Q: Our gas storage room has little mini-helium tanks which are full and under pressure. Are these tanks required to be restrained in the same way that the larger ‘E’ size cylinders are? The same room has a lot of O2 and CO2 tanks secured and stored. Is this room considered a hazardous room and does the door require a closer in existing healthcare occupancy?
A: Yes, the mini-helium tanks have to follow the same regulations as the larger compressed gas cylinders, and need to be properly secured. In regards to hazardous room… not necessarily. Once the total aggregate volume of non-flammable compressed gas exceeds 3,000 cubic feet, then the room has to be 1-hour fire rated and of course, the door would have to be fire-rated, positive latching and self-closing. If the quantity of compressed gas exceeds 300 cubic feet, but is less than 3,000 cubic feet, then the cylinders need to be stored in a designated room with 30-minute fire rated walls, have a lockable door and all cylinders must be separated from combustibles by 20 feet, or by 5 feet if the room is protected with automatic sprinklers.
Q: During a recent survey, an inspector cited us for not having the escutcheon (trim) plates around all of our sprinkler heads. I always thought these plates were for decorative purposes only and was surprised that the inspector would cite us for not having them. Is it a Life Safety Code requirement to have these plates on the sprinkler heads?
A: The escutcheon plate (or trim plate) around a sprinkler head serves a far greater function than just decoration. It serves to seal the rough opening made in the ceiling (or side wall) in order to install the sprinkler head. Without it, heat may go around and delay the activation of the sprinkler head. The escutcheon plate also creates a smoke resistant connection, which is required of the ceiling when the sprinkler option is used. LSC 22.214.171.124.1, exception no. 1, requires automatic sprinklers and a ceiling that limits the transfer of smoke in order to qualify for the exception where the corridor walls can be constructed with non-fire rated partitions and terminate at the ceiling. This is an important advantage by having a smoke compartment that is fully protected with automatic sprinklers, so those escutcheon pates are required. Not having them would constitute a life safety deficiency, and needs to be managed as such. Sounds to me like the surveyor was correct with this one.
Q: What ILSM’s apply to occupancies other than healthcare? For example, if a fire alarm/sprinkler system is out of service for more than 4 hours in a 24 hour period in one of our freestanding physician practices, we notify the local fire department. What about other ILSM’s such as altered exits, etc?
A: It is a NFPA Life Safety Code requirement, as you state, to notify the local fire department AND conduct a fire watch whenever the fire alarm system (or part of the system) and the sprinkler system (or part of the system) is out of service for 4 or more hours in a 24 hour period (LSC 126.96.36.199 and 188.8.131.52). Therefore, that action is required for any and all buildings subject to the NFPA Life Safety Code. This would include all healthcare occupancies, ambulatory care occupancies, business occupancies, etc. The Interim Life Safety Measures that you refer to are a product of the Joint Commission standards, and therefore, only apply to those buildings which the Joint Commission says it needs to apply to. Their Hospital Accreditation Standards manual, and their Ambulatory Health Care manual both require ILSMs to be implemented in healthcare occupancies, and ambulatory care occupancies, but does not require them in any other occupancy type. Therefore, one could conclude that ILSMs do not need to be implemented in business occupancies. However; many business occupancies that are contiguous to the main hospital are staffed with people who have come to expect the same level of fire protection in their building as the main hospital. Therefore, it is wise to go beyond the minimum requirements and implement ILSMs in those business occupancies that have a close tie with a healthcare or ambulatory care occupancy. To address your last question, an altered exit in a free-standing physician office which qualifies as a business occupancy, would not require an ILSM, although it would be wise to implement ILSMs
Q: What is actually required in order to perform a Fire Watch when the fire alarm system is inoperative? How often should a Fire Watch be performed?
A: The Life Safety Code (LSC) section 184.108.40.206 requires an approved fire watch be conducted whenever the fire alarm system is out of service for 4 or more hours in a 24 hour period. The Annex section A.220.127.116.11 explains that a fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard to walk the affected areas. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques.
NFPA 601 (1996 edition) Standard for Security Services in Fire Loss Prevention provides examples of procedures for fire loss prevention:
- Check permits for hot work
- Check for obstructed sprinkler heads or closed control valves
- Check portable fire extinguishers for availability
- Check temporary fire alarm equipment
- Check affected area is clear of discarded packaging
- Check affected area for clear path of egress
- Check for any forms of ignition
While there is not a specific requirement that fire watches be performed by security personnel, it is strongly recommended that you do not leave this important responsibility to someone who does not have an active stake in the safe operation of your facility. There is not a prescribed frequency in any NFPA code or standard on how often a fire watch should be conducted, so it is left up to the authorities having jurisdiction (AHJ) to make this determination. Joint Commission has indicated that two fire watch rounds per 8 hour shift would be acceptable, however it is recommended that you contact your local and state authorities to determine what frequency they require.
NOTE: Whoever you choose to perform the fire watch, they will need to have basic training on what to look for and what action to take. The Fire Watch form under the “Forms” page can be used for not only documentaing that a fire watch has been initiated, but also serves as an education tool for just-in-time training for the individual who conducts the fire watch.
Q: We are aware of the NFPA 99 requirements to separate the transfilling operation of liquid oxygen from our patient care areas with a 1-hour fire rated room with noncombustible floors, and mechanical ventilation, but what are the requirements for storing the portable hand-held liquid oxygen containers on the nursing units? Can they be placed in a clean supply room?
A: Yes they can, provided you have adequate ventilation. NFPA 99 section 8-18.104.22.168 requires compliance with Compressed Gas Association (CGA) Pamphlet P-2.7 Guide for the Safe Storage, Handling and Use of Portable Liquid Oxygen Systems in Health Care Facilities. The nature of these portable, hand-held canisters is they are constantly venting gaseous oxygen into the room, which in turns creates an oxygen enriched atmosphere. If not ventilated adequately, an oxygen enriched atmosphere can vigorously accelerate other combustible items to burn. CGA Pamphlet P-2.7 requires a well ventilated room in which to store these canisters. While the CGA pamphlet does not specify how many air changes per hour (ACH) constitutes a “well ventilated” room, air changes similar to what is required in an operating room should be acceptable. Check with your local and state authorities to determine if they have a specific air changes per hour.
The CGA pamphlet also requires the portable hand-held liquid oxygen canisters be stored in an upright position to prevent an accidental discharge of the liquid contents. The CGA pamphlet also recommends that the portable hand-held canisters of liquid oxygen be kept at least 5 feet from electrical appliances, and any other heat source.
Q: Like many older hospitals, we have areas with a mix of quick response sprinkler heads and standard response sprinkler heads. Are we required to go back and make them all quick response or just upgrade them as we remodel the areas?
A: For new and existing healthcare occupancies, the 2000 edition of the LSC (18.3.5/19.3.5) requires automatic sprinklers to be installed in accordance with section 9.7, and they must be the quick response type in smoke compartments containing patient sleeping rooms. There are some exceptions involving non-required sprinkler systems in existing occupancies, but for the most part section 9.7 must be followed.
Section 9.7 requires compliance with NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, and section 5-22.214.171.124 states if quick response sprinklers are used in a compartment, then all of the sprinklers must be quick response. If your existing healthcare occupancy has only standard response sprinkler heads in a smoke compartment that contains patient sleeping rooms, then you are permitted to allow them to remain until such time you renovate the area, or upgrade your sprinklers to the quick response type. At that time, all of the sprinkler heads would then need to be quick response.
Based on your question, it would appear to me that you are not allowed to mix the different types of sprinkler heads since you already started upgrading them to quick response. The only way you would be allowed to have mixed response type of sprinklers in the same compartment, is when a specific temperature range of sprinkler is not available in quick response type.
As always, please check with your local and state authorities for further requirements.
Q: Our project team insists on using non-combustible plastic sheeting for temporary barriers between construction areas and occupied areas of our hospital. Is this acceptable according to the Life Safety Code (LSC)? I thought we had to have 1-hour fire rated barriers in these applications.
A: The appropriate section of the LSC (2000 edition) that covers construction operations is 126.96.36.199/188.8.131.52. This section requires the means of egress must comply with section 184.108.40.206 and with NFPA 241 (1996 edition) Standard for Safeguarding Construction, Alterations, and Demolition Operation. Section 220.127.116.11 simply states that the means of egress must be free from obstructions and impediments. However, NFPA 241 has more information on temporary construction barriers.
Section 2-2 of the 1996 edition of NFPA 241 discusses temporary enclosures which are required to be noncombustible panels or flame-resistant tarpaulins or approved materials of equivalent fire-retardant characteristics. This section also requires appropriately sized and type of fire extinguishers be placed inside the enclosure. This is all the 1996 edition says about the requirement for temporary construction barriers.
However, we need to take a look at the 2000 edition of NFPA 241. In this newer edition, NFPA created an entire new section entitled “Temporary Separation Walls” and is found under section 8.6.2. This new section requires a temporary barrier between an occupied portion of the facility and the construction area to be 1-hour fire rated (with 45-minute fire rated doors) when such construction operations are considered to be a higher level of hazard. The 2000 edition permits nonrated walls and doors when an approved automatic sprinkler system is installed, and does not consider construction tarps as appropriate barriers or opening protectives.
So, technically speaking, the 2000 LSC requires compliance with the 1996 edition of NFPA 241, not the 2000 edition. And, as pointed out above, the 1996 edition does not have a requirement for 1-hour fire rated walls for temporary construction barriers. The Joint Commission has previously stated that they will accept noncombustible plastic sheeting for temporary construction barriers, and not require 1-hour fire rated barriers. However, in unofficial conversations with CMS inspectors from various states, I find that many CMS offices across the country will mandate 1-hour fire rated temporary construction barriers regardless what the 1996 edition permits. While it may appear that you have the right to decide when and where a 1-hour fire rated temporary construction barrier is required in your hospital, my advice to you is to contact your local and state authorities and ask what they require, and ask them to quote the standard reference and see which edition they are enforcing.
Q: We recently had a consultant advise us to always activate our fire alarm system whenever we conduct a fire drill. We don’t always do that because we perform so many fire drills we think the staff will ignore the alarm when there really is a fire. What do you see as the standard for fire drills?
A: I believe your consultant is correct, with the exception when a drill is performed between the hours of 9:00 pm and 6:00 am. Here is why: Section 18.104.22.168 of the LSC specifically requires the activation of the fire alarm system during drills, along with the transmission of the fire alarm signal. I asked the NFPA to clarify what is meant by the phrase “transmission of the fire alarm signal” and a representative said the intent means to transmit it to the point where you involve everyone in your fire plan. I also asked a representative from CMS how they view the phrase “transmission of the fire alarm signal” and they interpret it to mean the signal needs to go all the way to the fire department for each fire drill. Since the fire department is a large part of your fire response plan, they need to be included. The same section in the LSC also says you do not have to activate the fire alarm system during the hours between 9:00 pm and 6:00 am, as to not disturb sleeping patients. A fire drill is an excellent opportunity to document that the fire alarm transmission signal was received by the local fire department, even if you contract through a vendor to monitor your fire alarm panel. You are required to do so anyway, every quarter. Make sure you document it on your fire drill report.
Q: During a recent inspection, the surveyor cited our hospital for having dead-bolt locks on our patient room doors. None of the doors were locked at the time of the inspection, but the surveyor said the doors could be locked. Our state inspectors were OK with the locks on the patient room doors as-is, but is this a LSC violation and do we have to remove the locks?
A: Section 22.214.171.124.2 (126.96.36.199.2 for new construction) of the LSC says locks are not permitted on patient room doors. However, there are two exceptions to this requirement: 1) A key-locking device is permitted as long as it restricts access from the corridor to the patient room and is operable from the corridor side, and cannot restrict egress from the room, 2) Patient room doors may be locked where the clinical needs of the patient requires specialized security measures. You did not state whether or not the dead-bolt locks could be unlocked from the room side without the use of a key, tool, or special knowledge (see 188.8.131.52.1). If they can be unlocked from the room side without the use of a key, tool or special knowledge, then I believe they would be permitted, according to exception number 1. However, if the locks are not capable of being unlocked without the use of a key, tool or special knowledge, then that would be a code violation, and the surveyor was correct. Exception number 2 allows locks on patient room doors where the clinical needs of the patients require specialized security measures, such as a psychiatric unit. In those situations, the lock does not need to be un-lockable from the inside of the room, provided the patient is under constant observation and the staff is carrying a key (or other such device) at all times to unlock the door. So, your question as to whether or not the locks need to be removed is dependent upon the clinical needs of the patients for specialized security measures, and whether or not the locks can be unlocked from the inside of the room without the use of a key, tool, or special knowledge.
Q: Is it acceptable for a 20 minute fire door to be used for a hazardous room in a new construction of a hospital? I’m looking at the Life Safety Code (LSC) and it seems to be indicating no, but I just wanted to be sure that I was reading the code correctly.
A: It depends. Looking at 184.108.40.206, of the LSC, I see new construction hazardous rooms require ¾ hour fire rated doors. There are a few exceptions, though: 1) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard; 2) Storage rooms storing combustible materials larger than 50 square feet but not exceeding 100 square feet. In these two exceptions, a 20-minute rated door would be acceptable as long as it self-closed and positively latched. However, check with your local authorities to see if they have other requirements you need to comply with.
Q: We are completing a project that includes a new generator for our hospital. The installing contractor will conduct a 2-hour load test as part of his commissioning. My question is, are we required to conduct the 3-year 4-hour load test right away, or should we wait 3 years after we begin using the generator?
A: You need to conduct this 4-hour test right away. The Joint Commission standards references NFPA 110 Standard for Emergency and Standby Power Systems (2005 edition) and section 8.4.9 requires a 4-hour load test once every three years. If you wait until the third year to do this test, and you have a survey prior to completing this test, you may be cited by the accreditor for non-compliance with their standards. It is the intent of this test to provide a reasonable assurance that the generator is capable of running and delivering power during an emergency. It has been documented that some generators failed to continue to operate after only a couple of hours during an emergency due to overheating.
Q: What is the LSC stance on card swipe systems to access doors? We were told by a city inspector that we could not install access control locks because we are not fully sprinkled in the original section of our old building. In addition, if we finish installing sprinklers in this area, we were told we would need to issue keys as a backup to the access-control locks. Kind of defeats the purpose, doesn’t it?
A: It all depends on where the locks will be installed. If they will be in the path of egress, then you may have a problem. Exception number 2 under section 220.127.116.11.4 refers us to section 18.104.22.168.2 for access control locks. Access controlled locks are widely misunderstood and therefore greatly abused in hospitals. There are specific requirements of the access control locks that you must adhere to: 1) A motion sensor on the egress side to automatically unlock the door; 2) A manual release switch must be mounted 40 – 48 inches above the floor, and within 5 feet of the door. When depressed, the switch must interrupt the power to the lock for a minimum of 30 seconds. 3) Activation of the fire alarm system or sprinkler system (if provided) must unlock the doors. It doesn’t say, however, that sprinklers must be provided. If your card swipe readers are on the egress side of the locked door, and you do not comply with all of the above requirements, then you are not in compliance with the LSC. Having card swipe readers on the side of the door that is not in the path of egress is permitted. I do not see any code reference that requires you to have backup keys for access control locks. Ask the city inspector to provide you with a code reference for the interpretation. Perhaps it is a local or state requirement.
Q: Is it allowable to use clean compressed medical air to blow off equipment in central sterile? Currently, we use compressed air from our medical air distribution system to dry equipment in our central sterile area, and we have concerns if this practice is permitted.
A: No, it is not permitted. The LSC requires that you be in compliance with NFPA 99 (1999 edition). Joint Commission and CMS both have adopted the 2005 edition of NFPA 99 only for non-flammable compressed gas cylinder storage, but for all other aspects of NFPA 99, the 1999 edition is the one to follow. The annex section on 4-22.214.171.124(a) discusses the intent of the medical air piping distribution system should only be used for respiratory assistance needs involving breathable air. The medical air system is not intended to be used for general hospital support use. If the medical air system was used for purposes other than breathable air then there is a chance of cross-contamination, and it might increase service interruptions and reduce the service life of the equipment. While the annex section of NFPA 99 is not part of the enforceable standard, it does provide guidelines to follow for the authorities having jurisdiction (AHJ) on how to apply the standard. Therefore, it can be (and is) enforced by The Joint Commission, CMS and other AHJs. My advice is to discontinue using compressed medical air for drying equipment, and reserve the medical air only for breathing purposes.
Q: Is an elevator equipment room required to be sprinklered in a hospital? A consultant recently told us that NFPA 13 requires us to install sprinklers inside our elevator equipment room.
A: This is one of those “it depends” answers. NFPA 13 Standard for the Installation of Sprinkler Systems is a standard and not a code, and generally speaking it does not specify when you have to install sprinklers in a building, it specifies how you install the sprinklers. So we do not begin our search in NFPA 13 (1999 edition) for guidance on sprinklers in a hospital. Instead, we look at the Life Safety Code (LSC).
There is critical information missing here… Is the hospital considered existing healthcare occupancy or new healthcare occupancy? Or more specifically, is the area in question (the elevator equipment room) considered new or existing? That is a big issue, as there are very few requirements to install sprinklers in an existing healthcare occupancy. The only requirements are:
If the Construction Type requires it. Take a look at table 126.96.36.199 (2000 edition of the LSC). If your construction type requires the facility to be sprinklered, then the entire building has to be sprinklered, including the elevator equipment room.
- If the organization asked for and was granted an equivalency for some other life safety deficiency, and the organization claimed that the entire building was protected by automatic sprinklers, then the elevator equipment room would have to be sprinklered.
- Was there any renovation, equipment upgrade, construction or remodeling inside the elevator equipment room? If so, then the elevator equipment room would have to meet new construction requirements and must be sprinklered.
On the other side of the coin, if the building is considered new healthcare occupancy then the entire building must be sprinklered which includes the elevator equipment room.
NFPA 13 does not have any exceptions to installing sprinklers in an elevator equipment room in healthcare occupancies. Another standard that the LSC requires compliance with is the ASME / ANSI A17.1 Safety Code for Elevators and Escalators, and it discusses in length on how to install sprinklers by using different methods to stop and de-energize the power to the equipment before the discharge of the water. Some local and state governments have stated that they do not want automatic sprinklers in an elevator equipment room. Their reasoning is they do not want the electrical components to get wet before the power is shut off even with these special provisions. If your state or local authorities have such a rule, then most, if not all, AHJs will accept this provision, and not require sprinklers in your elevator equipment room.
So, you need to determine if the elevator room is required to be sprinklered due to the construction type, equivalency granted, or if it is newly constructed or renovated. Then contact your state and local authorities to determine if there are any exceptions that you must qualify with.
Q: We have multiple paths of egress from an area used by our Bio-Med staff, and for security reasons we lock the doors to and from this area. This is a former behavioral health unit that still has the security locks on the doors. During a recent survey, an inspector cited us for having a locked door in the path of egress. The only people that travel to and from this area are two Bio-Med employees, and they always carry a key to unlock the doors. Isn’t there an exception in the Life Safety Code (LSC) that permits this arrangement?
A: No, there is not an exception that would allow such an arrangement. Locked doors in the path of egress in a hospital are only permitted in the following manner: 1) Delayed egress locks; 2) Access-control locks, and; 3) Locked doors for clinical needs. The scenario you described does not appear to qualify for any of these situations.
You may be thinking of Exception No. 1 to 188.8.131.52.4 of the LSC that permits a locked door in the path of egress where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock the doors at all times. However, your situation does not qualify for the “clinical needs” exception. “Clinical needs” is defined for the protection of patients who are a danger to themselves or others, and by many AHJs, for the security of babies. The Bio-Med employees do not qualify for this exception.
It appears to me that the inspector was correct with this citation, and my advice is to change the locks on the doors so they no longer lock in the path of egress.