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But I never wave bye-bye: Closing out 2017 with some LSC goodies…

As noted last week, this week’s foray looks into the changes to the Life Safety chapter that will be onboarding at the turn of the new year (the details can be found here). I think (for the most part), there is nothing particularly earth-shattering in the new requirements: really just a mix of updating the NFPA standards edition numbers, some increased granularity relative to fire alarm systems, and a couple of opportunities for some quick risk assessments/evaluations to ensure that what you had is not going to get you into survey difficulty. Also (and I guess only time will tell us how important this is going to be), it is important to continue to monitor the practical applications of Chapter 43, especially when one is in the throes of changing utilization to the point of a shift in occupancy classifications. My not-insubstantial gut tells me that this has great potential for consternation in the field, including the ongoing impact of inconsistent (bordering on draconian) interpretations. Certainly some of the granularity indicated below will lessen some of the over-interpretation woes (definitive reads on square footage should help), but those hard lines drawn in the sand can also represent some challenges as you are planning and executing renovation, etc., projects. In my experience, there aren’t too many projects that remain the same (in terms of scope) through the design and build phases, so you may find yourself paying more attention to expanding project footprints.

And so:

LS.02.01.10

  • Building undergoing change of use or occupancy must be in compliance with 101-2012:43.7 (certain exceptions, as always, apply); likewise, any additions must comply with the requirements for new.
  • Any of you with non-sprinklered smoke compartments undergoing major rehabilitation are putting sprinklers in (I hope); major rehabilitation involves more than 50% of the area of the smoke compartment or 4500 square feet—whichever comes first.
  • Multiple occupancies in a building must observe the most stringent occupancy requirements—so keep those occupancy separations well-defined and tight; also, outpatient surgical departments must be classified as ambulatory healthcare regardless of the number of patients served. Those of you at organizations considering going to provider-based models need to keep those surgical procedure locations under close watch.

 

LS.02.01.20

  • Make sure your horizontal sliding doors that are not automatic closing are limited to a single leaf and have a latch or other mechanism to prevent the door from rebounding; also, there are some specific requirements for horizontal doors serving an occupant load of 10 or fewer, including operability from either side without special knowledge or effort and a couple other things. 101-2012: 18/19.2.2.2.10.2 will help you with the details.
  • Make sure that every corridor provides access to at least two approved exits; no passing through any intervening rooms or spaces other than corridors or lobbies.
  • Have you included a look at door widths in your ongoing rated door program? Existing exit access doors have to be at least 32 inches in clear width, though you can hold on to your 28-inch doors if you’re not evacuating by bed, gurney, or wheelchair. New exit access doors have to be at least 41½ inches in clear width (psych hospitals have to be at least 32 inches wide). Doors not subject to patient use, exit stairway enclosures or serving newborn nurseries can hold the line at 32 inches. Door pairs with an inactive leaf must have the inactive leaf secured with automatic flush bolts. There are a few other pieces of this, so make sure you transfer/transmit the particulars to the folks inspecting the doors.
  • Existing exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair.
  • Travel distances to exits are measured in accordance with NFPA 101-2012: 7.6.

 

LS.02.01.30

  • Laboratories using quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are in accordance with NFPA 101-2012: 8.7 and NFPA 99 requirements. I’m thinking most of you are probably not in position of severe hazardousness, but if you’re thinking what I’m thinking, a little risk assessment should solidify any of the particulars.

 

LS.02.01.34

  • Make sure your fire alarm system is up to snuff relative to the applicable requirements of NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code—probably worth a conversation and some verification by your fire alarm inspection, testing, and maintenance folks. This includes a more than passing familiarity with placement and types of devices, ensuring an alternative power supply for alarm systems, etc. Make sure that manual and automatic initiation of the fire alarm system is in accordance with the noted requirements, including pull stations. Also, make sure your alarm zones are not larger than 22,500 square feet (for some reason, I think that this might provide some angst for folks…) and spaces open to corridors are provided with appropriate smoke detection.

 

LS.02.01.50

  • Make sure that any spots containing equipment using gas or gas piping are up to snuff with NFPA 54 National Fuel Gas Code and electrical complies with NFPA 70. You can maintain existing installations that are not fully compliant as long as there are no life-threatening hazards.
  • Make sure those pesky heating devices are in appropriate compliance—with both code and your organizational policy.
  • Equipment using gas or gas piping complies with NFPA 54-2012, National Fuel Gas Code; electrical wiring and equipment complies with NFPA 70-2012, National Electric Code. Existing installations can continue in service provided there are no life-threatening hazards.
  • If you have fireplaces in your facility, there are specific considerations, including carbon monoxide detection; 101-2012: 9.2.2 will give you the lowdown.
  • 101-2012 9.4 will get you the straight dope on escalators, dumbwaiters, and moving walks—and don’t forget to consult ASME/ANSI A17.1 for new and ASME/ANSI A17.3 for existing equipment.

 

LS.02.01.70

  • If you’re hanging draperies, curtains (including cubicle and shower curtains), and loosely hanging fabric in non-sprinklered compartments, then 101-2012: 10.3.1 is the compliance source. Of course, if you have sprinklers, there are exceptions…
  • No sprinkler protection? Upholstered furniture purchased on or after July 5, 2016 must meet Class 1 or char length and heat release criteria—101-2012: 10.3.2.1 and 10.3.3; mattresses purchased on or after 7/6/2016 must meet 101-2012 10.3.2.2 and 10.3.4
  • If you have a new engineered smoke control system, it must be tested in accordance with NFPA 92-2012, Standard for Smoke Control Systems. If you have an existing engineered smoke control system, it must be tested in accordance with established engineering principles.

 

Since I don’t want you to be completely comatose for your New Year’s celebrations, I will cover the ambulatory occupancy changes sometime in January (please feel free to prod me if you’d rather I do it sooner than later). And on that note, I wish each and every one of you safe celebrations and a most prosperously compliant New Year!

No one told you when to run: Closing out one year, embarking on another…

Every once in a while, I like to poke back through recent missives from our friends in Chicago and elsewhere to see if there was anything that I missed on first review or something that didn’t really “pop” out at me at the time. And, somewhat typically, the really pressing hard news stories are in rather shorter supply as we get closer to year’s end. Truth be told, the whole ligature picture has really held sway in recent weeks, almost to the exclusion of everything else.

At any rate, in looking at the most recent (I think) slate of pre-publication standards, I noticed a couple of “new” requirements that gave me a little bit of pause. Due to some editorial constraints, I won’t identify the standards and EP numbers, but I will try to give you a sense of where there “live”: they are identified as “new” on the webpage, so that may be enough for you to find them (you’re a pretty smaht bunch and I have every confidence in your detective-ing abilities). This week we’ll cover the Environment of Care changes and hit the Life Safety changes next week (where did the year go!?!):

 

  • The hospital has a library of information regarding inspection, testing, and maintenance of its equipment and systems. Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information. (Safety Management)
  • Management of smoking materials for patients receiving respiratory therapy. (Smoking Policy)
  • Periodic evaluations of fire hazards during surgical procedures (don’t forget to define that period!) (Fire Safety Management)
  • Process for reducing risks when flammable germicides or antiseptics are using during “hot” surgical procedures (electrosurgery, cautery, lasers) (Fire Safety Management)
  • The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15. (Fire Safety Management)
  • Elevators with firefighters’ emergency operations are tested monthly. The test completion dates and results are documented. (Inspection, Testing & Maintenance of Life Safety Systems equipment)
  • Hyperbaric facility safety, including labeling of equipment used in oxygen-enriched atmospheres (we covered this a couple of weeks ago, with a couple of folks weighing in with questions on how far to go with Chapter 14 of NFPA 99; if the past is any indicator of the future, I would be moving towards adoption of the whole thing and probably start to extend the labeling of equipment out to all oxygen equipment—this is where they start digging into this—we know the targets will move over the next survey years, so better to be ahead of the game than behind). (Medical Equipment Inspection, Testing & Maintenance)
  • Inspection, testing, and maintenance of anesthesia apparatus, including gas flow and oxygen concentration verification; no oil, grease or flammables for oxygen equipment. (Medical Equipment Inspection, Testing & Maintenance)
  • ORs are wet locations unless you have a risk assessment that says otherwise and has been approved by the governing body (it appears that risk assessments done in “isolation” will no longer meet the mark—organizational leadership has to be involved in the process. Written record of the risk assessment is available for survey review. We covered this before.  (Utility Systems Management)
  • Risk level identification of electrical distribution; we did this one before as well.  (Utility Systems Management)
  • Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.  Keep an eye on those pediatric locations, particularly areas that can “swing” – tamper-resistant receptacles could well become a moderate risk of harm during survey. (Utility Systems Management)
  • Power strips must be appropriately listed for use in patient care vicinity, patient care rooms, etc. Focus on this has already started, so you better start working with your IT folks to make sure everything is going in the right direction. (Utility Systems Management)
  • Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was intended. I predict that this is going to keep this standard at the top of the most frequently cited standards list. (Utility Systems Management)
  • Areas designated for administration of general anesthesia using medical gases or vacuum are in accordance with NFPA 101-2012 and NFPA 99-2012 (Utility Systems Management)
  • Electrical system critical branch supplies power for specific needs (task illumination, fixed equipment, select receptacles, and select power circuits) in areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum. The EES equipment system supplies power to the ventilation system. (Utility Systems Management)
  • New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (Utility Systems – Emergency Electrical Power Source)
  • Equipment designated to be powered by emergency power supply are energized by the hospital’s design. Staging of equipment startup is permissible. (Utility Systems – Emergency Electrical Power Source)
  • For deemed status hospitals, battery lamps and flashlights are available in areas not serviced by the emergency supply source. (Utility Systems – Emergency Electrical Power Source)
  • Line isolation monitors are tested in accordance with NFPA 99-2012. (Utility Systems Inspection, Testing & Maintenance)
  • Risk level identification of medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems. (Inspection, testing & maintenance of medical gas system components)
  • All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (Inspection, testing & maintenance of medical gas system components)
  • Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012. (Inspection, testing & maintenance of medical gas system components)
  • Locations containing only oxygen or medical air have doors labeled “Medical Gases: NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” (Inspection, testing & maintenance of medical gas system components)
  • A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders. (Inspection, testing & maintenance of medical gas system components)
  • More cylinder storage stuff (I suspect you know the drill)—NFPA 99-2012 has a great deal of detailed requirements—and I have no reason to think that they won’t be kicking the tires pretty diligently. (Inspection, testing & maintenance of medical gas system components)
  • Also, transfilling of liquid oxygen is a process with very, very specific requirements; if you’re not transfilling liquid oxygen in your facility, you could count yourself fortunate, but be on the lookout for any evidence of liquid oxygen being transferred inside your “house”; NFPA 99-2012 is your guide. (Inspection, testing & maintenance of medical gas system components)
  • Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training. (Staff Competency & Education)

I know this is a lot of stuff to consider, but I wanted to put it out in front of you folks on the off chance that your bedtime reading hasn’t strayed into the realm of the 2018 standards changes. I have every reason to think that some of this stuff will show up again in this space (and what a space!), but if someone wants to start a particular conversation before we kick off (kick at?) 2018, please feel free.

I am barely breathing: Gas Equipment is on TJC’s Radar!

The past couple of weeks, I’ve been fielding some questions relative to some new performance elements under the Medical Equipment Management standard that covers inspection, testing, and maintenance activities. Apparently, folks have been receiving some sort of notifications from profession groups (in this case, it seems to be the respiratory therapy folks that are being targeted with the notifications.

At any rate, I think we can say (pretty much for all time) that any changes to the standards/EPs is likely to result in (at the very least) consternation and a potential uptick in findings related to said standards/EPs. At least some of the questioning is focused on a certain element of reliance on vendors (and we know how that can go). So, while I do believe that for the most part folks are going to be OK with the changes, I also recognize that a little conversation couldn’t possibly hurt…

In case you’ve not yet encountered the new stuff, what we have is this. For equipment listed for use in oxygen-enriched atmospheres (more on that in a moment), the following must be “clearly and permanently” labeled on the equipment (permanently meaning the labeling withstands cleaning and disinfecting—how many labels are like that?): 1) Oxygen-metering equipment, pressure-reducing regulators, humidifiers, and nebulizers are labeled with name of manufacturer or supplier; 2) Oxygen-metering equipment and pressure reducing regulators are labeled “OXYGEN–USE NO OIL”; 3) Labels on flowmeters, pressure-reducing regulators, and oxygen-dispensing apparatuses designate the gases for which they are intended; and 4) Cylinders and containers are labeled in accordance with Compressed Gas Association (CGA) C-7.

The source material for these “new” requirements is in NFPA 99-2012 11.5.3.1; and please note that color coding is not to be utilized as the primary method of determining cylinder or container contents; I suppose when you come right down to it, cylinders are no different than any other secondary container when it comes to identifying the contents.

The follow-up question becomes one of what constitutes an “oxygen-enriched atmosphere”; in the definitions section of NFPA 99-2012, section 3.3.131 gives us this: “3.3.131 Oxygen-Enriched Atmosphere (OEA). For the purposes of this code, an atmosphere in which the concentration of oxygen exceeds 23.5 percent by volume. (HYP)” Now, you may notice the little tag at the end of this definition, which gives us some indication of where we need to be particularly mindful, with “HYP” referring to hyperbaric therapy. I know there are more hyperbaric therapy locations than there used to be, but some folks aren’t going to have to worry too much about this. But in the interest of a complete picture, I looked over the materials in the NFPA 99 Handbook and I think the information there further narrows down the field of concern:

“The normal percentage of oxygen in air is 20.9 percent, commonly expressed as 21 percent. The value of 23.5 percent reflects an error factor of ± 2.5 percent. Such a margin of error is necessary because of the imprecision of gas measurement devices and the practicality of reconstituting air from gaseous nitrogen and oxygen. Hyperbaric chambers located in areas of potential atmospheric pollution cannot be pressurized with air drawn from the ambient atmosphere. Such chambers are supplied by ‘air’ prepared by mixing one volume of oxygen with four volumes of nitrogen. It is impractical to reconstitute large volumes of air with tolerances closer than 21 percent ± 2.5 percent. The code does not intend to imply that the use of compressed air cylinders in normal atmospheric areas (i.e., outside hyperbaric chambers) would create an oxygen-enriched atmosphere. The compressed air expands as it leaves the cylinder, drops to normal atmospheric pressure, and is not oxygen-enriched. This definition varies slightly from the one appearing in NFPA 53, Recommended Practice on Materials, Equipment, and Systems Used in Oxygen-Enriched Atmospheres [12], which states that the concentration of oxygen in the atmosphere exceeds 21 percent by volume or its partial pressure exceeds 21.3 kPa (160 torr). The scope of the definition is limited to the way the term is used throughout NFPA 99. The definition is independent of the atmospheric pressure of the area and is based solely on the percentage of oxygen. In defining the term, the issue of environments, such as a hyperbaric chamber, where the atmospheric pressure can vary, was taken into consideration. Under normal atmospheric conditions, oxygen concentrations above 23.5 percent will increase the fire hazard level. Different atmospheric conditions (e.g., pressure) or the presence of gaseous diluents, however, can actually increase or decrease the fire hazard level even if, by definition, an oxygen-enriched atmosphere exists. An oxygen-enriched atmosphere, in and of itself, does not always mean an increased fire hazard exists.”

At the moment, given the definition above, I can’t think of anything other than hyperbaric environments that would be covered under the new requirements, but I’ll keep my ear to the ground and pass on any information that seems worth sharing; beyond that, I would do an analysis of equipment for hyperbaric therapy and go from there.

When we consider how we’re going to make this happen (if it isn’t already; I’m thinking/hoping that the gas equipment suppliers are paying attention to the new rules), at the end of the day, compliance with Joint Commission standards and performance elements rests solely in the hands of the organization. Again, presumably/hopefully/expectantly, the vendors from whom you obtain medical gases, equipment, etc., will be familiar with the requirements as they are based on the currently adopted/approved version of NFPA 99, as well as the requirements of the Compressed Gas Association (CGA). I would reach out to them to see what their plans are for compliance, remembering that (at least for the moment) the new requirements apply only to the gases and equipment used in oxygen-enriched atmospheres. I suspect that there will come a time when all related equipment, etc., is similarly labeled, but you may find that in the short term that you will have to keep a close eye on equipment used in surgery, hyperbaric oxygen, etc., to ensure that everything is as it should be. The general concept of not using oil on oxygen equipment is not new, so it may be that this is not going to be as big a struggle as might first appear. I’d be interested in finding out what you learn from the vendors you’re using, just to establish a baseline for advising folks.

 

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here: https://www.jointcommission.org/prepublication_standards_%E2%80%93_standards_revisions_to_environment_of_care_and_life_safety_chapters_related_to_life_safety_code_update_/

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Do you know the way to TIA?

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 19.3.5.7. Originally, this section of the LSC referenced 19.3.5.1 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…

Doo doo doo, lookin’ out my back (fire) door…

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…

News flash: Vacuum cleaner sucks up budgie! Is you is or is you ain’t my baby?

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 101-2000:8.4.1.1 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?

And in the spirit of giving…

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).

May I? Not bloody likely! The secret world of ‘NO EXIT’ signs

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 7.10.8.1) 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: 7.10.8.1.) 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…

Perhaps one isn’t the loneliest number after all…

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.