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Strange Observations – Combustible Materials in Structural Support

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

So… I’m above a ceiling in a pre-assessment testing area and I see in the corner what appears to be a wood 2×4.

According to NFPA 220, construction types I and II cannot have combustible material in the structural components. (This hospital was a Type II (222).

This wood 2×4 is supporting an interior wall and the suspended ceiling.

You have to keep an eye on contractors while they are renovating your departments… they will do things like this that will eventually get you in trouble.

Strange Observations – Oxygen Cylinder Storage

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

Yes… we are looking at oxygen cylinder storage issues again… Yuck.

The sad thing is, scenes like this are not that uncommon in my line of work as a consultant. That means it is not as strange as I would like it to be.

NFPA 99-2012, 5.1.3.3.2 does require all compressed gas cylinders to be secured at all times. Presumably, those of you who are reading this realize this, and are as frustrated as I am when you find situations like this.

But put yourself in the position of the healthcare provider: Their number 1 priority is taking care of patients. Complying with Life Safety Codes, or other NFPA standards and regulations is not high on their list, and quite honestly, with everything they have to do, I’m okay with that. I’d rather they be concentrating on taking good care of me or my loved-one, rather than concentrating on making sure the corridor is not cluttered, or other basic LSC requirements.

So it is important for you to make compliance with the LSC as easy and simple as possible for those nurses, therapists, and technicians. That means, you need to do frequent rounding looking for basic violations as the one in the picture reveals. When you find these violations, you can do remedial training, but perhaps more importantly, make changes to eliminate the problem from happening again. In this case, obtain more storage racks so staff does not leave cylinders on the floor or unsecured.

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.

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.

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.

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.

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.

Last Day to Register for… Compliance One Presents Keyes Life Safety Boot Camp

TODAY IS THE LAST DAY TO REGISTER!

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.

NOTE: CEUs will be 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!

Presented by:

Strange Observations – Exit Enclosure

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

This is not corridor, but rather an exit enclosure to a stairwell. There was a construction project in progress and to achieve a negative air pressure in the project area, the contractor cut a hole (twice) in the 2-hour fire-rated barrier for the exit enclosure to run the temporary flex duct to the exhaust fan.

Section 7.1.3.2.1 (10) of the 2012 LSC does not allow penetrations into and through an exit enclosure for this purpose, even on a temporary basis.

If you’re asking what the hospital should have done if this was their only option to create negative air for the project, I would say they could have set-up a HEPA filter negative air machine inside the project area, and discharge the air from the HEPA blower to an adjacent corridor. Not the best solution, but one that is far better than making penetrations into the exit enclosure.

There is also the issue of headroom which must be at least 7-foot 6-inches, according to section 7.1.5.1.

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.

NOTE: CEUs will be 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: