Sep 29 2017

Path of Egress Through a Construction Area

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

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 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.

Sep 18 2017

Temporary Construction Barrier

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

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 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.

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.

May 18 2017

New Construction vs. Existing Construction

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

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”.

Apr 19 2017

Sprinklers in Construction Areas

Category: Construction,Fire Watch,Questions and Answers,SprinklersBKeyes @ 12:00 am

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.

Mar 22 2017

Temporary Construction Barriers

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

Q: Per NFPA 101 2012 edition: are plastic barriers (w/zippers) no longer acceptable around construction areas though the facility is fully sprinkled?

A: No… I wouldn’t say that. But the issue is being reviewed by NFPA Healthcare Interpretations Task Force (HITF) and a change may occur later this year.

Section of the 2012 LSC says the means of egress of any area undergoing construction, repair, or improvements must comply with NFPA 241, which is the standard for safeguarding during construction operations. Section 8.6.2 of NFPA 241-2009 says temporary construction barriers are required to be 1-hour fire rated, with ¾ hour fire rated doors assemblies if the construction area is not full protected with sprinklers. 1-hour barriers are typically steel studs with 5/8 inch thick gypsum board on both sides, with all seams taped and mudded and all screws heads mudded. If the construction area is protected with sprinklers, then the temporary construction barrier is permitted to be non-rated, but construction ‘tarps’ are not permitted as the non-rated barrier. At this time flame retardant plastic sheeting (i.e. Visqueen) will be permitted as a temporary construction barrier where the construction area is fully protected with sprinklers.

However, this issue is being reviewed by HITF of the NFPA. At the June, 2016 meeting of HITF, the members discussed whether or not flame retardant plastic sheeting was acceptable or if it was the same as ‘construction tarps’. At that time there was not a clear consensus so no decision was made. The committee said they would review it again next year.

Unless your AHJ has specifically ruled on this issue, the HITF seemed to say that flame retardant plastic sheeting would be permitted when the construction area is fully protected with sprinklers. But, of course, that is not in writing so it is not official.

I would say continue to use flame retardant plastic sheeting until you learn otherwise.

Mar 16 2017

Distance to a Storage Shed

Category: Construction,Questions and Answers,StorageBKeyes @ 12:00 am

Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any minimal distance that the out-building must be away from the protected facility?  The number that I keep hearing from people is 10 feet of clearance from the protected building but I have not been able to confirm that as a requirement or a best practice.

A: No… there does not seem to be a set number of feet for a non-compliant outbuilding that needs to be from a healthcare occupancy, written into the Life Safety Code. I was at a seminar recently where that question came up and the instructor admitted there was no definite set-back required. But… like everything else that is not definitive in the Life Safety Code, the AHJ can interpret (decide) what the set-back should be. I too have heard 10 feet is the distance a non-compliant building needs to be from a healthcare occupancy without a 2-hour fire rated separation. That is actually a sound interpretation, based on other Life Safety Code requirements. Take a look at section and of the 2012 LSC which discusses the need for a 10 foot section of wall to be 1-hour fire rated when the fire rated wall intersects with an outside barrier at an angle less than 180 degrees. While that does not specifically refer to a set-back of a non-compliant building, it does provide you with a distance to go on.

Mar 03 2017

Construction Barrier Doors

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

Q: Does a door that accesses a construction site within a hospital need to have an automatic closer installed on the access door? What if the door is constructed within temporary drywall barriers?

A: The 2012 Life Safety Code references the 2009 edition of NFPA 241 which has changed from previous editions to require fire-rated barriers separating construction areas from occupied areas. The 2009 edition of NFPA 241 now requires all construction areas to be separated from occupied areas with 1-hour fire rated construction, which will include ¾ hour fire rated doors that are self-closing and positive latching. There is an exception in the 2009 NFPA 241 that allows non-fire rated barriers if the construction area is protected with automatic sprinklers, but the Annex section of NFPA 241 specifically says ‘construction tarps’ would not be permitted. It is unclear if using flame retardant plastic visqueen to separate construction areas from occupied areas would be permitted since the standard does not allow tarps. The NFPA HITF committee began to deal with this issue but failed to come to a consensus.

That means steel studs and gypsum board would still need to be used to separate construction from occupied areas, however if the construction area is sprinklered then the separation barrier would not be required to be 1-hour fire rated. The construction area would still be considered a hazardous area which requires a self-closing door.

Apr 06 2015

Sprinklers in Construction Projects

Category: Construction,Questions and Answers,SprinklersBKeyes @ 6:00 am

Q: We have a construction project that involves removing all of the ceiling tiles in the area. Do we have to relocate the sprinklers 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 compliance with the 2000 edition of the Life Safety Code, then sections 18/ requires compliance with the provisions of NFPA 241 Standard for Safeguarding 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 everything, so it would be a safe bet that NFPA 241 applies whenever any construction or renovation is underway. The 1996 edition of NFPA 241 does not require an active water-based sprinkler fire protection system to be installed and operating during the construction phase, but if there is one, it must comply with NFPA 13 Standard for Installation of Sprinkler System, which means sprinkler heads would have to be mounted within 12 inches of the deck if the suspended acoustical tile ceiling had 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 undergo a change in regards to temporary construction barriers. The requirement for temporary construction barriers changed to be either 1-hour fire rated, or non-rated fire resistant if the construction area is fully protected with automatic sprinklers. Again, sprinklers are not mandatory, but if you have them, they must comply with NFPA 13. If the decision for temporary 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 with considerable expenses in other 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 barriers 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 occupied inpatient unit, then it makes much more sense to provide properly installed sprinklers in the construction project for added protection, which should reduce the risk of the renovation to the inpatients.

Mar 03 2014

Fire Alarm Devices in Construction Areas

Category: Construction,Fire Alarm,Questions and AnswersBKeyes @ 6:00 am

Q: Are we required to install fire alarm occupant notification devices and manual pull stations in construction areas? I couldn’t find anything in NFPA 72 or the Life Safety Code.

A: The 2000 edition of the Life Safety Code, section 3.4.1 requires the healthcare occupancy to be provided with a working fire alarm system, which would include construction areas as well. This would require you to install a temporary pull station every 150 feet and within 5 feet of the exits, and install occupant notification devices (strobes & chimes) in the construction area, or conduct a risk assessment for Interim Life Safety Measures (ILSM) and implement measures to compensate for the absence of pull station and occupant notification devices.  As mentioned in last week’s Q&A, section allows construction areas to be compensated for not having a working fire alarm system with ILSMs. I would recommend that you install the temporary pull stations and occupant notification devices in all construction areas, rather than conducting ILSMs, as it provides a higher level of safety for the construction workers and patients. Manual fire alarm system pull stations will allow for a quicker activation of the fire alarm system should an emergency present itself. This results in a higher level of safety for the patients and staff. Also, what ILSM is adequate to compensate for not have an operable fire alarm system in constructions areas? I could think of a few:

  • Fire watches
  • Extra fire drills
  • Staff and contractor education
  • Daily surveillance

Based on my experience, contractors (in general) are poorly educated in hospital fire safety programs and are unreliable to perform surveillances and daily inspections. The extra fire drills have to be conducted in the area (or areas) where the deficiency occurs, so that means you have to do fire drills with the contractors, which is not an easy task. When you add in the cost of labor to perform the ILSM compensating requirements, I would say it is safer and more cost effective to have the temporary pull stations and occupant notification devices.

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