Concealed Sprinklers

What are concealed sprinklers and are they allowed?

Eliminating Immediate Threat to Life Situation Time Limit

How much time does an organization have to eliminate an "immediate threat to life" situation discovered by a surveyor?

Disputed Survey Findings

Whenever you feel The Joint Commission (TJC) surveyors have mistakenly cited you for a Life Safety Code® violation or Environment of Care (EC) standards issue, what steps should you take before this issue becomes a part of the official accreditation report as a Requirement for Improvement (RFI)? 

Preventing Coil Freeze Up

There are some proactive steps you can take this fall to ensure your chilled water coils do not freeze up this winter. The first step is to make sure that the freeze stat on each of your air handlers has been tested in the last 60 days. If testing has not been done, you might want to check the freeze stats for proper operation. Typically, they should be set on 35 degrees F with the tubing on the leaving side of the chilled water coil. If you are not sure how to check your freeze stat, check with your controls contractor for assistance.

Difference between Smoke Barriers/Partitions/Walls/Compartments

What is the difference between Smoke Barriers/Partitions/Compartments?

Compliance News: Arrangement of Means of Egress

By Robert Trotter, CBO, CFM

The 2000 edition of NFPA 101®, Life Safety Code® requires all occupied rooms in a health care facility to have direct access to a corridor leading to an exit, or must be arranged to comply with one of the exemptions. The term “habitable room” does not include bathrooms, closets, and similar spaces as well as briefly occupied work spaces. Section 19.2.5.1 states “Every habitable room shall have an exit access door leading directly to an exit access corridor.” There are four exceptions to the prescriptive requirement:

Exception No. 1: If there is an exit door opening directly to the outside from the room at ground level.

Exception No. 2: Exit access from a patient sleeping room with not more than eight patient beds shall be permitted to pass through one intervening room to reach the exit access corridor.

Exception No. 3: Exit access from a special nursing suite shall be permitted to pass through one intervening room to reach the exit access corridor where the arrangement allows for direct and constant visual supervision by nursing personnel.

Exception No. 4: Exit access from a suite of rooms, other than patient sleeping rooms, shall be permitted to pass through not more than two adjacent rooms to reach the exit access corridor where the travel distance within the suite is in accordance with 19.2.5.8. [One intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet (example pictured above) and two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.]

Compliance News: Plenum Requirements for Egress Corridors in Health Care Facilities

By Robert Trotter, CBO, CFM


In the built environment a plenum is a separate space for air circulation for HVAC systems, typically provided in the space between the structural floor/ceiling and suspended-grid acoustical tile ceiling. Incorporating a plenum can have its design advantages but corridors serving adjoining areas of health care occupancies are prohibited from being used for a portion of an air supply, air return, or exhaust air plenum.

Using building cavities as return air plenums can draw them below atmospheric pressure if not properly designed, causing outdoor air to be drawn into the building fabric. In humid climates, this can result in condensation of moisture from outdoor air within architectural cavities, consequently resulting in mold and mildew growth. Also, under certain circumstances, plenum configurations can have an adverse effect on life/fire safety. Clearly, plenum returns should not be used where codes prohibit them, such as health care occupancies, where individual space pressures must be controlled. These provisions are prescribed in the NFPA 101®, Life Safety Code® and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

Compliance News: Preparing an Emergency Water Supply Plan

By Dean Samet, CHSP

The Centers for Disease Control and Prevention (CDC) and American Water Works Association (AWWA) recently released a guide entitled Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities¹. Guidance is provided to assist health care facilities in developing an Emergency Water Supply Plan (EWSP) that prepares for, responds to, and recovers from a partial or total interruption of the normal water supply. Obviously a water supply loss would have a significant adverse effect on the daily operations of any health care facility, potentially affecting both patient safety and the quality of patient care. While there is little that can be done to prevent losing an offsite supply, developing and exercising an EWSP can help lessen the impact should such an incident occur.

The CDC EWSP Guide provides a four-step process for developing an emergency water supply plan:

1. Assemble the appropriate EWSP team and the necessary background documents for your facility;

2. Understand your water usage by performing a water use audit;

3. Analyze your emergency water supply alternatives; and,

4. Develop and exercise your EWSP.

Above Ceiling Wiring & Cable

Is above ceiling wiring and cable in a hospital required to be plenum rated, and if so, where is the code reference?

Fuel Hours for Emergency Generators

For how many hours of run time is an emergency generator required to be fueled? EC.1.7.1 only states that a generator is required to have “adequate fuel supplies for emergency use and sustained operation.”

Sprinklers in Walk-in Boxes and Freezers

Does a hospital need to have sprinklers in walk-in boxes and/or freezers in order to be considered fully sprinklered?

Piped Medical Gas System in ASC

Can you tell me what types of ambulatory surgery centers (ASC's) require a piped medical gas system? 

Temperature/Humidity in Central Supply

Are the temperatures and humidity levels for Central Supply supposed to be monitored?  Based on the AAMI National Standards, 4 areas should be monitored and data recorded daily for temperature and humidity.

Fire Extinguisher Signage

Does The Joint Commission require signage above recessed fire extinguisher cabinets?

Routine Electrical Receptacle Testing

What are the requirements for routine electrical receptacle testing?

Clean Utility Rooms

Does a clean utility room require local exhaust fans?  I thought soiled utility rooms were the only rooms requiring exhaust fans to make the room negative.

Fire Alarm Testing

We are considering doing our annual fire alarm testing in 4 quarterly sections.  This has the advantage of having our contractor in the building, working with the system much more often; however, it presents the difficulty that parts of the building done in the 4th quarter will have gone past 12 months since their last test.  Given an intelligent F/A system, do you think this would be a problem with the Joint Commission? The alternative is to do an extra, very expensive, full system test before starting quarterly testing. 

Business Occupancies

Does the Joint Commission include business occupancies in determining how many days a Life Safety Specialist Surveyor will be at a facility?

Decorations in Corridors

Is there a specific reference to the amount of papers/posters that can be affixed to a corridor wall in hospital?