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Things that go bump (or don’t) in your egress stairwells

There has been a little increase in findings relative to various items (utility system components, security cameras, evacuation devices) being located in egress stairwells. NFPA 101-2000 Life Safety Code 7.1.3.2.1 (e) gets pretty specific about what you can have in terms of penetrations into and openings through an exit enclosure assembly:

(1) Electrical conduit serving the stairway

(2) Required exit doors

(3) Ductwork and equipment necessary for independent stair pressurization

(4) Water or steam piping necessary for the heating or cooling of the exit enclosure

(5) Sprinkler piping

(6) Standpipes

This means, strictly speaking, that things like security cameras, water lines, phone/radio system repeaters, electrical conduit that does not serve the stairwell, etc. are pretty much off the table, particularly if they have been installed after March, 2003 (the official dividing line between new and existing construction).

There is an exception for existing penetrations as long as they are appropriately protected (firestopping, etc.), but if you’ve got newer than ’03 stuff in your egress stairwells, you may have some work ahead to square things away (I’d start with a conversation with either your state AHJ or maybe the engineers at TJC).

And who do you think gave you permission to do that, mister man?

One of the interesting dynamics that can come into play relative to code compliance is the concept of getting permission for this, that, or the other thing, from our old friend the Authority Having Jurisdiction (AHJ).

For instance, there are probably a number of you who work in facilities of a certain vintage that indicated the installation of “occupant hoses”—you know, those canvas-y things that used to be coiled up in lovely cabinets. And many, if not most, of you who had such hoses were able to get the permission of the local fire folks to remove them. I mean, really—you’re not going to use them, your staff is not going to use them, and the fire department sure isn’t going to use them, so it’s not a difficult thing to imagine. In some instances, you may have to wait until your facility is fully sprinkled, but generally you can get the locals to sign off on it.

Likewise, you may have a fire pump that, for whatever reason, can’t undergo the annual test at a flow of 150% of the rating for the fire pump. Or you may have a medical gas system component that is not quite up to code, but is allowed by the AHJ as long as you agree to correct the condition when you renovate the applicable space. A common condition is the placement of medical gas zone shutoff valves in the same space as the outlets being controlled—no intervening wall to separate the valve from the outlet (I see this a lot in PACU’s of a certain vintage) and the condition poses no significant risk to occupants, etc. These are both examples of conditions that you wouldn’t have to fix as long as you had the permission of the AHJ.

So, you might ask, what’s the point of this? Well, an interesting phenomenon has been popping up periodically this survey year and it revolves around reliance on the permission of the local AHJ to defer correction of certain items like those noted above. And the sticking point is this – if you have not, upon receipt of this “permission” from the AHJ, then submitted that permission to TJC as a request for a traditional equivalency (you can submit the request on-line through the e-SOC portal – I think you’re going to find you’re using this portal more and more frequently in the future).

To be honest, the process of submitting equivalency requests with TJC has long been in the mix, but it appears that it is becoming a focus in survey year 2012. So, if you’ve been given permission from your AHJ for whatever little condition it might be, you better make sure you’ve submitted the equivalency request to TJC. I have no reason to think that these requests wouldn’t be approved, so long as they are reasonable (i.e.,not indicative of a significant risk). After all, I think one of the key elements in the relationships we have with the folks in Chicago is to let them know what’s going on in an open and forthright manner. I suspect it’s what we would all want if the roles were reversed.

I ain’t missing you (are you sure about that?)

As much as I had hoped for a reduction in findings relative to EC.02.03.05 (maintaining fire safety equipment and fire safety building features), that hope is being dashed on the rocks of reality. And once again, it appears that a lot of it has to do with the quality of the documentation provided to us by our fire alarm and sprinkler testing vendors.

Where this has been cropping up most recently is in the realm of ensuring that each of the applicable devices is tested in absolute accordance with the requirements for frequency. For example (this from a recent survey), if you have your vendors doing 25% of your inventory each quarter (for the devices that need to be tested annually), then you need to make sure that the number of devices tested in the 1st quarter of last year matches up with the number if devices tested in the 1st quarter of this year, or you need to have a very clear understanding of why the numbers don’t match up. Maybe you installed and/or removed devices from service; maybe there are devices that they could get to in one quarter and couldn’t in the subsequent (more on this in a moment).

Ultimately, we need to make sure that each of the devices in our inventory is being tested at the appropriate frequency. A question for those of you who have your fire alarm testing done on a once-a-year schedule: If a device can’t be tested during the regularly-scheduled activity– say, for instance, a patient room is occupied and the smoke detector can’t be tested– how are you making sure that that device doesn’t fall out of the testing loop?

I know it’s just a single device, but if it’s in a place that’s tough to get to, the next thing you know, you’ve got a couple of years passing without that device being tested… and it becomes low-hanging fruit for a diligent surveyor. I’m just saying…

How long has this been going on?

We’re rounding the turn and headed for home – no squeeze play at the plate this time…I hope!

EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems (#16, with 24% of hospitals having been cited)

It seems to me that we’ve discussed this in the past as well, but it appears that, in this survey year, everything bears repeating.

Anything that your medical gas and vacuum testing activities generate as deficiencies/recommendations/hints from Heloise/etc. needs to be accounted for somehow. Maybe your medical air intake is right next to an isolation exhaust, or it’s nothing more than a leaky outlet, or the issue is non-compliant construction (a favorite is the medical gas zone shutoff valve in the PACU with no intervening wall) that can wait until you do a remodel/renovation project. Whatever it is, you need to say, “This is what we’re doing about that, based on our assessment of the involved risks.” And don’t wait to get ahead of the curve on the fixes: As soon as the activity is completed you are on the hook for the fixes, so you need to know what’s on that list even before you get the pretty report. The clock starts ticking upon identification of the condition, so if you have to wait a month or 45 days for the report, you (and more importantly, your patients) are at some level of risk.

The other thing to do is make sure that your vendor is not using this process to drum up work; I can’t tell you how many times I look at multiple years of testing documentation and find the same “deficiency” over and over again – and then find out, well, it’s not really a deficiency at all. You will get slapped during a survey for this – if it’s a critical fix, then fix it, if it’s not a critical fix, then dot the “I’s” and cross the “t’s” and make sure they are accounted for.

Another component of this is obstructed access to zone shutoff valves, as well as making sure that the labeling of valves is accurate (areas served, contents of piping – labels have to be accurate, accurate, accurate). Also, make sure that what you are calling the area of coverage is in some sort of accordance with what the staff calls the area. I can’t tell you how many times that I’ve seen zone valves labeled in accordance with the architectural drawings and find out that front line staff really doesn’t know which areas are served by the valves. Knowledge is very powerful, and certain knowledge is an invaluable commodity during surveys.

EC.02.05.07 – Inspection, testing and maintenance of emergency power systems (#17, with 23% of hospitals having been cited)

Emergency generators and automatic transfer switches have to be tested in accordance with the requirements of EC.02.05.07 – if you need me to tell you what those are at this point, you may be in the wrong line of work. However, I am more than happy to answer any questions you might have regarding this most important subject. 30%, 30 minutes, no closer than 20, no greater than 40 between tests, run it for 4 hours at a minimum 30% load every 36 months – these are a few of my favorite things.

EC.02.03.01 – Management of fire risks (#20, with 19% of hospitals having been cited)

Breathing a sigh of relief, we’re near the end of our little journey through time and (interstitial) space.

This is another of those findings that it becomes a question of how far one must look before one can encounter enough deficiencies to drive an RFI (the answer in this case being 2). The question I have for you is this – how many junction boxes do you have in your facility. 100? 1,000? 10,000? So, the follow-up question is: How many would an individual (say, a Joint Commission Life Safety surveyor) have to look at before they found two that didn’t have a cover? There are so many opportunities to drop the ball on this one – mechanical spaces, comms closets (it’s very rare that I find an open j-box in an electrical closet – but not impossible). You know they’re going to look above the ceiling – and they’re not just looking for penetrations – and cabling on sprinkler piping – and, and…

You need to enlist the efforts of everyone who does work above the ceiling in your facility; they don’t necessarily have to fix it, but if you know where it is, then you have a shot at being able to address it before it gets ID’d during a survey. The proactive approach works unbelievably well for stuff like this.

And on the horizon looms the specter of a return to focus for the prevention of surgical fires – including the participation of physicians. Too many (and my stance is that one surgical fire is too many) surgical fires occur for my (or anyone’s) liking, so it’s time to kick this process into high gear. I know they’re busy, and may not always seem to be the most cooperative bunch on the planet, but this I see as a moral imperative (and it appears that TJC is similarly inclined – so if you won’t do it for me, do it for them). We can do a better job of educating folks about the risks of surgical fires – and so, we must do just that.

One other related thought is to make sure that you are appropriately managing amounts of compressed gas – don’t go over 12 e-cylinders in an unprotected area. And make sure that your gas storage rooms (for amounts greater than 300 cubic feet of gas) are appropriately fire-safe, etc.

This concludes our test of the emergency survey broadcasting system – this was only a test. We now return you to our regular programming, which is already in progress. If you have any questions or concerns about this or any other topic, you know where I am…