the life safety surveyor facility tour how should i prepare for the facility tour? healthcare...

The Life Safety Surveyor Facility Tour

How Should I Prepare for the Facility Tour?

Healthcare Engineering Consultants

Will limit


Typical Tour Sequence

1. Start in the operating rooms, central supply and endoscopy areas, right after the documentation review.

2. Continue to the roof, penthouse, mechanical equipment rooms

3. Take the “most traveled stairwell” from the top to the bottom

4. Take the elevator back up to the top patient floor

5. Check smoke/ fire doors, compartmentation features and corridor storage on the inpatient areas

6. Continue with an inspection of chutes, storage areas, utility chases, hazardous areas

7. Evaluate clinical areas of interest, including inpatient areas, special care units and other special units, such as MRI, dialysis, physical therapy, ED, behaviroal health, etc.



Typical Tour Sequence (continued)

8. Continue down to the lower and basement levels to specific areas on the checklist, such as mechanical equipment rooms, the kitchen, loading dock, fire pump, emergency generators, fire annunciator panel, compressed gas and infectious waste storage, chemical storage areas, manifold rooms, dirty and clean linen storage rooms, and other areas of interest

9. If construction areas are present, expect a visit to review the area(s) and question contractor staff who are present

10. Expect a validation of interim life safety measures that have been implemented and are in effect and “open” and “closed” PFI’s

11. A walk outside to view storage areas, liquid oxygen bulk tank storage and smoking compliance may occur



Checklist for the Facility Building Tour

Operating rooms

Check: 1) Positive pressure for OR’s with “tissue test”

2) Cleanliness of exhaust vents, OR cabinets

3) Type of portable fire extinguishers (ABC, water mist,

carbon dioxide, halotron, Clean-Guard, etc.)

4) Gas scavenging, isolated power panels, redundant

grounding receptacles, medical gas alarms and valves

5) Temperature and humidity logs and policy

6) Area a suite? Corridor storage?

7) Clean supply storage areas


1. Suite perimeter walls and doors must meet the same requirements as for corridors

2. Walls inside the suite must be non-combustible, but are not required to meet any fire rating or be full height to deck above

3. Maximum suite size is 5,000 square feet for sleeping areas and 10,000 square feet for non-sleeping suites

4. Corridors become “access aisleways” and must only meet the 36 inch free and clear width

5. Suites must be designated on the compartmentation drawings and include square footage and whether the suite is “sleeping” or “non-sleeping’


Suites in Healthcare Facilities



Central Sterile Supply

Check: 1) Air movement from “clean to dirty”

2) Clean side positive relative to outside corridor

3) Dirty side negative relative to outside corridor

4) Ethylene oxide monitoring, staff exposure, emergency

procedure for EtO spill


6) Cross-contamination issues?

7) Unblocked egress from storage areas




Endoscopy

Check: 1) Are procedure rooms “positive pressure”?

2) Is the equipment re-processing area “negative

pressure”?

3) Bronchoscopy procedures – negative pressure room?

4) Endoscope storage – clear of cabinet bottom and walls?


6) Cross-contamination issues?

Code Reference: 2010 FGI Guidelines Document, ASHRAE

supplement standard 170Healthcare Engineering Consultants



Roof Area

Check: Evidence of smoking, contractor supplies, safety curbs,

labeling of toxic vapor exhaust fans, unusual items

Penthouse

Check: Unsealed vertical penetrations, evidence of smoking,

portable fire extinguisher test tags, unlabeled containers




Exit Stairwells

Check: Floor signage; door, frame and panic hardware rating; exit

discharge signage, door closure and latching, unsealed

horizontal penetrations, stored or mounted items in stairwell



Checklist for the Facility Building Tour (continued)

Smoke and Fire Compartments

Check: Proper sealant used for penetrations; open junction boxes;

cables touching or hung from sprinkler pipes; unusual items

on top of lay-in ceiling



Compartmentation Deficiencies

Repair of Smoke and Fire Wall Penetrations

Polyurethane foam should never be used as a sealant!

Intumescent materials should not only be tested, but pass the tests!

Smoke and fire ratings apply to the entire assembly

Smoke barriers (1/2 hour) need at least 1/2” sheetrock (each side)

1-hour fire barriers require at least 1-1/4” of sheetrock (2 layers)

2-hour fire barriers require at least 2-1/2” of sheetrock (4 layers)

Insulation or mineral wool requires intumescent capping

Use the manufacturer applications book for proper installation

Unusual applications require an “engineering judgment”

The use of labels describing the seal is recommended

Compartmentation Deficiencies


What’s wrong with these seals?


Rated Fire Wall Penetration Examples

Life Safety Compartmentation


Smoke Barrier Compartmentation Requirements

Extends from floor to deck above

Barrier penetrations protected by smoke dampers, although smoke dampers not required in ducted penetrations where QRS sprinklers are installed

All penetrations must be sealed with appropriate materials

Doors labeled 20-minute or 1-3/4” solid core or equivalent

Doors must be self-closing

Positive latching is not required

½-hour smoke compartment must be at least two layers of ½” or more sheetrock (existing construction, one sheet on each side)

1-hour compartment for new construction, 5/8” on each side



1-hour Fire Barrier Compartmentation Requirements


Transfer air grilles protected by fire dampers; fire dampers not required for ducted penetrations, unless required by AHJ

All penetrations sealed with appropriate materials

Doors are labeled 45-minute or 1-hour (except 1-hour smoke barrier for new construction, 20 minutes on cross-corridor doors)

Doors are self-closing

Positive latching is required

1-hour fire compartment must be at least two layers of 5/8” sheetrock (X-type, one layer on each side) or equivalent



2-hour Fire Barrier Compartmentation Requirements


All duct penetrations protected by fire dampers

All penetrations sealed with appropriate materials

Doors are labeled 1.5 hour

Doors are self-closing

Positive latching is required

2-hour smoke compartment must be at least four layers of 5/8” sheetrock or equivalent (X-type, two layers on each side)



Smoke and Fire Doors

Check: Door, frame and hardware rating; undercuts, warpage,

gaps, closure; latching and “kick plates” on fire doors

Exit Doors

Check: Exit signs properly placed with direction of travel; doors free

of mirrors, draperies or hangings




Smoke and Fire Door Requirements

Undercut to floor not more than ¾” at any one point

Vertical gap between doors not more than 1/8”

Warpage to frame less than ½”

All fire doors, frames and panic hardware must be labeled

Smoke doors must be labeled or 1-3/4” solid core or equivalent

Doors must be self-closing

Positive latching is required for fire doors; not for smoke doors

Fire door tampering is not permitted; will alter the rating

Field installed protective plates >16” not permitted on fire doors

(exceptions exist for doors to hazardous rooms and factory installed plates)


Checklist for the Facility Building Tour (continued) Corridors

Check: Equipment on one side only for “in use” items, other than

isolation and emergency “crash” carts; portable fire

extinguishers; wall hangings and decorations; exit signs;

patient chart boxes in “down” position; wall protrusions

Important Note: “Categorical Waiver” from CMS for items in corridor



Egress Corridor Deficiencies

Are these corridors OK?


Corridor Requirements – 2012 Life Safety Code

19.2.3.4 (4) – Projections into the required width shall be required for wheeled equipment, provided that all of the following conditions are met:

1. Clear unobstructed width is not reduced to less than 5 feet

2. Fire plan requires relocation of wheeled equipment during a fire or similar emergency

3. Wheeled equipment is limited to equipment and carts in use, medical emergency equipment not in use and patient lift and transport equipment



Corridor Requirements – 2012 Life Safety Code

19.2.3.4 (5) – Where the corridor width is at least 8 feet, projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:

1. Furniture is securely attached to floor or wall

2. Unobstructed corridor width is less than 6 feet

3. Furniture is located on one side of the corridor only

4. Grouped so that total area is less than 50 square feet and each grouping is at least 10 feet apart

5. Furniture does not block emergency equipment and valves

6. Smoke compartment with QRS sprinklers and smoke detection or direct staff supervision of furniture spaces



Additional Joint Commission Interpretations

1. Egress corridors greater than 8 feet in width may be partitioned to provide alcove storage for computers, equipment

2. Small (less than 50 square feet) dead-end corridors beyond the exit stairwell doorway may be used to store equipment

3. Where only offices exist in an egress corridor beyond an exit stairwell door, only 44 inches of clearance is required to be maintained in the corridor!

Important Note: Although these interpretations were provided by George Mills (Joint Commission Senior Engineer) at the 2008 ASHE Annual Conference, local AHJ’s may not permit these exceptions! Be careful!!

Egress Corridor Storage


Joint Commission Corridor Interpretations


8’ Width Egress Corridor

Staff Office

Exit Stair

Permitted Storage Space

(if <50 sq ft)


Joint Commission Corridor Interpretations


8’ Width Egress Corridor

Staff Office

Exit Stair

Permitted Storage Space (if <50 sq ft)

44”



Patient Treatment Areas

Check: Crash cart logs; compressed gas cylinders; blanket

warmer temperatures; refrigerator logs; unlocked

medication carts; portable radiology units with key

installed; trash receptacles greater than 32 gallons,

portable heaters, power strips




Patient Treatment Area Clarifications

Compressed Gas Cylinders:

EMPTY and FULL cylinders must be physically separated

Segregated = physically separated with separate racks, physical barriers or color codes to indicate FULL and EMPTY

Unopened cylinder = FULL; Opened cylinder = EMPTY

Don’t store partially filled cylinders with FULL cylinders

Noncompliance cited under EC.02.06.01, EP1

Solutions?

Reference: EC News, February 2014 issue, pages 5-6





Blanket and Liquid Warmers

Blanket warmer temperatures should not exceed 130 degrees F

Solution warming cabinets should not exceed manufacturer recommendations, typically from 104 to 110 degrees F

A method to determine the temperature is essential

A daily manual log or electronic monitoring system is suggested

Noncompliance cited under EC.02.06.01, EP1

References: ECRI Health Devices, 2009; volume 38, issue 7, pages 230-231; AORN Perioperative Standards and Recommended Practices, 2013, pages 217-242





Portable Heaters (LSC 18/19.7.8)

Permitted only in non-patient, non-sleeping staff areas

Heating elements may not be “exposed” and not exceed 212 F

UL listing and tip protection is strongly recommended

Hospital policy for use is required

Power Strips (G. Mills, BI&T, October, 2012)

Should not be used in patient care areas and tested before initial use

Should be “hospital-grade” and never daisy-chained

Should not be used for high power appliances

Should be issued/ controlled by a hospital department (biomed, facilities)

Approved hospital policy for use required
