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Changes with generators and testing procedures

Major changes are in store for healthcare facilities in

regards to generators and the way they are tested, the

chairman of the NFPA 110 (Standard for Emergency and

Standby Power Systems) Technical Committee on Emer-

gency Power Supplies (EPS) said recently.

David Stymiest, PE, CHFM, FASHE, senior

consultant for Smith Seckman Reid, Inc., who spoke

at the American Society for Healthcare Engineering

(ASHE) annual conference in San Antonio in July

2012, shared his insights and opinions on how the 2010

edition of NFPA 110 will affect healthcare organizations

when the 2012 edition of the Life Safety Code® (LSC) is

finally adopted by CMS.

“Loading percentages in regards to generator

testing are changed to ‘not less than’ [NLT] rather

than absolute percentages, such as 25%, 50%, and

75%,” said Stymiest. “Some inspectors were citing

non compliance if the percentage was greater than that

listed. If someone wants to go beyond the minimum

requirements for a load test, we don’t want that

organization penalized.”

NFPA 110 has detailed instructions for required

testing of generators after repairs are made to the emer-

gency power supply system (EPSS), including transfer of

all automatic transfer switches (ATS) for NLT 30 minutes.

Essentially this is a monthly test.

“The purpose is to ensure the system is capable of

doing what it is

supposed to do,”

said Stymiest. “I

don’t know about

you, but in my

hospitals there

have been situa-

tions where we

had a test failure

and a repair was made, but a test of the system was not

conducted. Then we found out during the next monthly

load test that something was wrong.”

There have been major rewrites to clarify the in-

stallation acceptance test requirements on generators.

According to Stymiest, the previous editions of NFPA

110 were difficult to follow. The first routine monthly

test must be made immediately after the passing of

the acceptance test, which essentially is the same day.

Stymiest said all test records must be permanent, mean-

ing they must be kept forever, and electronic records are

permitted. Even though The Joint Commission or CMS

may only request three years worth of documents, NFPA

110 requires those documents to be maintained as long

as the facility remains in operation.

Maintenance of paralleling gear is now stipulated

and similar to ATS maintenance, which Stymiest re-

ferred to as basic for healthcare engineering profession-

als. Previously, manufacturers’ recommendations on

paralleling gear maintenance prevailed. Generator bat-

tery conductance testing will now be accepted in lieu of

specific gravity readings, according to Stymiest.

IN THIS ISSUE

p. 6 Maintaining physical features of Life SafetyFind out about a new organization dedicated to advancing safety by advocating for the adoption of current building and safety codes.

p. 10 Questions & Answers This month’s Q&A talks about waiting areas, business occupancy storage rooms, and more.

p. 12 Quick tipThis month’s quick tip is a tool for monthly inspections for cooking hood fire suppression systems.

Complimentary Issue

The newsletter to assist healthcare facility managers with fire protection and life safety

HealtHcare life Safety compliance

“ If someone wants to go

beyond the minimum

requirements for a load

test, we don’t want that

organization penalized.”

—David Stymiest,

PE, CHFM, FASHE

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“The monthly load tests must operate the genera-

tor at NLT 30% of the EPS nameplate kilowatt [kW]

rating for a minimum of 30 minutes at normal operating

temperatures,” said Stymiest. “Previously, it was an

either/or situation. This change means for every monthly

test, the generator has to warm up before you start the

30-minute clock.”

Monthly generator testing is required to meet NLT

30% of the kW rating on the generator nameplate, not

the amperage rating. All too often facilities will test to

the amperage rating because on older equipment, the

control panel does not display the kW readout. While a

mathematical conversion between amperage and kilo-

watt can be calculated, it is important to remember that

meeting 30% of the amperage rating is not the same as

meeting 30% of the kW rating.

When asked whether weekly run tests are required

by NFPA 110, Stymiest said generators are not required

to be tested weekly; however, they are required to be

inspected weekly.

“If you are going to do a weekly run test, my recom-

mendation is to start it, get it warm, get it wet, then

shut it down,” said Stymiest. “You don’t have to trans-

fer loads. The whole thing with running diesel engines

unloaded is wet stacking. Running for a brief period will

not cause wet stacking.”

Stymiest reminded those in attendance to check with

their local and state authorities to determine whether

they have any weekly run test requirements.

Spark-ignited generators now must operate their

monthly test for NLT 30 minutes or until the water tem-

perature and oil pressure stabilize.

When a monthly load test is incapable of achiev-

ing the 30% nameplate kW rating, then the generator

must have an annual load test, which will now only be

required to operate for 90 minutes instead of the previ-

ously required two continuous hours. The new revised

test consists of the generator operating at NLT 50%

nameplate rating for 30 minutes, then NLT 75% name-

plate rating for 60 minutes, for 90 continuous minutes.

This change to 90 minutes will only occur when the

2012 edition of the LSC is adopted.

“Looking at the old annual load test, the first 30 min-

utes at 25% really does not give us what we need,” said

Stymiest. “The whole purpose of the annual load test is,

if you’ve been running lightly loaded with a diesel en-

gine, you have gunk in your exhaust system; let’s burn

it off before it gets really bad. That’s what the annual

load test is all about. This makes the annual test a little

bit greener.”

When asked what the scope of NFPA 110 is, Stymi-

est said the scope does not go beyond the load terminals

Managing Editor: Matt Phillion, CSHA [email protected]

Senior Editor: Brad Keyes, CHSP

Senior Consultant

Keyes Life Safety

Compliance

www.keyeslifesafety.com

Healthcare Life Safety Compliance (ISSN: 1523-7575 [print]; 1937-741X [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate is $289 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, P.O. Box 3049, Peabody, MA 01961-3049. Copyright © 2012 HCPro, Inc. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance, call 781-639-1872 or fax 781-639-7857. For renewal or subscrip-tion information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be in cluded 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 As-sociation codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Information should not be construed as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter or otherwise. Advisory board members are not responsible for information and opinions that are not their own.

Editorial Advisory Board Healthcare Life Safety Compliance

Henry KowalenkoSupervisor, Design Standards UnitOffice of Healthcare Regulation, IL Department of Public Health Chicago, Ill.

Peter LeszczakNetwork 3 Fire Protection EngineerU.S. Department of Veterans Affairs West Haven, Conn.

David MohilePresidentMedical Engineering Services, Inc. Leesburg, Va.

James MurphyConsultantThe Greeley Company Danvers, Mass.

Thomas SalamoneDirector of EC and Regulatory ComplianceGannett Fleming Yonkers, N.Y.

William Wilson, CFPS, PEMFire Safety CoordinatorBeaumont Hospitals Royal Oak, Mich.

James R. Ambrose, PETechnical Director, HealthcareCode Consultants, Inc. St. Louis, Mo.

Frederick C. Bradley, PEPrincipalFCB Engineering Alpharetta, Ga.

Michael Crowley, PESenior Vice President, Engineering ManagerRolf Jensen & Associates, Inc. Houston, Texas

Joshua W. Elvove, PE, CSP, FSFPEFire Protection EngineerAurora, Colo.

A. Richard FasanoManager, Western OfficeRussell Phillips & Associates, LLC Elk Grove, Calif.

Burton Klein, PE PresidentBurton Klein Associates Newton, Mass.

Complimentary Issue Healthcare Life Safety Compliance Page 3


of the ATSs or transfer devices if you’re using transfer

breakers. The scope of NFPA 99, Health Care Facilities Code

(2012 edition) talks about the essential electrical system,

while NFPA 110 talks about the EPSS. Stymiest was

asked to explain the difference.

“The scope of NFPA 110 is the generator and the stuff

that makes it run, down to and including the transfer

switches, and it stops there,” said Stymiest. “So, when

we’re talking about circuit breaker exercising of NFPA

110, we’re talking about the circuit breakers between

the generator and the transfer switches, and we’re not

talking about the breakers on the branches. There has

always been a requirement that you exercise the break-

ers between the generators and the transfer switches

annually. How many people do this every year? Very

few. But you should be doing it; it’s a requirement. It’s

easy to do because the generators are off. What I recom-

mend to my clients is, once a year at the beginning of a

monthly load test, go to the generator breakers and turn

them off/on, because the generator is off. Exercising is

real easy. Do it at the beginning of the load test once per

year, and document that you did it.”

The three-year four-hour load test was not a require-

ment of the 1999 edition of NFPA 110, which is refer-

enced by the 2000 LSC, but was introduced in the 2005

edition of NFPA 110 and adopted by The Joint Commis-

sion. The three-year four-hour load requirement does

not change for the 2010 edition of NFPA 110, which

is referenced by the 2012 LSC. NFPA 110 requires that

you transfer your ATS during the annual load test, even

though The Joint Commission does not. The annual

load test and the three-year four-hour load test are per-

mitted to be combined, provided the conditions of both

tests are met.

Stymiest said generator engine operating tem-

peratures and the battery temperatures are no longer

specified by NFPA 110, but refer to the manufacturer’s

recommendations.

“The generator engine room minimum tempera-

ture was previously set at 70°F for indoor applications

and 32°F for outdoor applications,” said Stymiest.

“ Generators located outdoors must be enclosed in a

room that protects the generator from rain and snow,

and maintains proper temperature. These outdoor

units are frequently called gen-sets. Now the minimum

room temperature is 40°F for both indoor and outdoor

applications.”

Previously, storage was not permitted in emergency

power generator rooms and some authorities took this

literally. The new NFPA 110 standard will now allow

parts, tools, and manuals for routine maintenance and

repairs to be

located in the

generator room.

In the previous

editions of NFPA

110, the annex

section discussed

fuel storage and

fuel shelf-life is-

sues. Fuel quality

testing is now a

required annual

test, using methods that are approved by American So-

ciety for Testing and Materials standards.

“For the first time since I’ve been on the technical

committee, we now have experts in fuel oil who actual-

ly gave us input for this standard,” said Stymiest. “What

happened is the standard has been a little deficient with

respect to fuel oil in the past. Members of the ASTM

committee submitted proposals to NFPA 110 to reflect

modern fuel oil concepts. It’s good stuff and I suggest

you get it, read it, and follow it.” n

Contact Managing Editor Matt Phillion

Telephone 781-639-1872, Ext. 3742

Email [email protected]

Questions? Comments? Ideas?

“ Members of the ASTM

committee submitted

proposals to NFPA 110 to

reflect modern fuel oil

concepts. It’s good stuff

and I suggest you get it,

read it, and follow it.”

—David Stymiest,

PE, CHFM, FASHE



Waiver request catch-22By now, most readers should be aware of the memo-

randum issued in March by Thomas E. Hamilton,

director of the Survey and Certification Group for CMS,

announcing a process in which healthcare organizations

may adopt certain sections of the 2012 edition of the Life

Safety Code® (LSC). In his memo, Hamilton explained why

CMS decided to proceed with this partial acceptance of

the 2012 version, rather than wait until the entire new

edition is adopted.

The sections of the 2012 edition of the LSC that CMS

will allow are summarized here. Please refer to the actual

code references for additional requirements and details:

➤ 18/19.2.3.4(4)—permits medical emergency equip-

ment, patient lift and transport equipment to be left

unattended in the corridor provided 5 feet of clear

width in the corridor is maintained

➤ 18/19.2.3.4(5)—permits fixed seating in corridors

provided 6 feet of clear width is maintained, with no

more than 50 square feet of fixed seating per group

and at least 10 feet between groupings

➤ 18/19.2.3.5—permits one cooking area limited to

preparing meals for 30 persons or less to be open to

the corridor per smoke compartment, provided there

are no deep oil fryers, there is safety equipment to

deactivate fuel supply, and no solid fuel is used

➤ 18/19.5.2—permits direct-vent gas fireplaces in

smoke compartments with patient sleeping rooms

provided they are not installed in patient sleeping

rooms; and solid-fuel-burning fireplaces are permit-

ted in non-sleeping areas provided they are separated

from patient sleeping areas by a one-hour fire-rated

barrier

➤ 18/19.7.5.6—permits varying quantities of combus-

tible decorations on walls, doors, and ceilings, based

on the level of automatic sprinkler protection in the

area or rooms

“A National task force developed these changes

over three years subsequent to public comments at

the CMS/Pioneer Network 2008 National Symposium

on Culture Change and the Environment Require-

ments,” Hamilton said in the March memo. “These

NFPA approved changes give nursing home providers

additional ways to enhance resident autonomy and

quality of life.”

The Pioneer Network was formed in 1997 by a group

of prominent professionals in long-term care to advocate

for person-directed care. Based in Chicago, this nonprofit

organization calls for radical change in the culture of

aging to create a community-based setting in nursing

homes. The Pioneer Network was successful in getting

CMS to make the decision to accept certain sections of

the new code. In subsequent communications, CMS

made it clear that these changes apply to all healthcare

occupancies governed under Chapters 18 and 19 in the

2012 edition of the LSC, which would include hospitals

as well as nursing homes.

The issue here is not whether the sections selected

were a good choice (which they are, to those health-

care organizations that would like to use them), but

rather the process organizations must follow in order

to gain approval from CMS to do use them. In his

memo, Hamilton provided an explanation on how to

request this approval.

“In support of these changes and the positive im-

pact they may have on residents’ lives, CMS will allow

providers to implement these changes by considering

waivers of the current LSC requirements found in the

2000 edition of the LSC without showing ‘unreasonable

hardships,’ ” said Hamilton.

What Hamilton failed to mention in his memo is

that healthcare providers are not permitted to submit

a request for a waiver until such time as they are cited

for noncompliance with the 2000 edition of the LSC.

This means the hospital or nursing home is encouraged

to intentionally violate the conditions of the 2000 edi-

tion of the LSC by implementing the changes allowed

by the 2012 edition. This appears to conflict with



other CMS requirements, specifically the Conditions

of Participation standard §482.41(b), which requires

organizations to comply with the provisions of the

2000 edition of the LSC.

When this catch-22 was brought to CMS’ atten-

tion, it responded with the unofficial explanation that

the S&C memorandum issued in March would allow

facilities to implement the changes permitted by the

2012 edition prior to the waiver approval. It appears

that CMS is allowing facilities to intentionally violate

the provisions of the 2000 edition of the LSC, and then

they must wait until they get caught in order to request

a waiver. This is an interesting way to regulate compli-

ance, to say the least.

The above information does not address how the

accreditation organizations (AO)—The Joint Commis-

sion, Healthcare Facilities Accreditation Program (HFAP),

and Det Norske Veritas (DNV)—are looking at the CMS

memorandum. The AOs have each set clear guidelines

on how they expect their accredited organizations to

address the issue of following certain sections of the new

2012 edition of the LSC that CMS is allowing.

“HFAP will consider a Fire Safety Evaluation

System equivalency from our accredited organizations

for any of the five areas that the CMS memorandum

addresses,” says Joseph Cappiello, HFAP’s chief

operating officer. “The important aspect of the process

for organizations to remember is they cannot adopt

these changes until HFAP approves their equivalency

requests.”

“Joint Commission will grant traditional equivalencies

in the five areas of the 2012 LSC, based on the affirma-

tion by your local fire safety [authority having jurisdic-

tion (AHJ)], registered architect, or fire safety engineer

that you meet the expectations listed in the 2012 edition

of the LSC,” said George Mills, director of engineer-

ing for The Joint Commission, who spoke at the recent

American Society for Healthcare Engineering Annual

Conference and Exhibition in July. “CMS is willing to do

the same thing, but they do not do it proactively. What

CMS will tell you is not to bother them with a waiver

request. They will arrive on-site for a validation and cite

you for noncompliance with the 2000 edition on these

five issues and your Plan of Correction will be to ask for

a waiver.”

“If a hospital chooses to proceed using the new CMS

directive, then they must be prepared to request a waiv-

er as part of the corrective action process if they desire to

keep the cited deficiency,” says Randy Snelling, chief

physical environment officer with DNV. “Of course, DNV

as the AO must agree with the waiver request. We just

don’t see the need to issue an AO equivalency that will

not be honored by CMS surveyors.”

While CMS is ready to accept waiver requests to al-

low organizations to use certain sections of the 2012

edition of the LSC, two of the three AOs are saying

you must first request permission from them through

equivalencies before implementing any changes. Only

DNV is allowing hospitals that choose to proceed with

using the new section to go ahead and do so, but when

cited, a waiver request must be made. According to the

The Joint Commission and HFAP, the request for a CMS

waiver has to wait until such time the organization is

cited by a state agency conducting a validation survey.

For most hospitals, this may be a very long wait as CMS

only conducts validation surveys on 5% of hospitals ac-

credited by the AOs each year.

In regards to 18/19.2.3.4(4), one more thing to con-

sider is the difference between equipment “not in use”

and “stored.” This section specifically permits medical

emergency equipment not in use to be located in the

corridor. The annex section of 18/19.2.3.4(4) tries to

clarify this issue by saying wheeled emergency equip-

ment is permitted to be located in the corridor when

“not in use” because it needs to be immediately acces-

sible during a clinical emergency. However, the annex

section also says “not in use” is not the same as “in stor-

age” but does not offer guidance on how to determine

the difference. What is the difference between “in use”

and “in storage”? This will be left up the AOs, CMS, and

your local and state AHJs to decide, and if history repeats

itself, they will not all agree. n



Quick, answer this question: What edition of NFPA

101, Life Safety Code® (LSC) are hospitals and nursing

homes required to be in compliance with if they re-

ceive reimbursement funds for Medicare and Medicaid

services?

Answer: the 2000 edition. Okay, so that really wasn’t

a difficult question. But the point is, the version of the

code that most healthcare facilities need to be in com-

pliance with today is currently 12 years old, and when

the 2012 edition of the LSC is finally adopted by CMS, it

likely will not even be the most current edition available

at that time.

The last time CMS adopted a newer edition of the

LSC, it jumped from the 1985 edition to the 2000 edition

on March 11, 2003. That means there were six cycle

revisions of this code between the last two updates by

CMS.

The point is, from 1988 until 2003, CMS was not en-

forcing the most recent edition of the code.

Beginning this past June, a new professional group

was founded by the International Code Council (ICC)

and the NFPA dedicated to advancing safety by advocat-

ing for the adoption of current building and safety codes.

This new nonprofit organization, called the Coalition for

Current Safety Codes (CCSC), already has an impres-

sive list of government entities, member organizations,

corporations, and individual members.

The ICC and the NFPA each have a long history of

dedicated members who are devoted to furthering the

development of safe and sustainable buildings in our

communities.

Even though these two code-writing entities are also

competitors, they decided to come together to cochair

this new initiative because of their mutual commitment

to public safety. Working together, they plan to create

public awareness and broader support for the adoption

of current codes that protect the health and welfare of

our society, which obviously includes the healthcare

industry.

“We believe adopting and enforcing the most up-to-

date building codes and standards is the most efficient

and effective way to create safe and sustainable commu-

nities,” says Sara Yerkes, senior vice president of gov-

ernment relations for the ICC and official spokesperson

for the CCSC.

Yerkes describes the code process in America to

be unique, in that it is a combination public-private

partnership.

“By that I mean the responsibility of developing

these codes and standards is in the private sector,” says

Yerkes. “It does not cost the taxpayer a cent because

the organization that develops the codes subsidizes the

process through the sale of the products, codes, and

services.”

The United States enjoys strong building and safety

codes, says Yerkes.

Recent earthquakes in Greece, Haiti, and Mexico

show tremendous devastation and loss of life. Compara-

tively, the 2001 earthquake in Seattle was a 6.8-magni-

tude quake and there was minimum property damage

and no loss of life.

“We attribute that to strong codes and standards, and

the enforcement of those codes and standards,” says

Yerkes. “So this coalition is not about any one set of

codes or standards, it is about advocating for the code

system we have in this country and sustaining current

editions of those codes.”

The following list illustrates significant changes to

the 2003, 2006, and 2009 editions of the LSC, which

the typical hospital or nursing home has not been able

to take advantage of because they have not yet been

adopted by CMS:

➤ Soiled linen and trash collection rooms no longer

need to be one-hour fire rated if they contain no

more than 64 gallons of soiled linen or trash

➤ Gift shops are no longer considered hazardous areas

even if they display combustibles

➤ The maximum size of a sleeping suite was changed to

New safety coalition formed



7,500 square feet if provided with direct supervision

and smoke detection

➤ Hazardous areas inside a non-sleeping suite are not

required to be separated if the entire suite is classified

as hazardous

➤ For suites requiring two means of egress, one means

of egress may be through an adjoining suite

➤ The maximum travel distance of 150 feet between a

room door and an exit was eliminated

➤ Locks on egress doors are now permitted (with some

requirements) for patients with “special needs” and

do not have to qualify as “clinical needs”

➤ Multiple delayed egress locks are permitted in the

path of egress

Currently, the accreditation organizations (AO)—The

Joint Commission, Healthcare Facilities Accreditation

Program, and Det Norske Veritas—are restricted to enforc-

ing the 2000 edition of the LSC because that is what CMS

is currently enforcing and the AOs receive their authority

from CMS and must be in compliance with its conditions.

We all should be aware by now that CMS is reviewing

the 2012 edition of the LSC for consideration of adop-

tion, but that process may not be completed until 2014

or 2015.

By then, the 2015 edition of the LSC may be pub-

lished and any code improvements in that edition will

not be available for consideration. The CCSC is advocat-

ing for CMS and other government entities to devise a

system whereby new editions of the codes and standards

may be adopted without the long waiting periods for

public comments and review.

“Individual companies and corporations research

and develop new products and constantly invest

money into innovative systems, which leads to safer

and more efficient designs in building construction and

safety,” says Yerkes. “Even if these new systems and

products are consistent with updated standards, if the

codes are not adopted and enforced by the government

entities, then what good are they? There is a whole

world out there that is negatively impacted for years

because these new products and systems are not avail-

able to them for use.”

Yerkes acknowledges that the healthcare industry

spends a considerable amount of money building new

facilities each year. They want to avoid duplicative,

redundant, and out-of-date methods required by older

editions of the code.

“Changes that happen with each revision cycle of the

code is not just adding new requirements,” says Yerkes.

“Sometimes methodology changes and certain require-

ments are removed from the code.”

This new coalition is not to be confused with other

interest groups who are trying to change the codes or

eliminate a set of codes. According to Yerkes, the goal of

CCSC is to bring together as many stakeholders as pos-

sible for the advancement of current safety codes.

“[The goal of] this coalition is going to be very

simple: to encourage the adoption and enforcement of

the current editions of the codes,” says Yerkes. “It’s to

educate the decision-makers who look out for the wel-

fare of our community.”

In August, Chad Beebe, AIA, SASHE, CHFM,

director of codes and standards for the American Soci-

ety for Healthcare Engineering, posted a blog comment

concerning the CCSC:

I encourage every hospital to become a member of this

coalition. The purpose of this coalition is to develop a net-

work of people and organizations that support updating

codes on a regular basis. Given our current struggle with

CMS to update to a new edition of the Life Safety Code

(from the 2000 edition to the 2012 edition), we need to see

hospitals join this coalition as well. As community leaders,

hospitals could have a great impact.

Yerkes encourages everyone to join the coalition by

going to www.coalition4safety.org and signing up as a com-

pany or as an individual.

“I would hope this coalition will bring our voices to-

gether and encourage the federal government to rely on

the private sector and work harder to stay current on the

codes,” says Yerkes. n



Nearly every healthcare facility manager knows that

the fire suppression system on their cooking hoods in the

kitchen must be maintained on a semiannual basis. This

is typically contracted to a qualified vendor who appears

twice a year and performs the routine maintenance.

The 2000 edition of the Life Safety Code® (LSC) requires

commercial cooking equipment to be installed and

maintained in accordance with NFPA 96, Standard for

Ventilation Control and Fire Protection of Commercial Cooking

Operations (1998 edition). Section 7-2.2.1 of NFPA 96

requires automatic fire-extinguishing equipment to be

installed and maintained in accordance with specific

standards. Among the different types of extinguishing

systems used over the years are CO2, wet sprinkler, dry

chemical, and wet chemical.

Of these types, dry and wet chemical are by far the

most common systems used in hospitals and nursing

homes. But the dry chemical extinguishing systems ap-

pear to be losing popularity with state and local authori-

ties. Changes in cooking oils and their auto-ignition tem-

peratures have necessitated a design of a wet potassium

carbonate solution. The main extinguishing action in the

wet chemical system is by the cooling effect caused by the

evaporation of the wet solution, leaving a fine soapy layer

at the surface to seal off the fuel from the oxygen, allow-

ing the oils to cool below their auto-ignition temperature.

The wet chemical systems are not new, as they came into

existence in the early 1980s, but when the Underwriters

Laboratories created new testing criteria (called UL 300) in

1994, the dry chemical extinguishing systems were found

to be ineffective in extinguishing fires involving veg-

etable oils. Many state and local authorities then ordered

the change-out from dry to wet chemical extinguishing

systems in commercial cooking installations. The wet

chemical systems proved to be ideally suited to meet the

demands associated with today’s busy healthcare kitchens.

But what the editors of HLSC have discovered is

many healthcare organizations across the nation have

failed to meet the monthly inspection requirements for

these dry or wet chemical extinguishing systems. Many

facility managers are reporting that Joint Commission

and state agency surveyors performing validation surveys

on behalf of CMS are citing them for not following the

specific standards for the dry chemical (NFPA 17) or wet

chemical systems (NFPA 17A). According to NFPA 17A,

Standard for Wet Chemical Extinguishing Systems, the month-

ly inspection for the wet system is virtually the same as

that for the dry system. The standard calls for a quick

check of the following each month:

➤ Ensure the extinguishing system is in its proper location

➤ Verify that the manual “pull station” actuators are

unobstructed

➤ Verify that the tamper indicators and seals are intact

➤ Make sure the semiannual maintenance tag or certif-

icate is in its proper place

➤ Make sure no obvious physical damage or condition

exists that might prevent operation

➤ Inspect the pressure gauges (if provided) to verify

they are in the operable range

➤ Confirm that the nozzle blow-off caps are intact and

undamaged

➤ Verify that the hood, duct, and protected cook-

ing appliances haven’t been replaced, modified, or

relocated

If any deficiencies are found, appropriate corrective

action must be taken immediately. Documentation such

as work orders or contractor work tickets demonstrating

corrective action on all deficiencies must be maintained

for review by the authorities.

The monthly inspection is required to be recorded,

usually on the same inspection tag as the semiannual

maintenance. Initials and date of the monthly inspec-

tion are required. n

Editor’s note: See p. 12 for a sample inspection form.

Monthly inspections of cooking hood fire suppression systems



Editor’s note: Each month, Senior Editor Brad Keyes,

CHSP, offers his thoughts, concerns, and comments on issues

pertaining to healthcare life safety.

ASHE advocacy

The American Society for Healthcare Engineering

(ASHE) has certainly been very busy recently on behalf

of hospitals and nursing homes. In April, Dale Woodin,

executive director of ASHE, along with key leaders of

the Association for the Advancement of Medical Instru-

mentation, met with CMS representatives to discuss

changes with the CMS policies on medical and utility

equipment maintenance strategies. Also, Chad Beebe,

director of codes and standards for ASHE, has been

active on many fronts, including the ASHE-supported

changes presented to the International Code Coun-

cil (ICC) Committee in April. ASHE is advocating for

changes to the International Building Code for standards

that are consistent with the NFPA LSC. In August, Beebe

met with attendees at the National Conference of State

Legislators to explain how the healthcare industry has

the potential to save billions of dollars by streamlin-

ing conflicting, outdated, and needless codes, while

still keeping patients, visitors, and staff safe. ASHE is

also asking its members to sign up and support the

ICC-NFPA led Coalition for Current Safety Codes (see

the article on p. 6). With all of that advocacy activity,

ASHE stills finds time to assist with the development

of the new 2014 edition of the Guidelines for Design and

Construction of Health Care Facilities. The public comment

period is now open and runs through November 22.

Visit the FGI website at www.fgiguidelines.org to comment

on the proposed changes.

Problems with the 2012 edition of the LSC

Call me stupid or too old to change, but the changes

in corridor width requirements found in the new 2012

edition of the Life Safety Code® (LSC) do not make sense to

me. Section 18/19.2.3.4(4) allows medical equipment,

patient lift equipment, and transport equipment to be

left unattended in the corridor provided a minimum of 5

feet of clear width remains in the corridor. The Technical

Committee on Health Care Occupancies for NFPA 101

did not all agree on these changes. Committee members

representing certain authorities having jurisdiction ve-

hemently opposed this change because they fear hospital

staff will overload the corridors with stored items that

will impede evacuation. Take the situation at St. John’s

Hospital in Joplin, Mo. In last month’s issue of HLSC,

George Mills, director of engineering for The Joint Com-

mission, reported that St. John’s conducted a disaster drill

just months before an F5 tornado devastated the hospital.

In this drill they discovered that corridor clutter hin-

dered the quick evacuation of the mock patients. Their

after-action report identified a solution to this problem

by maintaining clear corridors, which contributed to the

rapid evacuation of their patients during the real emer-

gency. If the corridors were permitted to have equipment

“left unattended” with only 5 feet of corridor width avail-

able, how would they effectively evacuate their patients

and still allow emergency service personnel to pass by in

the corridors? The annex portion of 18/19.2.3.4(4) says

equipment “left unattended” is not the same as “in stor-

age.” But the technical committee did not explain how to

determine the difference. Also, with all this added equip-

ment “left unattended” in the corridor, where will it be

moved to in the event of an emergency? Space must be

allocated for each piece, and it cannot be a spare patient

room, as there may not be a spare room during an emer-

gency. It just doesn’t make sense. n

Editorial speaking …

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&AnswersQuestions

Clarification

In the August issue of HLSC, a reader’s question dealt

with whether or not storage was permitted in an elec-

trical room. The editor’s answer did not take into ac-

count that NFPA 70, National Electrical Code (1999

edition), section 110.26 requires a clear working space

of a minimum 36 inches deep and 30 inches wide, or

the width of the equipment, whichever is greater. This

means some small electrical rooms or closets may not

allow any storage (even a stepladder) due to the mini-

mum clearances required around the electrical panels

and equipment.

Editor’s note: Each month, Senior

Editor Brad Keyes, CHSP, consultant

for Keyes Life Safety Compliance, answers

your questions about life safety compli-

ance. 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.

Waiting areas

Q Our risk management department has conduct-

ed an assessment of our hospital’s waiting areas.

They are stating that staff should be able to see all pa-

trons who are waiting in lobbies and corridors. If they

cannot, then mirrors or cameras should be installed al-

lowing staff to monitor patrons’ behavior. I’m guess-

ing their concern is for an individual passing out in the

waiting area. Is there a code requirement for staff ob-

servation or cameras?

A It depends on the circumstances. Waiting areas

that are open to the exit access corridor are

required to meet criteria found under section

19.3.6.1 in the 2000 edition of the Life Safety Code®

(LSC). These criteria include, among other things, either

direct supervision by a staff member or smoke detec-

tion in the open areas. Depending on your accredita-

tion organization and your local and state authorities,

direct supervision may be interpreted to mean staff in

attendance to observe the waiting area, or a closed-cir-

cuit television system that is monitored by another in-

dividual. The code at this point does not say “constant

supervision,” which would imply the supervision by

staff must remain constant. Direct supervision implies

observation of the open areas is not constant. As far as

meeting the code requirements, it seems to me that the

addition of smoke detectors would far exceed the cost

of having staff observing the open areas. As always,

please check with your local and state authorities to see

whether they have other requirements.

Business occupancy storage room

Q We have a new facility that has recently opened,

and it is a physician’s office/business occupancy.

There is a medical record storage room that contains

combustible files, which we have determined to be a

general hazard. Per the LSC, the hazardous room needs

to be either one-hour fire-rated or sprinkled. If sprin-

kled (which we are), the room needs to be smoke par-

titioned with a smoke door and a closer (no mention of

latching). The door to the room has a closer and opens

onto an egress corridor, yet it is not supplied with a

latch. My gut tells me this door should latch. What are

your thoughts?

A My thought is a gut reaction is usually very re-

liable. The storage room is required to comply



If you have a question about life safety compliance,

fire codes and standards, or the EC, pass it along to us

and we’ll include it in one of Healthcare Life Safety

Compliance’s future “Questions & Answers” columns.

Send us your questions in writing by:

➤ Mail to Healthcare Life Safety Compliance, P.O.

Box 3049, Peabody, MA 01961-3049

➤ Email to [email protected] (include “Q&A” in the

subject line)

➤ Fax to 781-639-2982 (to the attention of Healthcare

Life Safety Compliance)

Send us your questions

with section 38.3.2.1 of the 2000 edition of the LSC,

which refers to section 8.4. Section 8.4 requires a

hazardous area to be protected with either one-hour

fire-rated barriers or an automatic sprinkler system,

so your code assessment is correct. In your case, the

storage room is protected with automatic sprinklers

and smoke- resistant barriers since new construc-

tion requires that. Technically, the door to the stor-

age room is not required to latch because it is not a

fire-rated door and corridor doors in business occu-

pancies are not required to latch according to sec-

tion 38.3.6. I agree with you that one would think

it should latch, especially since the same scenario in

a hospital would require it to. But the LSC does not

require it in a business occupancy, which is one of

the many advantages to having an area classified as

a business occupancy. I still would check with your

local and state authorities for any additional require-

ments. One final thought: If your gut tells you the

door needs a latch, then by all means, follow your

instinct. The codes are minimum standards, and

there is nothing wrong with exceeding the minimum

standards.

Circuit breaker testing

Q During a recent survey, the inspector cited us for

not exercising our circuit breakers downstream of

our generator. Does the LSC require annual exercising

of all circuit breakers between the generator and the

connected load?

A LSC section 9.1.3 requires emergency power

generators to comply with NFPA 110, Standard

for Emergency and Standby Power Systems, 1999 edition.

Section 6-4.6 of NFPA 110 requires the main and feed

circuit breakers between the generator and the trans-

fer switch terminals to be exercised annually with the

generator in the off position. So it appears to me that

all emergency source circuit breakers are required to

be exercised annually. This would include the gen-

erator output breaker and all downstream distribu-

tion breakers, up to and including any breakers that

feed the emergency feed side of the automatic transfer

switch (ATS). I believe that would exclude any loads

connected to the load side of the ATS, such as motors,

lights, pumps, etc. The process is a simple one because

all affected breakers are normally in a de-energized

state. I do not recall ever seeing a reason for this pro-

cedure published, although I’m sure there is a good

reason. In my experience though, breakers that are

not exercised regularly can be extremely difficult (if

not impossible) to reset, even though the internal trip

mechanism may work perfectly. This may lead an or-

ganization to not conduct the annual test, which may

result in a citation for noncompliance. Some orga-

nizations will purchase replacement circuit breakers

and have them available on a shelf in case the breaker

will not reset. While this is a very proactive approach

to testing and a quick response to potential repairs,

it can be rather costly as the large current breakers

are a bit pricey. While annual testing of circuit break-

ers may not come up very often during a survey, it

is an LSC requirement and the surveyor has the ob-

ligation to cite the issue if he or she sees it as being

noncompliant. n



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Quick tip

Monthly inspection of cooking hood fire suppression system

Name of property:

Cooking hood location:

Inspected by: Date:

Inspection activity Yes No N/A Comments

1. Are all the features of the fire extinguishing system located in

their proper place?

2. Is access to all of the manual actuators (pull stations) free and

unobstructed?

3. Are the tamper indicators and seals intact?

4. Is the maintenance tag or certificate readable and on display in

its designated location?

5. Is there any physical damage to the system or a condition that

might prevent operation?

6. Is the pressure gauge (if provided) reading in the approved,

operable range?

7. Are the nozzle blow-off caps (if provided) intact and undamaged?

8. Has the protected equipment been replaced, modified, or

relocated?

All “No” answers must be fully explained. Source: NFPA 17, 1998 edition, and NFPA 17A, 1998 edition.

Supervisor’s initials: Date: Work order #:

1. (T) (F) During a generator load test, meeting 30% of the amperage rating on the nameplate is the same as meeting 30% of the kilowatt (kW) rating.

2. (T) (F) Emergency power generators are required to be load-tested and inspected on a weekly basis.

3. (T) (F) According to a March memo issued by CMS, the Pioneer Network was instrumental in CMS deciding to issue permission to use certain sections of the 2012 edition of the Life Safety Code® (LSC).

4. (T) (F) CMS requires providers to request a waiver to use certain sections of the 2012 edition of the LSC prior to a survey and before any finding.

5. (T) (F) The last time CMS adopted a newer edition of the LSC was when it jumped from the 1988 to the 2000 edition in March 2003.

6. (T) (F) The Coalition for Current Safety Codes (CCSC) was founded by the International Code Council (ICC) and the American Society for Healthcare Engineering.

7. (T) (F) Only companies and corporations can join the CCSC.

8. (T) (F) Joint Commission and CMS surveyors are now citing hospitals for not conducting monthly inspections of the cooking hood fire suppression systems.

9. (T) (F) Brad Keyes, HLSC senior editor, may be too old to make any sense of the new corridor width requirements found in the 2012 edition of the LSC.

10. (T) (F) Non-fire-rated doors that open onto a corridor in a business occupancy are required to latch.

QuizQuizHealtHcare life Safety complianceThe newsletter to assist healthcare facility managers with fire protection and life safety

Vol. 14 No. 10Complimentary Issue

Quiz questions Complimentary (Vol. 14, No. 10)

A supplement to Healthcare Life Safety Compliance

1. False. A mathematical conversion between amperage and kW can be calculated, but meeting 30% of the amperage rating is not the same as meeting 30% of the kW rating.

2. False. Emergency power generators are required to be load-tested monthly, but are required to be inspected weekly.

3. True.

4. False. CMS will not accept a waiver request until the deficiency is cited during a survey. The waiver request will become part of the Plan of Correction.

5. False. In March 2003, CMS jumped from the 1985 edition to the 2000 edition.

6. False. The CCSC was founded by the ICC and the NFPA.

7. False. Individuals may join as well.

8. True. 9. True.

10. False. Non-fire-rated doors and corridor doors in business occupancies are not required to latch.

Quiz answers Complimentary (Vol. 14, No. 10)

Copyright 2012 HCPro, Inc. 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.

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