Q: We are a hospital and if there was a fire, say at the northeast part of the building does everyone throughout the whole building have to evacuate the building or only the ones on that side of the building? Same thing with fire drills; does everyone have to evacuate?
A: No… Everyone does not have to evacuate. You never want to evacuate the building unless it is absolutely necessary. Evacuation should always be horizontal and local. This means if 4 west has a fire, then the occupants on 4 west evacuate to 4 east, (or 4 north, or 4 south). You do not take patients down the stairs unless it is absolutely necessary. If you do have to evacuate vertically, you use an elevator that is not actively involved with the fire to evacuate the patients. Forget all those signs that say “In Case of Fire – Use Stairs”. That does not apply to evacuating patients. The Life Safety Code actually says it is permissible and recommended that you use elevators in the evacuation of patients, as long as the elevator is not actively involved in the fire.
For fire drills, you use simulated patients (put a staff member in a wheelchair and observe the other staff members push the wheelchair to an adjoining smoke compartment). You must observe that they did evacuate a simulated patient to the adjoining (horizontal) smoke compartment. That is why it is important to identify which set of cross-corridor doors are smoke barriers.
Q: What is the standard on fire extinguishers in work vehicles? We have them in our transit vans to our home health nurses. Do we need them inspected and retagged every year like our buildings? Also do they need a monthly check as well?
A: I am not aware of any NFPA code or standard that requires portable fire extinguishers inside vehicles used/owned/leased by healthcare organizations. If there is a requirement to have them, it may come from your insurance provider.
However, the expectation is once you have them, you must maintain them. So that would mean you need to inspect them monthly, and provide maintenance service on an annual basis.
Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or inspections on fire alarm systems and sprinkler systems?
A: NFPA 72-2010, section 10.4.3.1 requires a certified individual to perform service, testing, inspection and maintenance on fire alarm systems and components. The certification must be one (not all) of the following:
- Factory trained and certified for the specific type and brand of systems being serviced
- Persons who are certified by a nationally recognized certification organization (NICET, IMSA, etc.)
- Persons who are registered, licensed or certified by the state
- Persons who are employed and qualified by an organization listed by a national recognized testing laboratory for servicing fire alarm systems.
I have seen some larger hospitals that do employ people who meet one of the above requirements, but most hospitals contract this work to a qualified vendor who has these credentials. When it comes to sprinkler system testing/inspecting, NFPA does not require certification of the individuals performing the test/inspection. However, please check with your state and local AHJ to determine if they have additional requirements.
Q: Years ago, our state health department approved an addition to a hospital that I supervise. The addition is wood framed, not sprinkler protected, and does not have the required 2-hour fire barrier separation (yes, I’m serious). Recently, sprayed-on fire proofing began to fall from the deck. After consultation, we’ve decided the best course of action is to add complete sprinkler protection to this area. This is a costly project and will take time for approval. What are your thoughts on implementing some sort of ILSM? There is no egress blocked, or obstructed, but this is an area where there are MRI machines and I believe the wood framing with no sprinkler and fire proofing issues can be a serious concern.
A: Wow… that is a serious problem. You did not say what your Construction Type is. Since it involves wood-frame, it has to be one of the following:
- Type III (211) with sprinklers
- Type IV (2HH) with sprinklers
- Type V (111) with sprinklers
But you say it does not have any sprinklers? Yeah… that’s serious problem. And there is no 2-hour fire-rated vertically aligned barrier to separate this non-compliant construction type from the rest of the hospital? That means the rest of the hospital is also now non-compliant.
You absolutely need to assess this issue for ILSMs and document your assessment. The whole hospital is now out of compliance with the Life Safety Code regarding Construction Type (see Table 18.104.22.168 of the 2012 Life Safety Code). When there is no proper 2-hour fire rated vertically aligned barrier separating different construction types, then the lesser construction type prevails, and the rest of the hospital is not permitted to have this type of construction type.
You need to get professional help. Contact your architect, or a different architect if the one you currently use got you into this pickle. Discuss this with your CEO and tell him/her that you have three serious issues that will require funds:
- Reapply the failing fire-proofing
- Install sprinklers in the addition
- Create a 2-hour vertically aligned barrier to separate the different construction types.
Develop a plan and time-line to implement all of these changes and improvements, but you need to discuss this with your architect, and before you do any construction, you need to submit a plan to the state and local authorities for their review.
Please understand that if you fail to resolve these issues, your next survey could end up being a Conditional Level Finding, based on the seriousness of the deficiencies.
Q: Do you know anything about fire drills on weekends? What is the requirement?
A: Section 22.214.171.124 of the 2012 LSC says fire drills must be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required, under varied conditions.
The accreditation organizations (AOs) have standards that say similar things. The term ‘under varied conditions’ is used to mean not only different scenarios are used for fire drills, but the fire drills are conducted in different locations, at different times (up to 2-hours different start time for same-shift drills), and on different days of the week. This is often interpreted by the AOs to mean fire drills must include the weekend and holiday shift personnel.
You will not find a specific standard in the CMS Conditions of Participation, or the AOs manual that states fire drills must be conducted on weekends and holidays, but the expectation of the surveyors is you will. If you fail to include those workers, then you are not conducting drills under ‘varied conditions’.
Continuing in a series of strange things that I have seen while consulting at hospitals…
Where do you see public pay-phones in a hospital, anymore….?
In the behavioral health unit, that’s where. Or at least, that is where I saw this one.
The problem here is the phone and the wood booth projects more than 4-inches into the corridor, which is the maximum allowable amount by CMS.
Another problem that many of you readers pointed out that I forgot to mention, is the long cord on the telephone is a ligature risk.
Q: Do fire door inspection records need to be maintained for 3 years?
A: I would say at least 3-years, and longer as needed. NFPA 80-2010 section 5.2.1 says fire door assemblies must be inspected and tested not less than annually, and a written record of the inspection must be signed and kept for inspection by the AHJ. Since your routine accreditation surveys are once every 3-years, and since the purpose of the accreditation survey is to determine compliance with the standards since the last survey, then I would say you need to retain all records at least 3 years so the surveyor can confirm your level of compliance during that 3-year period. Now, it is my position that you should never throw away any document confirming regulatory compliance as you may need it someday, for other AHJs or maybe even litigation purposes. You can purge your files of test reports older than 3 years but make sure you box them up and store them somewhere safe and dry.
Q: I have a contractor coming in to put up a wall in our nursing home dining room. He is wanting to use fire treated wood. Would this be acceptable to the Life Safety Code?
A: Did you first discuss this with your architect? Or did you first discuss this with your state agency that licenses nursing homes? You need to do that to make sure what you install is compliant with codes and standards.
I cannot answer your question because I do not know what your construction type is, how many stories you have, and whether or not you are fully protected with sprinklers. Is this wall going to be load bearing or non-load bearing?
If your facility is Type I or Type II construction, then combustible materials are not permitted on load-bearing walls, and other structural members. Fire-treated wood is considered combustible, so it would not be permitted for use on structural members of the building.
According to section 126.96.36.199 of the 2012 Life Safety Code, it says interior nonbearing walls required to have a minimum 2-hour fire resistance rating shall be permitted to be of fire retardant treated wood enclosed within noncombustible or limited-combustible materials, provided that such walls are not used as shaft enclosures. Is the wall going to be fire-rated to a minimum of 2-hour rating? But this section does not permit fire-retardant wood to be used on walls that are less than 2-hour fire rated.
According to section 188.8.131.52, fire-treated wood that serves as supports for the installation of fixtures and equipment shall be permitted to be installed behind noncombustible or limited combustible sheathing. You definitely need the gypsum board sheathing to cover all of the fire-retardant-treated wood, but that’s only for fixtures and equipment supports.
The way I read the LSC, unless the fire-treated wall is a 2-hour fire-rated wall, or the fire-treated wood is used to support equipment or fixtures, then it is not permitted in a healthcare occupancy.
Before you let this contractor begin, you really need to contact your architect and have him/her design the proper wall assembly, and then have it approved by your state and/or local authorities.
Q: I have a question regarding access-control locks. I’m told that a PUSH TO EXIT button is required. My question: Is a PULL TO EXIT lever equivalent?
A: No… I would say a “PULL TO EXIT” lever is not equivalent. Section 184.108.40.206.2 of the 2012 Life Safety Code refers to access-control locks which calls for a manual release device, located on the egress side, 40 inches to 48 inches vertically above the floor, and within 60 inches of the secured opening. The manual release device must be readily accessible and clearly identified by a sign that reads “PUSH TO EXIT”. When operated, the manual release device must result in direct interruption of power to the lock – independent of the locking system electronics – and the lock must remain unlocked for not less than 30 seconds.
A “PUSH TO EXIT” manual device is what’s required… not a “PULL TO EXIT” device.
Q: Our original hospital was constructed in 1968, then we had an addition in 1992 and our newest addition completed in 2013. Do the hazardous rooms in our buildings that are all fully sprinklered have to be maintained as 1-hour fire-rated walls with 3/4-hour fire-rated doors, or can we maintained them to just resist the passage of smoke based on the “existing” chapter? I was told that anything constructed before the date the Life Safety Code was adopted is now considered existing conditions.
A: To answer your question, the new construction healthcare occupancy chapter 18 applies to all buildings designed, approved and constructed after July 5, 2016, which is the date that CMS adopted the 2012 life Safety Code. That means all conditions designed, approved and/or constructed on or before July 5, 2016 would comply (as a minimum) to the existing healthcare occupancy chapter 19.
However, there are other conditions that you need to be aware of. According to section 4.5.8 of the 2012 Life Safety Code, whenever a feature of life safety is required by the LSC, it must be maintained as such, unless the LSC changes and the feature is no longer required. This means, if at the time the hazardous room was constructed the walls needed to be 1-hour fire rated and the door ¾-hour fire rated and the room be sprinklered, then you must maintain it that way, even though the room may now qualify as existing conditions and the walls and door only need to be smoke resistant.
So, for new construction hazardous rooms, section 220.127.116.11 of the 2012 LSC requires the room to have 1-hour fire-rated protection which requires ¾-hour fire rated doors assemblies that self-close and positively latch. Section 18.104.22.168 also requires the room to be protected with sprinklers. You would build your new construction (or renovated existing) hazardous rooms to 1-hour fire-rated walls (which must extend from the floor to the deck) and have the door assemblies meet ¾-hour fire rating.
Understand, the hazardous rooms constructed in the 1968 building would qualify for the existing conditions healthcare occupancy chapter 19 today because they were constructed before July 5, 2016, and at the time of their construction the Life Safety Code had not yet been adopted by any national governmental or accreditation organization. But the hazardous rooms constructed in the 1992 addition would have been required to be 1-hour fire rated with a ¾-hour fire rated door, and be protected with sprinklers, because that is what was required for new construction in 1992 for hazardous rooms. Therefore, since 4.5.8 says once it is built, you have to maintain it, it must remain 1-hour fire rated walls with ¾-hour fire rated doors and be fully sprinklered, even though it was built before July 5, 2016. Yes, it qualifies for existing conditions under the 2012 LSC, but since it was built to new construction requirements, that is what you must maintain, until the LSC changes.
Now, some hospitals have older hazardous rooms that for one reason or another, were not constructed to 1-hour fire-rated construction and protected with sprinklers, although they were supposed to. This was likely an oversight at the time of the construction by the AHJ or perhaps the hospital constructed the room without the AHJ’s knowledge or permission. When these old mistakes are caught, many authorities having jurisdiction (AHJs) are actually requiring the hospital to upgrade their old hazardous rooms to 1-hour fire-rated construction and meet new construction requirements. Their logic is, that is what was required back when the hazardous room was constructed, so it is being enforced now. Right or wrong, they have the authority to enforce that onto the hospital.
Q: Are alcohol-based hand rub (ABHR) dispensers allowed in Operating Rooms or Operating Room suites. We could not find a prohibition of them in LSC — just double checking.
A: The Life Safety Code does not prohibit ABHR dispensers in operating rooms or operating room suites.
Please check with state and local authorities to determine if they have any restrictions on ABHR dispenser locations.
Q: Our hospital has a few offsite locations – family practice clinic, occupational health clinic, and soon to be an urgent care clinic. It is my understanding that these facilities are considered a business occupancy. They are not licensed as a department of our hospital. Do they need Interim Life Safety Measures (ILSM) for construction projects?
A: Yes, all construction projects should be evaluated for Alternative Life Safety Measures (ALSM), also known as Interim Life Safety Measures, regardless in what building they are conducted. This is a requirement of section 22.214.171.124 of the 2012 Life Safety Code, to evaluate any impairment of a life safety feature for consideration of implementing compensating measures. Even if an accreditation surveyor does not make an onsite assessment of the facility, the organization is still obligated through section 126.96.36.199 to conduct an ALSM risk assessment.
Q: Do missing ceiling tiles in a suspended ceiling create a Life Safety Code deficiency in an existing business occupancy? Should section 188.8.131.52 of the 2012 Life Safety Code apply to require the maintenance of broken or missing ceiling tiles in a business occupancy?
A: The complete membrane that the ceiling forms is required if sprinklers or smoke (or heat) detectors are installed in the room or area served by the ceiling. The ceiling acts to trap the heat and smoke and allows the sprinklers or detectors to operate. Otherwise, if a ceiling tile is missing, or has excessive gaps around penetrations, or the ceiling tiles have holes, then heat and smoke can continue up into the interstitial space above and the operation of the sprinklers and/or detectors would be delayed, thus causing an impairment.
If there are no sprinklers or smoke (or heat) detectors in the room or area, then there may not be any Life Safety Code reason for the ceiling system, unless it serves as part of the fire-rated floor/ceiling system, such as UL-G227 or UL-G235. Section 184.108.40.206 would not apply if the ceiling is not serving a purpose of life safety. Now, the suspended grid and tile ceiling may serve an Infection Control purpose, and you would have to maintain it for that reason, but that is not a Life Safety Code purpose.
Yes… this would apply to business occupancies. It is not dependent on any particular occupancy.
Q: One of our doctors wants me to mount a large sharps container just inside the wall. It won’t hinder the door, but I’m wondering if there are any safety issues regarding how high or low the sharps container can be mounted.
A: Inside the wall? If I understand you correctly, you will be cutting open the wall to insert the container inside the wall?
If so, you need to confirm that the wall is not a rated wall of any type. There are multiple different ratings for walls in a hospital, such as: 2-hour fire-rated, 1-hour fire-rated, smoke barrier, and smoke partition. These walls cannot be breeched to insert a sharps container.
Once installed, the sharps container cannot project more than 4-inches into the corridor. This applies if the container is surface mounted or mounted inside the wall.
As far as height of the container is concerned, the Life Safety Code does not address this issue, but there are likely other standards that may apply, such as CDC standards, AAMI standards, AORN standards, FGI Guidelines, etc. Please check with your state and local authorities before making any decisions on mounting these containers.
UPDATE: I was informed by a reader that the gold standard for placement and handling of sharps containers (including height and reasoning for determination) is NIOSH document 97-111 Selecting, Evaluating, and Using Sharps Disposal Containers.
Q: Can oxygen tanks be stored under a stretcher or on a wheelchair when no patient is present.?
Would this be considered in use?
A: Yes… As long as the wheelchair or gurney is designed to secure an oxygen cylinder, it may be placed there even when it is not in use. According to CMS S&C letter 07-10, oxygen cylinders secured in wheelchairs and gurneys are considered in use and not considered in storage, and do not have to be included when calculating the total amount of compressed gas stored per smoke compartment.