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Q&A: The new Life Safety Code brings changes to the HFAP standards manual


December 8, 2016

Editor’s note: The following is a Q&A excerpted from the Healthcare Facilities Accreditation Program (HFAP) and Accreditation Association for Hospitals/Health Systems (AAHHS) webinar, titled “Changes to Accreditation Requirements for Ambulatory Surgical Centers Chapter 5: Physical Environment.” The webinar covers how the adoption of the Life Safety Code® by CMS has changed the 2017 HFAP manual. Speaker Brad Keyes, CHSP, HFAP’s engineering advisor on all issues involving emergency management, physical environment, and life safety, provides the answers.

Q: Can you explain the intent for the five-year private fire service mains?

Brad Keyes: I think you’re referring to the internal inspection of the sprinkler piping, and I don’t want to speak on behalf of the NFPA technical committee. But, my understanding of why they require that now is [because] the older systems are having foreign material in the pipes: gunk, slime, rocks, things that might cause an impairment to the sprinkler head.

Now it’s a requirement that once every five years we do a spot inspection looking for foreign material. Quite honestly, in some situations they’ve found rags and tools left in the pipes by the installers. That’s my understanding of why it’s a requirement now.

Q: Is the fire watch for sprinkler impairment or fire alarm impairment?

BK: Fire watch is for both, and you’ve always had to have a fire watch. Under the 2000 Life Safety Code (LSC), you had to have a fire watch if you had a sprinkler impairment or a fire alarm impairment.

The difference now is that CMS is now defining what a fire watch is. Before it was never truly defined; no [hospital jurisdiction] was really putting in writing what it required. Hospitals were free to interpret it however they wanted.

CMS for the last three or four years have been saying in various opportunities that they wanted a continuous fire watch. So now they’ve finally put it in writing, it’s enforceable, and we have to comply with that.

Q: What training is required for fire watch? Does the person have to be a certified firefighter?

BK: No. NFPA 25—I think it’s Chapter 15 in the annex section—will tell you the details of what’s required.

But off the top of my head, you need to provide basic training as to the individual who’s doing it. That person needs to know what to look for, know where to go, and have the ability to communicate with the fire department. What that means is they carry a two-way radio with security or a switchboard. If they see something that [requires] the fire department there right away, they can communicate right away to the switchboard or security and they can call the fire department. That would be sufficient. But, it’s not like they have to be fire department–trained.

Q: How should we document the sprinkler head inspection? Can they be grouped by department or areas?

BK: The easiest way to do a sprinkler inspection is to use your life safety drawings. Identify the areas on the drawings that are sprinklers, and as you go through each room, put a checkmark for every room, closet, office, and corridor. As you finish one area, the inspector signs off and dates that. Then [the
inspector moves on, and] maybe has another 11 x 17 page for another part of the hospital.

So you break up your hospital into many different levels and layers. That way if someone says, “Well, show me you got every sprinkler head,” you’ve got these drawings and they show that you’ve got every area. That’s truly the easiest and most effective way of doing that.

Q: How many inches do fire extinguisher cabinets need to stick out into the corridor to meet the standards for not needing the signs or identification?

BK: That’s not specified. So essentially, if it’s a 0.5-inch projection into the corridor, that would be sufficient.

I think if the cabinet was red and you could easily see the extinguisher, that helps, too.

Q: Is there a requirement that the fire extinguisher have a sign that protrudes into the hallway and can be seen from a distance? Are there requirements for that sign?

BK: My recollection is no. This comes from NFPA 10; the requirement is that it just has to be marked. Some organizations will put a red dot on the ceiling, 1 inch in diameter, so when people walk by they can see it. Some will just paint the cabinet red. While signs are the most obvious [way of marking extinguisher locations], they aren’t required.

Q: Is there a standard risk assessment to use, so we’re all kind of equal on those things? In particular, for building assessment under the Healthcare Facilities Code.

BK: NFPA 99 doesn’t specify that you use a specific template for the risk assessment. However, they do identify multiple forms that are available that are considered to be acceptable. So you can go to NFPA 99 Chapter 4, and that has some references there to some risk assessments you can consider using.

Q: How do we score if the local water authority fails to do the water testing over the past 12 months? If they fail to do it, will that affect our score?

BK: Yes, a surveyor will cite the organization for not having documentation over the past calendar year that proves that the test was conducted. If the municipality doesn’t do it for you, you have to do it on your own.

Q: Is there a standard for testing potable water?

BK: I’d be surprised if there wasn’t a standard on potable water, but there’s no HFAP or CMS standard as far as I know. It’s one of those things that’s not included as far as how that test should be done. We just say that has to be tested; we don’t say what those tests have to consist of.

Q: And that can probably be coordinated with your municipality, correct?

BK: Yeah, if you’re getting your water from the municipality]. Often the hospital gets a copy from the local municipality of the test report and that’s sufficient.

Q: Speak to decorations hung from the ceiling grid. So let’s say we have some really nice decorations that are hung from a drop ceiling—is that acceptable?

BK: It’s in the section of the LSC pertaining to combustible decorations. However, you still have to comply with the installation of the sprinkler standards that talks about distances that a ceiling-mounted object has to be away from a sprinkler head. So if you’re putting up ceiling mounted decorations and the area has sprinklers, then there is a standard.

Under the old Chapter 5 (maybe Chapter 8) of NFPA 13, it specifically states how far away any ceiling-mounted object can be from a sprinkler head. So you have to follow those particular rules; you can’t just put them up there willy-nilly. Somebody familiar with the NFPA standards should be consulted before any mounting of any decorations.

Q: Is the five-year sprinkler obstruction investigation the same as the five-year internal inspection?
BK: No. There’s two different inspections; one is required, one is not.

The five-year internal inspection is required; the obstruction investigation is only required if the internal inspection warrants an investigation. I believe in Chapter 14 of NFPA 25, they go into detail about the circumstances where an investigation is required.

Off the top of my head, I remember one of them is very ambiguous. If the municipality has a breach in their water supply nearby, then you have to do an obstruction investigation. But they don’t define what “nearby” means; is it within 3 blocks, 3 miles, 30 miles? That’s not defined, so there are some ambiguous issues there that you need to be concerned about and be very conservative when you apply those issues to your own application.

But no, they are not the same, and only one is required. The other is only required when you meet the conditions for an obstruction investigation.

Q: For quarterly fire drills, do we still need to do three shifts? Currently we do a drill “day,” “evening,” and “night,” which equals one drill each month. Is this still required, or just quarterly?

BK: Both: It’s still required, and it’s required quarterly. So if you have three shifts, you’re doing 12 drills per year minimum.

The requirement says once per shift, per quarter. That means if you have three shifts, then each quarter you’re going to have three drills. And there’s four quarters, and three times four is 12, so yes, it’s quarterly and each shift.

Q: Are our existing smoke barrier doors required to have the same annual fire door inspections as the fire doors?

BK: No. If you look at Chapter 8 of the new LSC, they talk about doors in a smoke barrier that require inspection. But the way that standard is prefaced, it says it’s required by the occupancy chapter.
So if you go back to the occupancy chapter in healthcare, it really doesn’t require smoke barrier doors to be inspected. Now NFPA 105 is the standard on smoke doors, and they do have provisions on how to inspect that door. But since the occupancy chapter does not require it, you are not required to inspect smoke barrier doors.

[Now] if that door has a fire-rated label on it, that’s a totally different animal. [If] it’s a fire-rated door, you do have to test and inspect it.

Which leads to the next question that someone may have: “If we have a fire-rated door in a barrier that’s not a fire-rated barrier, do we still have to inspect the door?” And the answer is yes, because Chapter 7 talks about inspecting all fire-rated doors—it doesn’t say if it has to be in a fire barrier or not.

Q: Does one need to still maintain a waiver for humidity levels for storage of sterile items? I was told that CMS didn’t adopt amendments in NFPA 99.

BK: They did adopt. When CMS adopted the NFPA 99 2012 edition, they did adopt the change in humidity levels to 20%. I’ve not heard anything where they didn’t adopt the [American Society of Heating, Refrigerating and Air-Conditioning Engineers] ASHRAE 170 because that’s where the humidity requirements are derived from. I’ve not heard that they excluded that.

So there isn’t a requirement that you maintain a waiver on that, and you do have to maintain a risk assessment. That comes from a CMS [Survey & Certification] S&C memo that requires the healthcare organization conduct a risk assessment of the medical equipment and supplies that are in an environment that has a humidity of less than 30% to be evaluated to make sure that the medical equipment and supplies is suitable for that level of humidity. So yes, you do have to maintain a risk assessment, but not a waiver.

Q: Do we have to maintain paper copies of all safety data sheet (SDS) forms, if we can already retrieve those in an online database and an SDS emergency call center is available?

BK: Yes and no. HFAP requires that you have a backup, because if you have a retrieval system—fax, computers, electronic—you have to have a system available in case that backup system is down (i.e., the internet is down, fax is down, etc.).

Initially, HFAP was saying, “You’ve got to have paper copies.” Then somebody at a hospital contacted us saying, “We don’t have paper copies; is it okay if we have all the SDS mounted in a laptop and available?” And that serves that purpose, so yes, you don’t have to have paper copies.

But you have to have backups, and in this case it was on a laptop hard drive that they could access without using the internet. I think they had it on CDs or flash drive for a while, too, and those are fine so long as you have a battery-operated computer where you can retrieve that information.

So yes, originally we said you had to have paper copies, but now we’re backing off that and allowing other electronic formats, so long as there’s a retrievable backup in the facility.

Q: Do we expect to see any alcohol-based hand sanitizer dispensers that will exceed the 4-inch projection into the corridor?

BK: I have seen that; some of the really older models did exceed the 4-inch. Though I haven’t seen a whole lot—they were older models, so they lost favor in a lot of organizations.

And as long as we’re talking about alcohol-based hand sanitizer dispensers, even though the standards are very clear that they are allowed in ambulatory healthcare occupancies, they aren’t allowed in corridors of business occupancies. Just so that people are aware.

Q: Do we still need the categorical waiver for the Underwriters Laboratories–approved power strips to be used in patient care areas? NFPA 99 Chapter 4 does not list any acceptable risk assessments.

BK: No, all categorical waivers are completed. All the categorical waivers did was allow hospitals to use either sections of the new LSC or the new NFPA 99. Now that these codes have been adopted, there’s no reason to continue those categorical waivers.

Just file those documents away in a file somewhere, but you don’t have to maintain them. The examples of the risk assessments aren’t in Chapter 4. They must be in the S&C memo from CMS or in the final rule.

Q: Do you need to keep different types of compressed gases physically separated from each other by type within smoke compartments (i.e., oxygen, nitrous oxide)? And can you expound on separating full, empty, and partially full cylinders?

BK: You do have to separate oxidizing gases from flammable gases. Other than that, no. You can mix medical air and test gases (nitrous oxide with oxygen) in storage.

The NFPA 99 says you can’t store empty cylinders with full cylinders. There are other accreditation organizations that have taken that further to say that you have to store partial cylinders separate from full and separate from empty. You can do that if you want, but we don’t require that you have three different categories for the oxygen cylinders.

Next question [is], “What constitutes an empty cylinder? What constitutes a full cylinder?” As long as a cylinder has its plastic cover tab on it from the supplier, then it’s considered full. Once that tag is removed, it’s no longer considered full. Even if no oxygen has been taken from it, it is now considered partial. And since it’s no longer “full,” you’d have to store it with the empties. Again, if you want to go to the trouble of creating a third designated spot, that’s perfectly fine. But you don’t have to.

Q: So you can’t reseal the cylinders?

BK: If your people are qualified to seal the cylinders—those plastic caps that go around the port that the regulator hooks up to—I guess we would accept that if it looks like all the others. We’ll deal with that problem when we come to it. And that’s why we have trained surveyors; they get to make that decision.

Q: For LS.13.03.12 (Cooking Hood Fire Suppression), who qualifies as the owner’s representative?

BK: The owner’s representative is anyone who represents the owner. In general, that’s typically the facilities management department when you’re dealing with the NFPA. But, in this case it can be the food service department if it’s decided that they should be the ones to inspect it. So either one can inspect it; it doesn’t matter as long as they are trained in what to look for.

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