The newsletter to assist healthcare facility managers with fire protection and life safety
Healthcare
Life Safety
Compliance
Volume 16
Issue No. 11
P5
Fire door deficiencies
P8
HFAP findings
P10
Questions & Answers
P12
Power strips
Read about the top-cited deficiencies
for fire doors and what can be done to
avoid common pitfalls.
The Healthcare Facilities Accreditation
Program has revealed its top surveyor
findings. Get the latest inside.
This month’s Q&A looks at portable fire
extinguishers, door hooks, and more.
In late-breaking news this month, CMS
has issued categorical waivers on
power strips. What does this mean for
your organization?
NOVEMBER 2014
Door locking arrangements (Part 1)
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
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 different 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
­ rofessional to ensure proper exiting is maintained.
p
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 requiring 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.
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.
James R. Ambrose, PE
Technical Director,
Healthcare
Code Consultants, Inc.
St. Louis, Missouri
EDITORIAL ADVISORY BOARD
Senior Managing Editor
Matt Phillion, CSHA
mphillion@hcpro.com
Senior Editor
Brad Keyes, CHSP
Senior Consultant
Keyes Life Safety
Compliance
www.keyeslifesafety.com
Follow Us
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@HCPro_Inc
Joseph A. Berlesky, CHFM, CHE
Director, Plant Facilities
Baptist Medical Center Beaches
Jacksonville Beach, Florida
Frederick C. Bradley, PE
Principal
FCB Engineering
Alpharetta, Georgia
Jamie Crouch
Safety and Security Manager
Metro Health Hospital
Wyoming, Michigan
Michael Crowley, PE
Senior Vice President,
Engineering Manager
Rolf Jensen &
Associates, Inc.
Houston, Texas
A. Richard Fasano
Manager, Western Office
Russell Phillips &
Associates, LLC
Elk Grove, California
Burton Klein, PE
President
Burton Klein Associates
Newton, Massachusetts
Henry Kowalenko
Supervisor, Design
Standards Unit
Office of Healthcare
Regulation, Illinois Department of
Public Health
Chicago, Illinois
David Mohile
President
Medical Engineering Services, Inc.
Leesburg, Virginia
James Murphy
President
MRF, Ltd.
Western Springs, Illinois
Thomas Salamone
Director, Healthcare Services
Telgian Corporation
Atlanta, Georgia
Terry Shultz, PE
Principal
Code Consultants, Inc.
St. Louis, Missouri
William Wilson, CFPS, PEM
Fire Safety Coordinator
Beaumont Hospitals
Royal Oak, Michigan
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
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to selected companies/vendors. If you do not wish to be in­cluded 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
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November 2014
“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.”
Ingress
Generally 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 intervening 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 occupancies 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
Healthcare Life Safety Compliance
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 extremely 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.
Egress
The 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 signal, does not apply because the LSC permits the locks
to not be connected to the fire alarm system by virtue
of omission.
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Healthcare Life Safety Compliance
“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 constantly 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
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November 2014
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 Sounds
Door 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 misunderstood 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 healthcare facility. H
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November 2014
Healthcare Life Safety Compliance
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 legible, 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 acceptable 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 intended 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,
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HCPRO.COM
5
Healthcare Life Safety Compliance
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 maximum 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
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November 2014
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 electric 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
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November 2014
constant-latching. They typically project into the frame
head and into the floor, although there are some automatic 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
Healthcare Life Safety Compliance
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 susceptible 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 inspections
In 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 jurisdiction. 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
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Healthcare Life Safety Compliance
November 2014
Top surveyor findings announced by HFAP
During the American Society for Healthcare Engineering 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 standards 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
8
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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 accreditation 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:
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November 2014
•
•
•
•
•
•
•
•
•
•
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 firerated 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 considered 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
Healthcare Life Safety Compliance
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 permitted 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 extinguishers 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 identification of the cabinet; and failure to conduct monthly
inspections.”
Eyewash stations and emergency showers made the
list. “HFAP expects compliance with ANSI Z358.12009 for eyewash stations and emergency showers,”
said Keyes. “This means they must be mounted correctly; 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. “Surveyors 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
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9
Healthcare Life Safety Compliance
November 2014
&Answers
Questions
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.
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.
Portable fire extinguishers
Door hooks
Q
Q
What is the requirement for inspecting fire
With regards to installing a hook on a fireextinguishers in our medical office building? Is it
rated door, would an adhesive-backed hook be
different than what is expected in our hospital?
considered a modification to the door?
A
The monthly inspection and annual maintenance requirements for the portable fire extinguisher 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
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
This inspection needs to be recorded, preferably on
could ask them, but whatever answer they give would
the maintenance tag, with name (initials are acceptable) only apply to their inspections.
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November 2014
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 firerated 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
Healthcare Life Safety Compliance
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
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HCPRO.COM
11
Healthcare Life Safety Compliance
November 2014
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
order to use the new categorical waiver:
• Patient bed locations in new healthcare facilities, or in existing
that made allowances for healthcare organizations to utilize
facilities that undergo renovation or a change in occupancy,
power strips in patient care areas.
shall be provided with the minimum number of receptacles as
“CMS has determined that the 2000 edition of the Life Safety
Code [LSC] contains provisions on the use of power strips in
®
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
healthcare facilities that may result in unreasonable hardship for
power rack-mounted, table-mounted, pedestal-mounted,
providers or suppliers,” says Hamilton. “Further, an adequate
or cart-mounted patient care–related electrical equipment
alternative level of protection may be achieved by compliance with
assemblies, provided all of the conditions are met in section
the 2012 edition of the Life Safety Code, which has extended
10.2.3.6. They do not have to be an integral component of
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
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
in ‘patient care rooms,’ which replaces the term ‘patient care
related to patient care must be relocatable power taps
areas,’ ” he says.
listed as UL 1363.
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
and suppliers, who need only to document their decision to use
place, the 2012 edition has increased the minimum number of
the waiver, stating that they comply with all of the requirements
receptacles in patient care rooms for new construction.
to do so. This document must be provided to the surveyor
“Accordingly, we are permitting a categorical waiver to allow
team at the entrance conference. Organizations wishing to use
for the use of power strips in existing and new healthcare facility
categorical waivers need not apply for them or wait until they
patient care areas/rooms, if the provider/supplier complies with
are cited to use them.
all applicable 2012 NFPA 99 power strip requirements and with
This change in how CMS views power strips is the result
all other 1999 NFPA 99 and 2000 Life Safety Code electrical
of advocacy work conducted by the American Society for
system and equipment provisions,” says Hamilton.
Healthcare Engineering (ASHE) and other related organizations.
A patient care room is defined as any room in a healthcare
“We give kudos to CMS for working so quickly to resolve
facility wherein patients are intended to be examined or treated.
this issue,” says Chad Beebe, AIA, SASHE, CHFM, CFPS,
This definition appears to include operating rooms and procedure
CBO, deputy executive director for ASHE. “The categorical
rooms as well.
waivers should give hospitals relief and bring a sense of reality
The S&C memo issued by Hamilton describes basic
requirements that healthcare facilities must comply with in
12
The categorical waiver is available to all healthcare providers
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to today’s patient care environment, while keeping patients,
staff, and visitors safe.”
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Healthcare Life
Safety Compliance
Vol. 16 No. 11
November 2014
The newsletter to assist healthcare facility managers
with fire protection and life safety
z
i
u
Q
Quiz questions
November 2014 (Vol. 16, No. 11)
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.
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.