How Should I Prepare for the Facility Tour?

How Should I Prepare for the Facility Tour?
The Life Safety Surveyor Facility Tour How Should I Prepare for the Facility Tour? Will limit Healthcare Engineering Consultants

The Life Safety Surveyor Facility Tour
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. Healthcare Engineering Consultants

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 Healthcare Engineering Consultants

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 Healthcare Engineering Consultants

Suites in Healthcare Facilities
Suite perimeter walls and doors must meet the same requirements as for corridors Walls inside the suite must be non-combustible, but are not required to meet any fire rating or be full height to deck above Maximum suite size is 5,000 square feet for sleeping areas and 10,000 square feet for non-sleeping suites Corridors become “access aisleways” and must only meet the 36 inch free and clear width Suites must be designated on the compartmentation drawings and include square footage and whether the suite is “sleeping” or “non-sleeping’ Healthcare Engineering Consultants

Checklist for the Facility Building Tour 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 5) Temperature and humidity logs and policy 6) Cross-contamination issues? 7) Unblocked egress from storage areas Healthcare Engineering Consultants

Checklist for the Facility Building Tour 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? 5) Temperature and humidity logs and policy 6) Cross-contamination issues? Code Reference: 2010 FGI Guidelines Document, ASHRAE supplement standard 170 Healthcare Engineering Consultants

Checklist for the Facility Building Tour 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 Healthcare Engineering Consultants

Checklist for the Facility Building Tour 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 Healthcare Engineering Consultants

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 Healthcare Engineering Consultants

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 Healthcare Engineering Consultants

Compartmentation Deficiencies What’s wrong with these seals?
Healthcare Engineering Consultants

Rated Fire Wall Penetration Examples
Healthcare Engineering Consultants

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 Healthcare Engineering Consultants

1-hour Fire Barrier Compartmentation Requirements Extends from floor to deck above 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 Healthcare Engineering Consultants

2-hour Fire Barrier Compartmentation Requirements Extends from floor to deck above 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) Healthcare Engineering Consultants

Checklist for the Facility Building Tour (continued) 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 Healthcare Engineering Consultants

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) Healthcare Engineering Consultants

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 Healthcare Engineering Consultants

Egress Corridor Deficiencies
Are these corridors OK? Healthcare Engineering Consultants

Corridor Requirements – 2012 Life Safety Code (4) – Projections into the required width shall be required for wheeled equipment, provided that all of the following conditions are met: Clear unobstructed width is not reduced to less than 5 feet Fire plan requires relocation of wheeled equipment during a fire or similar emergency Wheeled equipment is limited to equipment and carts in use, medical emergency equipment not in use and patient lift and transport equipment Healthcare Engineering Consultants

Corridor Requirements – 2012 Life Safety Code (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: Furniture is securely attached to floor or wall Unobstructed corridor width is less than 6 feet Furniture is located on one side of the corridor only Grouped so that total area is less than 50 square feet and each grouping is at least 10 feet apart Furniture does not block emergency equipment and valves Smoke compartment with QRS sprinklers and smoke detection or direct staff supervision of furniture spaces Healthcare Engineering Consultants

Egress Corridor Storage Additional Joint Commission Interpretations
Egress corridors greater than 8 feet in width may be partitioned to provide alcove storage for computers, equipment Small (less than 50 square feet) dead-end corridors beyond the exit stairwell doorway may be used to store equipment 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!! Healthcare Engineering Consultants

Egress Corridor Storage Joint Commission Corridor Interpretations
Staff Office Permitted Storage Space (if <50 sq ft) 8’ Width Egress Corridor Exit Stair Healthcare Engineering Consultants

Egress Corridor Storage Joint Commission Corridor Interpretations
Staff Office 44” Permitted Storage Space (if <50 sq ft) 8’ Width Egress Corridor Exit Stair Healthcare Engineering Consultants

Checklist for the Facility Building Tour (continued) 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 Healthcare Engineering Consultants

Checklist for the Facility Building Tour (continued) 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 , EP1 Solutions? Reference: EC News, February 2014 issue, pages 5-6 Healthcare Engineering Consultants

Checklist for the Facility Building Tour (continued) Patient Treatment Area Clarifications 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 , EP1 References: ECRI Health Devices, 2009; volume 38, issue 7, pages ; AORN Perioperative Standards and Recommended Practices, 2013, pages Healthcare Engineering Consultants

Checklist for the Facility Building Tour (continued) Patient Treatment Area Clarifications 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 Healthcare Engineering Consultants

How Should I Prepare for the Facility Tour?

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