Christmas Decorations

Q: I notified our administration that Christmas decorations are basically forbidden in a healthcare occupancy. We do have a few floors that are business occupancy and they were wondering what the restrictions of decorating are within a business occupancy (we are fully sprinkled). I do not see anything about this in the Life Safety Code pertaining to business or mixed occupancy. Do you mind sharing any advice?

A: Well…. Actually, the Life Safety Code does address this issue and there is a difference between occupancies. Section 19.7.5.6 of the 2012 LSC prohibits combustible decorations in a Healthcare Occupancy (i.e. hospital), with the exception (and this is a rather generous exception) of wall and/or ceiling mounted combustible decorations that cover 20% of the wall and ceiling surface in non-sprinklered smoke compartments, 30% of the wall and ceiling surface in a sprinklered smoke compartment, and 50% of the wall and ceiling surface in patient sleeping rooms that have a capacity of no more than 4 persons in smoke compartments that are full protected with sprinklers.

In chapter 39 for Business Occupancies, there are no restrictions, so decorations are not restricted. However, you cannot have non-UL listed electrical decorations, and the National Electrical Code prevents you from using extension cords to power electrical decorations.

Corridor Doors

Q: I have a healthcare occupancy under existing construction. The building was built back in the 50’s and 60’s, with a major renovation in 1992. The available plans have indicated the fire-rated walls and doors, but there are other doors not specifically designated as smoke doors or fire-rated doors. My question is, what doors would fall under the description of corridor doors? Would it be all doors that exit directly into the egress corridor? Some of these doors are to normally occupied offices, some are to patient rooms, and some are to conference rooms that are only occupied during meetings.

A: Corridor doors are those that separate the corridor from a room, suite, or area. They are not cross-corridor doors that separate a corridor from another corridor. Do not be fooled by a double set of doors, as they can be either corridor doors (an entrance to a room, or suite), or cross-corridor doors (smoke barrier doors, or privacy doors in a corridor).

Here is a summary of the Life Safety Code requirements for corridor doors:

  • Corridor doors must comply with section 19.3.6.3 of the 2012 LSC, and have certain requirements that they must meet, such as:
    • They must resist the passage of smoke (no holes in them)
    • They must be 1¾-inch thick, solid-bonded wood core
    • Constructed with materials that resist fire for a minimum of 20 minutes (NOTE: This does not mean the corridor doors must be 20-minute fire rated).
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials are not required to comply with the above requirements.
  • In smoke compartments protected throughout by automatic sprinklers the corridor door construction requirements listed above are not mandatory, but the corridor doors must resist the passage of smoke (no holes).
  • Corridor doors are not required to meet the NFPA 80 standards for fire-rated door assemblies, unless the door also serves a fire-rated barrier.
  • The clearance between the bottom of the corridor door and the floor (i.e. undercuts) must not exceed 1 inch.
  • The corridor doors must have positive latching hardware.
  • Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have positive latching hardware.

You will notice section 19.3.6.3 does not say anything about self-closing devices for corridor doors, because they are not required on corridor doors, unless the corridor serves another purpose, such as a smoke barrier, horizontal exit, or hazardous area.

Check with your state and local authorities before you make any modifications, to determine if they have other regulations or requirements regarding corridor doors.

Battery Powered Emergency Lights

Q: NFPA 101-2012, section 7.9.3 requires 1½-hour testing of battery powered emergency lights annually. The Joint Commissions wording of EC.02.05.07 EP-2 states to do that OR the hospital replaces all batteries every 12 months and performs a random test of 10% of all batteries for 1½-hours. Because NFPA 101 does not give that second option, can we really do that (the second option) and be compliant? We’ve felt it’s easier to replace the batteries annually and test a random 10% during that time period than to test all of the over 100 battery powered emergency lights we have. Secondly, NFPA 101-2012, section 7.9.3 does not mention egress vs. task battery powered emergency lighting. Seeing it is located in chapter 7 ‘Means of Egress’, is it implied it only means battery powered emergency lights used for egress? Joint Commission specifically says egress lighting. Several of our battery powered emergency lights are task lights and this would allow us to cut down on monthly and annual testing. Do we need to be as stringent on task lighting as we are on egress lighting to remain compliant?

A: First of all, Joint Commission dropped the option of replacing the batteries and testing 10% of the battery powered emergency lights, in the 2018 CAMH manual, standard EC.02.05.07, EP 2. Starting January 1, 2018, you need to conduct monthly tests and annual tests of all battery powered emergency lights.

I am aware that Joint Commission tries to give the hospitals a break by saying only the battery powered emergency lights used for egress and Exit signs need to be tested. And in their 2018 manual, standard EC.02.05.07, EP 2 they inserted a new section that says battery powered emergency lights in new construction/renovated sedation and anesthetizing areas are tested for 30 minutes annually. But please understand that Joint Commission’s standards are not compliant with the 2012 Life Safety Code, section 7.9.31.1 (3) which requires 90-minute annual test. If you follow Joint Commission’s standards on this issue, you may be cited by a state surveyor for not complying with the annual testing requirements of section 7.9.3.1.1 (3).

Section 4.6.12.3 of the 2012 LSC says if you have an existing feature of life safety that is not required by the LSC but is obvious to the public then you must maintain it or remove it. I think we’d all agree that battery powered emergency lights would be obvious to the public whether they are used to supplement the EM powered egress lighting or if they are used for task lighting in certain areas. According to the 2012 LSC, section 7.9.3, maintaining it includes the monthly 30-second test and the annual 90-minute test.

To be compliant with the 2012 LSC, you need to test the battery powered emergency lights monthly and annually. I suggest you re-evaluate the need for all of the battery powered emergency lights that you have, and invest into self-diagnostic units to eliminate the monthly test requirements.

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.

 

Generator Starting Batteries

Q: I’m getting conflicting answers as to when generator batteries need to be replaced. Some say in a hospital they need to be replaced every 5 years unless the hospital is a trauma center then it is every 3 years. I have also been told that it doesn’t matter if it is a trauma center; hospital or nursing home; the batteries need to be replaced every 3 years. Can you please tell me what is correct?

A: The correct answer as to how often generator starting batteries need to be replaced in hospitals depends on which authority having jurisdiction you’re talking to. That may be why you are receiving conflicting answers. The typical hospital has 5 or 6 different authorities having jurisdiction (AHJ) that enforce the Life Safety Code:

  • CMS                                             (Medicare/Medicaid)
  • Accreditation Organization    (i.e. Joint Commission)
  • State health department
  • State fire marshal
  • Local fire inspector
  • Insurance company

Any one of these AHJs may have a requirement for testing/inspection/replacement of generator starting batteries that the other AHJs may not have. The hospital would have to comply with the most restrictive.

First… I cannot find any specific requirements in the NFPA codes and standards for generator starting batteries to be replaced at a different frequency if the generator serves a trauma center or not. But the hospital’s state or local AHJ may have a specific requirement that addresses trauma centers that I am not aware of.

Second… According to NFPA 110-2010, the hospital is required to replace lead-acid batteries used for generator starting every 24 – 30 months. This would be enforced by the CMS standards and the accreditation organization (AO) standards. This is found in the Annex section A.5.6.4.5.1 of NFPA 110-2010, and CMS and the AOs usually (not always) enforces the Annex section requirements of the NFPA standards.

I checked the 1999 edition of NFPA 110 and the Annex section in that edition recommended replacing the batteries every 24 – 30 months, so I don’t see anything in current or past NFPA standards that would support your 5-year frequency to replace generator starting batteries.

NFPA 101-2012 Life Safety Code requires all healthcare occupancies and ambulatory healthcare occupancies to comply with NFPA 110-2010, so this means all hospitals, nursing homes, and trauma centers, would have to have their generator starting lead-acid batteries replaced every 24 – 30 months, according to CMS and AO standards.

I suggest you contact the hospital’s state and local authorities to determine if they have more restrictive requirements.

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.

Fire Extinguishers in Vehicles

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.

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.

Qualifications of Personnel

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.

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.