Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):
- TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
- TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
- Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with 184.108.40.206. Originally, this section of the LSC referenced 220.127.116.11 which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.
I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.
As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…
Something old and something new(ish): old rant, new requirement.
As we move ever onwards toward the close of our first year “under” the 2012 Life Safety Code® (talk about a brave new world), there was one item of deadline that I wanted to touch upon before it got too, too much further into the year. And that, my friends, is the requirement for an annual inspection of fire and smoke door assemblies—for those of you keeping track, this activity falls under the EOC chapter under the standard with all those other pesky life safety-related inspection, testing, and maintenance activities (don’t forget to make sure that your WRITTEN documentation of the door assembly inspection includes the appropriate NFPA standards reference—in this case, you have quite a few to track: NFPA 101-2012 for the general requirements; NFPA 80-2010 for the fire door assemblies; and, NFPA 105-2010 for the smoke door assemblies). Also, please, please, please make sure that the individual(s) conducting these activities can “demonstrate knowledge and understanding of the operating components of the door being tested” (if this sounds like it might be a competency that might need to be included in a position description and performance evaluation, I think you just might be barking up the correct tree). The testing is supposed to begin with a pre-test visual inspection, with the testing to include both sides of the opening. Also, if you are thinking that this is yet another task that will be well-served by having an inventory, by location, of the door assemblies, you would indeed be correct (to the best of my knowledge). As a caveat for this one, please also keep in mind that this would include shaft access doors, linen and trash chute—while not exactly endless, the list can be pretty extensive. At the moment, from all I can gather, fire-rated access panels are optional for inclusion, though I don’t know that I wouldn’t be inclined to have a risk assessment in one’s back pocket outlining the decision to include or not to include (that is the question!?!) the access panels in the program.
I’m thinking you will probably want to capture this as a recurring activity in your work order system, as well as developing a documentation form. Make sure the following items are covered in the inspection/testing activity:
- No open holes or breaks in the surfaces of either the door or the frame
- Door clearances are in compliance (no more than ¾ inch for fire doors; no more than 1 inch for corridor doors; no more than ¾ inch for smoke barrier doors in new buildings)
- No unapproved protective plates greater than 16 inches from the bottom of the door
- Making sure the latching hardware works properly
- If the door has a coordinator, making sure that the inactive door leaf closes before the active leaf
- Making sure meeting edge protection, gasketing, and edge seals (if they are required—depends on the door) are inspected to make sure they are in place and intact
I think the other piece of the equation here is that you need to keep in mind that “annual” is a minimum frequency for this activity; ultimately, the purpose of this whole exercise is to develop performance data that will allow you to determine the inspection frequency that makes the most sense for compliance and overall life safety. Some doors (and I suspect that you could rattle off a pretty good list of them without even thinking about it too much) are going to need a little more attention because they “catch” more than their fair share of abuse (crash, bang boom!). Now that this isn’t an optional activity (ah, those days of the BMP…), you might as well make the most of it.
Putting on my rant-cap, I’d like to steal just a few moments to lament the continuing decline of decency (it used to be common; now, not so much) when it comes to interactions with strangers (and who knows, maybe it’s extending into familial and friendial interactions as well—I sure hope not!) I firmly believe that any and every kindness should be acknowledged, even if it’s something that they were supposed to do! My favorite example is stopping for pedestrians (and if you’ve been behind me, yes that was me stopping to let someone complete the walk); yes, I know that in many, if not most, places, the law requires you to stop for pedestrians in a crosswalk, but I think the law should also require acknowledgement from the pedestrians. Positive reinforcement can’t possibly hurt in these types of encounters. Allowing merging traffic to move forward (signaling is a desirable approach to this, but you should also signal the person who let you in). I’m not sure if we’re just out of practice or what, but I’d ask you to just try a little more to say “hi” or “thanks” or give somebody a wave when they aren’t jerks (and just so we’re straight, a wave includes more than just the middle digit). Maybe I’m going a little Pollyanna here, but the world is just not nice enough lately. Hopefully we can make an incremental improvement…
As we continue our crawl (albeit an accelerated one) towards CMS adoption of the 2012 edition of NFPA 101 Life Safety Code® (LSC), we come face to face with what may very well be the final step (or in this case, leap) in the compliance walkway. While there is some language contained in the final rule (and in the press release) that I feel is a little contradictory (but after all, it is the feds), the summary section of the final rule does indeed indicate that “(f)urther, this final rule will adopt the 2012 edition of the Life Safety Code (LSC) and eliminate references in our regulations to all earlier editions of the Life Safety Code. It will also adopt the 2012 edition of the Health Care Facilities Code, with some exceptions.” I suspect that there will be multiple machinations in the wake of this, but it does appear that (cue the white smoke) we have a new pope, er, Life Safety Code®! You can find all 130+ pages here.
Interestingly enough, the information release focuses on some of the previously issued categorical waivers seemingly aimed at increasing the “homeyness” (as opposed to homeliness) of healthcare facilities (primarily long-term care facilities) to aid in promoting a more healing environment. It also highlights a couple of elements that would seem to lean towards a continuation of the piecemeal approach used to get us to this point, so (and again, it’s the feds), it’s not quite framed as the earth-shattering announcement that it appears to be:
- Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date. So, the clock is ticking for you folks in unsprinklered tall buildings
- Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler system is out of service for more than 10 hours. So, a little more flexibility on the ILSM side of things, though that building evacuation element seems a little funky (not necessarily in a bad way).
- For ambulatory surgery centers (ASC), all doors to hazardous areas must be self-closing or must close automatically. To be honest, I always considered the requirements of NFPA 101-2000:18.104.22.168 to be applicable regardless of occupancy classification, but hey, I guess it’s all in the eye of the beholder.
- Also, for ASCs, you can have alcohol-based hand rub dispensers in the corridors. Woo hoo!
I guess it will be interesting to see what happens in the wake of this final rule. I guess this means we’ll have to find something else upon which to fret…
As a related aside, if you folks don’t currently subscribe to CMS News, you can sign up for e-mail updates by going to the CMS homepage and scrolling down to the bottom of the page. I will tell you that there’s a lot of stuff that is issued, pretty much on a daily basis, much of it not particularly germane to the safety community, but every once in a while…
It’s a new dawn, it’s a new day, it’s a new life for you. What do you plan on doing now?
I couldn’t find any indication that I’d covered this before (mea culpa, mea maxima culpa), so it’s probably past time—but it’s a pretty quick one. One thing to put on the pre-survey to-do list is to inspect the environments in which your emergency generator (or generators, if you are fortunate to have multiples) are located and check to see if you have battery-powered emergency lights in those locations. Now, you can correctly indicate that there is no TJC requirement to have battery-powered emergency lights in emergency generator locations—and you’ll get no disagreement from me. However, as an Authority Having Jurisdiction, The Joint Commission can indeed cite you for not having them, based on the introduction of this requirement (I will use the 2010 edition of NFPA 110 for the source on this; other editions of 110 include this requirement, but for this discussion, we’ll say NFPA 110-2010: 7.3.1).
Also, you probably want to be sure that you have battery-powered emergency lighting in any other spots that might benefit from some illumination if your generator fails and you need to do some work (I’m thinking transfer switch locations would be good). At any rate, I think it makes perfect sense (even if it weren’t required somewhere) to have provisions in place for providing illumination to certain areas if your generator poops out. (I’m almost certainly over-simplifying this, but I think the key piece of this is to look and see what you have and make sure that you can effectively deal with an equipment failure that results in very little in the way of illumination).
There’s been something of a “run” on a particular set of findings and since this particular finding “lives” in LS.02.01.20 (the hospital maintains the integrity of egress), one of the most frequently cited standards so far in 2015 (okay, actually egress findings have been among the most frequently cited standards pretty much since they’ve bene keeping track of such things), it seems like it might not be a bad idea to spend a little time discussing why this might be the case. And of course, I am speaking to that most esoteric of citations, the “NO EXIT” deficiency.
For my money (not that I have a lot to work with), a lot of the “confusion” in this particular realm is due to The Joint Commission adopting some standards language that, while perhaps providing something a little bit more flexible (and I will go no further than saying perhaps on this one, because I really don’t think the TJC language helps clarify anything), in doing so, creates something of a box when it comes to egress (small pun intended). The language used by NFPA (Life Safety Code® 2000 edition 22.214.171.124) reads “any door, passage, or stairway that is neither an exit nor a way of exit access and that is arranged so that it is likely [my italics] to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.” To be honest, I kind of like the “likely” here—more on that in a moment.
Now our friends in Chicago take a somewhat different position on this: Signs reading ‘NO EXIT’ are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may (my italics, yet again) be mistaken for an exit. (For full text and any exceptions, refer to NFPA 101 – 2000: 126.96.36.199.) If you ask me, there’s a fair distance between something that “may” be mistaken for something else, like an exit and something that is likely to be mistaken for something else, like that very same exit. The way this appears to be manifesting itself is those pesky exterior doors that lead out into courtyard/patio areas that are not, strictly speaking, part of an egress route. Of especially compelling scrutiny are what I will generally describe as “storefront doors”—pretty much a full pane of glass that allows you to see the outside world and I will tell you (from personal experience) that these are really tough findings to clarify post-survey. Very tough, indeed.
So it would behoove you to take a gander around your exterior doors to see if any of those doors are neither an exit nor an access to an exit and MAY be mistaken for an exit. For some of you this may be a LIKELY condition, so you may want to invest in some NO EXIT signs. And please make sure they say just that; on this, the LSC is very specific in terms of the wording, as well as the stroke of the letters: “Such sign shall have the word NO in letters 2 inch (5 cm) high with a stroke width of 3/8 inch (1 cm) and the word EXIT in letters 1 inch (2.5 cm) high, with the word EXIT below the word NO.” This way you won’t be as likely to be cited for this condition as you may have before…
This past week, my travels brought (or, more appropriately, returned) me to the environs of the New English, where I got to work a little out of my normal scope of practice: a health center setting. Now typically, as business occupancy settings, health center environments (I thought) tend to be a little less complicated than hospitals and ambulatory surgery centers, etc., but I learned last week that even business occupancies can experience the “bliss” of competing jurisdictions—oh, what fun!
So, typically using Chapter 38 (new) or 39 (existing) from NFPA 101 as my baseline expectation for compliance, we started the document review (this particular organization is looking at embarking upon Joint Commission accreditation). A couple of tweaky things in the fire alarm testing documentation, but nothing of great concern; some tweaks relative to some utility systems testing, but again, nothing major. Then we started looking at the documentation of fire inspection reports and I ran into a somewhat unanticipated condition: the local fire inspector was using the state fire code (in this case, Massachusetts), which is based primarily on NFPA 1 Fire Code. I will freely admit that my familiarity with NFPA 1 as a specific document is rather limited, but I was able to make use of NFPA’s free access to important codes and standards through its online portal. Interestingly enough, there are a lot of common threads between 1 and 101, but for those of you with business occupancies separate from your main campus, it might behoove you to acquaint yourself with some of the basics, particularly if your state fire code is based on NFPA 1 (if I was good, I’d figure out which states those were—maybe another time).
Anyhoo, where things got kind of interesting was that the regional authority having jurisdiction for this particular organization was the state Department of Public Safety (DPS), who it appears are using NFPA 101 as their consensus standard for life safety. This organization is in what I will call a reclaimed warehouse (circa early 1900s), where things like egress may have been considered, but not to the degree in present day. The basement level is more than one-half story below the level of exit discharge (actually, the stairwell goes two levels below the level of exit discharge), so the DPS inspector told them they have to install a gate in each of two stairwells to prevent folks from heading down past the level of discharge. I think you’re probably familiar with that condition. Well, when the local inspector saw the gates, he cited the organization for obstructing egress (I looked at the area where the gates were installed and they were well out of the way of the egress route, but close enough to prompt departure from the stairwell). Now, I did look in NFPA 1 and cross-referenced it to the state fire code (there are certain elements of NFPA 1 that the state code does not adopt, but this wasn’t one of them) and the allowance (actually, I guess it is really a requirement) for the gates in the stairwells is clearly indicated in this particular situation. I encouraged the plant ops director to try and figure out a solution in coordination with the local guy when he returns for his re-inspection. I suspect (hope) that this was just an interpretation based on a partial familiarity with the code in question (that’s never happened before, has it?) and that all will end well. I’ll keep you posted if I hear anything.
We’ve been observing Fire Prevention Week (Fire Safety Week’s “real” name) since 1920, when President Woodrow Wilson issued a proclamation establishing National Fire Prevention Day, and was expanded to a week in 1922. If you’re interested in the “story” of Fire Prevention Week, please check out the National Fire Protection Association (NFPA) website—it even includes mention of Mrs. O’Leary’s cow.
While there is much to applaud in the healthcare industry relative to our maintaining our facilities in fire-safe shape, there are still improvement opportunities in this regard. And one of the most compelling of those opportunities resides in the area of surgical fire prevention. According to the Association of periOperative Registered Nurses (AORN) in the October 2014 issue of AORN Journal, 550 million to 650 million surgical fires still occur annually in procedural environments where the risks of fire reach their zenith.
As we’ve seen from past experiences, AORN is certainly considered a source of expert information and guidance and I think the surgical environments would be well-served to start looking at the three strategies for strengthening their fire safety programs:
– Bring together a multidisciplinary team of fire safety stakeholders
- Think about fire safety in the context of high reliability to tackle the systematic and non-systematic causes for surgical fires
– Make fire prevention part of daily discussion
I don’t want to steal all the thunder, so my consultative advice is to seek out a copy of the article (you can try here and make preventing surgical fires part of your Fire Prevention Week).
One of the time-honored pursuits, mostly as a function of what you can and cannot manage through the plan for improvement (PFI) process, is what exactly constitutes a Life Safety Code® (LSC) deficiency. Just so you know, I used the “exactly” descriptor for a reason—because the definition, while pretty clear (at least to my mind—feel free to disagree) is a fair distance from exact, but read on and maybe it will become a little more clear.
The “secret” to all of this can be found on pp. 24-25 of the 2000 edition of the LSC. Contained on these two pages are the “documents or portions thereof” that “are referenced within this (Life Safety) Code as mandatory requirements and shall be considered part of the requirements of this (Life Safety) Code.” Thus, these requirements include some of the items you’d probably expect to be there: NFPA 10 Standard for Portable Fire Extinguishers, NFPA 13 Standard for the Installation of Sprinkler Systems, NFPA 70 National Electrical Code, NFPA 99 Standard for Health Care Facilities; and maybe some that you wouldn’t necessarily include in the mix, but make sense when you think about it: NFPA 30 Flammable and Combustible Liquids Code, NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations. Not that I usually get into product endorsements, but I think even a casual glance at the list of required elements would point you towards having a subscription to all the NFPA codes—and that’s not getting into the other publications cited as required (ANSI, ASME, UL) because they all have a share in the mandated references. Oh yes, and the final “other” publication mentioned is Webster’s Third New International Dictionary of the English Language, Unabridged; you could probably get into a lot of trouble with that…
Therefore, an LSC deficiency is really any condition or practice that is not compliant with any of the referenced codes (is your head spinning yet?), so you can probably craft a PFI for just about any safety-related hazard. In this world of ever-shrinking operational budgets, the PFI process may become an everyday tool as opposed to the once in a blue moon process it has sometimes been in the past. Remember, if the deficiency can be resolved within 45 days, then you can use your work order system. But if you can’t resolve the deficiency within 45 days (and budget constraints are no doubt going to have a greater impact on that in the future), then the PFI could become your new BFF.
One group of findings that I have seen with increasing frequency in survey reports are those relating to the segregation of stored compressed gas cylinders. Now I think we can agree that the general concept of enforcing the appropriate segregation of cylinders makes some sense. We certainly would not want to put folks in a position where they would have to hunt around for a full cylinder in an emergency—or worse, grab a nearly empty cylinder when responding to an emergency (and yes, I understand everyone’s belief that grabbing a not full cylinder would never happen “in their house,” but I also know that there is a great belief that nothing could ever get into the MRI magnet field, etc. and I know that sometimes the human element doesn’t work exactly as you would prefer).
I’ve seen many different strategies: “full” and “empty” signs on the storage racks or on the walls above the storage racks; racks painted different color (red for the empties, green for the fulls), etc. There is no specifically prescribed method for ensuring appropriate segregation, but I can tell you one thing: if you have locations for full and empty storage in close physical proximity, it is inevitable (in my experience, natch) that the separation will become blurred and you’ll end up with in use or empty cylinders (more on that in a moment) stored in your full rack. I think the strategy that gives you the best shot at compliance is having the storage racks in completely separate spaces (if the room is big enough for separation, that may work, but I’m really talking one room for the fulls and another room for the empties).
One sticking point in this whole magillah is: how do we manage the cylinders that are not full, but not yet empty? Oxygen ain’t cheap and nobody wants to be in the position of returning partially filled cylinders to their vendors—it’s kind of wasteful. So when you come right down to it, we’ve really got three “classes” of cylinders to manage: full cylinders, in-use cylinders, and empty cylinders. But somehow the code doesn’t necessarily capture the in-use cylinders as a specific concept (NFPA 99-1999 4-188.8.131.52 (b)(2) says: “if stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.” (By the way, I think this particular code reference tacitly supports having the full and empty cylinders in separate rooms) But our friends from Chicago (aka The Joint Commission) provide us with a little more specificity; in the December 2012 issue of Perspectives, we find the following passage “(r)acked full cylinders must be segregated from those that have been opened or used (see NFPA 99-1999 4-184.108.40.206.(b)(2)). There should be no confusion for health care personnel who need a cylinder for patient care about which cylinder to select. If empty and full cylinders are comingled in the same rack without clearly separating the two groups, staff might accidentally retrieve a partially full or empty cylinder rather than a full cylinder.”
So, the acid test, so to speak, is keeping the full cylinders separate from “those that have been opened or used). To that point, I think the way to move forward on this is to establish a policy (you might consider a little risk assessment at the front end) that clearly indicates compliance as a function of the full cylinders being in their own location and once a cylinder is used, moves to a location separate from where the full cylinders are stored. That way you can start to measure compliance with your policy as a function of a compliance rate; you collect data during hazard surveillance and safety rounds (maybe even during fire drills). Once you start tracking your compliance rate, even if there happens to be a misplaced cylinder during a survey, you can use the historical compliance data to support clarification of the finding. This is one of those compliance shortfalls that can come up during survey that can almost always be clarified—as long as you know what your compliance rate is over time. Think of it this way, for every cylinder you might find in the wrong spot (or even not properly secured), there was (I hope!) way, way more that are being appropriately managed—that’s the compliance number that you want to track. It will help get you out of survey trouble!
Recently, a client sent me a question regarding assessing his surgical procedure rooms as wet locations. This was primarily as a function of the changes to NFPA 99, which brings the concept of wet locations and surgery back into the mix (the 2012 edition of NFPA 99 defines wet procedure locations as the “area in a patient care room where a procedure is performed that is normally subject to wet conditions while a patient is present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff,” NFPA 99 – 2012: 3.3.184). Previously, operating rooms were not considered wet locations as a rule, but now it appears that the pendulum has swung in the other direction.
To that end, the American Society of Healthcare Engineering (ASHE) issued an advocacy statement last year recommending that organizations form a risk assessment group to develop a process for evaluating surgical procedure rooms to determine which of these areas, if any, might legitimately be considered wet locations. Now based on the definition from NFPA 99, you could probably rule out a lot of procedure areas (rooms designated for eye surgery, neurosurgery, ENT surgery, etc.), but in other areas it may require some observations of the procedures being performed to determine the extent of standing fluids, etc. Once you’ve determined that you have wet locations, then you would need to move to provide appropriate protection (GFCI protection, isolated power, etc.). And there are other considerations as well, based on the activities in the space, the “state” of the equipment used in the space, etc. There can be any number of contributing factors that could increase the risk to staff and patients in wet locations; Appendix B of the 2005 edition of NFPA 99 speaks of such things as line-powered equipment that is within reach; a damaged line cord, attachment plugs, or exposed metal presenting a risk of direct exposure to a conductor; damaged equipment with “live” metal, exposed metal that has become ungrounded, a person making contact with a live metal surface, etc.
As with so many things, the key process is the almighty risk assessment, so if you’ve not yet wrestled with this bear, you might find it useful to start the process (in full disclosure, the ASHE advocacy statement came out last year—and if you don’t think certain three-letter regulatory agencies are not familiar with this bit of news, I would encourage you to think otherwise). Sometimes codes change for good reasons, sometimes maybe not so much, but we have an obligation to provide the safest possible environments for patients and staff and this looks like something that can be at least determined fairly simply (fixing this if you have issues is likely to be much less simple).