the deficiencies that I find, they often ask, “Well, shouldn’t the vendor know what is required by NFPA?” That’s a great question, but does the vendor know that your facility has to follow the NFPA standards? Not every one of their clients does. The vendor usually knows exactly what is required by the standards, but they will only perform the tasks that are spelled out in the service contract that they have with the ASC or building management.
One of the main issues is that the ASC staff does not know what is required by the NFPA standards. The best way to solve the problem is through education; taking the time to review the standards and getting to know the requirements is very beneficial for anyone who is responsible for making sure that the ASC’s utilities are properly maintained. A basic internet search for testing, inspection, and maintenance requirements for the specific utility systems leads to many resources. Even contact with the vendor can be enlightening. It is also a good time to make sure that the vendor is aware of standards the ASC has to follow and if the vendor has a good grasp on what is required by those standards.
Another issue is that ASC staff does not really review the contracts to make sure that all required elements of the standards are covered. If it is not in the contract, it probably doesn’t get done. Over the years, as ASC personnel change and new individuals are responsible for the care of the ASC utilities, they often assume that whoever approved the service contracts in the past actually read them and made sure that the contracts included all the required tasks. Requirements also change over the years and the changes need to be reflected in the contract; therefore, service contracts should be reviewed periodically and they should especially be reviewed when they have reached their end and a new contract is going to be signed.
Q: We have two open-heart OR’s. Each has a full 42″ wide door leaf that opens to the corridor, and each has a 3’0″ door in the rear of the OR that opens into a central sterile core. The OR walls other than the corridor side are not labeled as a fire/smoke barrier on the life safety drawings. The main OR entrance door that opens into the corridor has a door closer, is rated, and has latching hardware. My question is: The 3′ 0″ doors opening into the sterile core have closers but do they have to be fitted with latching hardware?
A: Does the Life Safety drawings identify the sterile core area and the operating room together as a suite-of-rooms? What does the life safety drawings say about the sterile core area? Is it classified as a suite? If so, then the door could be fine without a latching door between the OR and the sterile core area, because it is all one suite. However, if the life safety drawings clearly identify the internal walls of the sterile core area as corridor walls, then the door between the OR and the sterile core area would have to latch. Remember: All corridor doors must latch.
There is another issue here… Most sterile core areas that I have seen qualify as an hazardous area, due to the many combustible items stored in the room. If the walls surrounding the sterile core area are 1-hour fire-rated, then the door itself would have to be 3/4-hour fire-rated (see 126.96.36.199 of the 2012 LSC), and it would have to be self-closing and positive latching. If the walls surrounding the sterile core area are smoke partitions and the sterile core area is protected with sprinklers, then the door is not required to be fire-rated, but it must be self-closing (see 188.8.131.52.3) and positive latching (see 184.108.40.206.2, which references 220.127.116.11 which references 18.104.22.168.10).
Based on the information you provided, it is probable that the door between the OR and the sterile core area would have to positively latch.
Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have different interpretations of 22.214.171.124.1.2.
A: No. Corridor entrance doors to suites must latch. Section 126.96.36.199.5 requires all corridor doors to latch. CMS does not allow the exception for a device that holds the door closed with 5 lbs. of force.
Since a suite is nothing more than a large room with smaller rooms inside, the barrier that separates the suite from the corridor must meet the conditions for corridor walls, which means the door must latch. The provision in 188.8.131.52.1.2 (2) is written to allow existing suites to have smoke resistant walls when fire-rated barriers are required by the corridor walls.
Q: My question is in regards to alcohol-based hand rub (ABHR) dispensers in a recovery area in our Cath lab. Does an open bay in the recovery area count as a patient room and not in the overall count of dispensers in a smoke compartment?
A: No. Open bays for recovery do not count as individual rooms in regards to the count of ABHR dispenser locations. The reason why is, those bays are located in one room, not in separate rooms. According to section 184.108.40.206.1 of the 2012 LSC, areas used for patient treatment or sleeping have to be separated from the corridor. So, they are either in a large room, or a suite (which is a large room as well). They cannot be open to the corridor, and if they are, you have other problems.
Q: What is the most common deficiency that you cite during a Life Safety Code survey?
A: Improper inspection, maintenance, and testing of the building features that protect occupants from smoke and fire seem to be the area I tend to cite the most. The focus in ambulatory surgery centers (ASCs) has changed from evacuation of patients to shelter-in-place. Staff is trained to move patients and themselves to safety behind barrier walls that are designed to limit the transfer of fire and smoke.
The following features are often neglected:
- Fire and smoke dampers – Many times, ASC staff have no idea if the facility even has fire and smoke dampers. Since the dampers are usually located above the ceiling tiles, they are often forgotten. Dampers are required to be inspected and tested one (1) year after inspection and every four (4) years after that. I have found that ASCs that are maintained by hospital maintenance staff often only conduct the testing every six (6) years, as required for a hospital, instead of every four (4) as required for ASCs. I am often asked who inspects and tests fire dampers. I usually suggest that the original HVAC contractor be contacted first for guidance. If they can’t help, I suggest that they contact other ASCs or the hospital to find out who they need to conduct the work.
- Barrier walls – Once above the ceiling tiles, barrier walls are often forgotten. Regardless of the type of barrier wall, the wall needs to be inspected and maintained to ensure that it is compliant with the standard. There shouldn’t be any open holes. Penetrations should be properly sealed. Walls should be properly constructed for their type. I often suggest that at least annually ASCs should have someone, with knowledge of the standards, inspect the barrier walls for deficiencies. Deficiencies should be repaired by trained individuals.
- Rated fire doors – Rated fire door assemblies are required by NFPA 80 edition 2010 to be annually tested and inspected. Usually, the doors are not inspected, or the inspection does not meet the standard. Besides deficiencies related to door inspections, the next prevalent deficiency is fire doors being propped open.
Q: Are smoke detectors required in individual hospital patient rooms, and what are the exemptions to not have a detector in individual rooms?
A: There is no Life Safety Code or NFPA 72-2010 requirement to have smoke detectors in hospital patient sleeping rooms or treatment areas. There may be other standards or regulations that could require them, so check with your state and local authorities.
Typically, the only areas that are required to have smoke detectors in a hospital are:
- Elevator lobbies and elevator mechanical rooms
- Near doors that are held-open by magnets
- In the same room with fire alarm control panels that are not constantly supervised
- In areas open to the corridor that are not constantly supervised
- Inside locked areas that use the Specialized Protective Measure locking arrangement identified by 220.127.116.11.5.2
- Patient sleeping suites that do not provide direct supervision
- Smoke compartments containing patient sleeping suites over 5,000 square feet but not exceeding 7,500 square feet and are not equipped with Quick Response (QR) sprinklers
- Patient sleeping suites over 7,500 square feet but not exceeding 10,000 square feet
Additionally, smoke detectors may be required in patient sleeping rooms if an Equivalency was submitted and approved.
Q: I need you to settle an argument for us, and your answer will settle this situation for all. We have a fire door to a hazardous room, that has lockers behind it when you open the door. The lockers will not allow the door to open fully. Since this door is not in the means of egress, is this situation allowable?
A: All doors are in the means of egress as long as you can physically be inside the room. Once you’re in the room, the door is now in the path of egress to get to the outdoors. Section 18.104.22.168.1 of the 2012 Life Safety Code says all doors in the means of egress shall be capable of swinging from any position to the full required width of the opening. So, the door must swing open to at least 90 degrees. I would say your situation is not permitted and the lockers should be relocated to allow the door to open fully.
Q: What is the allowed distance a non-sprinkled stick-built building can be located beside a hospital?
A: Your question encompasses a couple of different issues. When you say “stick-built” building, I think of wood frame construction, which is Construction Type V (000) in accordance with the Life Safety Code and NFPA 220. Construction Type V (000) is not permitted in healthcare occupancies unless the hospital is only one story and is fully sprinklered. So, let’s assume your hospital is more than one story and is at least Construction Type II (222), which is non-combustible construction with beams, columns, joists and floors fire rated at 2-hours. If you have an adjoining wood-frame building with Construction Type V (000), then it must be separated from the healthcare occupancy with a 2-hour fire rated barrier. However, there is a caveat with this requirement. If the wood-frame construction building is separated by a minimum of 10 feet and is not-connected to the building containing the healthcare occupancy, then a 2-hour fire rated barrier is not required. This 10-foot gap would act as a fire barrier is one building were to catch on fire. This 10-foot gap is an interpretation based on section 22.214.171.124.2.1 that requires 10-feet of the horizontal exterior of the building wall to be fire-rated where unprotected exterior walls of a stairwell connect to the building at an angle less-than 180 degrees.
Q: Housekeeping products like germicidal, glass cleaner, air freshener are stored in a locked metal box on housekeeping cart. All of our stock of these and other products are stored in two large locked metal lockers. They are not fire rated cabinets. The surveyor said aerosols all have to be stored in fire rated cabinets. While they are in use while on housekeeping carts, they will have to be checked in and out daily from a fire cabinet.
The surveyor did not cite a tag or code for this he just told us we had to do it. I have searched and so much is left to interpretation I am confused on what to do. With all the changes occurring and more to come with state regulations and inspections I would like to be prepared.
A: It is safe to say that there is no NFPA standard, no CMS standard, and no accreditation standard that specifically says aerosol cans must be stored in a fire rated cabinet. However, if access to these aerosol products by unauthorized individuals is a safety risk (i.e. can children get into them) then it may be perceived as an unsafe environment and the surveyor would have a legitimate concern about them.
I suggest you go back to the surveyor and ask them why they believe the aerosol products have to be stored in a fire-rated cabinet. Ask for a specific code, standard, or regulation that they are using to make this recommendation.
Otherwise… it’s not a code violation, but a surveyor’s preference.
Q: In regards to corridor width, section 126.96.36.199 of the 2012 LSC discusses that a corridor has to be at least 48-inches outside of a sleeping room in clear width. Does that mean that you only need to worry about situations where your corridor projection will reduce the hallway to less than 48 inches? Is clear width from wall to wall, or from projection to wall? When I had asked our Accreditation Organization for guidance on this issue they stated that we did not need to worry about a projection so long as the corridor still maintained 8 feet from the projection to the other wall. I don’t see that that stated anywhere in my copy of the LSC. Is this true?
A: No… it is not true. Let’s put to rest the erroneous comment that you do not need to worry about a corridor projection so long as the corridor still maintained 8 feet from the projection to the other wall. This is absolutely false. A projection into the corridor is not affected by how much distance to the other wall remains. If someone wants to cling to that statement, then ask them to identify where in the Life Safety Code it permits it (they won’t find it).
According to the CMS Final Rule to adopt the 2012 Life Safety Code that was published May 4, 2016, all CMS-certified healthcare providers cannot have a wall-mounted projection of more than 4 inches. This is measured from 27-inches above the floor to 80-inches above the floor according to the ANSI standard A117.1-2009, section 307.2, which is referenced in the ADA standard. But this also allows for wall-mounted items (i.e. clocks, signs, monitors) to extend more than 4-inches into the corridor as long as they are at least 80-inches above the floor.
This is true no matter how wide your corridor currently is, although some exceptions apply for areas open to the corridor like lobbies and waiting areas.