Safety Compliance. A look at recent and upcoming changes. Joint Commission update

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1 September 2012 Vol. 14, No. 9 Healthcare Life Safety Compliance The newsletter to assist healthcare facility managers with fire protection and life safety Joint Commission update A look at recent and upcoming changes During the 49th Annual Conference & Exhibition for the American Society for Healthcare Engineering (ASHE) in San Antonio July, Dale Woodin, CHFM, FASHE, ASHE s executive director, expressed the industry s appreciation while introducing George Mills, MBA, FASHE, CEM, CHFM, director of engineering at The Joint Commission. George Mills is a fellow with ASHE; he is a certified healthcare facility manager and a certified energy manager. He is one of us, said Woodin. And he is our friend. Mills began his annual update by describing the top surveyor findings in 2011 for the Life Safety and Environment of Care areas. The most cited standard this year was LS (cited on 56% of all surveys). If the corridor looks cluttered, it probably is, said Mills. We can learn a lot from the horrific events that St. John s Regional Medical Center in Joplin, Missouri, went through last year with the tornado that hit their facility. A couple of months prior to the tornado, they IN THIS ISSUE p. 7 Maintaining physical features of life safety Hear what a national expert advises on complying with the most-cited life safety challenges. p. 10 Questions & Answers This month s Q&A talks about corridor doors, storage issues, and more. p. 12 Quick tip We take a brief look at plenary session codes and standards. conducted some aggressive evacuation exercises and identified a couple of areas of improvement, one of which was corridor clutter. When the tornado actually hit the facility, they evacuated 183 patients, plus visitors, plus staff from the building in less The lesson we need to than 90 minutes. learn from this event is The lessons they clear corridors save lives. learned in their George Mills, MBA, FASHE, exercises led them CEM, CHFM to remove clutter from their corridors, which allowed them to evacuate so quickly. The lesson we need to learn from this event is clear corridors save lives. Mills further explained that anything left unattended in an egress corridor for more than 30 minutes is considered stored, with the exception of crash carts, isolation carts, and chemo carts. However, he noted that dead-end corridors may be used to store noncombustible items provided they do not cover more than 50 square feet. Another item we are now scoring under LS is suites, said Mills. It is frustrating for me because the biggest problem with suites is they are not on the life safety drawings. Folks, this is just attention to detail. There is no mystery here that when we come to survey, we ask you for a couple things to conduct the survey, such as a ladder and a flashlight, and we ask for life safety drawings. You give us the drawings that we are assessing your facility against, and we arrive at the ICU. We ask that you show us the boundaries of the suite on the life safety drawing and they are not identified. Your response is, Oh, I gave you the wrong set of drawings. Well, that response just doesn t fly. The drawings you gave us at the beginning of the survey are the drawings we are going to survey you against. So now the surveyor is writing findings

2 Page 2 Healthcare Life Safety Compliance September 2012 with the suite because they are not identified on the drawings. What s the solution to this problem? Update your drawings. It s not rocket science some things are, but not this. Mills told the 3100 attendees of the annual ASHE conference that life safety drawings need to have the following information clearly expressed: A legend that clearly identifies life safety features Areas of the building that are fully sprinklered (if the building is partially sprinklered) Locations of all hazardous storage areas Editorial Advisory Board Healthcare Life Safety Compliance Managing Editor: Senior Editor: James R. Ambrose, PE Technical Director, Healthcare Code Consultants, Inc. St. Louis, Mo. Frederick C. Bradley, PE Principal FCB Engineering Alpharetta, Ga. Michael Crowley, PE Senior Vice President, Engineering Manager Rolf Jensen & Associates, Inc. Houston, Texas Joshua W. Elvove, PE, CSP, FSFPE Fire Protection Engineer Aurora, Colo. A. Richard Fasano Manager, Western Office Russell Phillips & Associates, LLC Elk Grove, Calif. Burton Klein, PE President Burton Klein Associates Newton, Mass. Matt Phillion, CSHA mphillion@hcpro.com Brad Keyes, CHSP Senior Consultant Keyes Life Safety Compliance Henry Kowalenko Supervisor, Design Standards Unit Office of Healthcare Regulation, IL Department of Public Health Chicago, Ill. Peter Leszczak Network 3 Fire Protection Engineer U.S. Department of Veterans Affairs West Haven, Conn. David Mohile President Medical Engineering Services, Inc. Leesburg, Va. James Murphy Consultant The Greeley Company Danvers, Mass. Thomas Salamone Director of EC and Regulatory Compliance Gannett Fleming Yonkers, N.Y. William Wilson, CFPS, PEM Fire Safety Coordinator Beaumont Hospitals Royal Oak, Mich. Healthcare Life Safety Compliance (ISSN: [print]; X [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate is $289 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, P.O. Box 3049, Peabody, MA Copyright 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be in cluded on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of HLSC. Mention of products and services does not constitute endorsement. Advice given is general and based on National Fire Protection Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Information should not be construed as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter or otherwise. Advisory board members are not responsible for information and opinions that are not their own. Locations of all rated barriers Locations of all smoke compartment barriers Suite boundaries, including the size of the identified suites (for both sleeping and non-sleeping suites) Locations of designated smoke compartments Locations of chutes and shafts Any approved equivalencies or waivers If you don t already have this on your drawings, you need to get this as soon as possible, said Mills. How else can you manage your building if you don t know where these barriers are located? You should be dependent on these life safety drawings long before our surveyors come on-site. Next was LS (cited on 52% of the surveys). Last year when I spoke with you, I asked you to manage your rated barriers better, said Mills. The number of findings on penetrations in rated barriers has reduced, but it s still showing up as a high number in our surveys. You still need to be diligent in managing those barriers. Next on the list: LS (cited on 45% of the surveys). The issue with doors still shows up, said Mills. These are doors to hazardous areas and fire-rated doors where we operate them and they fail to latch. You should put your doors on a routine schedule to have them checked for proper operation. Start managing those doors. Next, Mills addressed EC (cited on 40% of the surveys). Next on our list are features of fire safety, said Mills. You know, I hate talking to you about this as I discussed it with you at last year s conference, and it is very frustrating for me. This is the one where our surveyors ask you for the fire alarm testing report and you say I don t have the report; the contractor has not sent it to us yet. We re not going to wait for it so our surveyors will write a finding. What s the solution for managing this problem? If you re waiting for the contractor to give you the report, you re not managing the process.

3 September 2012 Healthcare Life Safety Compliance Page 3 Why not write into your contract that at the end of each testing day you receive a list of all the deficiencies? This way you can have those deficiencies fixed right away and continue to have a safe environment. If you don t have the report but have a complete list of all the deficiencies and you can show us that you are managing the problems, we will accept that. The solution is management. It is as simple as that. During the survey, specific documentation on fire safety systems will be reviewed. Mills described the process the surveyors will follow when the documentation is not available: The observation will be scored under the appropriate EC element of performance (EP) It will also be scored under LD , EP 4 (staff are held accountable for their responsibilities) If the documentation becomes available later in the survey, the surveyors may consider removing the EC finding if the documentation proves the discussed activity was completed, and the LD , EP 4 finding may be removed at the discretion of the survey team If the survey team prefers not to evaluate the documentation, then the organization may submit a clarification after the survey If the organization clarifies after the survey, Standards Interpretation Group (SIG) engineers will review and evaluate compliance, but the LD , EP 4 finding will remain Quite frankly, folks, what we re hearing when our surveyors are out and about is it seems you re missing a lot of the detailed things, said Mills. I remember talking to one of my Life Safety Specialists and he asked the organization if they read the fire alarm report. They answered that they had, and when he got to the end summarizing the deficiencies, nearly 70% of the devices were suspect and potentially failing. Now, wouldn t the organization be fixing those problems if they read the report? You should be reading these reports. Next up was LS (cited on 31% of the surveys). Regarding sprinkler head clearance, Mills informed the audience that perimeter shelving in a room may extend all the way up to the ceiling provided a sprinkler head is not located directly over the shelves. The tops of shelves and items on the top shelf may not extend beyond an imaginary horizontal plane, 18 inches below the deflector on the sprinkler head. This imaginary horizontal plane extends from wall to wall. However, items stored on the top shelf of perimeter shelving may extend above this imaginary horizontal plane, provided there is not a sprinkler head directly above the shelf. Sprinkler clearance is something you put on your daily rounds, with security, said Mills. If you need to, start getting the nurses, the users involved with this. We shouldn t be seeing 31% of the hospitals with this finding. Life Safety Code surveyors Mills told the ASHE members that life safety surveyors will no longer be called specialists. To be fair to all our field survey staff, the surveyors will now be called Life Safety Code surveyors, said Mills. It s a small thing, but it s important to some people. Mills continued to describe the background and roles the Life Safety Code (LSC) surveyor will play. Each surveyor will have a facilities or an environment of care background. Mills said he prefers the CHFM certification for his surveyors, but admitted that he has a few CHSPs as well. All hospitals (including critical access hospitals) will receive an LSC surveyor for a minimum of two days. If there is more than 1.5 million square feet of healthcare occupancy, then the hospital will receive an additional survey day. A survey day is also added for every three buildings classified as healthcare occupancy. So ultimately, a hospital with 2 million square feet and five buildings classified as healthcare occupancy could have an LSC surveyor for as many as four days.

4 Page 4 Healthcare Life Safety Compliance September 2012 The LSC surveyor will survey the organization s compliance with the following standards: EC : Fire safety systems EC : Emergency power systems EC : Medical gas systems LD , EP 4: Staff accountability LD , EP 2: Appropriate priority LD , EP 5: Resources provided and are not local AHJs, so they don t have the skills to do a traditional equivalency. So they will default to a FSES equivalency and charge you real money. FSES costs for a 300-bed hospital can be somewhere from $20,000 to $35,000 from what I heard. I would just caution you, if you re paying somebody for a FSES, to push a little bit and ask why we cannot do a traditional equivalency. Mills explained that the surveyors may write findings to other standards as appropriate. The LSC surveyor may conduct the Environment of Care sessions as well as the Emergency Management sessions. Equivalencies The Joint Commission will accept two different types of equivalencies for life safety deficiencies that cannot be resolved without significant hardship. The traditional equivalency is a process of field verification identifying alternative methods of fire safety that offset the identified deficiency. The field verification must be in written form and be issued by one of the following: Registered architect Fire protection engineer Local authority having jurisdiction (AHJ) responsible for fire safety The other equivalency is NFPA 101A, Fire Safety Evaluation System (FSES), which is a process of calculating the features of life safety and deducting any deficiencies, with the outcome determining whether the building is deemed equivalent based on the FSES. If either equivalency is accepted by The Joint Commission, then the identified deficiency does not have to be resolved, and the equivalency is good until major renovation occurs in the area containing the deficiency. Unlike waivers, equivalencies do not have to be annually renewed. One of the reasons I wanted to share this with you is I think there is a bit of a scam going on in the industry, said Mills. Some consultants are not registered architects and are not fire protection engineers History Audit Trail The History Audit Trail is used by the SIG engineers to communicate to the organization when considering extensions or other activities. If an equivalency is approved, it will be posted into the History Audit Trail. Prior to the start of a survey, a surveyor is instructed to review the organization s History Audit Trail to discover if equivalencies or other actions from SIG engineers have occurred. When we make a decision on anything submitted to us, we re posting that decision to your History Audit Trail found in your Statement of Conditions, and we will add our comments there as well for you, said Mills. The 2012 LSC Where are we at in regards to adopting the 2012 edition of the Life Safety Code? asked Mills. First of all, we like it and we can hardly wait for somebody else to adopt it. [CMS] seems to like the new code as well, and they are doing the research required in order to adopt the new code. You will remember that they adopted the 2000 edition in March of 2003, so that is a three-year cycle of time to adopt a new edition. We re hoping they can fast-track the process and reduce it by a year, but worst-case scenario, we will be in the new 2012 edition by We re excited about that and we re getting a feeling from CMS that they re on board with that. But now we re in an election year and that may or may not help the process. But we re ready to go and it will take a meeting with our board asking for permission to adopt the 2012 edition, and six months later we can have an adoption date.

5 September 2012 Healthcare Life Safety Compliance Page 5 Immediate upgrades to the 2012 edition In keeping with CMS Survey & Certification Letter S&C LSC, issued March 9, The Joint Commission will accept equivalencies on five specific areas to upgrade to the 2012 edition of the LSC: Means of egress: Patient lift and transport equipment may be stored in the corridor, provided 5 feet of clear corridor width is maintained, and provided the fire plan addresses management of storage and accommodates current equipment in use. Fixed seating: Seating that is secured to the floor or wall may be located in the egress corridor provided 6 feet of clear corridor width is maintained. The groupings of fixed seating may not be more than 50 square feet in area with 10 feet between groupings, and they must be on the same side of the egress corridor. Cooking facilities: One cooking area may be open to the egress corridor per smoke compartment. Additional cooking areas must be in a protected room similar to hazardous areas. Provisions for the cooking area open to the corridor are: No deep fat fryers Safety equipment to deactivate fuel supply Grease baffles installed No solid fuel (i.e., charcoal) The goal here is to deinstitutionalize our nursing units even further, and it makes a lot of sense, said Mills. Fireplaces in smoke compartments: The new 2012 section 18/ (2), (3), and (4) allow the installation of direct vent gas fireplaces in smoke compartments which contain patient sleeping rooms. The installation of solid fuel burning fireplaces in areas other than patient sleeping areas will be permitted, provided these are separated from patient sleeping areas with one-hour barriers. Combustible decorations: Combustible decorations will be allowed on the walls, doors, and ceilings of patient sleeping rooms and corridors. The amount of wall surface that can be covered with combustible decorations is dependent upon the level of sprinkler protection. Joint Commission will grant traditional equivalencies in the five [above] areas of the 2012 LSC, based on the affirmation by your local fire safety AHJ, registered architect, or fire safety engineer that you meet the expectations listed in the 2012 edition of the LSC, said Mills. CMS is willing to do the same thing, but they do not do it proactively. What CMS will tell you is not to bother them with a waiver request. They will come on-site for a validation and cite you for noncompliance with the 2000 edition on these five issues, and your Plan of Correction will be to ask for a waiver. General interpretations The following are some general interpretations Mills covered in the ASHE conference: Alcohol-based hand rub (ABHR) dispenser placement: The current codes state dispensers shall not be installed over or directly adjacent to an ignition source. The Joint Commission published information in 2006 defining adjacent to as no closer than 6 inches from the center of the dispenser to the center of the ignition source. According to Mills, The Joint Commission has adopted the 2012 edition of the LSC language, which says ABHR dispensers shall not be installed in the following locations: Above an ignition source for a horizontal distance of 1 inch to each side of the ignition source To the side of an ignition source within a 1-inch horizontal distance from the ignition source Beneath an ignition source within a 1-inch vertical distance from the ignition source Don t miss your next issue! If it s been more than six months since you purchased or renewed your subscription to HLSC, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price.

6 Page 6 Healthcare Life Safety Compliance September 2012 Fire and smoke damper inspections: Surveyors will ensure inaccessible dampers are appropriately installed by random sampling. In addition, they will confirm that an interim life safety measures policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers. They will also evaluate the adequacy of the organization s damper accessibility plan. We are seeing a lot of inaccessible dampers so I ve asked my surveyors to obtain a list of dampers and take a look to see if they are truly inaccessible, said Mills. And having to get a taller ladder is not inaccessible. Inaccessible means there is a superstructure there preventing access to the damper. That s inaccessible. Surgical site fires: In 2011, it is estimated that there were more than 50 million surgeries in U.S. hospitals and ambulatory surgical centers. It is also estimated that there are at least 100 surgical fires per year, with 20 serious injuries and 1 2 deaths each year. The majority of these fires are reported to be in oxygen-enriched environments, and caused by electrosurgical equipment and lasers. The Joint Commission recommends the following actions specifically for the surgery staff: Fire drills and staff education Review of alarm procedures Review of rescue techniques Review of shutoff locations Our LSC surveyors are going into the surgery department and asking clinicians and nursing staff and the doctors what would they do in the case of a fire at the surgical site, said Mills. We re looking to see if they know the fire response plan and what they need to do. If the doctor says All I do is get out of the way Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving HLSC, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at and that s what the fire response plan says, that s fine with me. Mills wrapped up his address to the ASHE conference attendees by describing his tireless activities to invoke change in the CMS equipment maintenance procedures. Starting in January 2010, CMS instructed The Joint Commission to change its standards to read that medical and utility equipment must be maintained according to manufacturer s recommendations only. The then-current practice of allowing the use of equipment history and risk would no longer be acceptable. This raised quite a stir among hospitals, and Mills met with CMS representatives explaining the additional cost of test equipment and additional employees needed to comply with this request. Besides, according to Mills, there has not been an adverse patient outcome in the decades that hospitals have been using PM strategies as an alternative to manufacturer s recommendations. CMS officials verbally agreed with The Joint Commission s standards on equipment maintenance, and on July 26, 2010, Mills received a communication from CMS that indicated the agency would change its position. I thought we were good to go, said Mills. I told you last year that our process was accepted by CMS and we were both on the same page. That s what I thought. Apparently CMS thought differently, as it issued another S&C letter in December 2011 explaining its position on medical and utility equipment maintenance a position that did not permit alternative maintenance strategies on life-saving or life support equipment. Mills had another meeting with CMS in April, and ASHE and the Association for the Advancement of Medical Instrumentation (AAMI) had a follow-up meeting in June. Mills reported that the meetings went well and noted that CMS actually believed it was making things easier for hospitals with the December 2011 S&C letter. ASHE and AAMI are currently collecting data that will be used to further this discussion, and it appears CMS will eventually accept The Joint Commission s strategy on equipment maintenance. n

7 September 2012 Healthcare Life Safety Compliance Page 7 Maintaining physical features of life safety For the past three years, the top three findings by Joint Commission surveyors while surveying hospitals have involved fire and life safety systems, according to Frank Van Overmeiren, president of FP&C Consultants, Inc. Overmeiren spoke during the 49th Annual Conference & Exhibition for the American Society for Healthcare Engineering (ASHE) in San Antonio in July, and shared with his audience strategies on the proper maintenance of such systems. When you deal with fire and life safety systems, the No. 1 problem with these systems is documentation, said Overmeiren. Adding to the problems with documentation are incorrect testing and inspection procedures performed on the fire safety systems and no testing or inspections at all. Working with ASHE, Overmeiren has developed multiple sets of forms that will be available to ASHE members early in The forms will provide everything you will need to know to be compliant with Joint Commission testing and inspection, he said. For example, main drain testing requires comparing the current test result with the previous test. If your form does not have that, then you are deficient. Overmeiren then proceeded to review with his audience the fire and life safety systems that frequently receive poor testing and inspection or receive no testing or inspection at all. monthly inspection, the extinguisher must be hefted, which means it needs to be removed from its mounting bracket (or cabinet) and held to confirm it still has its original weight. I know of two surveyors that cited a hospital for failing to heft the extinguishers, said Overmeiren. If you currently are not conducting this important part of the monthly inspection, start doing so. Underground piping An annual flush of private-owned fire hydrants is required. The hydrant is required to be fully opened to allow water to flow for a When you deal with fire minimum of one and life safety systems, minute. Underground piping with these systems is the No. 1 problem that is privately documentation. owned is required Frank Van Overmeiren to have a water flow test every five years. The results of the flow test need to be compared with previous tests to ensure that appropriate water capacity for the sprinkler system is still available. The problem is contractors rarely do the five-year water flow test, said Overmeiren. Since it is more than an annual cycle, they think it is being done by others. Fire extinguishers Fire extinguishers must be maintained in accordance with NFPA 10, which requires a monthly inspection. During this inspection the extinguisher must be assessed to determine that it is in its designated location, and is accessible and visible. The pressure gauge (if equipped) must be inspected to ensure the pressure of the extinguisher is in the operable range, and the condition of the hose and nozzle must be examined to confirm that there are no abnormalities. To complete the Standpipe flow tests Once every five years, a water flow test is required on each zone of the standpipe system. For the purpose of this test, a zone is defined as each standpipe riser, according to Overmeiren. Water needs to be flowed and measured at the top of each standpipe riser, either out onto the roof or out into the yard or parking lot. The flow results of this test must be compared to previous tests to ensure there are no obstructions or restrictions in the piping.

8 Page 8 Healthcare Life Safety Compliance September 2012 Fire department connections On a quarterly basis, the fire department connections (FDC) need to be inspected. Frequently, hospitals mistake the fire hose connections located inside the building as FDCs. An FDC is located outside the building and is available for the fire department to pump water into the building if need be. FDCs are found on fire pump systems, standpipe systems, and sprinkler systems, and may be combined if the systems are integrated. I would recommend at least 2 different FDC locations for each system, said Overmeiren. This way, if one FDC was blocked or inaccessible, there is another that can be used during an emergency. Annual sprinkler inspections This is an annually required test, but it is rarely done properly, said Overmeiren. Each and every sprinkler head in the building needs to be visually inspected to ensure there is no leakage, corrosion, paint, foreign material, or physical damage to the head. The problem is whoever is doing the inspection fails to inspect each head due to patient activity or locked doors. Overmeiren explained that sprinklers must be installed in their proper orientation. This means different styles of heads, such as pendant, upright, and sidewall, all need confirmation that they are installed correctly. Also, clearance between sprinkler heads and ceilingmounted obstructions must meet specific parameters, so keep an eye out for newly installed ceiling-mounted equipment, such as patient lift systems. Removal of escutcheon plates [the decorative covers or rings around a sprinkler] is not required for this visual inspection, said Overmeiren. I suggest you add sprinkler inspections to your routine semiannual hazardous rounds in order to cover all the heads in the building. Annual sprinkler hanger and piping inspections Once per year, the sprinkler piping and hangers must be inspected to ensure nothing (other than sprinkler piping) is suspended from them. This inspection can be conducted from the floor; climbing a ladder and lifting ceiling tiles is not required. However, once a surveyor is above the ceiling to inspect fire barriers, there is nothing stopping him from looking around at your sprinkler pipe and hangers, noted Overmeiren. If anything is attached to or suspended from the pipe or hangers, it will most likely be a finding. Pressure gauges On a weekly basis, pressure gauges serving dry pipe systems, pre-action systems, and deluge systems must be inspected and have their pressure readings recorded, according to Overmeiren. The same is required, albeit on a monthly basis, for wet sprinkler systems and fire pumps. Every five years the pressure gauges are required to be calibrated, said Overmeiren. Hospitals rarely do this unless they have expensive oil-filled gauges. They simply purchase new gauges and replace them every five years. Sprinkler replacement According to Overmeiren, quick response (QR) sprinklers started to really take off and hospitals began installing them about 23 years ago. A certain sample size of QR sprinklers must be tested 20 years after installation, then every 10 years thereafter. It seems to be much less expensive to just replace all of them. Dry sprinklers, which are used in areas where freezing is likely (such as building overhangs or walk-in coolers and freezers), have a 10-year testing cycle. It would seem that nearly every hospital which has dry sprinklers or quick-response sprinklers may very well be noncompliant with this requirement, said Overmeiren. Main drain testing There are quarterly as well as annual main drain tests. The quarterly test is only required on one main drain located downstream of the backflow preventer. The annual test is required at each system riser at the point where it

9 September 2012 Healthcare Life Safety Compliance Page 9 turns vertically and extends through the deck above. A main drain test is conducted with a pressure gauge and a certain-sized valve, piped either to a drain that can handle the flow of water or the outdoors. The test is usually conducted with the fire pump in the off position, but the jockey pump in the on position. The system static pressure is observed and recorded on the pressure gauge, then the main drain valve is fully opened. Once the pressure gauge is stabilized, the residual (or flow) pressure is observed and recorded. Then the main drain valve is slowly closed, and the amount of time to restore the pressure back to the static reading is observed and recorded. The results of this test must be compared to previous tests to ensure there are no restrictions or obstructions in the pipe. Fire pump test A weekly churn test at no-flow conditions is required for a minimum of 10 minutes. The test must be initiated by reducing the water pressure to allow the pressure switch to start the pump. Suction and discharge pressure must be observed and recorded. An annual water flow test is required to measure the flow and capacity of the fire pump. Pressure and electrical readings are required at each step. The first test is a 30-minute churn test at no-flow conditions, the second test is to flow water at 100% (or design) capacity of the nameplate rating on the pump, and the third test is to flow water at 150% (or peak) capacity of the nameplate rating on the pump. Once the readings are made at peak capacity, for fire pumps that are connected to the emergency power generator, an electrical failure must be simulated to see whether the pump continues to operate at peak capacity under emergency management (EM) power. This must be confirmed by recording the water flow values. Then, the pump needs to be restored to normal power and ensure it continues to operate. All too often, the contractor performing this annual test fails to record the length of time for the churn test and fails to record whether the pump operated at peak capacity under EM power. Smoke detectors at fire alarm panels The 1999 edition of NFPA 72, which the 2000 edition of the Life Safety Code (LSC) references, requires a smoke detector mounted in the room where the fire alarm control panel is located. Subsequent editions did not require a detector over the panels if the building was fully protected with sprinklers. However, the 2010 edition of NFPA 72, which the 2012 edition of the LSC will reference, resorted back to requiring a smoke detector above all fire alarm panels, regardless if the building is fully sprinklered or not, said Overmeiren. This includes notification appliance circuit panels as well. Off-site alarm transmission Currently, the requirement to verify that your fire alarm panel transmits a signal to the local fire department is a quarterly requirement, said Overmeiren. That will change to annual once the 2012 edition of the LSC is finally adopted. Cooking hood fire suppression systems The 1998 edition of NFPA 96 (which the 2000 edition of the LSC references) requires that the fusible links on cooking hood fire suppression systems be replaced annually. This will change to semiannually when the 2012 edition of the Life Safety Code is finally adopted, noted Overmeiren. A monthly test of the elevator recall system must be initiated at the keyed switch in the hallway, as well as from the smoke detectors that are connected to the recall system, according to Overmeiren. The Life Safety Code requires testing the recall system monthly in accordance with the ASME/ANSI [American Society of Mechanical Engineers/American National Standards Institute] A17.1 Safety Code for Elevators and Escalators, he explained. That means the firefighter s service features inside the elevator car must be tested. n

10 Page 10 Healthcare Life Safety Compliance September 2012 Questions&Answers Editor s note: Each month, Senior Editor Brad Keyes, CHSP, consultant for Keyes Life Safety Compliance, answers your questions about life safety compliance. Our editorial advisory board also reviews the Q&A column. Follow Keyes blog on life safety at for up-to-date information. Corridor doors: Part 1 Q Are we allowed to install a hook on the inside of a patient room corridor door? Our nurses would like a hook installed on our wood patient room doors to hang some items on the inside of the room. These patient room corridor doors are not part of a smoke compartment or fire-rated wall. A You kind of answered your own question when you said the corridor doors are not required to be fire rated. If for some reason the door to the patient room is fire rated, then installing a hook on the inside of the door would be considered a modification, and that is not permitted. However, corridor doors to patient rooms that do not serve a smoke compartment barrier or a fire-rated barrier are not required to be fire rated. Section of the 2000 edition of the Life Safety Code (LSC) says the corridor doors are required to be 1¾-inchthick, solid-bonded wood core or of construction that resists fire for not less than 20 minutes, and must resist the passage of smoke. That may sound like a similar description as the phrase 20-minute fire rated, but it s not. If the corridor door is not fire rated, then field modifications of the door are permitted as long as it still resists the passage of smoke. It appears to me that adding hooks to this type of door does not inhibit its ability to resist the passage of smoke. Corridor doors: Part 2 Q Do corridor doors have to have door closures on them? I know they have to latch, but an architect said all corridor doors have to have closures on them. What does the LSC require? A For the sake of clarity, corridor doors are defined as those doors that separate a room or closet from a corridor. They are not doors that form a barrier across the corridor, separating one corridor from another, nor are they doors that separate a corridor from an exit or a stairwell. Some corridor doors may have a dual purpose, not only separating a room from a corridor but also forming part of a smoke compartment barrier, a horizontal exit, a fire-rated barrier, or a hazardous room. According to section and in the 2000 edition of the LSC, corridor doors are not required to be self-closing unless they also serve the following: A hazardous room An exit A horizontal exit A stairwell A smoke compartment barrier However, they are required to be positive latching. If the door is part of an original installation (prior to 1970), it can be kept closed with a device, such as a closure, that has at least 5 lbs of force as measured at the latch edge of the door. This device cannot be used in a retrofit application. If you wanted to install door closures on corridor doors, there is nothing in the code preventing you from doing so. In fact, some local and state building codes require corridor doors to have

11 September 2012 Healthcare Life Safety Compliance Page 11 closures installed, so please check with your local and state authorities prior to removing any door closures. Storage in a patient sleeping suite Q Can we install shelving along the walls within a patient sleeping suite? This shelving would not be limited to a supply room, but would be permanently affixed to the walls inside the main room in the suite and would not obstruct sprinkler heads or visual contact with the fire alarm notification strobe. A It all depends on what you put on the shelves. Since you are making a modification of the suite, you would have to comply with new construction requirements found in chapter 18 of the 2000 edition of the LSC. Take a look at section on hazardous areas. It describes a room that is greater than 100 square feet and stores combustible material as a hazardous area. Section does not allow intervening rooms to be hazardous areas, and the main room inside the suite would definitely be an intervening room and be greater than 100 square feet. If the supplies that are placed on these shelves are combustible, then this arrangement is not allowed in a patient sleeping suite. Most supplies used in patient care are packaged in combustible material, such as cardboard boxes, plastic, paper, or linen. Even if you think staff won t place combustibles on these shelves, I would strongly suggest that you do not go this route. You can never be sure what staff will place on the shelves after they are installed. Linen chute doors Q Do linen chute doors have to be locked? Our risk manager says they are required to be locked, but I don t see anything in the LSC that says that. What are the requirements for chute doors in regards to the LSC? A I will assume you are referring to an existing occupancy. There is no requirement in the LSC to lock linen (or trash) chute doors. Also, there are no direct standards from The Joint Commission, the Healthcare Facilities Accreditation Program, or Det Norske Veritas that require locks on linen (or trash) chute doors. Where hospitals get into trouble with this issue is failing to assess the perceived risk. Any surveyor or inspector can look at a chute door that is not locked and ask to see the risk assessment that allows the door to be left unlocked. The perceived risk is that an unauthorized individual may open the door and fall into the chute. An assessment could analyze that risk and determine if it is a low, medium, or high risk for that particular area. If the chute door is located in an area where there are children, patients, or visitors, then the risk is naturally higher than in areas where there are no children. Other factors must be assessed as well, such as behavioral health or Alzheimer s units, forensic units, and unsupervised areas. Whenever a risk assessment is conducted, make sure you include a wide variety of stakeholders in order to gain a well- rounded perspective. Once the assessment is completed, have your safety committee review it and approve it, and get the committee s decision posted in the minutes. Additionally, keep in mind that for new construction, access to linen and trash chute doors must be within a room, and either the chute door or the access room door must be locked, but not both. n Questions? Comments? Ideas? Contact Managing Editor Matt Phillion Telephone , Ext mphillion@hcpro.com

12 Page 12 Healthcare Life Safety Compliance September 2012 Quick tip Plenary session on codes and standards This month s issue focuses on the 49th Annual Conference and Exhibition of the American Society for Healthcare Engineering, held in San Antonio in July, and how it applies to life safety compliance. A plenary panel consisting of five industry experts answered key questions from the members. The following questions on smoke dampers were answered by Bill Koffel, president of Koffel Associates, Inc., and Frank Van Overmeiren, president of FP&C Consultants, Inc. Q Where are smoke dampers required to be installed in a hospital? A The issue with smoke dampers results in the differences between the International Building Code (IBC) requirements and the Life Safety Code (LSC) requirements. For example, the LSC allows us to omit smoke dampers in duct penetrations of many smoke barriers in buildings protected with a sprinkler system with quick response sprinklers on both sides of the smoke barrier. That exception is not in the IBC and it is one of the issues the ASHE-IBC ad hoc committee is working on at this time. Also, the IBC requires smoke dampers at duct penetrations of shafts, so there are more smoke damper requirements in the IBC than the LSC. There are also some folks who recall some previous building code requirements for smoke dampers where dampers were required in all duct penetrations of corridor walls. And some design professionals will require them in their documents. Q After my building has passed the final inspection with the building department, can I take those smoke dampers which are not required by the LSC out of service? A It depends. If the building code requires it, you need to comply with the building code and you can t diminish the protection feature from the building code. If it is not required by the building code and it is not required by the LSC for new construction, then it would be permitted to be taken out of service. Once you have determined that the damper can be removed, you can secure the damper in the open position. You can leave it in place, but you need to do some sort of documentation on your fire and smoke damper drawings to indicate that it has been affixed in the open position and taken out of service. n Subscriber Services Coupon Start my subscription to Healthcare Life Safety Compliance. Options No. of issues Cost Shipping Total Electronic 12 issues $289 (HLSCE) N/A Print & Electronic 12 issues of each $289 (HLSCPE) $24.00 Order online at Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total For discount bulk rates, call toll-free at *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NV, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge from HCPro, the publisher of HLSC.) Mail to: HCPro, P.O. Box 3049, Peabody, MA Tel: Fax: customerservice@hcpro.com Web:

13 Vol. 14 No. 9 September 2012 Healthcare Life Safety Compliance The newsletter to assist healthcare facility managers with fire protection and life safety Quiz Quiz questions September 2012 (Vol. 14, No. 9) 1. (T) (F) St. John s Regional Medical Center in Joplin, Mo., evacuated 183 patients in less than 90 minutes after a tornado hit the facility last year. 2. (T) (F) The number of findings by Joint Commission surveyors on rated wall penetrations has not diminished from last year. 3. (T) (F) George Mills, director of engineering at The Joint Commission, said he is hearing that a lot of hospitals are missing the details when it comes to documentation on fire alarm reports. 4. (T) (F) Life safety surveyors will now be referred to as life safety specialists. 5. (T) (F) The History Audit Trail is found on the Statement of Conditions. 6. (T) (F) CMS prefers that you submit a waiver on the five issues of the 2012 edition of the Life Safety Code before a validation survey. 7. (T) (F) Surveyors have cited hospitals for not hefting their fire extinguishers. 8. (T) (F) A fire department connection (FDC) is where the fire department connects fire hoses inside the building to fight the fire. 9. (T) (F) Quick response sprinklers have been around for about 23 years, and many hospitals will have to start testing them or replacing them soon. 10. (T) (F) Main drain testing is only required to be conducted on an annual basis. A supplement to Healthcare Life Safety Compliance

14 Quiz answers September 2012 (Vol. 14, No. 9) 1. True. 2. False. The number of findings on this issue has gone down, but it s still a high number. 3. True. 4. False. Life safety surveyors will now be referred to as Life Safety Code surveyors. 5. True. 6. False. CMS only wants a waiver request as a Plan of Correction after a validation survey. 7. True. 8. False. An FDC is located outside the building, and the fire department pumps water into the building to assist the building s sprinklers or standpipe systems. 9. True. 10. False. Main drain testing has quarterly and annual testing requirements. Copyright 2012 HCPro, Inc. Current subscribers to Healthcare Life Safety Compliance may copy this quiz for use at their facilities. Use by others, including those who are no longer subscribers, is a violation of applicable copyright laws. Registered trademark, the National Fire Protection Association, Inc.