Healthcare Life Safety Compliance - HCPro · Healthcare Life Safety Compliance The newsletter to...

Volume 17Issue No. 3 MARCH 2015

Healthcare Life Safety Compliance

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

It’s all in the pullAre your pull stations up to speed? Now might be the time to check. Find out how inside.

Transitioning to the new Life Safety Code (Part 2) In the second half of this series, HLSC provides tips for transitioning to the new Code. Life Safety during constructionIn the first of this series, HLSC takes a look at how construction can impact life safety, particularly in areas such as Interim Life Safety Measures.

Q&AThis month’s Q&A looks at signs on fire doors, sprinklers in construction projects, handrails in corridors, and more.

Quick tip This month’s quick tip provides a Building Tours by the Numbers tool.

P5

P6

P8

P10

P12

James Lake, vice-president of training and com-munications for the National Fire Sprinkler Association (NFSA), spoke at the recent annual conference of the American Society for Healthcare Engineering (ASHE) in Chicago, Illinois on the requirements for inspection, testing, and maintenance (ITM) of sprinkler systems. During his presentation, he often stated that ITM is a necessary pain in the neck to facility managers.

In 1905, three sprinkler contractors met in St. Louis, MO, and established what eventually became the Na-tional Fire Sprinkler Association (NFSA). Their mis-sion today is “To protect lives and property from fire through the widespread acceptance of [the] fire sprin-kler concept.” Now located in Patterson, New York, this membership organization is not affiliated with the National Fire Protection Association, but works col-laboratively with them in promoting the use of water-based fire protection sprinklers.

Sprinkler inspection and testing (Part 1)“As long as you maintain your system, your building

is going to be way better off in a fire situation,” says Lake. “Especially in the healthcare area. The average damage from a fire to a healthcare facility with sprin-klers is less than $5,000 compared to over $14,000 without sprinklers.”

Lake explains that the healthcare industry does well with limiting fire damage due to other features of fire safety, such as compartmentalization, smoke detection, and staff training.

“But let’s take a look at sprinkler system success, overall,” says Lake. “This is why sprinkler system main-tenance is critically important. What the data from NFPA tells us is 95% of the time that the sprinklers go off in a healthcare setting, the result was considered a success, meaning the sprinkler did what we intended it to do.”

Lake shared that NFPA annually sends out a new re-

Healthcare Life Safety Compliance March 2015

2 HCPRO.COM © 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

port of actual fire-related events. This report describes the experience of systems used and experiences learned from these events.

“In healthcare occupancies, what we intended sprin-klers to do is control the fire,” says Lake. “Most of the time it extinguished the fire before anybody got there to do anything about it. But that was not what the system was actually designed to do in accordance with NFPA 13, which is our standard for installation for sprinkler systems. It’s designed to control and prevent the spread of the fire to other rooms.”

Lake explained that in many ways, facilities protected with sprinklers during a fire are a victim of their own success because the sprinklers are very effective in controlling the fire.

“What gets reported in the media with sprinkler systems in a fire?” asks Lake. “What gets the headline? Water damage. Nobody stops to say there would have been $14,000 worth of damage in that building if the facility did not have sprinkler systems. Nobody reports that with sprinkler systems the facility is back up and operating within a few days.”

So, what about that 5% of the time that the activa-

tion of sprinklers in a fire situation did not perform as expected in healthcare facilities? Lake offers an explanation.

“Let’s take a look when sprinkler systems don’t do what we think they will do, which is control the fire,” says Lake. “What would define the situation where ‘Sprinkler systems are ineffective’? In a hospital it may be when a fire went beyond the room of origin. The sprinklers still operated, but it did not do what we wanted it to do, which was control the fire. In these situations 44% of the time, water did not reach the fire.”

Lake offers some common reasons why the water did not reach the fire.

When it comes to ‘When water did not reach the fire,’ the data tells us the sprinkler system did activate,” says Lake. “Why didn’t the water reach the fire? The most common reason was obstructions to the spray pattern. That is critically important, but it is also a pain in the neck to try and police. Whether it is privacy curtains, signage, or HVAC ductwork that gets installed after the sprinkler system, monitoring is a pain in the neck.”

Most healthcare facilities contract with a qualified

Follow UsFollow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc

Healthcare Life Safety Compliance (ISSN: 1523-7575 [print]; 1937-741X [online]) is published monthly by HCPro, a division of BLR®. Subscription rate is $329 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, 100 Winners Circle, Suite 300, Brentwood, TN 37027. Copyright © 2015 HCPro, a division of BLR. 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 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 subscription 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 Association 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 interpreta-tions 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

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

Joseph A. Berlesky, CHFM, CHEDirector, Plant FacilitiesBaptist Medical Center Beaches Jacksonville Beach, Florida

Frederick C. Bradley, PEPrincipalFCB Engineering Alpharetta, Georgia

Jamie Crouch Safety and Security ManagerMetro Health Hospital Wyoming, Michigan

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

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

Burton Klein, PEPresidentBurton Klein Associates Newton, Massachusetts

Henry KowalenkoSupervisor, Design Standards UnitOffice of Healthcare Regulation, Illinois Department of Public Health Chicago, Illinois

David MohilePresidentMedical Engineering Services, Inc. Leesburg, Virginia

James MurphyPresidentMRF, Ltd. Western Springs, Illinois

Thomas SalamoneDirector, Healthcare ServicesTelgian Corporation Atlanta, Georgia

Terry Schultz, PEPrincipalCode Consultants, Inc. St. Louis, Missouri

William Wilson, CFPS, PEMFire Safety CoordinatorBeaumont Hospitals Royal Oak, Michigan

Senior Managing EditorMatt Phillion, [email protected]

Senior EditorBrad Keyes, CHSP Senior Consultant Keyes Life Safety Compliance www.keyeslifesafety.com

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

Healthcare Life Safety ComplianceMarch 2015

3HCPRO.COM© 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

vendor to perform the annual inspection of the sprin-kler system, but Lake offers advice that surprises many individuals.

“It is not up to the contractor that you hire to test or inspect the sprinkler system to look at obstructions to sprinkler spray patterns,” says Lake. “It’s not his job. The contractor you hire to assess compliance with NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) is not there to evaluate if there are obstructions to the spray pattern. This is really important to understand because NFPA 25 clearly states that design issues, and obstructions, are not part of the ITM process.”

So, whose responsibility is it? According to Lake, it is the job of the owner of the facility, or the owner’s repre-sentative, to ensure there are no design issues or spray pattern obstructions. For most healthcare organiza-tions, that responsibility falls squarely on the shoulders of the facility manager. Making sure the owner’s repre-sentative fulfills this responsibility is another matter.

“This is something that the sprinkler industry cannot control,” says Lake. “Once the sprinkler system is in-stalled and determines that it works, we cannot control what happens next. It is up to the facility manager.”

Lake explains that 30% of the time sprinklers are considered ineffective, not enough water is released on the fire.

“This is another thing the sprinkler industry can-not control once we put the system in,” says Lake. “What happened in the room with the fire where not enough water was released? It could be an old system with obstructions in the piping. But another reason is we design systems based on a hazard classification assigned to the room. We design sprinkler systems to spray so much water, calculated as a density over the floor. And we have five different categories of hazard classifications: • Light• Ordinary group 1• Ordinary group 2• Extra hazard group 1• Extra hazard group 2

“And all five of these designs require a different amount of water coming out of the sprinkler systems. So if I’ve got a room classified as light hazard when the

sprinkler system was designed, and somebody comes along and changes that to a characteristic of an ordi-nary hazard group 2, my sprinkler system is going to operate, but what’s going to happen? Not enough water is going to come out. This is a critically important pain in the neck that everyone needs to be aware of.”

Lake explains that every time a room is changed as to what you’re doing in that room or what you’re storing in that room, the sprinkler system should be evaluated as to what it is capable of doing.

“And that is not the sprinkler testing and inspection contractor’s job,” says Lake. “His job is to make sure the sprinkler system is operating; not whether it is designed correctly.”

Lake also talks about when the sprinkler system did not operate at all.

“This is commonly caused by a closed valve in the system 72% of the time,” says Lake. “Another critically important pain in the neck: Make sure the valves that are supposed to be open, are open. The inspecting and testing contractor that you hire to inspect your system is only going to come in once or twice a year. How-ever, your facility’s staff are looking at those valves all the time, as required under NFPA 25. Or at least they should be.”

NFPA 25 is designed to provide a reasonable degree of protection to life and property through minimum inspec-tion, testing, and maintenance methods for water-based fire protection systems. NFPA 25 is not intended to ad-dress design deficiencies. The basic premise of NFPA 25 is it assumes the system has been properly installed.

“The definition of inspection is a visual check of the component to ensure it appears to be in good operating condition and free of physical damage,” says Lake. “So you walk up to this component and give it an inspec-tion: Does it pass inspection? If it is a control valve, is the valve open? Are all control valves on a sprinkler system required to be open? No, not necessarily. Con-trol valves to a test header for a fire pump for example need to be kept closed until the test header is needed. That leads to the question ‘What position does the valve need to be in?’ This needs to be documented for the visual check.”

Lake explains that testing is a process. A written procedure is obtained and the technician ensures that it is conducted. This involves multiple operations such as



flowing water; opening and closing valves; taking mea-surements; and evaluating the results against previous data. Maintenance is basically anything else that you do to the system to keep the system functioning properly, such as repair and replacement.

“Once you start making those kinds of evaluations, there is a difference as to who can do these things, and it mostly based on licensure laws within the states,” says Lake. “What qualifies an individual to do an inspection, a test, or maintenance on a system? What qualifies an individual to make a determination whether a sprinkler is installed correctly? Or to look at an alarm valve and identify a problem? NFPA 25 uses a definition from another standard, NFPA 96 (Stan-dard for Ventilation Control and Fire Protection of Commercial Cooking Operations), that says: ‘A quali-fied individual is a competent and capable person or company that has met the requirements and training for a given field acceptable to the authority having jurisdiction (AHJ).’ So it is the AHJ who determines who is qualified.”

Normally, when it comes to a qualified individual to do an inspection, Lake says the AHJs do not get too far involved with inspections. They will accept just about anyone who has gone and received some training to be able to identify the systems and how they are supposed to operate. However, that does not seem to apply to testing and maintenance of sprinkler systems.

“When it comes to testing and maintenance and lay-ing hands on that particular system, and opening and closing valves, and making evaluations of the system, typically if your state has a licensing law where contrac-tors are required to be licensed to work on the sprinkler system, those are the only individuals who should be touching the system and doing that work,” says Lake. “There are a few states that have limited licensing laws that allow owners up to a certain point in to test the fire pump. All other states require a license to test a fire pump. Usually, the state’s fire marshal office qualifies you to conduct the fire pump testing. But it is usually a state-recognized process.”

In the new 2011 edition of NFPA 25, it has added a couple of terms that is causing some problems, accord-ing to Lake.

“They have clarified some things but they have mud-died the waters as well,” says Lake. “The first one is,

they added the definition of the term ‘deficiency.’ Now the reason for this is previously in NFPA 25, the only definition that we had concerning problems with the sprinkler system was ‘impairment.’ The only formal definition that anything was wrong with the system was the system was impaired. And by virtue of the defini-tion of ‘impairment’, the system would not operate. Well, you’ve got lots of things that can happen to the system and the system will still operate.”

So in 2011, it was suggested that the technical com-mittee come up with the term ‘deficiency.’

“And deficiency was basically there’s something wrong with the system that is citable in NFPA 25 as a problem but the system will probably still operate,” says Lake. “For example, if I have a gauge that is too old, and has not been recalibrated or replaced, the system will still operate, but it is a violation of NFPA 25. Another example is if I have a hydraulic calculation plate (that is required on all system risers), but this plate does not have any information on it. While that is a problem, the system will still operate. That fits the definition of deficiency.”

But there are other deficiencies like a missing oc-cupant fire hose on a standpipe system which would result in the standpipe system not operating correctly.

“This leads to problems with the two subdivision categories of a deficiency: Critical deficiency and a non-critical deficiency,” says Lake. “This is where the water starts to get a little cloudy because the critical deficiency is the one that is really bad, and the system might not work. Non-critical deficiency is where you have a problem and the system will still operate, but you better get it fixed.”

Misunderstandings begin as to what qualifies as a critical deficiency and what qualifies as a non-critical deficiency. While NFPA 25 does offer definitions on these two sub-categories, it may take some time before the industry catches up. Lake discussses why impair-ments are different than deficiencies.

“What is an impairment and why is it important?” asks Lake. “By definition, an impairment to the sys-tem means it will not work. In the case of a valve that is required to be open, but is closed, the valve is not impaired; but the system is. The owner of the building, or its representative, is responsible.”

Check back next month for Part 2 of this series. H



It’s all in the pull The nurse finished with her patient and walked to the

utility room to replenish some of her supplies. While in the room, she noticed a burning odor and started looking for its source. After looking for a minute, she noticed there was a faint haze in the room that ap-peared to be smoke. She left the room and went to the nurse station and announced a Code Red situation in the utility room, and instructed the unit coordinator to call the special telephone number to report a fire. She then went to the fire alarm pull station and acti-vated the manual alarm box. Only, it did not actuate the alarm. She looked again at the pull station, and the handle was pulled all the way, in the farthest down position, and no amount of jiggling the lever was going to activate the fire alarm system. She then decided to go to the other end of the unit and activate that pull sta-tion. Fortunately, that manual station did activate the fire alarm system, which resulted in onsite responders arriving to assist.

The scenario described above actually did happen, and as luck would have it, the burning odor turned out to be a defective ballast in the light fixture in the utility room. No one was injured and no one had to be evacu-ated. But what about the pull station? Why did the one next to the nurse station fail to activate the fire alarm system, but the one at the end of the unit did?

A subsequent investigation by the Safety Officer of the hospital found that the mechanical lever action on the manual fire alarm box (NFPA no longer re-fers to them as pull stations) at the nurse station was defective, and the casting which was required to flip the switch to actuate the alarm had broken. In fact, there was physical evidence to suggest this particular manual fire alarm box had been defective for some time, based on small amounts of corrosion on the bro-ken edges of the casting. The Safety Officer remem-bered that the fire alarm system in this area had just been tested a few weeks prior. Going to the fire alarm test report, the Safety Officer discovered that the fire alarm technician marked this manual fire alarm box as having passed its test. Based on what the Safety Officer observed, there is no way the device could have passed any test.

It turns out the fire alarm technician did not falsify any results of the test, but he did not actually perform the test of the manual fire alarm box correctly. The method the technician used to test the device was to use a key to open the cover of the box and manually flip the internal switch, bypassing the lever action. Why did he decide to do it that way? Because he didn’t want to break the glass rod placed in front of the lever. This way, he did not have to replace any broken glass rods.

This is not an uncommon technique used by fire alarm service technicians across the country. They are performing their service based on what they were taught, and by the quickest and most efficient method available to them. However, the way technicians are taught to test fire alarms needs to comply with NFPA codes.

The 2010 edition of NFPA 72, Table 14.4.2.2 and the 1999 edition of NFPA 72, Table 7-2.2 both describe the test methods that technicians are required to follow when performing a test on the manual fire alarm box: “Manual fire alarm boxes shall be operated per the manufacturer’s published instructions.”

One typical manufacturer of manual fire alarm boxes states the following in its installation and op-erating instructions: “Operation – To activate a sin-gle-action pull station, simply pull down the handle. To activate dual-action stations, push in, then pull down the handle.” Note that the instructions make repeated reference to pulling down the handle. This manufacturer offers two styles of manual fire alarm boxes; single-action and double-action, and provides the operating instructions for each. Service techni-cians in the field test the manual fire alarm box by using a key or Allen wrench, without actually pulling down the handle as described, must also understand that such action does not constitute a code-compli-ant test.

The argument that some types of manual fire alarm boxes are too difficult or costly to test in this manner (those with break-glass front, or a glass rod to discour-age false alarms) does not negate the requirements to test by manual actuation. H



Transitioning to the new 2012 Life Safety Code: Part 2

Editor’s note: This is another article in a con-tinuing series to inform our readers on expected changes when the new 2012 Life Safety Code is finally adopted. Frank Van Overmeiren, presi-dent of FP&C Consulting, Inc. of Indianapolis, Indiana spoke at the recent Midwest Healthcare Engineering Conference in Indianapolis, Indiana, and offered some basic logic and understanding to the upcoming changes.

It is absolutely necessary to discuss how the new Life Safety Code® impacts suites in healthcare facilities.

“There have been lots of changes for suites,” says Van Overmeiren. “The new LSC says if you have direct supervision or smoke detection in your space (and most suites have direct supervision), you can now increase your suite size and get bigger. Now in the 2012 edition, we can go up to 7,500 sq. ft. where we have quick-response sprinklers or smoke detec-tion, and if I get both along with direct supervision, then I can go up to 10,000 sq. ft. for patient sleeping suites.”

You have to be careful with the smoke detection piece, notes Van Overmeiren.

“There is a way that NFPA defines smoke detection that is complete smoke detection throughout, so that means every occupiable space within the suite gets a smoke detector. So housekeeping closets, clean linen space, the IT closet; if it is in the suite, it gets a smoke detector,” he says. “I see many arrangements that have a clean linen room or a clean supply room that has an entry off the suite and an entry off the corridor. For those situations, I don’t have to classify that space as part of your suite. I can use the exit that is directly con-nected to the corridor and it is just a convenience open-ing to the suite for that clean linen room, and it doesn’t count as part of my 7,500 or 10,000 square feet.”

Van Overmeiren shared his dismay that it took this long to clean up the LSC when it was based on old technologies.

“In my 30 years history with suites, and my history is

based on facilities that were non-sprinklered, and prior to 25 years ago we had very limited smoke detection in our facilities,” says Van Overmeiren. “We didn’t even have smoke detection more than 35 years ago. So why did NFPA base limitations on suites that the indus-try had 35 years ago, where hospitals have increased fire safety by other features like sprinklers and smoke detection?”

According to Van Overmeiren, there are even more changes in the 2015 edition of the LSC which we cannot use. However, if you are a military hospital, a VA hospi-tal, or an Indian Affairs hospital, then the 2015 edition of NFPA 101 is available to them since they are not recipients of Medicare & Medicaid reimbursements.

“We also have an excellent change in the 2012 LSC that allows you to exit from suite to suite,” continues Van Overmeiren. “This now gives us the ability to have two ICU suites together, back to back, each having its own entrance from the corridor but an exit between the two that provides the means of a second exit. In your surgery space there may be a door opening between the suite containing the operating rooms, and the suite containing the PACU. Now this may be used as a legiti-mate second exit as long as each has its own corridor entrance.”

In previous editions of the LSC there were limitations on maximum travel distance and intervening room arrangements in suites. Some travel distances were 100 feet to get to an exit, while other travel distances were 50 feet if the path was through two intervening rooms. It became confusing on where doors had to be installed, and where openings without doors could be placed. It gave architects a lot of challenge based on how many intervening rooms there were from any location in the suite to exit to the corridor.

“All of that was eliminated in the process of the 2012 LSC changes,” says Van Overmeiren. “Now the new LSC has no intervening room rules and the maximum travel distance is 100 feet from the corner of the far-thest room to get to an exit access corridor door, for all suites.”

Similarly to other issues, the CMS categorical waivers



allow hospitals to utilize the new provisions on suites from the 2012 LSC today, and not wait until the new LSC is finally adopted.

Based on changes to the NFPA 96 Standard for the Ventilation Control, and Fire Protection of Commer-cial Cooking Operations, 2011 edition which the new 2012 LSC references, limited cooking facilities are now permitted to be open to the corridor under very re-stricted circumstances.

“Previously, there was only one category for commer-cialized cooking equipment for UL-listed fire suppres-sion systems,” says Van Overmeiren. “The 2012 edition of NFPA 101 now allows the smaller grade commercial cooking system to be open to our corridors. This is used primarily in our hospice areas and our long-term care spaces. We can have a traditional residential style stove in an alcove of the corridor, provided it is a fully sprin-klered space, with a smoke alarm, lockable electrical timer that restricts power to the stove to 120 minutes, and a lower level commercial hood. The hood is limited to 500 cubic feet per minutes (cfm), directly vented to the outside, and must have a fire-suppression system. The suppression system must still have a manual release, and a fuel shut-off. Most importantly, no solid fuel or deep-fat frying cooking is permitted under the hood.”

Previous editions of the LSC had strict limitations on the size of recycling containers we could have in our public spaces or rooms, without needing to store them in a hazardous room.

“The containers were basically limited to 32 gallons capacity,” says Van Overmeiren. “Anything over 32 gallons had to be stored inside a space classified as a hazardous room. The new 2012 LSC now allows con-tainers to be up to 96 gallons outside of the hazardous rooms.”

Interior finish rules changed as well with the new 2012 LSC. But there have been multiple surveys where incorrect citations were made on plywood mounted to walls used for backing when mounting equipment in electrical rooms.

“The new 2012 LSC lightened up the restrictions on interior finishes, permitting more levels of interior fin-ish limitations in our spaces,” says Van Overmeiren.

A variety of things have changed for sprinklered fa-cilities. Many of the older hospitals are becoming fully

sprinklered, which allows them to take advantage of exceptions for facilities that are fully sprinklered.

“We have provisions in the new 2012 NFPA 101that require sprinkler installation in existing buildings,” says Van Overmeiren. “The new chapter 43 specifically defines the different levels of rehabilitation in your facility, such as repair, renovation, modification, re-construction, change of use or occupancy classification, and addition. Chapter 43 now draws the line in the sand and explains what is required for each level of re-habilitation. When modifications are made, installation of sprinklers will be required. Likewise, chapter 19 re-quires that in any rehabilitation involving 50% or more of an existing smoke compartment, or more than 4500 sq. ft. of an existing smoke compartment, sprinklers need to be installed in the entire smoke compartment. For those hospitals that are not fully sprinklered yet, this is now being clarified and tightens up those rules where you have to install sprinklers. You’re going to get there so you need to be putting it into your projects.”

More changes involving sprinklers include patient clothes closets in hospitals.

“There are now provisions in the new 2012 LSC that clarift small closets in hospital spaces do not require sprinklers,” says Van Overmeiren. “The LSC finally got rid of trying to clarify what is a bureau, what is a piece of furniture, or what is a closet. It basically eliminated all of those and says six square feet or less in hospital environment - not nursing homes - does not require sprinklers.”

The previous editions of the LSC referenced older versions of NFPA 25 Standard for the Inspection, Test-ing, and Maintenance of Water-Based Fire Protection Systems, such as the 1998 edition. Now the 2012 LSC will reference the 2011 edition and some interesting changes are in store.

“Some of the changes relate to water flow switch testing,” says Van Overmeiren. We can now switch from quarterly testing and inspection of our water flow switches to semiannually. And CMS permits you through the categorical waiver process to utilize this change today, and not have to wait for CMS to adopt the 2012 LSC. Another change is the weekly churn test of the fire pumps. It is now a monthly churn test for electric-driven fire pumps only. Engine-driven fire pumps still have to be churn tested weekly.” H



Life Safety during construction (Part 1)

Editors note: Oftentimes construction projects inside the healthcare organization can affect life safety com-pliance for the entire facility. The following informa-tion is a guide of best practices cultivated from many different healthcare organizations, and is included here for you to share with your contractors.

Interim Life Safety MeasuresInterim Life Safety Measures (ILSM) are imple-

mented when certain features of life safety are either removed or impaired. The actual measures that need to be implemented are determined in accordance with the ILSM policy created by the healthcare organization. Check with the facilities management department prior to starting the construction project to determine what ILSM (if any) must be implemented and maintained. Review the life safety drawings to be familiar where required, rated barriers are located to ensure they are not damaged or removed.

Staging MaterialsCheck with the facilities management department to

determine where you are permitted to stage your ma-terials. Placing cardboard boxes of supplies in a room that previously did not store combustibles changes the characteristic of that room. Any room greater than 100 square feet that stores combustibles (i.e. cardboard, paper, wood, plastic, linens) is required to be one-hour fire-rated, with ¾ hour fire-rated doors that self-close and positively latch; and the room is required to be fully protected with automatic sprinklers.

Places where materials are never permitted to be staged are:• Corridors• Lobbies• Rooms with other occupants• In front of doors, preventing them from opening or

closing• Obstructing access to building operation functions,

such as electrical panels, fire alarm pull stations, or other devices

When supplies are used, the packaging material must

be removed from the work site on a daily basis. It is un-acceptable to allow wood, paper, cardboard or plastic packaging to accumulate, which creates a fuel load and potential danger.

Compressed Gas CylindersCompressed gas cylinders, regardless if they are

full or empty, must be properly secured at all times. “Secured” means chained to a tank holder, or to a wall or post. The intent is to prevent the compressed gas cylinder from falling over and breaking the valve stem, which would cause a dangerously rapid decompression of the cylinder. It is never permissible to lay a com-pressed gas cylinder over on its side.

Portable Fire ExtinguishersIf asked to provide portable fire extinguishers, they

must be properly marked with a tag indicating it has received its annual maintenance within the past 12 months. Additionally, once a month the extinguisher needs to be inspected for the following items:• Make sure the extinguisher is located in its proper

place• Ensure access to the extinguisher is free and

unobstructed• Operating instructions must be legible and pointed

outwards• Ensure the safety seal and tamper indicators are

unbroken and in place• Remove the extinguisher from its mounting and

“heft” it to determine if it is full• Inspect extinguisher for any obvious signs of dam-

age, corrosion, leakage or plugged discharge nozzle• Ensure pressure reading is in the operable range (if

equipped with a gauge)• For wheeled extinguishers, check the condition of

the tires, wheels, carriage, hose, and nozzle• Ensure the annual maintenance tag is attached,

and mark the monthly inspection with the date (month/day/year) and initials of the inspector

Mount the portable fire extinguisher on a wall in the project area, or on a post, or on a stand that can be eas-



ily moved around the area as needed. The bottom of the extinguisher must be mounted at least 4 inches above the floor, and the handles cannot be mounted any high-er than 60 inches above the floor. The fire extinguisher must be sized and classified for the anticipated type of fire. If the anticipated fire is normal combustibles (wood, paper, cardboard, plastic, linen) then a Class A extinguisher - minimum of 10 lb. size, mounted so the maximum travel distance to reach an extinguisher does not exceed 75 feet - is required. If the anticipated fire includes flammable liquids, then a Class B extinguisher - minimum 20 lb. size, mounted so the maximum travel distance to reach an extinguisher does not exceed 50 feet - is required.

Temporary Construction BarriersThe need to erect temporary construction barriers

between construction projects and occupied areas is primarily to prevent construction dirt and dust from migrating to occupied areas. The need for this goes beyond simple housekeeping measures. Construction dirt and dust frequently contain pathogens such as Aspergillus, which can be deadly to individuals with compromised immune conditions.

The most effective method to restrict Aspergillus from migrating to immunocompromised individuals is to control the dust. Dust is controlled by utilizing tem-porary construction barriers and negative air fans. A negative air fan is placed inside the construction area, and the discharge of the fan is ducted to the outdoors. When outdoor connections cannot be made, check with the facilities management department to determine if you can connect the discharge to an HVAC exhaust duct. Never connect the discharge of the negative air machine to an HVAC return duct, as mixing pressur-ized construction air with the HVAC return air system may cause an unbalanced air-pressure relationship somewhere else in the system. Even when the negative air machine is filtered with a HEPA filter, it is too risky to the patients and staff to have a pressurized return air system.

At times, the discharge of the negative air machine with HEPA filtered air is ducted to the corridor of the occupied area on the other side of the temporary con-struction barriers, thereby creating a negative pressure in the construction area. This is only permitted when

approved by the facilities management department. The discharge of the negative air machine can be noisy, which may be inappropriate in some locations. Howev-er, the discharge of the negative air machine is ducted, and all negative air machines must operate 24 hours per day, 7 days a week, until there is no more threat of dust or dirt from the construction area. It is not accept-able to turn off the negative air machines at the conclu-sion of the normal workday.

Walk-off tacky mats, or blankets that are constantly wetted, must be located at every exit from the construc-tion area that enters the healthcare facility. All equip-ment removed from the construction area that enters the healthcare facility must be wiped down to have all the dust and dirt removed. This also includes clothing worn by workers in the construction area.

While flame-retardant plastic visqueen barriers were frequently allowed in the past as temporary construc-tion barriers, the new 2012 Life Safety Code will no longer permit them. For construction areas that are not protected with automatic sprinklers, the temporary barriers must be 1-hour fire resistive rated construc-tion. This means 3½ inch steel studs, with one layer of 5/8 inch thick gypsum board on both sides of the studs, taped and mudded, along with a 3/4 hour fire-rated door and frame assembly that self-closes and positively latches the door.

For construction areas that are protected with auto-matic sprinklers, the temporary barriers do not have to be 1-hour fire resistive rated construction. However, tarps are not permitted to be used, so this means steel studs and gypsum board on one side would still be re-quired. Non-rated doors and frames would be permit-ted, but the door still has to self-close and positively latch.

Doors in the temporary construction barrier are not permitted to be secured with deadbolt locks. In a healthcare environment, a door in the path of egress is not permitted to have more than one releasing action to operate the door. A deadbolt lock that has a thumb-turn on the egress side and a door latch set requires two actions to operate the door. The door would have to be secured with a lock that automatically unlocks when the door latch handle is operated.

Next issue, we conclude this series in Life Safety During Construction. H



&AnswersQuestions

Editor’s note: Each month, Senior Editor Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, answers your questions about life safety compliance. 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.

Temporary signs on fire doors

Q Are handmade temporary directional signs per-mitted to be taped to fire doors? We had a sur-

veyor tell us that nothing can be taped to a fire door.

A Yes, temporary signs are permitted to be taped to a fire door, but they are limited in size. NF-

PA 80, Standard for Fire Doors and Fire Windows, 1999 edition, section 1-3.5, says informational signs installed on the surface of fire doors are permitted. The total area of the attached signs is not to exceed 5% of the area of the face of the fire door to which they are attached. Signs are required to be attached to fire doors using an adhesive. Mechanical attachments such as screws or nails are not permitted. Signs are not to be installed on glazing material in fire doors, and signs are not to be installed on the surface of fire doors so as to impair or otherwise interfere with the proper operation of the fire door. With a fire door size of 80” x 32” (approximate guess of the fire door in question), a single 8½ x 11 sheet of paper is well be-low the 5% maximum which the code permits. You state that the paper sign was observed to be attached to the door with adhesive, so it appears it meets the requirements for signage on fire doors. Sounds like a case for an appeal or clarification.

Sprinklers in construction projects

Q We have a construction project that involves re-moving all of the ceiling tiles in the area. Do we

have to relocate the sprinkler heads to within 12” from the deck above? Do you have any guidance on what’s required for fire protection in the construction area?

A If your organization is required to be in com-pliance with the 2000 edition of the Life Safe-

ty Code, then sections 18/19.7.9.2 require compliance with the provisions of NFPA 241 Standard for Safe-guarding Construction, Alteration and Demolition Operations (1996 edition), during renovation and construction that includes a means of egress. The phrase “means of egress” pretty much covers every-thing, so it would be a safe bet that NFPA 241 applies whenever any construction or renovation is under way. The 1996 edition of NFPA 241 does not require an active water-based sprinkler fire protection system to be installed and operating during the construc-tion phase, but if there is one, it must comply with NFPA 13 Standard for Installation of Sprinkler Sys-tem, which means sprinkler heads would have to be mounted within 12 inches of the deck if the suspend-ed acoustical tile ceiling has been removed. The 1996 edition of NFPA 241 also only requires fire resistant and smoke resistant temporary construction barriers, rather than 1-hour fire-rated barriers. Now, the 2012 edition of the Life Safety Code requires compliance with the 2009 edition of NFPA 241, which did un-dergo a change in regards to temporary construction barriers. The requirement for temporary construc-tion barriers changed to be either 1-hour fire-rated, or non-rated fire-resistant if the construction area is ful-ly protected with automatic sprinklers. Again, sprin-klers are not mandatory, but if you have them, they must comply with NFPA 13. If the decision for tem-porary construction barriers is to go with 1-hour fire-rated walls, then a ¾ hour fire-rated door, which is self-closing and positive latching, must be provided. To answer your question directly, I would say “No,” there is no requirement whereby you must relocate



the heads to within 12 inches of the deck. However, if you do, it may save you considerable expenses in oth-er areas. If the area is properly sprinklered according to NFPA 13, then a fire watch would not have to be implemented, and the temporary construction barri-ers would not have to be 1-hour fire-rated. This may become a significant expense which could be avoided. If this construction area is located underneath an oc-cupied inpatient unit, then it makes much more sense to provide properly installed sprinklers in the con-struction project for added protection, which should reduce the risk of the renovation to the inpatients.

Handrails in corridors

Q I am working on an aesthetic corridor remodel for a hospital. Can you please tell me if there are

specific requirements as to handrail locations (i.e., one side of the wall vs. both sides, at what locations, for what amount of distance, etc.)?

A In regards to healthcare occupancies, and spe-cifically hospitals, there is no Life Safety Code

requirement for handrails in an exit access corridor. There are requirements for stairs, exit enclosures, ramps, and exit passageways to have handrails, but the LSC does not have any requirements for corri-dors. However, there are other codes and standards to consider. The Facility Guidelines Institute re-quires hospitals to comply with ADA requirements in regards to handrails in corridors, unless the func-tional program narrative specifically decides against them. What this means is, if the hospital has a writ-ten program that describes the use and activities that the corridor serves is not consistent with handrails, then it is permissible not to install them. An exam-ple of this may be a Psychiatric unit where a hand-rail could possibly be removed and used as a weapon. In essence, the hospital gets to decide if there will be handrails, but the reason needs to be plausible and written down in a program narrative. Also, compli-ance with ADA requirements is required whenever new construction or renovation of an existing area is conducted. I do not believe just installing new wall-paper qualifies as renovation, so compliance with ADA would not be required. I strongly recommend

that you contact the local and state authorities to de-termine if they have regulations that would require handrails.

Soiled utility room door signage

Q Are you aware of any door signage requirements for soiled utility rooms and/or trash rooms?

A There is no Life Safety Code requirement for signs on a soiled utility room door or a trash

collection room door, unless the door could some-how be confused with an exit door. Then a “NO EX-IT” sign will have to be posted on the door, with the word “NO” 2 inches tall, and the word “EXIT” 1 inch tall, and the word “NO” has to be on top of the word “EXIT”. If the doors to the soiled utility room or the trash collection room are fire-rated doors, then the sign must be no larger than 5% of the overall surface area of the door, and can only be attached to the door with adhesives. Nails and screws are not permitted to attach a sign to a fire-rated door.

Helium tank/ ABHR dispenser location

Q Can we have a helium tank if secured prop-erly in gift shop? And what are requirements

for hand sanitizer locations-proximity to switches or outlets?

A Provided the tank is secured properly, and there is less than 300 cubic feet of compressed

gas total in the gift shop, you may have a helium tank in the shop. The typical “H” tank (which is approxi-mately 9 inches in diameter and about 55 inches tall) contains 250 cubic feet, so one “H” tank properly se-cured in the gift shop would be permissible (but only one tank). Joint Commission has changed their re-quirements to allow the Alcohol Based Hand Rub (ABHR) dispensers to be mounted no less than 1 inch side-to-side to an electrical outlet or an electrical switch. However, CMS is still on the definition of no less than 6 inches center-to-center between an ABHR dispenser and an electrical outlet or switch. Once the new 2012 edition of the Life Safety Code is adopted, then CMS will be on the same page as the Joint Com-mission. H



Quick Tip

The building tour, by the numbers: Part 2

Source: Brad Keyes, CHSP, Senior Consultant, Keyes Life Safety

Number Unit of Measure Requirement Standard

28 inch The minimum width of an exit access that is not a corridor in existing construction NFPA 101 (2012) 7.3.4.1.2

30 square feet The aggregate area per patient required for each smoke compartment NFPA 101 (2012) 19.3.7.5.1

30 percent The maximum area of wall, ceiling and door permitted for combustible decorations in a space located in a smoke compartment protected with automatic sprinklers NFPA 101 (2012) 19.7.5.6

30 feet The maximum length of existing dead-end corridors in healthcare occupancies NFPA 101 (2012) 19.2.5.2

30 lbs. The maximum force permitted to set a door leaf in motion NFPA 101 (2012) 7.2.1.4.5.1

32 gallon The maximum capacity of trash collection receptacles that are stored outside of a hazardous room NFPA 101 (2012) 19.7.5.7.1

32 inch The minimum clear width for door openings in the mean of egress for existing healthcare occupancies NFPA 101 (2012) 19.2.3.6

36 inch The minimum distance smoke and heat detectors must be located from a supply or return air diffuser NFPA 72 (2010) A.17.7.4.1

36 inch The minimum width of an exit access that is not a corridor in new construction NFPA 101 (2012) 7.3.4.1

41½ inch The minimum clear width of door openings in the means of egress for new construction healthcare occupancies NFPA 101 (2012) 18.2.3.6

44 inch The required width of corridors not intended for the use of inpatients in new and existing healthcare occupancies NFPA 101 (2012) 19.2.3.4

48 inch The required width for corridors serving the means of egress for patient sleeping rooms in existing healthcare occupancies NFPA 101 (2012) 19.2.3.4

50 feet The maximum travel distance from any point in a healthcare sleeping room to an exit access corridor NFPA 101 (2012) 19.2.6.2.3

50 percentThe maximum area of wall, ceiling and door permitted for combustible decorations in a patient sleeping room not exceeding four persons, located in smoke compartment protected with automatic sprinklers

NFPA 101 (2012) 19.7.5.6

50 percent One of two factors used to determine major vs. minor rehabilitation. If renovation is 50% or more of a single non-sprinklered smoke compartment, then the entire smoke compartment must be sprinklered NFPA 101 (2012) 19.1.1.4.3.1

80 square inches The maximum area of an opening for pass-throughs in corridor walls located in smoke compartments that are fully protected with automatic sprinklers NFPA 101 (2012) 19.3.6.5.2

96 gallon The maximum capacity of a recycling container that is left unattended outside of a hazardous room NFPA 101 (2012) 19.7.5.7.2

100 feet The maximum travel distance from any point in a suite to reach an exit access corridor NFPA 101 (2012) 19.2.5.7.2.4

150 feet The maximum travel distance from any point in a room or suite to reach an exit, in a building not fully protected with automatic sprinklers NFPA 101 (2012) 19.2.5.7.2.4

200 feet The maximum travel distance from any point in a room or suite to reach an exit, in a building that is fully protected with automatic sprinklers NFPA 101 (2012) 19.2.5.7.2.4

200 feet The maximum travel distance from any point to reach a smoke compartment barrier door NFPA 101 (2012) 19.3.7.1

200 feet The maximum travel distance to reach a fire alarm manual pull station. NFPA 72 (2010) 17.14.8

212 degrees The maximum temperature (F) of the heater elements on portable heaters used in healthcare occupancies NFPA 101 (2012) 19.7.8

4500 square feetThe second of two factors used to determine major vs. minor rehabilitation. If renovation is 4,500 square feet or more in a non-sprinklered smoke compartment, then the entire smoke compart-ment must be sprinklered

NFPA 101 (2012) 19.1.1.4.3.1

5000 square feet The maximum area of sleeping suites that are located in a smoke compartment not protected with automatic sprinklers NFPA 101 (2012) 19.2.5.7.2.3

7500 square feet The maximum area of sleeping suites in smoke compartments that are protected with standard-response sprinklers and smoke detectors; or protected with quick-response sprinklers NFPA 101 (2012) 19.2.5.7.2.3

10,000 square feet The maximum area of sleeping suites that have direct supervision of patients, total smoke detection, and protected with quick-response sprinklers NFPA 101 (2012) 19.2.5.7.2.3

10,000 square feet The maximum area of non-sleeping suites. NFPA 101 (2012) 19.2.5.7.3.3

22,500 square feet The maximum area of a smoke compartment NFPA 101 (2012) 19.3.7.1

The following chart lists many of the life safety requirements that one may use during the building tour of the healthcare occupancy. The following information is based on codes and standards referenced by the 2012 Life Safety Code®. Check out the first half of this list presented in last month’s issue.

1. (T) (F) The National Fire Sprinkler Association is an independent affiliate of the National Fire Protection Association.

2. (T) (F) It is not up to the contractor hired to perform the tests and inspections on the sprinkler system to look for obstructions to sprinkler spray patterns.

3. (T) (F) When you change the use of a room that is protected with sprinklers, it is not necessary to review the design parameters of the sprinkler system.

4. (T) (F) Normally, when it comes to determining the qualifications of the individual doing the sprin kler inspection, the AHJs do not get to far involved with that.

5. (T) (F) When testing a fire alarm pull station, it is acceptable to open the pull station box and acti vate the internal switch manually.

6. (T) (F) When looking for a place to stage construction materials, corridors, lobbies and rooms with occupants are not acceptable locations.

7. (T) (F) Removing and “hefting” a portable fire extinguisher during the monthly inspection is no lon ger a NFPA requirement.

8. (T) (F) The most effective method to restrict Aspergillus from spreading to occupied areas is to control the dust in construction projects.

9. (T) (F) Handmade temporary signs are not permitted to be attached to fire-rated doors.

10. (T) (F) When removing a ceiling during a renovation project, the sprinkler heads in the ceiling need to be replaced with upright type heads and mounted within 12 inches of the deck.

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

Vol. 17 No. 3March 2015

Quiz questions March 2015 (Vol. 17, No. 3)

A supplement to Healthcare Life Safety Compliance

Quiz answers March 2015 (Vol. 17, No. 3)

1. False. The NFSA is not affiliated with the NFPA, even though they collaborate on many programs.

2. True. The owner (or owner’s representative) of the facility is responsible to ensure the spray pattern of the sprinklers is not obstructed.

3. False. You must review the design hazard classifications of the sprinkler system when you change the use of a room that is protected with sprinklers.

4. True.

5. False. When testing the fire alarm pull stations, NFPA 72 requires them to be operated per the manufacturer’s instructions.

6. True.

7. False. Hefting is still a requirement during the monthly inspections.

8. True.

9. False. Temporary signs are permitted to be attached to fire-rated doors as long as the sign does not exceed 5% of the door area, and the sign is attached with adhesive material.

10. True.

Copyright 2015 HCPro, a division of BLR®. 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.

Healthcare Life Safety Compliance - HCPro · Healthcare Life Safety Compliance The newsletter to...

Documents

Transcript of Healthcare Life Safety Compliance - HCPro · Healthcare Life Safety Compliance The newsletter to...