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Answers on business occupancies, power taps and monthly load tests

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January 19, 2020

By Brad Keyes, CHSP (www.keyeslifesafety.com

Q: If I have a new freestanding business occupancy that is licensed, would CMS enforce the provisions of the 2012 edition of NFPA 101 (LSC)? I wasn't able to find anything in the Conditions of Participation that specifically addresses this. I know that The Joint Commission (TJC) would not enforce their Life Safety (LS) chapter, but wasn't sure if CMS had a different take on this.

A: I don’t agree with your statement that TJC would not enforce their LS chapter at a freestanding business occupancy that is part of the hospital’s CMS Certification Number (CCN). On the contrary, I know that TJC will expect compliance with their LS chapter standards at off-site business occupancies (since I was a TJC surveyor) and their standards EC.02.03.01, EP 4 and EC.02.03.03, EP 2 support that. What you may be referring to is that TJC will likely not send their LS surveyors to the off-site business occupancies, but instead they will send other surveyors who will look for basic LS issues.

Likewise for CMS. I have reviewed hundreds of state agency validation surveys on behalf of CMS, and they always go to the off-site business occupancies that are under the same CCN. 

Q: What are the requirements or standards for a remote power tap (RPT) preventive maintenance procedure?

A: NFPA 99-2012, section 10.3.1, requires the physical integrity of power cords to be confirmed by visual inspection. The Annex section A.10.3.1 specifically says this visual inspection is not required to be a formal inspection or documented, but intended for all users to be observant of the condition of the power cords. Now, each AHJ can interpret this as they see fit, and while I have not seen any AHJ cite an organization for not having a formal, documented visual inspection program on their power cords, I can see where an AHJ could expect such a documented program since the Annex section is not part of the formal code of NFPA 99.

CMS and the accreditation organizations (AO) require the healthcare facility to comply with the manufacturer’s recommendations regarding preventive maintenance (PM) procedures. Therefore, if the manufacturer has a recommendation that says the RPT must have PM activities accomplished at certain frequencies, then that is what you must do. CMS and the AOs could cite you for not following the manufacturer’s recommendations if that is the case. However, there is an exception that is rather difficult to comply with: the CMS Alternate Equipment Management (AEM) program. This AEM program allows you to deviate from the manufacturer’s PM recommendations on certain equipment, provided you comply with all of the conditions CMS has set forth in their AEM program.

The AEM program is not for everyone. It is very time-consuming, and small- to medium-sized facilities will have difficulty complying with all of the conditions CMS has imposed on the program.     

Q: When doing monthly generator testing, do you have to maintain 30% for 30 minutes, or does hitting the 30% some time during the 30 minutes suffice? In other words, if I run for 30 minutes loaded and reach the 30% for 15 of those minutes, does the test pass? Thanks in advance. I take care of an Air Force hospital and my understanding is, during the 30 minutes you capture your peak, whether it be for 10 minutes or the whole 30, as long as it reaches 30% sometime during the test. Actually, the Air Force runs for an hour instead of 30 minutes.

A: According to section 8.4.2 of NFPA 110-2010, diesel generators must be exercised at least once monthly for a minimum of 30 minutes using one of the following methods:

  • Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
  • Under operating temperature conditions at not less than 30% of the nameplate kW rating

So this means, once the generator achieves 30% of the nameplate kW rating, the test begins and continues for at least 30 minutes, and must maintain a minimum of 30% of nameplate kW rating for the length of the 30-minute test. 

I would say that the way you have been conducting the monthly load test on the generator would not meet the requirements of NFPA 110-2010, section 8.4.2.

Q: Are there any restrictions to storing medical gas cylinders in the same room as industrial gas cylinders? Specifically, can we store oxygen cylinders used for cutting torches in the same room as medical oxygen cylinders?

A: NFPA 99-2012, section 3.3.107 describes medical gases as those used on patients. Chapter 5 of NFPA 99-2012 discusses the requirements for storage of medical gases, and section 5.1.3.2.3 says only gas cylinders, reusable shipping containers, and their accessories shall be permitted to be stored in rooms containing central supply systems or gas cylinders.

So one could draw the conclusion that section 5.1.3.2.3 is specifically referring to medical gases since it is located in Chapter 5, and section 5.1.3.2.3 says only (medical) gas cylinders and their accessories are permitted to be stored in rooms containing (medical) gas cylinders. By that conclusion, oxygen cylinders used for welding or cutting are not permitted because they are not medical gases.

On another note, section 5.1.3.3.1.6 says indoor locations for oxygen, nitrous oxide, and mixtures of these gases shall not communicate with (among other items) locations storing flammables. While oxygen is not a flammable gas, propane and acetylene are, and this section would prevent flammable gases from being stored with oxygen or nitrous oxide.

I have not seen any accreditation organization cite a hospital for having cylinders of welding oxygen gases stored with cylinders of medical oxygen gases, but I can see where it would not be permitted in NFPA 99-2012.  

Q: We are in a very old hospital, which has exit stairwells on each level with at least three exit enclosures on nine of the levels (10 levels total with the 10th level being the penthouse). The stairwell doors have cylindrical locksets that are not UL listed and each floor has more than 50 people on it. I was under the impression these fire doors should have panic devices. What is the right answer here?

A: Oh, boy. What you are describing is a very serious problem. How could it pass life safety inspections all these years and remain so noncompliant?

First, let’s clarify: Do you mean the stairwell doors have locks or latches? You say locksets … do you mean to say the stairwell doors are locked? Every door has latch sets, but not every door has locksets. A latch set is the door handle and latch that holds the door closed, but retracts when the door handle is turned. A lockset secures the door closed and does not allow anyone to pass through the door without a key or device to unlock the lockset (such as a dead-bolt lock). You cannot lock a door in the path of egress in a hospital, unless it qualifies for one of the exceptions found under 19.2.2.2.4 of the 2012 LSC.

Second, are the stairwell doors fire rated? If not, then that’s a serious problem. They must be fire rated because the stairwell is a vertical opening. The rating on the doors depends on the year the building was constructed and what codes or standards were in effect at the time. At a minimum, the doors must be ¾-hour fire rated, perhaps more, depending on the number of stories in the stairwell.

Third, the locksets or latch sets you describe must be UL listed if the doors are fire rated.

To directly answer your question, horizontal crash bars on the door leaf are not required in healthcare occupancies, unless the door serves an area that could qualify as an assembly occupancy, such as cafeteria, auditorium, etc.

Editor’s note: This is an excerpt from HSL sibling publication, Healthcare Life Safety Compliance, where each month, Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, answers questions about life safety. Follow Keyes’ blog on life safety at www.keyeslifesafety.com.  




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