Frequently Asked Questins (FAQs) Nursing Hme/Facilities Life Safety Cde 2000 Editin (Revised 3/30/07) 1. What decratins are allwable in a facility fr the facility t cmply with the life safety cde requirements regarding decrative materials? Chapter 19.7.5.4 f the Life Safety Cde 2000 Editin states that cmbustible decratins shall be prhibited in any health care ccupancy unless they are flameretardant. Exceptin: cmbustible decratins, such as phtgraphs and paintings, in such limited quantities that a hazard f fire develpment r spread is nt present. Chapter 10.3.5 states that furnishings r decratins f an explsive r highly flammable character shall nt be used. Examples f explsive r highly flammable decratins: Christmas trees; nt effectively flame-retardant treated crepe paper decratins; finely divided tinsel-like material; pyrzylin plastic decratins; and real pine trees r branches. Attaching decratins t drs in the means f egress is viewed in the cntext f a fire cmprmising the fire rating f the dr. While a small amunt f decratin n a dr may be acceptable, such as names f the residents in a rm r schedules; ttal cverage is nt. Decratins may nt be hung frm sprinkler heads and decratins cannt be hung in such a manner that exit signs r exit drs are blcked frm view. Items such as rdinary phtgraphs, paintings, greeting cards, psters and pictures clred by grandchildren are nt cnsidered r classified as hazardus. Decratins cannt exceed 10 percent f the ttal wall cvering. Centers fr Medicare and Medicaid Services (CMS) relies n the surveyr t exercise gd judgment in determining what is acceptable r what is excessive. Use f bales f hay r crnstalks as decratins utside the facility may present a hazard as these areas are frequently unattended and ignitin frm a careless cigarette can easily ccur. The use f cut r dead Christmas trees in healthcare facilities is prhibited because f their highly flammable nature when dry. Even thse trees kept in water r treated with fire-retardant material tend t dry ut ver a perid f time, making them flammable. Live ptted plants r trees are acceptable as lng as prper care f the plant is taken t prevent the plant frm drying ut. 2. What are the ventilatin requirements fr xygen strage? When the ttal vlume f the xygen cylinders is less than 3000, cubic feet there are n ventilatin requirements. When the ttal vlume is greater than 3000, cubic feet, the area must be mechanically ventilated per NFPA 99, 1999 Editin, Chapter 4-3.1.1.2(b)4. Lcatins fr supply systems f mre than 3000, cubic feet ttal capacity 1
(cnnected and in strage) shall be vented t the utside by a dedicated mechanical ventilatin system r by natural venting. If natural venting is used, the vent pening r penings shall be a minimum f 72 square inches in ttal free area. 3. What is required fr separatin f xygen frm cmbustibles r incmpatible materials? NFPA 99, 1999 Editin Chapter 8-3.1.11.2 (c) 2 requires a minimum distance f five feet if the entire strage lcatin is prtected by an autmatic sprinkler system designed in accrdance with NFPA 13, Standard fr the Installatin f Sprinkler Systems, 1999 Editin; r Chapter 8-3.1.11.2 (c) 3 requires an enclsed cabinet f nncmbustible cnstructin having a minimum fire prtectin rating f ne-half hur fr cylinder strage. Als an apprved flammable liquid strage cabinet shall be permitted t be used fr cylinder strage. 4. What are the requirements fr transferring f liquid xygen? NFPA 99, 1999 editin, Chapter 8-6.2.5.2 sets frth the requirements fr transferring liquid xygen. The transferring f liquid xygen frm ne cntainer t anther shall be accmplished at a lcatin specifically designated fr the transferring that is as fllws: (a) Separated frm any prtin f a facility wherein patients are hused, examined, r treated by a separatin f a fire barrier f ne hur fireresistive cnstructin; and [Nte: Drs must be equipped with self-clsing device, psitive latching hardware, and must have at least a ¾ hur fire rating t establish the required separatin. (Explanatin added)] (b) (c) The area is mechanically ventilated, is sprinklered and has ceramic r cncrete flring; and The area is psted with signs indicating that transferring is ccurring and that smking in the immediate area is nt permitted. Transferring shall be accmplished utilizing equipment designed t cmply with the perfrmance requirements and prducers f CGA (Cmpressed Gas Assciatin) Pamphlet P-2.6, Transfilling f Lw-Pressure Liquid Oxygen t be Used fr Respiratin, and adhering t thse prcedures. The use and peratin f small prtable liquid xygen systems shall cmply with the requirements f CGA Pamphlet P-2.7, Guide fr the Safe Strage, Handling and Use f Prtable Liquid Oxygen Systems in Health Care Facilities. CGA pamphlets may be purchased at http://www.cganet.cm. 2
5. Is the transferring f liquid xygen allwed in resident/patient sleeping rms? N, the transferring f liquid xygen in resident sleeping rms is strictly prhibited accrding t NFPA 99, 1999 Editin. Refer t questin 4 abve fr acceptable lcatins fr the transferring f xygen. 6. What are the xygen cylinder sizes as in cubic feet? T determine what the ttal cubic feet f xygen strage fllw the listed size chart: D cylinders - 15 cubic feet E cylinders - 24 cubic feet M cylinders - 122 cubic feet G cylinders - 244 cubic feet H r K cylinders - 250 cubic feet 7. Are n smking signs required t be psted n the utside f resident sleeping rms that use xygen? Yes, Ohi Administrative Cde rule 3701-17-20 requires that N Smking signs be psted in areas and n drs f rms where xygen is stred r in use. Therefre, the psting f n smking signs is required in all facilities including designated nn-smking facilities. 8. Is it permitted t stre a limited number f xygen cylinders in an area that des nt meet the cde requirements pertaining t the strage f xygen? Yes, ne r tw cylinders may be stred at a nurse s statin r n a crash cart when they are ging t be used fr emergency prpses nly. They must be secured in an upright psitin with a regulatr attached t the cylinder. 9. Can a Rubbermaid shed be used fr utside strage f xygen cylinders? NFPA 99, 1999 Editin, Chapter 8-3.1.11.2 (a) prvides that strage lcatins shall be utdrs in an enclsure r within an enclsed interir space f nncmbustible r limited-cmbustible cnstructin, with drs that can be secured against unauthrized entry. Therefre, a Rubbermaid shed may be used if it is f nncmbustible r limited-cmbustible cnstructin with drs that are secured against unauthrized entry. 3
10. Can alchl based hand cleaner dispensers be placed r munted in the crridrs? Yes, under the fllwing cnditins prescribed by the Centers fr Medicare and Medicaid Services: Only alchl based hand rub (ABHR) slutins frm single use bags that are cmpressed t dispense are acceptable (nn-aersl). The crridr must be at least six feet wide. Maximum individual dispenser fluid capacity is: 1) 0.3 gallns (1.2 liters) fr dispensers in rms, crridrs and areas pen t crridrs 2) 0.5 gallns (2.0 liters) fr dispensers in suites f rms. Dispensers shall have a minimum hrizntal spacing f fur feet frm each ther. Nt mre than an aggregate 10 gallns (37.8 liters) f ABHR slutin in use in a single cmpartment utside f a strage cabinet. f. Strage f quantities greater than 5 gallns (37.8 Liters) in a single smke cmpartment shall meet the requirements f NFPA 30, Flammable and Cmbustible Liquids Cde. The dispensers shall nt be installed ver r directly adjacent t an ignitin surce such as an electrical utlet r switch. In lcatins with carpeted flr cverings, dispensers installed directly ver carpeted surfaces are permitted nly in sprinklered smke cmpartments. N cnflict with lcal cdes. Installatin minimizes spills and leaks. Dispensers are installed in a manner that adequately prtects against inapprpriate access (e.g. dementia units). Dispensers must be adequately maintained. 4
11. Is uphlstered furniture that is lcated in business ffices r similar areas required t be rated? Life Safety Cde 2000 Editin, Chapter 19.7.5.2 prvides that any newly intrduced uphlstered furniture within health care ccupancies shall meet the criteria specified when tested in accrdance with the methds cited in 10.3.2 (2) and 10.3.3. Existing uphlstered furniture shall be permitted. 12. Des uphlstered furniture wned by residents need t be fire rated? N, patient wned uphlstered furniture des nt need t be fire rated, if the facility is cmpletely sprinklered. (Life Safety Cde 2000 Editin, Chapter 19.7.5.2 exceptin #1.) 13. Are surge prtectrs (multi-plug strips) permitted? Pwer strips with surge prtectin may nt be used in resident rms in the patient vicinity. This means the area arund the patient bed. Pwer strips may be used be in nn-wet, nn direct patient areas. N medical equipment, including the resident bed r any high current draw devices can be plugged int a pwer strip. N hair dryers r refrigeratrs may be plugged int pwer strips. Equipment such as televisins, DVD players, and clcks, may be plugged int a pwer strip. Pwer strips are nt allwed t be plugged int anther pwer strip and extensin crds can nt be plugged int them. Where additin utlets are needed in the patient vicinity they must be installed in accrdance with NFPA 70 1999 editin, The Natinal Electrical Cde Pwer strips can nt be cvered with rugs r ther material. 14. What is defined as a hazardus strage area? Any area that pses a degree f hazard greater than that nrmal t the general ccupancy f the building r structure, such as areas used fr the strage r use f cmbustibles r flammables; txic, nxius, r crrsive materials; r heat prducing appliances. Life Safety Cde 2000 Editin, Chapter 19.3.2.1 (7) includes rms r spaces larger than 50 square feet, including repair shps, used fr strage f cmbustible supplies and equipment in quantities deemed hazardus by the authrity having jurisdictin (AHJ). In this case the AHJ wuld be the Life Safety Cde Surveyr cnducting the survey. 5
15. D laundry / linen chutes between flrs need t be lcked? Laundry/linen chute drs must have psitive latching hardware. Lcking f these drs is nt a Life Safety Cde requirement. Hwever, t cmply with state and federal requirements related t resident safety, laundry/linen chutes must be prtected frm unauthrized entry. Fr example, the laundry/linen chute culd be lcked r culd be lcated in a secure lcatin inaccessible t residents 16. If a facility is currently being surveyed under the Fire Safety Evaluatin Survey, r FSES, and the facility is nw in cmpliance because f changes in the life safety cde requirements, des the facility still have t be surveyed under the FSES? N, the FSES is a measuring system which is an alternative apprach fr cmpliance with the Life Safety Cde. It cmpares the level f safety prvided by an arrangement f safeguards that differ frm thse specified in NFPA 101, Life Safety Cde t the level f safety prvided in a building that cnfrms exactly t the details f the cde. It is the respnsibility f the facility t request an FSES. 17. Des the Life Safety Cde prhibit windw stps t prevent a windw frm pening mre than six inches? N, Life Safety Cde 2000 Editin, Chapter 19.3.8 states that each patient sleeping rm shall have an utside windw r utside dr, it des nt require the windw t be perable. Additinally, there is n requirement in the Ohi Building Cde 2002 editin fr windws t be perable in a nursing hme. 18. What are the requirements fr trash cans in resident rms? Life Safety Cde 2000 Editin, Chapter 19.7.5.5 prvides that siled linen r trash cllectin receptacles in resident rms shall nt exceed 32 gallns in capacity. Althugh these trash cntainers are nt required t be fire rated, under the Life Safety Cde requirements, the nursing hme licensing rules establish requirements fr ash trays and waste baskets as discussed belw. Under the Life Safety Cde 2000 Editin, large mbile siled linen r trash receptacles with capacities greater than 32 gallns can be mved alng the crridr as cllectins ccur but must be fire rated and attended by staff. If staff must leave the area, then the cntainer must be stred in a rm designed and maintained as a hazardus area in accrdance with Chapter 19.3.2.1. Ohi Administrative Cde rule 3701-17-20 pertaining t nursing hme licensure, states that ash trays, waste baskets r cntainers where burnable materials may be placed shall nt be made f materials which are flammable, cmbustible r capable f generating quantities f smke r txic gases. Ash trays and waste baskets and cntainers where burnable materials may be placed shall be nncmbustible r carry a fire resistant UL r FM rating. 6
19. Wh d I cntact t reprt an incident f fire? Send reprts f incidents f fire t the Divisin f Quality Assurance, Bureau f Regulatry Cmpliance t the attentin f the Safety and Health Cnsultant and t the State Fire Marshal. The frm is available n the Ohi Department f Cmmerce s Website at http://www.cm.state.h.us/sfm/firefrm.htm#cde. 20. Wh d I cntact t reprt that the fire alarm r sprinkler system will be dwn fr mre than fur hurs and the initiatin f a fire watch? T cmply with the Life Safety Cde 2000 Editin requirements fr Medicare/Medicaid certificatin ntify the apprpriate Bureau f Lng Term Care District Office. We als recmmend that yu als cntact yur lcal fire department. 21. Is it permissible t cnduct a silent fire drill n third shift and still be in cmpliance with federal and state requirements? Yes, the Life Safety Cde 2000 Editin Chapter 19.7.1.2 and Ohi Administrative Cde rule 3701-17-25 state that drills cnducted between 9 p.m. and 6 a.m. may use a cded annuncement instead f an audible alarm. 22. A three bin siled utility/ trash cntainer has a cmbined capacity f ver 32 gallns. Each individual cntainer has a separate lid and a capacity f less than 32 gallns. Is this cnsidered a cntainer ver 32 gallns? Yes, the cntainer is cnsidered t be ver 32 gallns and wuld, therefre, have t be lcated in a rm prtected as a hazardus area. (Life Safety Cde 2000 Editin, Chapter 18.7.5.5 and Chapter 19.7.5.5) Fr additinal infrmatin cntact: Safety & Health Cnsultant Bureau f Regulatry Cmpliance 614-644-6220 Nte: Respnses t questins are intended t assist prviders in their effrts t cmply with the Life Safety Cde in a general manner. Terms that are used may nt be well understd by readers wh are unfamiliar with building and fire safety cdes. Cnsultatin with qualified fire safety engineers r ther qualified prfessinals is advisable. Cmpliance with Life Safety Cde requirements is determined at the time f a survey. 7