Compliance News: Noncombustible Sills for Fire Doors

By Robert Trotter, CBO, CFM

Fire rated doors must be installed properly so that fire cannot spread below, around, or above the door. To minimize the risk for fire spread at the undercut of a fire door, NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition describes the requirements for sills. Section 1- 1.2.1 states, “In buildings with noncombustible floors, special sill construction shall not be required, provided the floor structure is extended through the door opening.” Largely, healthcare occupancies have noncombustible floor construction and no special sill construction would be required. This means the example pictured would be compliant even though the carpet extends through the door opening. However, Section 1-11.2.3 states, “Combustible floor coverings shall not extend through openings protected by 3-hour rated fire protection door assemblies.”

In buildings with combustible floors or combustible floor coverings, special sill construction is required if the floor structure is extended through the door opening, as combustible floor construction is not permitted to extend through the door opening except door openings required to be protected by 20- or 30-minute doors. All sills must be constructed of noncombustible materials. Consult NFPA 80 for additional details regarding the arrangement of sills.

Compliance News: Unusual Observations

By Robert Trotter, CBO, CFM

Whether you complete your own life safety assessment for compliance with the Life Safety Code® or the work is performed by a third party, frequently an issue is discovered that is not described in the Statement of Conditions™. For the past several years we have been noting these issues as Unusual Observations. Starting in January 2009, as a result of The Joint Commission Standards Improvement Initiative, the new Life Safety Chapter incorporates an Element of Performance at the end of each individual standard to note other deficiencies. For example, under the Hospital Accreditation Program Standard LS.02.01.20 EP (32) states, “The hospital meets all other Life Safety Code means of egress requirements related to NFPA 101- 000: 18/19.2.” This Element of Performance gives you the latitude to create a Work Order or a Plan for Improvement (PFI) for any deficiency discovered that can not be associated with one of the Standard’s preceding Elements of Performance.

Regarding the example photograph, the Hospital Standard does offer Element of Performance (13) relative to the exit discharge and obstructions or impediments to the public way that may be acceptable for the landscape in the means egress. However, the full text and exceptions sends you NFPA 101-2000: 7.1.10.1 for means of egress reliability. Another key observation that may not be discernible in the photograph is the change in elevation in excess of 21 inches without a ramp or stair as required by NFPA 101-2000: 7.1.7.2. This would be an excellent example of when to cite noncompliance at LS.02.01.20 EP (32).

Compliance News: Magnetic Locks Create Headroom Obstruction

By Robert Trotter, CBO, CFM

As pictured in the example, magnetic locks installed to control access or egress often are located in a position that creates a headroom obstruction. According to section 7.2.1.2.2 of the NFPA 101®, Life Safety Code®, 2000 edition, “Projections into the required clear door opening width that are not less than 34 inches but that do not exceed 80 inches above the floor or ground shall be limited to the hinge side of each door opening and shall not exceed 4 inches.” This space allows for projections such as self-closing or automatic-closing devices, panic hardware and fire exit hardware. Projections exceeding 80 inches above the floor or ground are not limited.

Compliance News: Stair Identification Signs

By Michael L. Hawkins, CFSI, CHMT

All too often when conducting SOC surveys in Health Care Occupancies, we come across improper stair identification. NFPA 101 Life Safety Code®, 2000 ed., Chapter 19 “Existing Healthcare” requirements refers back to Chapter 7 “Means of Egress” for proper stair identification.

NFPA 101®, Life Safety Code® 2000 edition

7.2.2.5.4* Stair Identification Signs

Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 feet (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

7.2.2.5.5 Egress Direction Signs

Wherever an enclosed stair requires travel in an upward direction to reach the level of exit discharge, signs with directional indicators indicating the direction to the level of exit discharge shall be provided at each floor level landing from which upward direction of travel is required. Such signage shall be readily visible when the door is in the open or closed position.

Exception No. 1: This requirement shall not apply where signs required by 7.2.2.5.4 are provided.

Exception No. 2: Stairs extending not more than one story below the level of exit discharge where the exit discharge is clearly obvious shall not be subject to this requirement.

Stairwell signage is extremely important not only for the evacuation of occupants but for the responding fire and rescue personnel. Please check those in your hospital to ensure that the needed and appropriate signs are in place.

Compliance News: Power Strips in Patient Care Areas

By David Stymiest, PE, CHFM, FASHE, CEM, GBE

A subject that bears watching is the current concern about stand-alone power strips being used in General Patient Care Areas and Critical Patient Care Areas. ASHE/AHA Listserv users saw considerable traffic recently on this topic. The issue stems from a Centers of Medicare and Medicaid (CMS) document (Publication 100-07, Transmittal 27 dated August 17, 2007, entitled Revisions to Appendix PP – Guidance to Surveyors for Long Term Care Facilities) that includes the following excerpt: “Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas.” Some hospitals are reporting that CMS hospital surveyors have used this LTC Facility guidance to cite them for using power strips (called “Relocatable Power Taps” in UL terminology) in General Patient Care Areas and Critical Patient Care Areas.

It appears that this issue arose because of Underwriters Laboratories’ (UL’s) concern that there are no listed power taps for patient care areas of health care facilities per UL product category “Relocatable Power Taps (XBYS).” UL stated in a March 1, 2008 posting on the International Association of Electrical Inspectors (IAEI) website www.iaei.org, “The use is restricted from these patient care areas because UL cannot control what is connected to the power taps which could result in leakage current that would be in excess of what is permitted for patient care areas of hospitals.” UL further stated that “UL does Classify complete system medical cart assemblies for use in hospitals under the product category “Medical Equipment (PIDF).” Those medical cart assemblies may contain a power tap as part of the tested assembly per UL 60601-1 Medical Electrical Equipment (previously UL 2601-1.) Interpreting UL’s statements, it appears that external equipment (that not already tested as part of the listing process) may not be plugged into the cart-mounted power strips.

Some hospitals are taking the risk assessment approach to this issue – that is recognizing that power strips, or relocatable power taps, are subject to failure just like any other device and therefore inventorying them and subjecting them to the same risk-based testing and maintenance regimens as outlets and medical devices.

Stay tuned to ASHE’s ongoing advocacy efforts – this subject is likely to continue to be part of those efforts due to its potential cost impact on America’s hospitals.

As always, regardless of the area in which such devices are used, facilities need to be aware of the total loading of devices plugged into them and ensure that the portable devices themselves, and the branch circuits that feed them, do not become overloaded. If power strips are presently being used, regardless of the area, high current-draw equipment should not be plugged into them.

Compliance News: TJC Standards and Scoring Changes for 2009

There have been some significant changes to The Joint Commission’s (TJC) standards and scoring for 2009. The Emergency Management (EM) requirements have been removed from the Environment of Care chapter and incorporated into their own EM chapter. The Life Safety Code® requirements, Statement of onditions™ (SOC™), and Interim Life Safety Measures (ILSM) have all been relocated to a new Life Safety (LS) chapter. While there are purportedly no new requirements as a result of all these changes, there are some subtle nuances that may be viewed as new requirements along with items that might have been implied in the past which are now specified. However, the most significant changes can be found in the scoring.

Compliance News: TJC Thresholds to Serve as Screens for PDA & CA Decisions

By Dean Samet, CHSP

In their December 2008 The Joint Commission Perspectives, Volume 28, Number 12, The Joint Commission (TJC) reported that at its October 2008 meeting, TJC’s Accreditation Committee (AC) approved the remaining component for the 2009 accreditation decision methodology which included elimination of the use of thresholds” as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA). Thresholds have been used by TJC for years to determine whether to invoke or recommend CA or PDA if and when an organization had exceeded a preset number of Requirements for Improvement (RFIs).

Compliance News: Sprinkler Obstructions

By Robert Trotter, CBO, CFM

The Joint Commission’s Life Safety Standard LS.02.01.10 states, “…buildings contain approved automatic sprinkler systems as required…” In order to determine where sprinklers are required facility managers should consult NFPA 13, Standard for the Installation of Sprinkler Systems.  Recently, TJC surveyors have recognized deficiencies related to sprinkler obstructions and noted such observations.  NFPA 13 states, “Sprinklers shall be installed under fixed obstructions over 4 foot wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.  Sprinklers are not required under obstructions that are not fixed in place such as conference tables.” The example shows sprinkler protection under an HVAC duct which was an obstruction that prevents sprinkler discharge from reaching the hazard.  Consult your licensed fire sprinkler contractor for assistance.

Compliance News: Beyond Level of Exit Discharge

By Robert Trotter, CBO, CFM

NFPA 101®, Life Safety Code® states in section 7.7.3 “Stairs shall be arranged so as to make clear the direction of egress to a public way.  Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.”  The example shown is a barrier that restricts downward travel.  Upward travel to the rooftop may also require a barrier.  The LSC also prescribes provisions for signs.  Section 7.10.8.3.1 states,  “Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.”  The NO EXIT sign shall have the word NO in letters two inches high, with a stroke width of ⅜ inch, and the word EXIT in letters one inch high, with the word EXIT below the word NO, unless such sign is an approved existing sign.  The sign in the example may be an approved existing sign as it appears to be meeting the intent of the code.

Compliance News: Storage in Exit Enclosures

By Robert Trotter, CBO, CFM

Maintaining the means of egress is a critical role for any facility manager.  It is important to note that NFPA 101®, Life Safety Code® section 7.2.2.5.3.1 addresses storage in exit enclosures,“Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.”  Clearly by
the examples shown, this storage arrangement has the potential to interfere with egress by leaving this stairway completely inaccessible should these stored materials catch on fire. Moreover, it also presents an opportunity for an incendiary fire.

Compliance News: Combustible Decorations

By Robert Trotter, CBO, CFM


Evaluation of combustible decorations is always difficult because interpretation of the requirement is subjective.  One person may believe the decorations are acceptable and do not constitute a hazard, while another may feel that the decorations are too much.  Regardless, combustible decorations must meet the requirements of the Life Safety Code®. For those organizations accredited by The Joint Commission, requirements for combustible decorations are found in the Life Safety Chapter. For example, the hospital accreditation program Standard LS.02.01.70 Element of Performance (1) states, “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)”  Both the new and existing health care occupancy chapters state, “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception:  Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

Finding Emergency Power System Vulnerabilities in Healthcare Facilities

By David L. Stymiest, P.E., CHFM, FASHE (in Touch Briefings)

Healthcare facilities can be put at risk when a power failure occurs unexpectedly, particularly if the facility management has not made contingency plans for that particular failure. This article discusses a comprehensive approach to identifying emergency power system vulnerabilities in healthcare facilities. Vulnerabilities are most easily found when one considers the elements discussed below, which also affect emergency power reliability.

It is important to consider designs that can maximise reliability to make sure that the potential for common-mode failures is minimised or eliminated. Commissioning and comprehensive initial acceptance testing of new systems must be utilised to verify that the entire system works as intended, and that all necessary emergency power loads are actually connected to the emergency power system. Commissioning and acceptance testing of modifications to existing systems can also verify that deleterious changes have not inadvertently reduced system reliability. The documentation of maximum demand loading from comprehensive load profile analysis will ensure that the system will not accidentally become overloaded at any point. Proactive fuel management processes, including fuel oil testing and treatment, ensure that the fuel oil does not have impurities that will adversely affect engine operation. It is important to maintain accurate documentation that is user-friendly and useful in responding to both internal and external power failures. There must be a proven ability to manage system shut- owns successfully and proactively, verifying that system knowledge and contingency planning are accurate and effective.

Read entire article here: Finding Emergency Power System Vulnerabilities

Power Players: Finding Emergency Power System Vulnerabilities

By David L. Stymiest, P.E., CHFM, FASHE (in Health Facilities Management)

Power failures often occur with little or no warning, leaving hospitals and other health care facilities vulnerable. Facilities professionals must have well-considered power failure procedures in place to deal with these emergencies; it is too late to develop them after the failure.

Knowledge of effective power failure planning concepts—including power failure vulnerability analyses, emergency power risk assessments and emergency power gap analyses—is essential for facilities professionals seeking to develop such procedures. Professionals are also urged to explore financial business continuity practices for more information on advanced power system reliability planning and analyses.

Read entire article here: Power Players

Prescription for Power: Advice on EP System Reliability

By David Stymiest, P.E., CHFM, SASHE (in Health Facilities Management)

Emergency power (EP) reliability means having EP available in sufficient quantity where, when and for whatever duration it is needed. That is a tall order but one that every health care facility faces.

How can facilities professionals improve EP system reliability? The EP reliability equation demands holistic management that includes all of the following elements:

Read entire article here: Prescription for Power

Power When It Counts

By David L. Stymiest, P.E., CHFM, FASHE (on FacilitiesNet.com)

Hospital maintenance and engineering departments must have programs in place to monitor and test their facilities’ emergency power systems. With the recent release of the Sentinel Event Alert 37, the bar is higher for all health care organizations accredited by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).

Before the alert, the recordkeeping for many hospitals’ testing programs consisted mainly of generator loading and operating parameters, test times, and verification of transfer switch operation. Now managers must consider other issues, including test-related interactions with HVAC, vertical-transportation, and clinical systems and equipment.

Read entire article here: Power When It Counts