Strange Observations – Part 46

Continuing in a series of strange things that I have seen while consulting at hospitals…

The step up (or down) is more than 8-inches permitted for a riser. Steps will have to be made, and wood cannot be used.

Even existing conditions have to meet the maximum height requirement for risers, as referenced in section 7.2.2.2.1.1 (2) of the 2012 Life Safety Code.

Fire Rated Door in a Non-Rated Barrier

Q: If I replace a smoke barrier door with a fire door, does the wall now have to be brought up to fire-rated wall code or will it still be considered the same smoke barrier code? We were told by an inspector that now the wall would have to be a fire-rated wall even though it’s not needed to be.

A: This issue is becoming a sticky wicket. I’ve had this question raised numerous times recently. I kind-of see where the surveyor is coming from: If the fire-rated door assembly is obvious to the public as a fire door, then the public could conclude that the barrier is also a fire-rated barrier. Kind-of makes sense. But that’s not what the Life Safety Code says. It is clear to me that the LSC does require all fire-rated doors to be tested regardless if they are located in a fire-rated barrier or not.

Section 4.6.12.3 says existing features of life safety obvious to the public, if not required by the LSC must be maintained or removed. Most AHJs will say a fire-rated label on the door is obvious to the public, although an unofficial NFPA interpretation is saying a fire rated label is not obvious to the public. In this situation, we have to go by what the AHJ says. Section 8.3.3.1 says fire-rated doors must comply with NFPA 80-2010, so all fire rated doors must be tested and inspected regardless if they are located in a fire-rated barrier.

But there is nothing in this section of the LSC or any other section that clearly says a fire-rated door assembly located in a barrier requires the barrier to be a fire-rated barrier. The AHJ has the right to interpret the Life Safety Code, but in my opinion this interpretation is way over the top. But, if you do get cited for this, it really is an easy solution: Just pop the fire-rated labels off the door.

 

Strange Observations – Part 45

Continuing in a series of strange things that I have seen while consulting at hospitals…

In a Type I or Type II construction type structure (which most hospitals are) you are not allowed to have any combustible structural supports, including wood coverings over floors.

Overhead lift equipment raises elevator equipment to this platform, which serves as an extended floor. Then they roll the equipment to the elevator machines. Wood platforms are not permitted.

Remember what I said… Equipment rooms are a huge source of non-compliance on safety issues. They are out-of-sight/out-of-mind and nobody is assigned to maintain them.

ABHR Dispensers in Business Occupancies

Q: In the 2012 edition of the Life Safety Code, section 19.3.2.6 (9) states dispensers of alcohol based hand rub (ABHR) solution are permitted to be installed directly over carpeted floors in fully sprinkled smoke compartments. My question is: Does this go with business occupancies as well?

A: I would say surveyors would likely ‘borrow’ from chapter 19 and apply certain requirements regarding ABHR dispensers in business occupancies. But there is a huge difference between healthcare occupancies and business occupancies for ABHR dispensers. Section 19.3.2.6 is a healthcare occupancy chapter, and anything written in chapter 19 applies to just existing healthcare occupancies. The Life Safety Code requirements for a business occupancy are found in chapter 38 for new construction business occupancies and chapter 39 for existing business occupancies.

It is interesting to note that chapters 38 & 39 do not have the similar language found in chapters 18 & 19 for healthcare occupancies that permit ABHR dispensers in corridors (i.e. 18/19.3.2.6). Therefore, section 38/39.3.2.1 is the applicable standard and must be followed, which says hazardous areas must comply with section 8.7. Section 8.7.3.2 says no storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure. Where chapters 18 & 19 for healthcare occupancies have exceptions that actually permit ABHR dispensers in corridors, chapters 38 & 39 do not for business occupancies. In fact, chapters 38 & 39 actually requires compliance with section 8.7.3.2 which prohibits the handling of flammable liquids (and ABHR solution is considered a flammable liquid) in an egress.

That is why ABHR dispensers are not permitted in business occupancy corridors. Since the business occupancy chapters do not address ABHR dispensers, other than saying flammable liquids cannot be stored or handled in the egress, surveyors would likely follow the chapter 19 requirements on ABHR dispensers for other regulatory requirements in business occupancies. They could easily enforce the width separation and the requirement to keep the dispenser away from ignition sources and other requirements. Since chapters 38 & 39 are silent on the issue of ABHR dispensers, the surveyors could ‘borrow’ from chapter 19 and enforce that, as long as it does not conflict with section 8.7.3.2.

Evacuation During a Fire

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.

Strange Observations – Part 44

Continuing in a series of strange things that I have seen while consulting at hospitals…

I believe those electrical panels installed in this stairwell were for new access-control lock badge readers on a series of doors on the unit served by this stairwell.

Can’t do it… You cannot make new penetrations into a stairwell for anything that does not serve the function of the stairwell (with some exceptions, but this did not meet those exceptions).

As they should have done in the first place, they needed to relocate these panels to an equipment room on the unit.

Wood-Frame Addition

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 18.1.6.1 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.

Weekend Fire Drills

Q: Do you know anything about fire drills on weekends? What is the requirement?

A: Section 19.7.1.6 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’.

Strange Observations – Part 43

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.

Fire Door Inspection Records

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.