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Volume 16Issue No. 11 NOVEMBER 2014

Healthcare Life Safety Compliance

The newsletter to assist healthcare facility managers with fire protection and life safety

Fire door deficiencies Read about the top-cited deficiencies for fire doors and what can be done to avoid common pitfalls.

HFAP findings The Healthcare Facilities Accreditation Program has revealed its top surveyor findings. Get the latest inside.

Questions & AnswersThis month’s Q&A looks at portable fire extinguishers, door hooks, and more.

Power strips In late-breaking news this month, CMS has issued categorical waivers on power strips. What does this mean for your organization?

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Editor’s note: In this, the first of a two-part series, we examine the frequent challenges of door locking arrangements in healthcare facilities.

While it may not be the No. 1 issue to receive surveyor citations, improper installation of locks on doors in the path of egress is considered to be a major issue and one of the more frequently cited deficiencies by accreditation organizations. Locks on doors in healthcare occupancies are common, and facility managers often overlook the Life Safety Code® (LSC) requirements that regulate such locks when they install them.

“The locking of doors within healthcare organizations is becoming increasingly prevalent,” says Terry Schultz, PE principal at Code Consultants, Inc., in St. Louis, Missouri. “What used to occur primarily in behavioral health settings is now desired for mother/baby units, the ER, ICU and many other

Door locking arrangements (Part 1) departments. We see this trend with new construction and renovation projects, but also with existing facilities simply changing the door locking arrangements.”

Locks on doors are mainly mentioned in two differ-ent locations of the 2000 LSC: section 18/19.2.2.2 in the healthcare chapters and section 7.2.1 in the means of egress chapter. Section 18/19.2.2.2 says doors in the required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or a key from the egress side. The phrase “required means of egress” refers to those paths of exit that are required by the LSC for egress. Some rooms or areas may have more paths of egress than what is required by the code, so the code only applies to the paths that are required.

But be careful with your assessment of the required paths of egress. Your facility’s exits were originally calculated by its designing architects, and any changes must be reviewed by an architect or similar

Healthcare Life Safety Compliance November 2014

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professional to ensure proper exiting is maintained. You may even need approval from your state or local authorities if you intend to modify any path of egress.

The same section of the code (18/19.2.2.2.2, exception #1) says key-locking devices (locks) that restrict access to the patient room from the corridor are permitted, as long as they are only operable by the staff from the corridor side and do not restrict egress from the patient room. This means the locking device must be able to be unlocked from the inside. Usually, a thumb turning handle is provided on the lock on the inside of the room to allow occupants to get out in the event of an emergency.

Dead-bolt locks need to comply with section 7.2.1.5.4, which says doors shall be operable with not more than one releasing operation. This means you cannot have a door on the egress side with a handle or knob to unlatch the door and a separate dead-bolt lock thumb turn to unlock the lock, which is two actions. The solution is to install locks that interface with the latch set and unlock the door when the door handle is operated, not requir-ing any additional action. Understand, too, that these types of locks are special locks—not your basic hardware

store dead-bolt locks. These locks can only be locked from the corridor side by the staff. They cannot be locked from the inside (but must be able to be unlocked from there).

Some facility managers and safety officers have developed a program at their facilities to scrutinize for inappropriate locks before they become part of a survey deficiency report.

“I have found inappropriate use of door locks often throughout my career,” says Joe Berlesky, CHFM, CHE, director of plant facilities at Baptist Medical Center in Jacksonville Beach, Florida. “Dead bolts found in use on patient sleeping room doors are not uncommon. The opportunity for continuous compliance, in my opinion, is education. For example: Allow the facility manager to bring these types of issues to the environmental rounds committee. Then, during routine building inspections, should a dead bolt or other locking issue be found, it is evaluated. A commonsense approach for compliance is through awareness.”

Security in a healthcare facility is always a challenge, and facility managers often turn to door locks to limit access to sensitive areas.

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Healthcare Life Safety Compliance (ISSN: 1523-7575 [print]; 1937-741X [online]) is published monthly by HCPro, a division of BLR, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate is $329 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, P.O. Box 3049, Peabody, MA 01961-3049. Copyright © 2014 HCPro, a division of BLR. 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, a division of BLR, or the Copyright Clearance Center at 978-750-8400. 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 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. 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.

EDITORIAL ADVISORY BOARD

James R. Ambrose, PETechnical Director, HealthcareCode Consultants, Inc. St. Louis, Missouri

Joseph A. Berlesky, CHFM, CHEDirector, Plant FacilitiesBaptist Medical Center Beaches Jacksonville Beach, Florida

Frederick C. Bradley, PEPrincipalFCB Engineering Alpharetta, Georgia

Jamie Crouch Safety and Security ManagerMetro Health Hospital Wyoming, Michigan

Michael Crowley, PESenior Vice President, Engineering ManagerRolf Jensen & Associates, Inc. Houston, Texas

A. Richard FasanoManager, Western OfficeRussell Phillips & Associates, LLC Elk Grove, California

Burton Klein, PEPresidentBurton Klein Associates Newton, Massachusetts

Henry KowalenkoSupervisor, Design Standards UnitOffice of Healthcare Regulation, Illinois Department of Public Health Chicago, Illinois

David MohilePresidentMedical Engineering Services, Inc. Leesburg, Virginia

James MurphyPresidentMRF, Ltd. Western Springs, Illinois

Thomas SalamoneDirector, Healthcare ServicesTelgian Corporation Atlanta, Georgia

Terry Shultz, PEPrincipalCode Consultants, Inc. St. Louis, Missouri

William Wilson, CFPS, PEMFire Safety CoordinatorBeaumont Hospitals Royal Oak, Michigan

Senior Managing EditorMatt Phillion, [email protected]

Senior EditorBrad Keyes, CHSP Senior Consultant Keyes Life Safety Compliance www.keyeslifesafety.com

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

Healthcare Life Safety ComplianceNovember 2014

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“In an effort to help keep our hospitals, employees, and our patients safe and secure, we are constantly evaluating areas to improve security measures,” says Jamie Crouch, BSBM, MHA, CWCP, safety and security manager of Metro Health Hospital in Wyoming, Michigan. “The challenge that we face is that sometimes it is not as easy as just putting a lock on the door. The assessment process that we use to add security measures includes evaluating the Life Safety Code to ensure that the securing of the area or door will not violate requirements of the codes or standards.”

IngressGenerally speaking, the LSC does not restrict locking

doors on the ingress (entrance) to a building. The code is more concerned about preserving egress (exit) from the building.

But there are exceptions to this. Section 7.2.1.5.2 does allow stairwell enclosures serving more than four stories to have locks on doors preventing reentry (ingress) to the building, provided the following conditions are met:• There must be a minimum of two levels where it is

possible to leave the stairwell• There must not be more than four stories interven-

ing between stories where it is possible to leave the stairwell

• Reentry must be possible at the top or next to the top story that allows access to another exit

• Doors allowing reentry must be identified as such on the stairwell side of the door

• Doors not allowing reentry must be provided with a sign on the stairwell side indicating the location of the nearest door, in each direction of travel that allows reentry or exit

The 2000 LSC exempts existing healthcare occu-pancies from complying with the reentry provisions of section 7.2.1.5.2, allowing such hospitals to prevent reentry on all stories of stairwells. But when does an existing hospital qualify for this arrangement? This stairwell reentry provision was first introduced in the 1985 edition of the LSC, and CMS required compliance with the 1985 edition from January 1988 until March 2003. So if the stairwell was constructed since January 1988, it would have had to comply with the new

construction requirements, which require compliance with the stairwell reentry provisions; therefore it does not qualify for the 2000 LSC provision that exempts existing conditions from complying.

This provision to allow locking ingress doors in the stairwell is especially useful in those situations where you do not want unauthorized individuals entering a surgical department or other sensitive area. However, if a stairwell enclosure allows access to the roof of the building, the door to the roof must be kept locked or must allow reentry to the stairwell from the roof. The security risk of an unlocked door to the roof is ex-tremely high considering the emotional state of many patients in a hospital, so most authorities having jurisdiction (AHJ) would expect the door to be locked. The door cannot be locked for individuals egressing from the roof, though, as that would be in the path of egress.

EgressThe LSC specifically disallows locking doors in the

path of egress, according to section 18/19.2.2.2.4 of the 2000 LSC. But right away the code lists three exceptions:• Locks without delayed egress are permitted in

healthcare occupancies where the clinical needs of the patients require specialized security measures for their safety

• Delayed egress locks, provided not more than one such device is located in any egress path

• Access control locks

The unique issue with locks complying with the clinical needs definition is they are not required to be connected to the fire alarm system and automatically unlock with the activation of the fire alarm system. While the LSC specifically states delayed egress locks and access control locks are required to be connected to the fire alarm system, there is no such language for the description of clinical needs locks. Even the provision found in section 3-9.7 of the 1999 NFPA 72, National Fire Alarm Code, which says all exits with locks must unlock upon receipt of any fire alarm sig-nal, does not apply because the LSC permits the locks to not be connected to the fire alarm system by virtue of omission.



“The belief that a door locking arrangement is configured to unlock upon activation of the fire alarm system and therefore is compliant is probably the most common misnomer we encounter in the healthcare field,” says Richard Fasano, manager of the western office at Russell Phillips & Associates in Elk Grove, California.

Clinical needs locks are often used in psychiatric care areas or in areas with patients with dementia type symptoms. Where hospitals have difficulty with clinical needs locks is when they attempt to use them for infant/pediatric security or for special care units such as ICUs and ERs. The multiple AHJs who regulate hospitals cannot agree where these locks can be utilized, but CMS has stated clinical needs locks are only allowed in psychiatric and dementia care areas.

“I’ve heard numerous clients take the approach that since an infant or pediatric patient is in the hospital because they require clinical care, if they are abducted they would be deprived of this care and therefore the client feels that the clinical needs provision applies,” says Fasano. “However, I’ve also heard representatives of the accreditation organizations say that they do not accept this reasoning.” Since CMS is the AHJ regulating hospitals that are certified to receive Medicare and Medicaid reimbursements, the accreditation organizations have no choice but to comply with the agency’s interpretation.

The good news is the 2012 LSC has a new provision that allows the hospital to lock doors in the path of egress where patient special needs require specialized protective measures for their safety, such as infant/pediatric care units, ICUs, and ERs. This section, 18/19.2.2.2.5.2, allows doors to be locked where specialized protective measures are required for patient safety, provided all of the following conditions are met:• Staff can readily unlock the doors• The locked space is fully smoke detected, or the

locked doors can be remotely unlocked at a con-stantly attended location within the locked space

• The entire building is protected with sprinklers• The locks are electrical locks that fail safe (unlock)

on a power failure• The locks release upon activation of the fire alarm

smoke detection system or by the waterflow switches in the sprinkler system

And here’s some more good news: This provision of the 2012 LSC is allowed to be used now by order of the August 30, 2013, CMS S&C memo 13-58, which is commonly called categorical waivers. While CMS and the accreditation organizations will allow the use of this provision, remember to check with your state and local authorities to make sure they will allow it as well.

“It may sound simple, but it is also a good idea to walk the entire area of the affected area,” says Crouch. “When walking the area, look for your identified path of egress route. Look for other access limitations or regulations. The American with Disabilities Act is another code that can be easily overlooked. Developing a good checklist may prevent an oversight.”

Delayed egress locks are found in the 2000 LSC at 7.2.1.6.1 and are only permitted to be used in fully sprinklered or fully detected buildings. Special signage is required on these doors that says:

Push Until Alarm SoundsDoor Can Be Opened in 15 Seconds

Although the LSC says the AHJ can approve a delay up to 30 seconds, that will not happen for healthcare occupancies due to the multiple AHJs who regulate them.

The locks used for delayed egress must unlock upon loss of power; upon activation of the sprinkler system; and upon activation of a heat detector or a smoke detector. The code does not require releasing the delayed egress locks upon activation of a pull station because it would be too easy to circumvent the locks by simply pulling the manual alarm station.

The allowance for omitting the pull station activation to release the delayed egress lock is often misunder-stood by accreditation agency surveyors, according to Berlesky.

“Often surveyors will ask when a delayed egress system is observed, if it releases when the pull station is activated,” he says. “The appropriate response from facility managers should be ‘no’ and reiterate the code reference.”

Next month’s issue of HLSC will continue to examine the special locking arrangements on doors in a health-care facility. H



Top deficiencies cited for fire doors

With the adoption of the 2012 Life Safety Code® (LSC) expected to happen within a few months, a new requirement to inspect fire-rated door assemblies in all healthcare facilities on an annual basis will begin. It is not too early now to look at some of the more common deficiencies and problems when testing and inspecting fire doors, to provide you with some awareness on what to look for.

We interviewed Lori Greene, AHC/CDC, CCPR, FDAI, FDHI, manager of Codes & Resources for Allegion, a major manufacturer of doors and hardware, headquartered in Carmel, Indiana. During the interview, we asked Greene for her thoughts on the top 10 deficiencies identified during fire door inspections as listed in the summer 2012 issue of the Life Safety Digest (www.fcia.org/magazine.htm), a product of the Firestop Contractor’s International Association.

“Fire door assemblies and certain egress doors must be inspected annually per NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 edition, and the 2012 Life Safety Code,” says Greene. “Any deficiencies found must be corrected without delay.”

1. Painted or missing fire door labels. The label found on the edge or top of a fire door and in the rabbet of a fire-rated frame may be made of metal, paper, or plastic, or may be stamped or die-cast into the door or frame.

“Labels must be visible and legible,” says Greene. “Some embossed labels can still be read if they are painted, but if a painted label is illegible, the paint must be removed. If labels are missing or can’t be made leg-ible, the authority having jurisdiction may require the doors or frames to be re-labeled by a listing agency.”

2. Poor clearance dimensions around the perimeter of the door in the closed position. The maximum clearance allowed by NFPA 80 between a fire door and the frame at the head, jambs, and meeting stiles of pairs is 1/8 inch for wood doors, and 3/16 inch for hollow metal doors. The maximum clearance at the bottom of the door is 3/4 inch between the bottom of the door and the top of the flooring or threshold.

“For doors that have clearances which are larger than allowed by NFPA 80, there are gasketing products in development which may be allowed by the listing agencies as an alternative to replacing the door,” says Greene. “Shimming the hinges with metal shims may help to correct the problem, and there are metal edges available which are listed for use when a door needs to be increased in width to reduce the clearance.”

3. Flip-down door holders. A flip-down door holder is a simple mechanical device that is mounted on the bottom corner of the door and flips down to hold the door open. Because fire doors must be self-closing or automatic-closing, a flip-down holder is not an ac-ceptable way of holding open a fire door.

“A mechanical hold-open feature in a door closer and other types of hold-opens such as wedges, hooks, and overhead holders are not allowed for fire doors either,” says Greene. “An automatic-closing fire door is held open electronically and closes upon fire alarm. This may be accomplished with a wall- or floor-mounted magnetic holder, a closer-holder unit which receives a signal from the fire alarm system or incorporates its own smoke detector, or a separate hold-open unit which is paired with a standard door closer. There is also a battery-operated hold-open available which can be used in some retrofit applications.”

Existing fire doors may be equipped with fusible link closer arms, which incorporate a fusible link that is in-tended to melt during a fire and release the hold-open. The current edition of the LSC (and the 2012 edition as well) does not allow fusible link arms on doors in a means of egress because they do not allow the doors to control the spread of smoke. Automatic-closing doors must be initiated by the fire alarm system or smoke detection.

4. Auxiliary hardware items that interfere with the intended function of the door. These auxiliary items may include creative ways of holding open the door or providing additional security. In many cases, the auxiliary items create an egress problem. Examples include additional locks or surface bolts (most egress doors must unlatch with one operation), chains or creative devices used with panic hardware,



or electronic access control products that have not been installed with the required release devices for code compliance. Hardware used on fire doors must be listed for that use, and items not listed for use on a fire door must be removed.

“Holes left by the removal of auxiliary items must be filled in accordance with NFPA 80, typically either with steel fasteners or with the same material as the door or frame,” says Greene. “Field preparation for these auxiliary items may also create a problem on fire doors.”

NFPA 80 limits job site preparation of fire doors to holes for surface-applied hardware, function holes for mortise locks, and holes for labeled viewers.

“The maximum hole diameter is 1 inch, except holes for cylinders which may be any diameter,” says Greene. “Protection plates may be field-installed, and wood and composite doors may be undercut in the field a maxi-mum of 3/4 inch (check with the door manufacturer first). Field modifications beyond what is allowed by NFPA 80 may void the label and require re-labeling of the assembly if prior approval for the modification is not granted in advance by the listing laboratory.”

5. Fire doors blocked to stay in the open position. If a fire door is not able to close, it can’t compartmentalize the building and prevent the spread of fire and smoke.

“Fire doors are typically blocked open for the convenience of the building’s occupants,” says Greene. “Many people don’t understand the function of fire doors, and may compromise their own or the patient’s safety without realizing the results of their actions. Educating facilities staff and the building’s occupants on fire door requirements can help to avoid a problem and/or a fine from the local fire marshal.”

6. Area surrounding the fire door assembly blocked by carts or equipment. The area leading to fire and egress doors must be kept clear for egress purposes and to provide the required maneuvering clearance for accessible openings. A fire door typically carries a lower hourly rating than the wall because the fuel load against an operable door is much less than a wall with furniture and other materials against it.

“If a fire door is no longer used as a door, building occupants may store items against the door,” says Greene. “NFPA 80 requires fire doors that are no longer in use to be removed and replaced with wall

construction matching the adjacent wall. If a 45-minute door in a one-hour wall has an increased fuel load because it is no longer operable, it will not be able to withstand fire for the required amount of time. Check required egress routes before removing any door.”

7. Broken, defective, or missing hardware items. Hardware may not perform as designed and tested if it is missing parts or if the hardware has become damaged.

“Bent closer arms may not close the door properly,” says Greene. “Missing cover plates may create a passage for smoke, and a missing strike or latchbolt could mean that the door does not stay positively latched when exposed to the pressures of a fire. When defective hardware is noted, it must be repaired or replaced immediately.”

8. Fire exit hardware installed on doors that are not labeled for use with fire exit hardware. Fire exit hardware is essentially panic hardware listed for use on a fire-rated door. It is not equipped with mechanical dogging (the ability to hold back the latch) since fire doors need to positively latch, although elec-tric dogging may be used as long as the latch projects upon fire alarm.

“When fire exit hardware is used, NFPA 80 requires the door to have a label stating, ‘Fire door to be equipped with fire exit hardware,’ ” says Greene. “This ensures that the door is properly reinforced for the fire exit hardware. An existing door which is prepped for a lock set would not typically be reinforced for fire exit hardware or carry the proper label, so fire exit hardware should not be retrofitted to an existing door that was not originally prepped for it.”

9. Missing or incorrect fasteners. In most cases, hardware must be installed with the fasteners provided by the manufacturer.

“Installers sometimes use other fasteners for faster installation or because the original fasteners have been lost,” says Greene. “There must be no missing fasteners on hardware installed on fire doors, and some products may require through-bolts if the door does not have adequate blocking or reinforcing.”

10. Bottom flush bolts that do not project 1/2 inch into the strike. Flush bolts are used on the inactive leaf of pairs of doors when the active leaf has a lock set. There are three types: manual, automatic, and



constant-latching. They typically project into the frame head and into the floor, although there are some auto-matic and constant-latching bolts which have a top bolt only, and incorporate an auxiliary fire pin that projects when a certain temperature is reached and engages into the edge of the other door.

“Manual flush bolts are projected and retracted manually, and are only allowed by NFPA 80 on fire doors ‘where acceptable to the authority having jurisdiction, provided they do not pose a hazard to safety to life,’ ” says Greene. “The Annex explanatory material states, ‘This provision limits their use to rooms not normally occupied by humans (e.g., transformer vaults and storage rooms).’ The use of manual flush bolts is also limited to certain applications by the Life Safety Code requirements, because it requires two motions to unlatch the door when manual flush bolts are installed, and they are not within the allowable reach range for accessibility.”

Automatic flush bolts project automatically when the active leaf is closed, via a small trigger on each bolt. When the active leaf is opened, the bolts retract automatically, making them acceptable for use on most egress doors that don’t require panic hardware—as long as the inactive leaf is not equipped with “dummy” hardware (lever or bar), which suggests that the inactive leaf can be operated independently. Automatic flush bolts are considered positively latching and can be used on fire doors. A coordinator is also required to ensure that the inactive leaf closes before the active leaf.

Constant-latching flush bolts have an automatic flush bolt on the bottom, and the top is a spring-loaded bolt that is retracted manually to open the door.

“These bolts provide a higher degree of security than the other two because the inactive leaf is more likely to be closed and latched properly,” says Greene. “They can be an egress issue for some doors because the top bolt has to be retracted manually, and it is not within the accessible reach range. A coordinator is also required for this application.”

When the bottom bolt doesn’t engage properly, there is no assurance that the fire door will perform as it was designed and tested during a fire. The undercut of the door must be carefully coordinated to ensure the proper engagement of the bottom bolt.

“Another issue with flush bolts on fire doors is that the coordinator/auto-flush bolt combination can be

difficult to keep functional in a high-use opening,” says Greene. “If the latches don’t retract properly or if the inactive leaf is pulled or pushed without opening the active leaf first, the corners of the door can be sus-ceptible to damage because of the volume of material removed to prepare the door for the flush bolt. This is a particular problem on wood doors.”

Annual test and inspectionsIn addition to the annual inspection of fire doors,

section 7.2.1.15.1 of the 2012 edition of the LSC will require certain egress doors in assembly occupancies and residential board and care occupancies to be inspected annually as well. Those include:• Door leaves equipped with panic hardware or fire

exit hardware• Door assemblies in exit enclosures• Electrically controlled egress doors• Door assemblies with special locking arrangements,

such as delayed egress, access control, and elevator lobby exit access doors

“The new requirements for the annual inspection of fire and egress doors have drawn attention to the condition of existing doors and the potential failure of these doors to perform in a fire or emergency,” says Greene. “If the inspection requirements are not being enforced in your area, fire and egress doors are still required to be properly maintained, so now is the time to make a plan for inspecting the doors in your facility and repairing or replacing deficient components.”

Written documentation of fire door inspections must be kept for review by the authority having jurisdic-tion. Inspections may be conducted by an individual who is knowledgeable about the type of doors being inspected.

If you seek additional education and training for fire door inspections, there are several online training programs available, including:• The Door Hardware Institute’s Fire and Egress

Door Assembly Inspection Program (FDAI) at www.dhi.org/INDUSTRY/fdai/index.php

• The International Fire Door Inspector Association (IFDIA) at www.ifdia.org/elearning

• I Dig Hardware/I Hate Hardware at www.idigHardware.com H



Top surveyor findings announced by HFAP

During the American Society for Healthcare Engi-neering annual conference in Chicago last August, the Healthcare Facilities Accreditation Program (HFAP) announced its top surveyor findings for the first half of 2014. HFAP is the hospital accreditation arm of the American Osteopathic Association and is a direct competitor of The Joint Commission and Det Norske Veritas.

Brad Keyes, CHSP, is an independent consultant and advises HFAP on all issues of engineering, physical environment, emergency management, and life safety. He is also the senior editor of Healthcare Life Safety Compliance. In his presentation, Keyes explained how HFAP differs from other accreditation programs today.

“The HFAP accreditation requirements and stan-dards are closely tied to the corresponding Centers for Medicare & Medicaid Services [CMS] Conditions of Participation,” said Keyes. “This better prepares our clients for the inevitable CMS validation survey without requiring compliance with unnecessary standards.”

In January 2014, Keyes explained there were multiple changes to the acute care hospital manual in the physical environment area.

“We took the Physical Environment chapter and divided it into three chapters: Emergency Management, Physical Environment, and Life Safety,” said Keyes. “This allowed us to clean up some out-of-date standards and place emphasis on common issues hospitals have difficulties with.”

One of the changes established a new document called the Facilities Demographic Report (FDR), which replaced the older Life Safety Assessment.

“The FDR is a document that asks the hospital to provide basic engineering information about their facility,” said Keyes. “It would be similar to the Statement of Conditions.”

HFAP recently established the new life safety surveyor role, and Keyes identified the top life safety findings for the first half of 2014. The first was problems with exit signs.

“The main problem with exit signs is their location and the lack of monthly inspections,” explained Keyes. “Many exit signs were observed to be either obstructed by other

signs, or were nonexistent. Also, hospitals did not present evidence that their exit signs were inspected monthly.”

Installation of fire alarm system devices was the next finding identified by Keyes. “Smoke and heat detectors were observed to be mounted too close to HVAC air diffusers,” he said. “They must be at least 36 inches away from the diffusers. Also, detectors were observed to be mounted too far below the ceiling or deck, primarily in mechanical rooms. They cannot exceed 12 inches below the ceiling.”

Installation of water-based fire suppression system equipment also was frequently cited by surveyors. “Sprinkler heads were observed to be obstructed by items stored on shelves,” said Keyes. “Items cannot be closer than 18 inches to the sprinkler head.”

Additional problems with sprinklers included ceiling mounted obstructions; damaged sprinklers, such as bent deflector heads; sprinklers with missing escutcheon plates; and dust, dirt, and pieces of plastic bags hanging from the sprinklers.

Fire-rated door assemblies were identified as recurrent surveyor findings. “The labels on fire-rated doors were either painted over or missing,” explained Keyes. “Another common problem with fire-rated door assemblies was the latching hardware failed to secure the door closed.”

While corridor clutter is a common finding among surveyors, another problem surfaced as being observed more often: path of egress obstruction. “Findings under this standard include observations such as items stored in the stairwell, doors that do not fully open due to some obstruction, and obstructions to exiting that are not corridor clutter,” said Keyes.

A finding that is commonly cited by all of the accredi-tation organizations involves fire alarm system testing.

“Every device connected to the fire alarm system must be tested,” said Keyes. “Findings by our surveyors include a wide variety of devices where the hospital had no evidence that they were tested, including occupant notification devices, and interface relays to other features of life safety.” Interface relays are devices that connect the building’s fire alarm system to other features, such as:



• Magnetic hold-open for doors• Air handler shutdown• Kitchen hood suppression systems• Elevator recall• Magnetic locks• Fire pumps• Smoke dampers• Clean agent suppression systems• Sprinkler dry-pipe/pre-action systems• Overhead rolling fire doors

Another common finding, according to Keyes, is unsealed penetrations in fire-rated barriers. “It doesn’t matter who made the penetration in the fire-rated barrier,” said Keyes. “The penetrations must be sealed with appropriate fire stop material. This is where an above-ceiling permit program would be very helpful.”

Problems with hazardous areas were also on the list of frequent surveyor findings. “Our surveyors found that hazardous areas were not maintained correctly,” said Keyes. “They frequently found that there was no closer on the entrance door to a hazardous room, they found unsealed penetrations in the hazardous room partitions, and the room perimeter barriers did not always extend to the deck above when needed.”

Basic plant maintenance issues that surveyors cited included open electrical junction boxes; cables and wires attached to the outside of conduit; and obstructed access to electrical control panels.

“Not many people know and understand that you are not permitted to wire-tie cables and wires to conduit,” said Keyes. “According to NFPA 70, National Electrical Code (1999 edition), article 300-11(b), wires and cables can only be tied to conduit when the wires or cables control the circuit inside the conduit.”

When it came to medical gas systems, the HFAP surveyors observed improper storage of compressed gas cylinders. “Compressed gas cylinders must be secured at all times,” said Keyes. “Full and partially full cylinders must be stored separately from empty cylinders.”

Alternative life safety measures (ALSM) are consid-ered to be the same thing as interim life safety measures, and the surveyors found issues with them.

“The surveyors made observations where the organization had documented a feature of life safety

was impaired, but they failed to assess it for ALSM,” said Keyes. “The standard requires an assessment must be made and documented when a feature of life safety is found to be impaired and cannot be resolved the same day it is discovered.”

The required corridor width was observed to be obstructed with ... what else? Corridor clutter. “Items left unattended in the corridor were observed by the surveyors,” said Keyes. “Only certain items are per-mitted to be left unattended in the corridors, such as crash carts and isolation supply carts where a patient is actively on contact precautions. All other unattended items must be removed from the corridor after 30 minutes.”

Problems with portable fire extinguishers did not escape the observations of the surveyors. “Fire extin-guishers are required to be mounted on something … a wall or a post,” said Keyes. “Or they can be placed in a wall cabinet. The issues that the surveyors observed were improper mounting; improper identi-fication of the cabinet; and failure to conduct monthly inspections.”

Eyewash stations and emergency showers made the list. “HFAP expects compliance with ANSI Z358.1-2009 for eyewash stations and emergency showers,” said Keyes. “This means they must be mounted cor-rectly; located within proper travel limits; and tested weekly.”

Medical gas shutoff valves were identified as not being labeled; or not being labeled with the proper room numbers; and access to the shutoff valves was obstructed by carts or equipment.

“The worst situation is where one surveyor observed desks and countertops built into the wall directly in front of the shutoff valves,” said Keyes.

Problems with corridor doors were prevalent as well. “Corridor doors are required to latch,” said Keyes. “Our surveyors found doors to utility rooms to have the most problems. They were either wedged open or had their latching hardware impaired by tape.”

The surveyors even found deficiencies outside of the building. “The exit discharge is the path of egress from the building exit to the public way,” said Keyes. “Survey-ors often found the path on uneven or unimproved ground, which is not permitted. Also, the path wasn’t always free and clear of snow and ice.” H



&AnswersQuestions

Editor’s note: Each month, Senior Editor Brad Keyes, CHSP, owner of 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 www.keyeslifesafety.com for up to date information.

Portable fire extinguishers

Q What is the requirement for inspecting fire extinguishers in our medical office building? Is it

different than what is expected in our hospital?

A The monthly inspection and annual mainte-nance requirements for the portable fire extin-

guisher is the same for all occupancies and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:• Make sure extinguisher is in its designated place• Make sure the access to the extinguisher is not

obstructed• Make sure the operating instructions on the

nameplate are legible and facing outward• Make sure the safety seals and tamper indicators

are not broken or missing• Heft the extinguisher (pick it up and hold it) to

determine fullness• Examine the extinguisher for obvious damage,

corrosion, leakage, or clogged nozzle• Make sure the pressure gauge (if so equipped) is

in the normal operating range• For wheeled units, check the condition of the

tires, wheels, carriage, hose, and nozzle• Make sure the HMIS label is in place

This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable)

and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. Annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection. A 12-year hydro test of the extinguisher is also required.

Door hooks

Q With regards to installing a hook on a fire-rated door, would an adhesive-backed hook be

considered a modification to the door?

A As far as I can tell, NFPA 80 and NFPA 101, the Life Safety Code® (LSC), do not address

this specific issue. One could argue that the hook can be applied with the same adhesive that is permitted in section 1-3.5 in NFPA 80 (1999 edition), which discusses signs attached to fire doors, especially since the area of the hook would be presumably less than what is usually provided for signs. The difference is that when you hang a coat on the hook, you now have a fuel load. So even though the hook is not penetrating the door or affecting its integrity, the door might not perform the same in a fire because of the unexpected fuel load. It is not unusual (in fact, it’s quite common) for an NFPA code or standard to fail to address all possible considerations. When this happens, it is up to the authority having jurisdiction (AHJ) to make an interpretation on that issue. If the AHJ has indeed made such an interpretation, then that’s your answer.

But, to my recollection, I am not aware if CMS or any accreditation organization has made a written (formal) interpretation on whether or not hooks can be mounted to fire-rated doors with adhesive. You could ask them, but whatever answer they give would only apply to their inspections.



In other words, just because an accreditation organization says it is okay to do something, that does not mean it is okay with CMS or any of your other AHJs. When an AHJ has not provided a clear interpretation on an issue, the organization may conduct a risk assessment, considering the pros and cons of such action (using the adhesive hooks on fire-rated doors). However, just because you conducted a successful risk assessment does not mean the AHJ has to accept your conclusions. If the AHJ disagrees with your findings, it can cite you for safety-related violations even though there is no specific standard prohibiting the hooks on the doors. My advice is don’t do it. It’s not worth the hassle of defending yourself to an overzealous surveyor who just doesn’t agree with your conclusions. Also, once you allow one hook on the door, it will invite many others, quickly becoming a nightmare to monitor and enforce.

Ambulatory surgical center waiting rooms

Q Can an ambulatory surgical center (ASC) have a waiting room that is shared with another

physician’s practice that is not associated with the ASC, but is located in the same building?

A No, it cannot. Section 20/21.3.7.1 of the 2000 LSC states the ambulatory healthcare

occupancy must be separated from other tenants and occupancies with one-hour fire-rated barriers. The ASC is located in an ambulatory healthcare occupancy, and the physician’s practice is another tenant and is presumably located in a business occupancy. This separation between tenants and occupancies includes waiting rooms and areas. In addition, the CMS S&C memo 10-20-ASC dated May 21, 2010, specifically states ASC must have waiting areas that are separate from other tenants and occupancies by one-hour fire-rated barriers. The logic expressed in the CMS memo is patients occupying an ASC waiting area for the purpose of receiving treatment may not be capable of evacuating without assistance; therefore, the ASC waiting area needs to comply with all of the fire safety requirements afforded to ambulatory healthcare occupancies. The CMS memo does say existing ASCs that are

cited to be noncompliant in regard to the waiting area requirements may submit waiver requests, but waivers will not be allowed for ASCs classified as new construction facilities (designed or constructed prior to March 11, 2003). Please be advised that the CMS categorical waivers do not apply to this situation.

Hotel room evacuation during fire alarm

Q We own and operate a hotel on our hospital campus and are revamping our fire plan. Are

we required to have all the hotel guests evacuate their rooms upon activation of the fire alarm? Also, we have a marked exit into a courtyard with a six-foot-high fence around it. The gate in the fence then leads to the public way. Must this gate remain unlocked for egress to the public way, or can you have an assembly point inside the courtyard?

A Section 29.7.4.2 of the 2000 LSC states the fire safety information that is posted in the hotel

room is sufficient for the guests to make their own decision as to whether or not they evacuate their rooms and/or building during a fire alarm. In an obvious fire alarm testing situation, I can see that as a legitimate situation where evacuation is not necessary. But other than that, 29.7.4.2 appears to leave that decision up to the guests. However, it would seem logical to want everyone to evacuate whenever a fire alarm is activated. In regard to the fence surrounding the courtyard, that presents other problems. Since you say it is a marked exit, then the exit discharge is required to extend to the public way. The public way is defined as a street, alley, or other similar parcel of land essentially open to the outside air, which is dedicated or otherwise permanently appropriated to the public for public use. A fenced-in area that has a locked gate does not seem to meet this definition of public way. In my opinion, the gate would have to remain unlocked. The gate would also have to be an obvious point of exit, or it would have to be marked with an illuminated exit sign, and the path of egress to the public way would need to be illuminated with emergency power. Even if you got a local authority having jurisdiction (AHJ) to allow the locked gate in the courtyard, that does not mean other AHJs would see it the same way. H



Quick tip

CMS issues categorical waiver on power strips

Thomas Hamilton, the director of the Survey and Certification

unit at CMS, issued a new S&C memo 14-46 in late September

that made allowances for healthcare organizations to utilize

power strips in patient care areas.

“CMS has determined that the 2000 edition of the Life Safety

Code® [LSC] contains provisions on the use of power strips in

healthcare facilities that may result in unreasonable hardship for

providers or suppliers,” says Hamilton. “Further, an adequate

alternative level of protection may be achieved by compliance with

the 2012 edition of the Life Safety Code, which has extended

allowances on the use of power strips in patient care areas.”

CMS has determined that the 1999 edition of NFPA 99,

Standard for Health Care Facilities, section 3-3.2.1.2 (d)(2), which

requires a sufficient number of receptacles located so as to

avoid the need for extension cords or multiple outlet adapters,

is outmoded and unduly burdensome. NFPA 99 is referenced in

part by the LSC. Power strips are also known as multiple outlet

adapters, multiple plug adapters, and relocatable power taps.

Hamilton explains that the categorical waivers are based

on updated editions of NFPA 99. “By contrast, the 2012 edition

of NFPA 99 has extended allowances for use of power strips

in ‘patient care rooms,’ which replaces the term ‘patient care

areas,’ ” he says.

The requirement in the 1999 edition of NFPA 99 for sufficient

receptacles to be located in all patient areas to avoid the need

for power strips has been removed in the 2012 edition. In its

place, the 2012 edition has increased the minimum number of

receptacles in patient care rooms for new construction.

“Accordingly, we are permitting a categorical waiver to allow

for the use of power strips in existing and new healthcare facility

patient care areas/rooms, if the provider/supplier complies with

all applicable 2012 NFPA 99 power strip requirements and with

all other 1999 NFPA 99 and 2000 Life Safety Code electrical

system and equipment provisions,” says Hamilton.

A patient care room is defined as any room in a healthcare

facility wherein patients are intended to be examined or treated.

This definition appears to include operating rooms and procedure

rooms as well.

The S&C memo issued by Hamilton describes basic

requirements that healthcare facilities must comply with in

order to use the new categorical waiver:

• Patient bed locations in new healthcare facilities, or in existing

facilities that undergo renovation or a change in occupancy,

shall be provided with the minimum number of receptacles as

required by section 6.3.2.2.6.2 of the 2012 NFPA 99.

• Power strips may be used in a patient care vicinity to

power rack-mounted, table-mounted, pedestal-mounted,

or cart-mounted patient care–related electrical equipment

assemblies, provided all of the conditions are met in section

10.2.3.6. They do not have to be an integral component of

manufacturer-tested equipment.

• Power strips may not be used in a patient care vicinity to

power electrical equipment not related to patient care, such

as personal electronics.

• Power strips may be used outside of the patient care

vicinity for equipment both related and not related to patient

care.

• Power strips providing power to patient care–related

electrical equipment must be special purpose relocatable

power taps listed as UL 1363A or UL 60601-1.

• Power strips providing power to electrical equipment not

related to patient care must be relocatable power taps

listed as UL 1363.

The categorical waiver is available to all healthcare providers

and suppliers, who need only to document their decision to use

the waiver, stating that they comply with all of the requirements

to do so. This document must be provided to the surveyor

team at the entrance conference. Organizations wishing to use

categorical waivers need not apply for them or wait until they

are cited to use them.

This change in how CMS views power strips is the result

of advocacy work conducted by the American Society for

Healthcare Engineering (ASHE) and other related organizations.

“We give kudos to CMS for working so quickly to resolve

this issue,” says Chad Beebe, AIA, SASHE, CHFM, CFPS,

CBO, deputy executive director for ASHE. “The categorical

waivers should give hospitals relief and bring a sense of reality

to today’s patient care environment, while keeping patients,

staff, and visitors safe.”

1. (T) (F) Locks on doors in healthcare occupancies are not permitted.

2. (T) (F) Locks on patient room doors are permitted as long as they are operable from the corridor side only and do not restrict egress from the patient room.

3. (T) (F) When it comes to locks on doors in a healthcare institution, the Life Safety Code® (LSC) is more restrictive concerning ingress (entrance) to a building than egress (exit).

4. (T) (F) The 2012 LSC has a provision that allows doors in the path of egress to be locked where patients require specialized protective measures for their safety.

5. (T) (F) All that is required for access control locks is to unlock automatically upon activation of the fire alarm system.

6. (T) (F) According to Lori Greene, the label on a fire-rated door is permitted to be painted as long as you can read the label.

7. (T) (F) If a fire-rated door assembly is no longer used as an opening for entrance to or exit from a room, it is permissible to leave it in place and store items against the door.

8. (T) (F) According to HFAP surveys, the main problem with exit signs is their location and the lack of monthly inspections.

9. (T) (F) Fire extinguishers have a different inspection procedure if they are located in a business occupancy, such as a medical office building.

10. (T) (F) A coat hook mounted on a fire-rated door, even if it is applied with adhesive, would be a problem since a coat placed on the hook would increase the fire load on the door.

QuizQuizHealtHcare life Safety complianceThe newsletter to assist healthcare facility managers with fire protection and life safety

Vol. 16 No. 11November 2014

Quiz questions November 2014 (Vol. 16, No. 11)

A supplement to Healthcare Life Safety Compliance

Quiz answers November 2014 (Vol. 16, No. 11)

1. False. Doors in the path of ingress are permitted to be locked, and doors in the path of egress are permitted to be locked but only under the provisions of clinical needs, delayed egress, and access control.

2. True.

3. False. Generally speaking, the LSC is more restrictive on egress than it is on ingress.

4. True.

5. False. Access control locks are also required to have motion sensors and a “Push to Exit” button on the egress side.

6. True.

7. False. The door must be removed and the opening filled with the same rated material type of construction as the wall.

8. True.

9. False. The requirements for testing and inspection of portable fire extinguishers are the same regardless of occupancy type.

10. True.

Copyright 2014 HCPro, a division of BLR. 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.

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