Jun 26 2017

Carpet on Corridor Walls

Category: Carpet,Corridors,Questions and Answers,WallsBKeyes @ 12:00 am

Q: I have a nursing home that is over 20 years old that has carpet on the corridor walls below the handrails. I am been told that this carpet must be removed. I am not able to find any information on the 20-year old carpet that gives the flame spread rating. What are my options other than removing it?

A: It depends on who is telling you to remove the carpet and why. If you were cited by a state surveyor or an accreditation organization, ask them to please identify the standard and reason for the citation. They should be able to identify the precise standard, code, or regulation why the carpet needs to be removed.

I suspect the violation comes from of the 2012 Life Safety code where existing interior finish materials have to be Class A or Class B on corridor walls, which would require a flame spread rating between 0 – 75, and a smoke development rating of 0 – 450.

If you cannot prove that the flame spread rating and smoke development rating of the carpet falls within these parameters, then you have no choice but to remove the carpet from the walls. After 20 years… it’s time for an upgrade.

Jun 23 2017

Required Width of New Corridor

Category: Corridors,Questions and AnswersBKeyes @ 12:00 am

Q: We have a corridor that connects an existing elevator lobby on the 2nd floor of a three story hospital to a new addition. The corridor is used for the transfer of personnel and patients from one building to another. It is not an exit corridor; there are exits on each end of the connector. As designed the corridor is 7′-7″ clear. Is this width permitted, or do we need to re-design to get the 8′ clear width?

A: All corridors are exit access corridors and are part of the path of egress. They just aren’t all required to be 8 feet wide. Where there are no inpatients, the corridor can be 44 inches wide. In your situation, the corridor between the elevator lobby and the new addition would be considered an exit access corridor because inpatients are wheeled in this corridor. One may believe that this corridor would have to be 8 feet wide since inpatients use this corridor, but it is an existing condition that is connected to a new addition, which requires you to comply with Chapter 43 on rehabilitation, according to section of the 2012 LSC.

Now, section does define a modification as the reconfiguration of any space; the addition, relocation, or elimination of any door or window, the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment. Section requires all modifications to comply with the requirements for new construction.

The question is, does the existing corridor have to comply with and be modified to meet new construction requirements? I don’t believe it does, but that is a question for the authorities over design and construction of the healthcare facility.

My advice is as follows:

  1. Obtain a written interpretation from your state or local authority over design and construction.
  2. If it is possible and practical to do so, then widen the corridor to at least 8 feet;
  3. If it is ‘impractical’ to widen the corridor, then assess it for ILSM, and implement compensation activities as your policy dictates. You can then wait to see if the AHJ (i.e. a surveyor from your accreditation organization) considers it a deficiency, and submit your reasoning that it is impractical to resolve and see if they agree. If they do not, then you can submit a waiver request after the survey.

Jun 21 2017

Temporary Construction Barrier

Category: Construction,Questions and AnswersBKeyes @ 12:00 am

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.

Jun 19 2017

Healthcare vs. Ambulatory Healthcare Occupancy

Q: A surgery suite (5 ORs), PACU (8 bays), and ASU (17 rooms), newly built on the 3rd floor of a business occupancy building. A 2 hour box was constructed all the way around the floor (above, below, adjacent) and it was designed to meet healthcare occupancy. These are the operating rooms not only for ambulatory surgery (same day) patients but for the hospital’s in-patients as well. How should this area be classified in regards to occupancy designation? Does the potential for a large number of in-patients in the units mean it gets classified as healthcare even if there is no overnight sleeping?

A: One may agree with your logic that as long as there are not any overnight sleeping rooms provided within the unit, it could be classified as an ambulatory healthcare occupancy. But, to take an inpatient out of the healthcare occupancy and perform surgery on them in the ambulatory healthcare occupancy seems to be contrary to the intent of having different occupancies. Is the patient an inpatient or an outpatient? If inpatient, they have surgery in healthcare occupancies. If an outpatient, they have surgery in an ambulatory healthcare occupancy.

The bottom line… You are bringing inpatients from the hospital into the surgery area, therefore the surgery area must be healthcare occupancy. From my perspective, healthcare organizations should not be taking inpatients out of healthcare occupancies to ambulatory healthcare occupancies to perform surgery on them.

Jun 16 2017

Seclusion Rooms

Category: Questions and Answers,Seclusion RoomsBKeyes @ 12:00 am

Q: Our firm has designed several Psychiatric Units lately and there is a question regarding the seclusion room construction. There is a concern as to whether or not the Seclusion Room should be 1-hour fire rated construction. There is mention of this in older versions of FGI Guidelines but not currently. All other aspects of design are met as per DPH and code requirements. Is this a Life Safety Code regulation that has to be met?

A: I cannot speak to what the state or local authorities require, but as far as the NFPA 101 Life Safety Code (2012 edition), there is no specific requirement for a seclusion room to be constructed to meet 1-hour fire resistive rated construction.

The use of FGI guidelines is dependent on the accreditation organization and/or the state requirements. Most accreditation organizations require new construction to meet the current edition of the FGI guidelines, or the state requirements, whichever is more restrictive. Since the FGI guidelines are in fact guidelines and not standards, the accreditation organizations typically allow other design standards to be used when they are required by other authorities. Generally speaking, accreditation organizations do not comment on or approve designs or construction, but rather they evaluate the organization for compliance to the Life Safety Code.

You will need to contact the state and local authorities to determine what requirements in addition to the Life Safety Code the seclusion rooms need to be constructed to.

Jun 15 2017

Locked Mechanical Room

Category: Door Locks,Mechanical Rooms,Questions and AnswersBKeyes @ 12:00 am

Q: The computer server is located in the mechanical room. IT wants the room locked for HIPAA compliance. Is it permissible to lock a mechanical room? Doesn’t locking compromise access to electrical panels, fire panel, water shutoff, etc. in an emergency?

A: Yes… you can lock a door into a mechanical room, as far as NFPA is concerned; you just can’t lock the door in the path of egress. Does a locked door to a mechanical room restrict access to electrical distribution panels? Yes it does, but that is a good thing. According to NFPA 99-2012, section access to overcurrent protective devices (i.e. circuit breakers) serving Category 1 or Category 2 rooms must be secured to allow access for authorized individuals only. So, having these distribution panels inside a locked mechanical room meets the requirement of NFPA 99.

It is expected that authorized individuals will have a key or device to access this room in the event of an emergency. Make sure any locks that are installed on the door does not lock the door for those individuals exiting the mechanical room. It is not uncommon for Information Technology to place intermediate distribution frames containing servers in various locations around the facility. The challenge is to meet all of the requirements for limiting access for HIPAA compliance and still allow regular access for other items in the room.

Jun 14 2017

Annual Test on Fire Rated Door Assemblies

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am

Q: In regards to the new annual fire rated door assembly inspection, are we to inspect every door that has a fire rating or the doors that are located in fire-rated walls? I have noticed that not all fire doors in the building are located in fire rated walls, according to my Life Safety drawings. What do you say?

A: It is not uncommon for fire-rated door assemblies to be found in walls and barriers that are not fire-rated. This is often due to conflicting building codes that require 20-minute fire rated doors in all corridors, or a misunderstanding by the design professional. But make no mistake: You are required to test and inspect those doors on an annual basis.

My interpretation is based on section of the 2012 LSC which says: “Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80…” This section of the LSC does not have any exceptions for fire-rated door assemblies that are located in walls and barriers that are not fire-rated.

Therefore, all fire-rated door assemblies must be inspected and tested in accordance with NFPA 80 on an annual basis, regardless where they are located.

Another way of looking at this issue is to review section of the 2012 LSC which says existing life safety features that are obvious to the public, if not required by the LSC, must be either maintained or removed. The interpretation of what’s ‘obvious to the public’ is certainly open for discussion, but most fire-rated door assemblies can be determined by looking at a fire rating label on the hinge-side edge of the door, and that is viewable by the public. Whether it is obvious or not is a matter of opinion, but if you take the hardline on that, then all fire-rated doors (with a fire rating label) have to be maintained even if they are not located in a fire-rated barrier.

Either way… I think the LSC is pretty clear… you need to test and inspect all fire rated door assemblies regardless if they are located in a fire rated barrier. And by the way, the first test of the side-hinged swinging fire doors is due in a couple weeks: July 5, 2017. Better have it completed by then.

Jun 12 2017

Evacuation Chairs in Stairwells

Category: Evacuation,Questions and Answers,StairwellsBKeyes @ 12:00 am

Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but the surveyor did not care that state fire marshal gave his blessing 8 years ago to have chairs at tops of stairwell and during the previous two Joint Commission surveys the chairs were not an issue. Your thoughts on this would be greatly appreciated.

A: First of all, it doesn’t matter what a state or local inspector or fire marshal says. Joint Commission and/or CMS does not have to comply with what a state or local authority says on an issue, and often does not care. All authorities having jurisdiction (AHJ) are equal, but separate. To have the permission or interpretation of one authority does not provide you with any leverage or influence with any other authority. Often times the authorities simply do not care what the other authorities say.

The Life Safety Code is not entirely clear on the subject of evacuation chairs mounted in stairwells. At one point (section of the 2012 Life Safety Code) the code says no space in the exit enclosure may be used for any purpose that has the potential to interfere with egress. One may conclude that if the evacuation chairs are mounted off to the side of the top landing where there is no possibility of egress interference, then you can mount an evacuation chair there. But the code does not specifically say that and it would have to be an interpretation by the authority to allow it.

But section also says an exit enclosure cannot be used for any purpose that has the potential to interfere with its use as an exit. According to the Annex section, the intent of this standard is the exit enclosure should be sterile with respect for fire safety hazards. The authorities can interpret this any way they want since the code is not clear.

Apparently, the Joint Commission (through the surveyor) is saying they will not allow it, and it is well within their right to say so. I have been in conferences where representatives from the Joint Commission engineering department say they do not allow stairwell evacuation chairs to be stored inside the stairwell.

Jun 09 2017

Soiled Utility Rooms

Category: Questions and Answers,Soiled Utility RoomsBKeyes @ 12:00 am

Q: What is the protocol to maintain a soiled utility room on a patient floor? What guidelines have to be met?

A: As far as what guidelines have to be met, most states and accreditation organizations want you to follow the FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities, 2014 edition, unless there are more restrictive requirements from your state authorities. From a design standpoint, the FGI guidelines require the following:

  • Must be separate from and have no direct connection with clean workrooms or clean supply rooms;
  • Hand-washing station;
  • Flushing-rim clinical service sink with a bedpan washer (omission of the flushing-rim clinical service sick is permitted if the room is only to be used for holding soiled material);
  • Work counter;
  • Space for separate covered containers.

As far as general life safety requirements by accreditation organizations, soiled utility rooms in a healthcare occupancy must be treated as a hazardous room, regardless of the size. This is a requirement of the Life Safety Code (see 18/ of the 2012 LSC) which means if it is considered existing conditions (created before January 1, 1988, the date the 1985 LSC was adopted ) then the soiled utility room must be protected with 1-hour fire resistive rated barriers that extend from the floor to the deck above; or if it is protected with sprinklers, then it can be protected with smoke resistive rated barriers that extend to the ceiling, provided the ceiling also resists the passage of smoke. However, if it was constructed or renovated since January 1, 1988, then it must be protected with sprinklers and it must be protected with 1-hour fire resistive rated barriers.

There are other infection control issues that you must follow, such as clean supplies are not permitted to be stored in the soiled utility room, but you should check with your infection control practitioner for that.

Jun 08 2017

Stairwell Tread Marking

Category: Questions and Answers,StairwellsBKeyes @ 12:00 am

Q: We are being told that section of the 2012 Life Safety Code requires us to install paint on the nose tread on stairs in existing egress stairways as a requirement. I read it as if you want to install a paint stripe, here is what you need to do. Who is correct?

A: Section in the 2012 LSC is very clear: Where new contrasting marking is applied to stairs, there are four (4) criterions to follow. It does not say all stairs must have contrasting markings applied to the stairs. This section only applies if you decide to apply contrasting markings to the stairs. Also, section says exit stair path markings are only required if the occupancy chapter requires them. Healthcare occupancy does not require them.

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