Medical Gas Shutoff Valves
by Brad Keyes, CHSP, on Feb 19, 2021 1:00:00 AM
Q: We have oxygen and vacuum shutoff valves on many of our patient floors. On the 2nd, 3rd, and 4th floors (and maybe the 5th floor), the valves serving medical vacuum are above the ceiling. I’m guessing that, because they are above the ceiling, they would not qualify as an emergency shutoff valve since they can’t be easily accessed. The question is, do I need an emergency shutoff valve? Is there a requirement that all medical gas have an emergency shutoff valve located in the area that the gas serves? If not, I might call these valves above the ceiling a service valve and make no formal (sign) reference to them. What do you think?
A: I think, “How in the world do these things muster through survey inspections and never get cited?"
What you have described is a serious violation and one that could lead to an Immediate Jeopardy (IJ) decision if observed by a CMS surveyor. Section 18.104.22.168 of NFPA 99-2012 says all station outlets/inlets must be supplied through a zone valve, and then it continues to describe the requirements for the zone valves. I will summarize some of them here for you:
- Zone valves must be installed where they are visible and accessible at all times.
- Zone valves cannot be installed above a ceiling or in a room.
- Zone valves must be readily operable in a standing position in the corridor on the same floor where the outlets are located that they serve.
- Zone valves must be located such that a wall intervenes between the valve and the outlets/inlets.
- Zone valves cannot be located in the same room with the outlets/inlets that they serve.
- Zone valves cannot be installed behind normally open or normally closed doors or otherwise hidden from plain view.
What you describe is a real problem. It is a sad commentary that your survey inspections failed to identify this problem. I suggest you make plans to have these zone valves properly installed as soon as possible.