The following Questions and Answers were previously published in the Healthcare Life Safety Compliance newsletter, and all answers were provided by Brad Keyes.
Q: We have decorative wood panels in our cafeteria ceiling which do not provide a seal to limit the passage of smoke. In fact, there are wide gaps between the wood panels. HVAC supply ductwork is mounted above the wood panels and return air is drawn through the open space above the wood panels as well. Are we required to use plenum rated cabling above the wood panels?
A: The Life Safety Code, 2000 edition, section 3.3.150 defines a plenum as a compartment or chamber to which one or more air ducts are connected and that forms part of the air distribution system.Given that the above-ceiling space is used as a chamber for the return air of the HVAC system, the space appears to be a plenum and I would conclude that plenum-rated cable should be used. NFPA 70 (1999 edition), section 300-22(b) specifies that Type MI or Type MC cable must be installed in ventilating air plenums. This standard does allow limited lengths of flexible metal conduit and liquid-tight flexible conduit to devices permitted to be in the plenum.
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 22.214.171.124 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.
Q: We are renovating one of our patient sleeping suites in an existing area. Would it be permissible to stage construction materials (some of which will be combustible) in one of the vacant rooms in the suite?
A: When combustibles are stored in a room greater than 50 square feet, the room must comply with section 18/126.96.36.199 of the 2000 edition of the LSC in regards to hazardous areas. This means, if the room did not previously comply with the requirements for hazardous areas, then the room has to be upgrade with 1-hour fire rated walls that extend from the floor to the deck above, equipped with a ¾ hour fire rated self-closing positive latching door, and the room is required to be protected with automatic sprinklers. However, section 188.8.131.52 permits alternative life safety measures (some AHJs call this Interim Life Safety Measures, or ILSM) to be implemented to compensate when features of life safety are compromised during construction. Therefore, it is permissible to store combustibles in non-fire rated rooms on a temporary basis to accommodate construction activities, provided ILSM are implemented. Some suggested ILSM activities could include:
- Daily surveillance looking for unsafe conditions in the rooms
- Staff education, notifying staff in the area that combustibles are stored in a non-approved room
- Extra fire drills in the area
- Install a smoke detector in each room
Q: We just completed a renovation of our cafeteria dining area and as part of the project an 8 container trash cabinet was built and installed in a separated area off of the dining floor. It is sprinklered and the containers are all 32 gallons. The cafeteria area is a separate smoke compartment. Is this allowed?”
A: Well, this is an interesting question. The answer is… it depends on the square footage of the trash cabinet and how it is constructed. I would say each individual 32 gallon trash container would have to be physically separated from all the others by a cabinet wall, which would create a small, individual room or area for the container. The reason for this is section 184.108.40.206 of the 2000 edition of the LSC, which only allows up to 32 gallons of trash collection capacity in a given 64 square foot area. This means, if there are no physical separations between trash containers then I could see a surveyor or inspector citing you for having more than 32 gallons capacity in a given 64 square foot area. Since each individual compartment for the trash containers would presumably be less than 50 square feet in size, then you would not have any problems meeting the requirements of 220.127.116.11 for hazardous areas. It is interesting to note that the exception to 18.104.22.168 does allow more than 32 gallons capacity in a 64 square foot area provided the area qualifies as a hazardous area, but it is unlikely that an 8 container trash cabinet could do so. The key element in your question is the comment that the individual trash containers do not exceed 32 gallons each.
Q: We have an electrical room that is not protected with sprinklers and the old-timers here say the building department would not permit sprinklers in this room when the hospital was constructed 30 years ago. Otherwise, our facility is fully sprinklered. Is this nonsprinklered electrical equipment room going to prevent our building from being considered fully sprinklered?
A: My answer is most likely it would not. It all depends on the fire resistant rating of the barriers surrounding the electrical room. Take a look at section 22.214.171.124 in the 2000 edition of the LSC. The exception to 126.96.36.199 says in Type I or Type II construction alternative protection measures is permitted to be substituted for sprinkler protection where the authority having jurisdiction (AHJ) has prohibited them, without causing the building to be classified as nonsprinklered. Now, let’s take a look at NFPA 13, 1999 edition, section 5-13.11 where the exception says sprinklers are not required in electrical rooms, provided it meets all of the following requirements:
- The room is dedicated to electrical equipment only
- Only dry-type electrical equipment is used
- The electrical equipment is installed in a 2-hour fire rated enclosure including protection for penetrations
- No combustible storage is permitted to be stored in the room
So, if the room is fully protected with 2-hour fire rated barriers, which would include a 90-minute fire rated door assembly that is self-closing and positive latching, and all the penetrations in the barrier are properly sealed with firestop materials, then I would say you are good to go, and should not have any problems with an AHJ saying the building is not fully sprinklered.
Q: I came across a bunch of wheelchairs folded up in an equipment storage room. Each had an oxygen cylinder attached. Are these cylinders included in the tally for aggregate total stored in a smoke compartment?
A: No, they are not. CMS and most accreditation organization consider oxygen cylinder that are attached to a wheelchair, gurney or bed as being counted as ‘in use’. The cylinder must be properly secured in a designated holder in order to qualify.
Q: Are oxygen cylinder tanks (in holders) allowed to be stored in alcoves in corridors? Also, what about clean linen carts? I am told that our accreditation organization allows this, but I don’t know if CMS does.
A: Oxygen cylinders are permitted to be stored outside of a designated room, provided they are properly secured; they do not infringe upon the required corridor width; and the aggregate total of cubic feet of medical gas in cylinders (all gas, not just oxidizing gas) does not exceed 300 cubic feet per smoke compartment. So, a couple E size cylinders in holders, stored in an alcove sounds acceptable to me.
Under normal conditions, the presence of combustibles, such as paper, cardboard, plastics, and clean linen are not considered to be hazardous until the area in which they are contained exceeds 50 square feet. A clean linen cart in an alcove that does not exceed 50 square feet appears to not meet the requirements of a hazardous area (see 188.8.131.52), and therefore does not have to be contained in a room designated as a hazardous room. However, some accreditation organizations may take a different look at this, and consider the volume of a 6 foot tall, by 4 foot wide, by 2½ foot deep clean linen cart to be sufficient capacity of combustibles to be a significant threat, even though it does not meet the LSC definition of a hazardous area. I know that at least one accreditation organization requires the corridor and alcove to be sprinklered in order to store a clean linen cart there.
Q: We have a physician on-call sleeping room inside our labor and delivery unit. A surveyor told us that we need audible smoke alarms in each on-call sleeping room. We have smoke detectors, but rely on staff waking up any sleeping physicians in the event of a fire alarm. Isn’t that good enough?
A: Well, the surveyor is correct, although most AHJs usually allow smoke detectors connected to the building fire alarm system as being sufficient. Non-patient sleeping rooms in the healthcare occupancy do require single-station smoke alarms, such as the battery powered type found in residential homes. They are not required to be inter-connected with other smoke alarms or the building fire alarm system. Your hospital has multiple occupancies inside the facility, such as Healthcare, Ambulatory Care, Business, Mercantile, and Hotels & Dormitory Occupancies. If you have chosen to have mixed occupancies rather than separated occupancies (at least in the case of the on-call sleeping rooms) then you have to comply with the most restrictive requirement of the multiple occupancies. In the case of the on-call sleeping rooms, section 184.108.40.206 of the 2000 LSC does require single-station smoke alarms. I would not install your building fire alarm occupant notification device (horn/strobe unit) as they are not required and are too costly. Just buy simple 9 volt residential style smoke alarms and install them no more than 12 inches below the ceiling. Put these devices on your PM schedule to have the batteries replaced once per year.
However, there is one exception to the above requirement: The exception to section 220.127.116.11 allows the on-call sleeping rooms to be considered ‘incidental’ to the healthcare occupancy and the provisions of the predominate occupancy (in this case, healthcare) would apply, and single-station smoke alarms would not be necessary. However, since the NFPA code does not define how many on-call sleeping rooms qualify as ‘incidental’ to the predominate occupancy, then the AHJ gets to decide. In this case, the surveyor represents the AHJ and they apparently made that determination. You may consider appealing this decision to the AHJ based on the exception to 18.104.22.168 and see if they agree. If they do, then you’re not required to install single-station smoke alarms, but if they do not, then you have no recourse but to install the smoke alarms.
Q: Two different state authorities are telling me conflicting information concerning the maximum temperature for domestic hot water. The first one is telling me the hot water cannot exceed 100°F and he is basing that on the Uniform Fire Prevention and Building Code. The second one is giving me a range of 105° – 120°F and he is basing that on The Facility Guidelines Institute, 2010 edition. Which state authority is correct? Who trumps who?
A: To directly answer your questions, they are both correct and no one authority having jurisdiction (AHJ) can or does trump another AHJ. They are all AHJs who enforce the codes and standards that they are charged to uphold. The frustrating thing is they don’t always enforce the same codes and standards. Your responsibility as a facility manager is to comply with the most restrictive. If 100° is the most restrictive that is enforced by an AHJ, then that is what you must do. You indicated that the second AHJ gave you a range of 105° – 120° based on The Facility Guidelines Institute (FGI), 2010 edition. Table 2.1-5 in the FGI states the range of 105° – 120°F is both the minimum and maximum temperature of potable hot water for a hospital. Since both inspectors have authority over your hospital, you have a conflict as the second AHJ’s temperature range has a minimum requirement which is 5° higher than the maximum temperature of the first AHJ. My suggestion is to negotiate with both of them to form an agreement that they both can live with and allow you to have a consistent temperature for your hot water. The key point here is: All AHJs have the authority to enforce the codes and standards as they see fit, and no AHJ can trump any other AHJ. When AHJs differ on a specific issue, then the hospital must comply with the most restrictive. Get the two different state agencies together in your conference room and ask them to set a temperature that they can both live with.
Q: We are in the process of installing a door in a 2 hour fire barrier with an automatic door operator and positive latching. The door operator will be activated by two push plates mounted on the wall. In the event of a fire alarm, are we required to drop power to the door operator?
A: To be sure, fire-rated doors with automatic operators must close and latch during the activation of the fire alarm system, according to NFPA 80 (1999 edition), section 2-1.4.2. So, to answer your question: Yes, the power to the automatic operator on the fire-door you proposed would have to be interrupted during a fire alarm. The door must still be permitted to operate manually however, but the power to the automatic operator must be interrupted.