Spot Coolers in Corridors
Q: According to the 2012 Life Safety Code, the width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes shall be at least 8 feet. In limited care facility and psychiatric hospitals, width of aisles or corridors shall be at least 6 feet, except as modified by the 18.2.3.4 or 18.2.3.5 exceptions 18.2.3.4, 18.2.3.5. My question is: How do portable spot coolers relate to this standard if you have an HVAC unit that is not functioning at full capacity and you’re awaiting parts to repair the unit? Would being able to have 6 feet of corridor space be sufficient for them to be in the corridor? Would a waiver need to be applied for? I have a facility that is going to be facing accreditation very soon and it hit me in the middle of the night if this would end up as a life safety deficiency.
The facility is trying to maintain the acceptable temperature for patient care on one of its units.
A: Having a spot cooler in the corridor that obstructs the required width of the corridor is a life safety deficiency. What do you do when you have life safety deficiencies? You conduct an ILSM risk assessment. Get that done right away.
Now, having done a ILSM assessment is not a get-out-of-jail-card-free. Any surveyor worth their salt should (and will) cite the organization for having an obstruction in the required width of the corridor, even with an ILSM risk assessment conducted. What an ILSM risk assessment does for you is you assess the situation in accordance with your ILSM policy, and you implement the appropriate activities to compensate for the life safety deficiency in order to have an acceptable level of safety. Typically, an obstruction in the required means of egress warrants extra fire drills in the impaired area to ensure staff knows of the deficiency and implements appropriate alternative actions. But, this is left to the healthcare organization to determine.
CMS and the accreditation organizations (as well as the state agencies that survey on behalf of CMS) require you to conduct an ILSM risk assessment whenever you have a life safety deficiency that you cannot immediately resolve (Immediate in this case is usually interpreted to be by the end of the shift, or day, by most AHJs). Some AHJs require you to send a copy of that ILSM assessment to the local fire department or to the state agency who surveys on behalf of CMS.
Since it is a requirement to conduct an ILSM risk assessment for life safety deficiencies, if the surveyor discovers that you did not do the assessment, then they can cite you for that in addition to a citation for having an obstruction in the required means of egress. Some AHJs consider this an elevated citation that may warrant a return inspection.
No, a waiver is not appropriate because you have not been cited yet, and I very much doubt CMS would approve a waiver for a spot cooler in the means of egress. I suggest you do your best to get the HVAC system repaired/replaced in order to get the spot cooler out of the corridor, as soon as possible.
