Environment of Care/Fire Life Safety Issues

From fire code inspections conducted by the Washington State Fire Marshal's Office.

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Environment of Care/Fire Life Safety Issues
  • Power strips in a patient care vicinity are used only for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of
  • Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE.
  • Power strips for PCREE meet UL 1363A or UL 60601-1.
  • Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards.
  • All power strips are used with general precautions.
  • Extension cords are not used as a substitute for fixed wiring of a structure.
  • Extension cords used temporarily are removed immediately upon completion of the purpose for which they were installed and meet the conditions of 10.2.4. (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5.


How to Avoid or Address the Problem

  • Plugging power strips into power strips.
  • Using extension cords as a permanent power source.
  • Plugging appliances into power strips..
  • Complete frequent rounds and surprise inspections.
  • Install more outlets if necessary.
  • Educate staff..
Sprinkler System – Maintenance and Testing

Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.

9.7.5, 9.7.7, 9.7.8, and NFPA 25.

Problem How to Avoid or Address the Problem
  • Not completing the quarterly sprinkler inspections.
  • Not completing the five-year internal test or the three-year full trip test.
  • Having out-of-date sprinkler heads.
  • Put dates on calendar before they are due and have another person verify they are done.
  • Double-check that the work is being done, that the reports get sent in a timely manner, and that the facility receives them.
  • Have an inventory of the age of the sprinkler heads in the facility.
Corridor – Doors
  • Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1¾-inch solid-bonded core wood or capable of resisting fire for at least 20 minutes.
  • Doors in fully sprinklered smoke compartments are required only to resist the passage of smoke.
  • Doors shall be provided with a means suitable for keeping the door closed. There is no impediment to the closing of the doors.
  • Clearance between bottom of door and floor covering is not exceeding 1 inch.
  • Roller latches are prohibited by Centers for Medicare and Medicaid Services regulations on corridor doors and rooms containing flammable or combustible materials.
  • Powered doors complying with are permissible.
  • Hold-open devices that release when the door is pushed or pulled are permitted.
  • Nonrated protective plates of unlimited height are permitted.
  • Dutch doors meeting are permitted.
  • Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered.
  • Fixed fire window assemblies are allowed per 8.3.
  • In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies., 42 CFR Parts 403, 418, 460, 482, 483, and 485

Problem How to Avoid or Address the Problem
  • Doors not latching, delaminating, has holes, field modified.
  • Use only UL-rated parts to fix a fire-rated door.
  • Fix problems as they occur.
Emergency Lighting

Emergency lighting of at least 1½-hour duration is provided automatically in accordance with 7.9.,

Problem How to Avoid or Address the Problem
  • Not completing required tests.
  • Not having documentation.
  • Check monthly to ensure test was completed and documented.
  • Setting one month every year to complete annual testing.
Fire Alarm System – Testing and Maintenance

A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.

9.7.5, 9.7.7, 9.7.8, and NFPA 25.

Problem How to Avoid or Address the Problem
  • Not completing smoke detector sensitivity testing and/or not fixing any problems.
  • Addressing fire alarm panel troubles immediately.
  • Put dates on calendar before they are due and have another person verify they are done.
  • Double-check that the work is being done, that the reports get sent in a timely manner, and that the facility receives them.
  • Complete testing and repair troubles.
Electrical Systems Essential Electric System

The generator or other alternate power source and associated equipment are capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches.

Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours.

Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111.

Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable.

Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.

6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70).

Problem Solution
  • Not completing all required weekly inspections and monthly testing.
  • Not having fuel tested.
  • Not completing tri-annual four-hour load bank.
  • Have a back-up person to do inspections and testing in the event main person is gone.
  • Complete all testing and keep a calendar of when certain items are due.
Electrical Systems – Maintenance and Testing

Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of not more than one month by actuating the LIM test switch per, which activates both visual and audible alarm. For LIM circuits with automated self- testing, this manual test is performed at intervals of not more than 12 months. LIM circuits are tested per after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99).

Problem How to Avoid or Address the Problem
  • Not completing non-hospital grade receptacle testing and having it documented.
  • Not having performance data on hospital grade receptacles.
  • Put inspection and testing dates on calendars.
  • Double-check that the work is being done, that the reports get sent in a timely manner, and that the facility receives them.
Utilities – Gas and Elect

Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.,, 9.1.1, 9.1.2

Problem How to Avoid or Address the Problem
  • Having open junction boxes.
  • Having storage in electrical rooms.
  • Not having adequate work area around breaker boxes.
  • Doing audits to ensure junction boxes have covers.
  • Not using electrical rooms as storage.
Gas Equipment – Cylinder and Container Storage

At least 3,000 cubic feet storage locations are designed, constructed, and ventilated in accordance with and

At least 300 but less than 3,000 cubic feet storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited-combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (five feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum half-hour fire protection rating.

300 cubic feet or less in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of 300 cubic feet or less are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.

A precautionary sign readable from five feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."

Storage is planned so cylinders are used in order they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.

11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99).

Problem How to Avoid or Address the Problem
  • Having unsecured oxygen cylinders.
  • Not separating and labeling full versus empty cylinders.
  • Provide adequate restraint devices for medical gas cylinders.
  • Setting up oxygen storage rooms to comply with requirements.
Means of Egress – General

Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1,

Problem How to Avoid or Address the Problem
  • Having exit corridors or paths of travel blocked by storage.
  • Complete a daily walk-through.
  • Have alternative storage areas available.