Equipment in an Alcove

Q: We have an alcove in our surgery center that we are wanting to place patient refrigerator, ice machine, coffee pot. Currently there isn’t a door- it is an alcove. Is this acceptable or do these items need to be behind a door? Our surgery center has badge access, but this is in an area where patient family members are allowed.

A: If the equipment in the alcove is truly out of the required width of the corridor, then I don’t see any problem with it. Just because it is a refrigerator, ice machine or coffee pot should not make a difference. These items are not considered to be hazardous so they are not required to be kept in a designated hazardous room.

Now, if the surgery center is a suite of rooms, then of course there are no corridors inside a suite, and maintaining a certain corridor width is not required.

Corridor Obstruction for Construction

Q: Can an existing 8-foot wide corridor be reduced in width to 4 feet by temporary construction barriers?

A: Yes, but you will need to conduct an assessment for Alternative Life Safety Measures (or Interim Life Safety Measures as one accreditation organization calls it). All of the AHJs understand there will be times when you will need to have non-compliance with the Life Safety Code during periods of construction, maintenance, or emergency repairs.

It is understandable that you will need to build a ‘bump-out’ in an existing corridor of an occupied unit, in order to conduct demolition, and reconstruction, which will obstruct the required width of the corridor during the period of construction. The Life Safety Code already has considered this situation and section 4.6.10.1 of the 2012 LSC permits buildings to be occupied during periods of construction provided that ALSMs (or ILSMs) are in place.

So, when you know that the corridor needs to be obstructed for the purpose of construction, you assess the situation for ALSM (ILSM) and you follow what your ALSM (ILSM) policy requires you to do. For a corridor obstruction, it is likely that you would be required to do:

  • Staff education on the obstruction, informing them of alternative routes for exiting
  • Daily inspections, looking for accumulation of debris, supplies or other items
  • An additional fire drill in the affected area to ensure staff understands that an alternate route for exiting is required

There may be other measures that need to be implemented, such as additional education, or additional fire-extinguishment devices. Once the assessment is conducted, it must be recorded and available for review by surveyors.

Construction Safety at a Hospital

I learned recently that a hospital is being sued by the family of a woman who fell in a construction zone and subsequently died. The 85-year-old woman walked past an empty nurses station, through an unlocked door, and fell into a construction pit inside the facility.

The woman suffered a traumatic brain injury and subdural hematoma from the fall, according to court records. In the three weeks before she died, she could rarely recognize her daughter and suffered nightmares.

According to the lawsuit, the state department of health and social services had inspected the hospital 9 days before the accident and noted in a 58-page report that the center had three doors leading to construction areas that, in violation of state safety codes, were left unlocked.

This is a tragedy and I’m sure everyone involved feels terrible about the incident. I purposely did not identify the hospital because that’s not the point… I’m sure they are beating themselves up over this as well.

But it sure appears it was preventable… especially after the state inspectors came in and told them they needed to lock the doors to the construction area.

Every hospitals claims to have excellent patient safety at the foremost of their efforts. And I believe what they mean when they say patient safety is safety concerning clinical and medical issues. What many hospitals seem to overlook or flat-out ignore is Life Safety, Physical Environment Safety and Construction Safety is patient safety as well.

This story is a reminder that construction business is not business as usual when it happens in a hospital. Nothing is ‘as usual’ in a hospital. That is why the business of healthcare is one of the most regulated industries in America.

The hospital in the story had a warning from the state 9 days before the tragic accident. If they had complied with state’s findings, it is likely this tragedy would never had happened.

I want you to understand when the state agencies, accreditation organizations, and local authorities conduct a survey or an inspection at your facility, they are there to help you from hurting yourselves and your patients and staff from safety violations that you are not aware of. Embrace that process and learn from those surveys and inspections. It likely will keep you from tragic situations like the one described above.

Temporary Construction Barriers

Q: Regarding the 2012 Life Safety Code referencing the 2009 edition of NFPA 241 Standard for Safeguarding Construction, Alteration and Demolition Operations which does not allow “tarps” for construction barriers, what is their definition of a tarp? Will using fire resistant sheet poly be allowed or is that now defined as a tarp?

A: The definition of a tarp has yet to be explained. Since the NFPA 241 does not adequately explain it, it will be up to CMS and the accreditation organizations (AOs) to decide if flame retardant plastic sheets are acceptable or not. I suspect some AOs will be lenient and allow the flame retardant plastic, and I suspect some AOs will not, and consider flame retardant plastic sheet to not be acceptable. Until CMS provides a definitive answer, I suspect there will be different interpretations.

Section 8.6.2 of the 2009 edition of NFPA 241 has changed how the temporary construction barriers must be built. Now, a 1-hour fire rated barrier must be constructed to separate a construction area from an occupied area, if the construction area is not equipped with a properly installed active sprinkler system. This means steel studs and 5/8 gypsum board on both sides must be constructed from the floor to the deck above, and include a 3/4 hour fire rated doors assembly that is equipped with a closer and positive latching hardware. And the seams on the gypsum boards will have to be properly taped and mudded with joint compound.

However, if the construction area is protected with a properly installed active sprinkler system, then the temporary construction barrier is permitted to be non-rated. But it quickly says “tarps” are not permitted in the Annex section. That’s where the issue becomes cloudy. It seems without tarps, the only way you can achieve a non-rated construction would be by using steel studs and 1 layer of gypsum board.

The Annex section is not considered part of the enforceable standard, but information is inserted there as a guide to authorities having jurisdiction to help them understand what the technical committee was thinking when the standard was written.

But in conversations with un-named experts who are in a position to know, it appears that the major accreditation organization will not allow flame retardant plastic sheeting for temporary non-rated construction barriers.

I suggest you contact your AO directly and ask them what they will accept, before you are surprised during a survey.

Changing Construction Type

Q: We are looking to construct a surgery center which will be classified as Healthcare Occupancy on the third floor of an existing five story building which is classified as Business Occupancy (mainly doctor offices). The surgery center will be connected to an existing hospital with an enclosed bridge and will be servicing more than three inpatients from the hospital (via the bridge) and outpatients, but will have no overnight stays. The existing five story building is fully sprinklered, and is a Type II (000) construction. All elevator shafts and stairs are 2 hour fire rated. Our strategy for the surgery center, which is on the third floor is to change the construction type of the first through the third floors to a Type II (111) and keep the upper two floors as Type II (000). In addition we would provide a 2 hour occupancy separation between the third floor and the adjoining floors. Do you believe this meets the intention of the NFPA 101 Life Safety Code?

A: No… I do not.

You plan on having Type II (111) construction type for the first three floors which is business occupancy for the first two floors, and healthcare occupancy for the 3rd floor; and then you plan on having the fourth and fifth floor remain as Type II (000), which will be presumably business occupancy.

Even though the two different construction types will be separated horizontally by a 2-hour fire rated deck, this is not permitted for healthcare occupancy. According to NFPA 220 (2012), section 4.1.2,  where two or more types of construction are used in the same building, the entire building shall be classified as the least type of construction in the building and shall be subject to the requirements for that type. Since you will have Type II (000) construction on the 4th and 5th floors, that makes the entire building subject to Type II (000) construction and according to 18.1.6.1 of the 2012 LSC, Type II (000) construction is not permitted in stories greater than one for healthcare occupancies.

To effectively separate buildings (and their construction types) you need to have vertical fire-rated barriers that extend from the lowest level to the roof. Horizontal 2-hour fire-rated floors is not an acceptable separation barrier concerning different types of construction.

Path of Egress Through a Construction Area

Q: Are there any problems with maintaining an emergency exit for a hospital OR area that travels through an adjacent construction project? Also, can these doors be taped or sealed with a tape/barrier to limit construction dust?

A: In regards to your first question, what would your infection control practitioner say about exiting OR patients (who could possibly have open incisions) into and through a construction area? I’m sure that the IC person would have a fit about that. No… you can’t exit OR patients into and through a construction area. A construction area is typically a dirty, hazardous area depending on the level of demolition and construction. Section 7.5.1.6 of the 2012 Life Safety Code does not permit exiting through a hazardous area. Taping the seams and jamb of a door to prevent dust and dirt contamination would be a good approach to prevent dust and dirt from transferring from the construction to the clean side, but you can’t tape a door closed if the Exit signs tell you that is the path of egress.

You have to close the path of egress if the path is under construction. That is what alternative life safety measures are for (aka Interim life Safety Measures, or ILSM). It is okay to close one path of egress for the needs of construction as long as you conduct an assessment to evaluate what ILSMs are to be implemented. Then you follow what your ILSM policy says regarding closed (or obstructed) exits.

But you can’t tape a door shut that is in the path of egress and expect staff to use that door in the event of an emergency. And you need to come up with alternative measures to compensate for closing that path of egress. It is my observation that project people are not all that familiar with the ILSM method. It’s okay to close an exit if you have to remodel that exit. That’s why the LSC has a standard on ILSM. Most project people don’t know this and they try to maintain what they think has to be: two forms of exiting.

Temporary Construction Barrier

Q: Is there a fire rating requirement for a temporary construction barrier that will separate a construction area from a patient care area which will be an occupied space throughout demolition and construction (surgery ORs) in an area that is non-sprinklered on both sides of the construction barrier? This surgery modernization project will involve installing sprinklers throughout the entire smoke zone, but not until later phases of the project.

A: The new 2012 LSC references the 2009 edition of NFPA 241, and there have been some major changes with this edition. NFPA 241 (2009 edition) requires 1-hour fire rated barriers between occupied areas and construction sites where the construction site is not protected with automatic sprinklers. These barriers will have to extend from the floor to the deck above. Also, NFPA 241 (2009 edition) will allow non-rated barriers where the construction site is protected with sprinklers, but ‘construction tarps’ are not permitted. At this point, it is unclear if the flame-retardant visqueen plastic that is commonly used will be considered ‘tarpaulins’ by the accreditation organizations and CMS.

It is important to point out that during last June’s Healthcare Interpretation Task Force (HITF) meeting at the NFPA annual conference, the committee did discuss this issue regarding flame-retardant plastic sheeting being used when non-rated barriers are required. Overwhelmingly, the members said no, as NFPA 241-2009 section 8.6.2.4 requires non-rated walls when the construction area is protected with sprinklers. The consensus was flame-retardant plastic sheeting is not a “wall”; therefore, it would not be permitted.

The HITF did not make a formal decision on this issue, as the person who submitted the request rescinded it before a decision could be voted. This means there is no formal interpretation on this issue, so check with your accreditation organization, and your state and local authorities to determine what they allow and if they have any other regulations on this subject.

Temporary Construction Barrier

Q: We are planning to update a pair of fire-rated automatic corridor doors which happened to be located in our Emergency Room and in a 2-hour rated wall. The work cannot be done in one day. Besides the sensitive location, there is work to be done to reinforce the existing drywall partition, since the new doors are heavier. There are existing sprinklers on one side of the existing doors. Also, above the ceiling are existing ducts, medical gases and cabling that restricts me from installing a temporary rated partition up to the ceiling slab. Based on my criteria, what options do I have with setting up a temporary barrier before I can replace the doors?

A: Well… you said the work cannot be done in one day. If the existing sprinkler in the construction area can remain in service without any impairments, then I don’t see a problem with putting up temporary construction barriers between the floor and the ceiling, as long as they are made with flame retardant plastic sheeting. You will need to assess it for ILSM and with the temporary construction barriers in place that would constitute a blocked exit. Most ILSM assessments for a blocked exit would require one additional fire drill in the area, but if you can get everything done in 2 – 3 days, you may not have to do the extra fire drill. I don’t see a need to do a Fire Watch as long as the sprinkler is not impaired.

If the sprinkler is impaired then a Fire Watch may be needed, based on what your ILSM policy says. Some ILSM policies do not require a Fire Watch until a branch of the sprinkler system is impaired. If the construction area is not protected with sprinklers, then technically you would need to build 1-hour fire rated barriers that extend from the floor to the deck above. But that could take 2 – 3 days to build; if you can get the door replacement project completed within that time-frame, then I don’t see the need to build 1-hour fire rated barriers… But that’s me. Some other surveyor may disagree.

New Construction vs. Existing Construction

Q: Is there a specific date for construction that is a cut-off point between chapter 18 and chapter 19, or does chapter 19 always applies once the new construction is complete and occupied?

A: Yes…there is a specific date to determine the difference between using new construction occupancy chapters (i.e. chapter 18) or existing conditions occupancy chapters (i.e. chapter 19). For the purpose of the 2000 Life Safety Code, that date was March 11, 2003 because that is the effective date when CMS adopted the 2000 LSC. For the 2012 Life Safety Code, the date is July 5, 2016, as CMS explained in their Final Rule adopting the 2012 LSC:

“Buildings that have not received all pre-construction governmental approvals before the rules effective date, or those buildings that begin construction after the effective date of this regulation, will be required to meet the New Occupancy chapters of the 2012 edition of the LSC.”

July 5, 2016 is the effective date of the new 2012 LSC so anything approved by state or local building departments or if construction begins after July 5, it is considered “New Construction”.

Sprinklers in Construction Areas

Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the sprinklers in the area for eight weeks. The construction is located on the lowest level and is unoccupied with no patient care in the area (but there’s patient care in the building). With the sprinklers out of service 24 hours a day, is a fire watch required? We also are looking at using 1 hour barriers and 3/4 hour doors during that time. Do the barriers change anything with a fire watch? Thank you

A: Can’t you re-install temporary sprinklers in this construction area for the duration of the project? You will need to turn the sprinkler lines upward to within 12 inches of the deck and install upright sprinklers. It is imperative that you have sprinkler protection, otherwise you will need to conduct a fire watch, continuously for the 8 weeks there are no sprinklers.

Yes… a fire watch is required because you have impaired sprinklers. It doesn’t matter where the impaired sprinklers are located… if you have impaired sprinklers, you must do a fire watch. NFPA 25-2011 section 15.5(4) says where the sprinkler system is out of service for more than 10 hours in a 24-hour period, you need to conduct a fire watch. CMS has said in their Final Rule to adopt the 2012 Life Safety Code published May 4, 2016, that a fire watch is conducted continuously, without interruption. The designated individual who performs no other function, continuously walks the impaired area looking for fire and the potential for a fire to occur, without leaving the area. This means the individual may not leave the impaired area to use the restroom, take a lunch break or any other function unless he is relieved by someone else.

This ‘continuous’ fire watch must be conducted for the duration that the sprinklers are impaired … 8 weeks. Can you afford to have that many FTEs designated to do nothing else but a fire watch for 8 weeks? I would believe it would be less expensive if you would turn up the sprinklers and install upright sprinkler heads in the construction area.

The fire watch does not affect the rated barrier, but the 1-hour fire rated barrier is required to separate the construction area from the occupied area if there are no sprinklers in the construction area.