Questions and Answers

The following Questions and Answers were previously published in the Healthcare Life Safety Compliance newsletter, and all answers were provided by Brad Keyes.

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Fire Alarm System Upgrade

BKeyes : November 13, 2015 12:00 am : Fire Alarm, Questions and Answers

Q: I am doing a renovation project in our hospital and the area of renovation is 50% of the total building area. Part of the renovation scope is a fire alarm system upgrade. Is there any code or standard requirement that the fire alarm devices in the remaining 50% of existing building should be upgraded also before it can be occupied? 

A: Your question involves the fire alarm system in the existing area of the building which is not being renovated, and asks if the fire alarm system in that remaining 50% of the existing building should be upgraded as well, before the building can be occupied.

First let me say that this is a question that does not have a direct answer, from either the Life Safety Code (2000 edition), or the NFPA 72 National Fire Alarm Code (1999 edition). When there is not a direct reference to a question in the codes or standards, then the authorities having jurisdiction (AHJ) must be consulted for their interpretation. This means you need to contact the AHJs who have authority over the design of your fire alarm system and ask them how they interpret the issue. A hospital typically has 5 or 6 different AHJs that should be consulted:

  • State health department or agency on public health
  • State fire marshal
  • Local fire department
  • Local building authority
  • Insurance company

Having said that, it appears to me that you may not have to replace the devices in the existing area of the building that is not under renovation. Section 1-2.3 of NFPA 72 (1999 edition) says this: “Unless otherwise noted, it is not intended that the provisions of this document be applied to facilities, equipment, structures, or installations that were existing or approved for construction or installation prior to the effective date of the document. EXCEPTION: Those cases where it is determined by the authority having jurisdiction that the existing situation involves a distinct hazard to life or property.”

So, as long as the existing devices are still in good working order and do not pose a hazard to life or property, it appears to me that you do not have to upgrade them in your project. However, as I said, it really doesn’t matter what I think: All that matters is what the AHJ say. So, please consult with them for direction.

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Fire Dampers in Rated Walls

BKeyes : November 6, 2015 12:00 am : Fire & Smoke Dampers, Questions and Answers

Q: Are fire dampers required in 1-hour fire rated walls if the facility is fully sprinkled? Also, we have a couple of inaccessible dampers and I was wondering if I needed to add them on the Statement of Conditions PFI list? 

A: According to NFPA 90A (1999 edition), 1-hour fire rated barriers do not require fire dampers in fully ducted HVAC systems, unless the 1-hour fire rated barrier is a vertical shaft. If the air duct is an air transfer opening (meaning it is not fully ducted) at the fire rated barrier, then the duct needs a fire damper where other openings are required to be protected as well. However, 2-hour fire rated barriers do require fire dampers in fully ducted HVAC systems. Being fully sprinklered, or not, has no bearing on the requirement whether fire dampers are required. It does have a bearing on whether or not smoke dampers are needed, though.

Inaccessible fire dampers are a life safety code deficiency, and must be addressed by the following:

  • The inaccessible fire dampers must be assessed for Interim Life Safety Measures (ILSM)
  • A decision must be made as to whether or not you will make the fire dampers accessible, and therefore be able to test them
  • If you cannot resolve the inaccessible fire dampers within 45 days of discovery, they must be placed on the PFI list of the Statement of Conditions.
  • If you decide you will not resolve the inaccessible fire dampers, then the projected completion date for the PFI may be set at 6-years. After 6 years, re-examine the inaccessible fire damper to determine if the environment has changed, and if they are still inaccessible, then close out the PFI, and open a new one for another 6-year cycle.

Joint Commission surveyors are very astute to identifying inaccessible fire dampers, and whether or not you placed them on the PFI list, and whether or not you assessed them for ILSMs. So, make sure you assess them for ILSMs, and place them on the PFI list.

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Obstructions to Fire Alarm Control Panel

BKeyes : October 30, 2015 12:00 am : Clearance, Fire Alarm, Questions and Answers

Q: Where in the Life Safety Code does it require clearance in front of a fire alarm control panel? I have a situation in our hospital where we want to put a stanchion near the panel, but I thought we had to maintain a certain amount of clearance. Can you point me to the exact standard? 

A: The requirement to maintain a certain amount of clearance in front of all electrical panels (which includes the fire alarm panel) is found in NFPA 70 National Electrical Code (NEC), section 110-26(a), which says: “Sufficient access and workings pace shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.” The actual distance required for clearance is found in Table 110-26(a) and is required to be 36 inches.

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Quarterly Testing and Inspection Challenges

BKeyes : October 23, 2015 12:00 am : Joint Commission, Questions and Answers, Testing

Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not always able to schedule us within the tight 20-day window each quarter that Joint Commission will now require. So by definition our schedule will now be in flux, depending on the completion date of the last inspection, rather than set on the same month each quarter. I realize they do not want people to schedule inspections in back to back months, which we do not do, but this seems like it will cause more instability than anything. 

A: I see your dilemma and understand the difficulty in the logistics of your situation. Scheduling a contractor to be onsite within the new 20-day window each quarter will be a challenge to large organizations like yours.

For the record, the Engineering department at the Joint Commission was not in favor of the requirement that quarterly testing and inspections to be performed 3 months from the previous test/inspection, plus or minus 10 days. But the power-that-be above them made that decision.

To answer your question: I do not know what other organizations are doing in regard to challenges with the new quarterly testing requirements. However, I think there is a way you can deal with this issue.

I suggest you contact the Standards Interpretation Group at the Joint Commission and discuss your options concerning the challenges in meeting the quarterly test/inspection window. Ask them if you can have some leeway that would allow you a wider window each quarter for the testing/inspection frequency other than the plus or minus 10 day window. My guess is they will allow it as long as you can demonstrate the hardship in meeting this requirement.

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Fire Damper Installation

BKeyes : October 19, 2015 12:00 am : Fire & Smoke Dampers, Questions and Answers

Q: Do you need a fire smoke damper at floor level in an open duct shaft? Or where the duct comes out through the shaft wall?

A: Section of the 2000 edition of the Life Safety Code requires compliance with section 9.2. Section 9.2.1 requires compliance with NFPA 90A Installation of Air Conditioning and Ventilation Systems, 1999 edition. If you have a copy of that standard, take a look at Figure A-3-3 in the appendix of the book, and there is a real nifty diagram that points out all of the possible locations where fire and smoke dampers would be required. But, to directly answer your questions, section 3-3.2 of NFPA 90A requires a fire damper at the floor level of any HVAC duct that penetrates a fire-rated floor if the duct is not enclosed within a fire rated shaft. But section 3-3.4.1 says an air duct that pass through floors of buildings that require the protection of vertical opening (such as a hospital would), must be enclosed with walls with 1-hour fire resistance rating if the shaft penetrates 3 or less stories, and 2-hour fire resistance rating if the shaft penetrates 4 or more stories. The exception to 3-3.4.1 says you do not need a fire rated shaft if the air duct passes through only one floor, or if the air duct passes through only one floor and an air-handling equipment penthouse floor, whereby the air duct would require a fire damper where the duct penetrates the floor. In reply to your second question… According to section 3-3.4.4, fire dampers are required in any opening into or out of a shaft required in 3-3.4.1, whether or not the shaft opening contains an air duct or is ductless. A fire damper is required, even if the shaft is only 1-hour fire rated. So, in conclusion, you do need fire dampers if the duct is not enclosed in a fire rated shaft and penetrates one floor (but only one floor), and you do need fire dampers where the duct exits a rated shaft.

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Shower Curtains in Behavioral Health Units

BKeyes : October 16, 2015 12:00 am : Curtains, Questions and Answers, Shower Curtains

Q: Our facility uses full shower curtains mounted to tracks in the ceiling for all behavioral health units. These curtains and tracks are ‘break-away’ type for suicide prevention. Our administration does not want to use curtains with mesh at 18 inches below the sprinkler heads. I disagree and my contention is that the mesh is required unless there is a sprinkler head in the shower (which there is not). They counter that this has been in place through numerous state and Joint Commission inspections and has never been cited. Is there some exception or conflicting regulation of which I am unaware that permits this in behavioral health units? I know I have been cited on the acute care side for curtains without the mesh 18 inches below the sprinklers.

A: I have heard this argument made many times: “We have had numerous surveys and inspections and it has never been cited.” Just because it has never been cited does not mean it is not a LSC violation.

Surveyors and inspectors cannot see every deficiency during a survey; therefore, some deficiencies get over-looked. Also, ½” open spaces in the mesh curtain is a NFPA 13 Standard for the Installation of Sprinkler Systems, (1999 edition) requirement generated by the Life Safety Code (LSC). There are no distinctions between a behavioral health unit and an acute care unit for compliance with this NFPA 13 requirement. If a surveyor who is not familiar with the requirements of NFPA 13 (such as a nurse or an administrator) inspects the behavioral health unit and does not cite the curtain, then what does that mean? Nothing. It certainly does not mean the curtains are not a violation…. It just means the surveyor did not cite it.

Life Safety is Patient Safety, and not resolving a Life Safety Code deficiency is not meeting the minimum standards for Patient Safety. Most hospitals want to do more than the minimum requirements when it involves Patient Safety.

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Controlled Access Locks

BKeyes : October 12, 2015 12:00 am : Door Locks, Questions and Answers

Q: While conducting fire drills in the hospital, one of the questions on our drill evaluation sheet is, “Did the security doors in the fire zone release properly?” We have controlled areas where the doors are locked to control access into the unit. To exit the unit only requires the push of a button and the doors release. So are we in compliant with this controlled access not releasing during the fire alarm activation since the exit is not controlled? Or should the doors release to allow free entry and exits?

A: Doors in the path of egress in a healthcare occupancy are not permitted to be locked. However, there are three (3) exceptions to this requirement:

  • Delayed egress locks complying with section, 2000 LSC
  • Access-control locks complying with section
  • Clinical needs locks complying with section

By the sound of your situation, it appears to me that you do not have delayed egress locks and you do not have clinical needs locks, which leaves access-control locks. However, it also appears that your description of the security door locks may not be in compliance with section Here is a summary of the requirements for access-control locks:

  1. A motion sensor must be mounted on the egress side to detect occupants approaching the door, and automatically unlock the door in the direction of egress
  2. A loss of power to the control system automatically unlocks the door in the direction of egress
  3. A manual release button must be mounted 40 to 48 inches above the floor, and within 5 feet of the door, that when operated will directly interrupt the power to the lock, independent of the control system, for a minimum of 30 seconds. The button must be labeled with the words “PUSH TO EXIT”.
  4. The door must unlock in the direction of egress upon activation of the building fire alarm system or the building sprinkler system.

So, it appears to me that you are missing the motion sensor on the egress side of the door that would automatically unlock the door when someone approaches. Also, it sounds like your locks are not interconnected to the building fire alarm system to automatically unlock on an alarm. According to section, these are required. Also, check the ‘PUSH TO EXIT” button to make sure it interrupts power to the locks for a minimum of 30 seconds, when depressed.

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FGI Standards on Ventilation

BKeyes : October 9, 2015 12:00 am : CMS, Questions and Answers, Ventilation

Q: The Centers for Medicare & Medicaid Services (CMS) standard §482.41(c)(4) states in their Interpretative Guidelines that hospitals must comply with the Facilities Guidelines Institute (FGI) for ventilation in anesthetizing locations. The Joint Commission standard EC.02.06.05, EP 1 requires compliance with the same FGI standards on ventilation. Our operating rooms were designed more than 20 years ago when the AIA guidelines at the time had less air changes per hour than what the new 2010 FGI guidelines require. Am I supposed to modify my current ventilation equipment in order to comply with the new 2010 FGI guidelines for air changes per hour? 

A: This short answer is No; you do not have to modify your existing air handler to meet the new 2010 FGI guidelines on air changes per hour, unless you alter, renovate or remodel the rooms the ventilation equipment serves. The Interpretative Guidelines for the CMS standards are not part of the enforceable standards, and are considered references. CMS does not expect compliance with the new FGI guidelines on existing equipment; only on new construction. Also, CMS states “acceptable standards such as from the Association of Operating Room Nurses (AORN) or the FGI should be incorporated into hospital policy.” This means, the FGI guidelines are not the only standard you should consider when designing new construction or renovated areas.

In regards to the Joint Commission standard EC.02.06.05, EP 1, it clearly states in the standard: “When planning for new, altered, or renovated space…” This means the FGI guidelines only apply to new construction, and not to existing conditions. And the FGI guidelines are only one of a set of criteria that the organizations may choose to comply with. The others are state rules and regulations or other reputable standards and guidelines that provide equivalent design criteria.

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Business Occupancy Testing

BKeyes : October 5, 2015 12:00 am : Business Occupancy, Questions and Answers, Testing

Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual fire drill but what about the testing of fire alarm system and sprinkler system?

A: Assuming the two-story office building that you refer to is classified as a business occupancy, the requirements for testing, inspection and maintenance are found in section of the 2000 Life Safety Code, which refers to section 9.6. Section requires the fire alarm system to be tested, inspected and maintained in accordance with NFPA 72 (1999 edition). Likewise, section 9.7.5 requires required sprinkler systems to be maintained in accordance with NFPA 25 (1998 edition). If your sprinkler system is not a ‘required system’, you still need to maintain it, according to The testing, inspection and maintenance requirements found in NFPA 72 and NFPA 25 are the very same requirements that healthcare occupancies need to comply with. The bottom line is: You need to test, inspect and maintain the fire alarm system and the sprinkler system in a business occupancy at the very same frequency and level as you would in a hospital.

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Do Table Top Exercises Count as Fire Drills?

BKeyes : October 2, 2015 12:00 am : Fire Drills, Questions and Answers

 Q: Do table top exercises count as a fire drill? We are updating our old policies and traditionally it has been allowed to have tabletops count as a fire drill, as long as half of them were actual Evacuation Fire Drills.

A: No, table top exercises, while they can be very helpful in the planning phase, are not an acceptable substitute in lieu of actually performing the fire drill. The reason why is you are required to perform multiple functions during a fire drill:

  • Evaluate staff’s response to a fire situation, both at the point of the alarm and away from the point of the alarm
  • Evaluate the building’s response to the fire alarm
  • Evaluate the fire alarm’s response to the drill
  • Confirm that the alarm signal was transmitted to the fire department during the drill

In short: How are you going to confirm and evaluate all of that if you do not perform the drill?

Actual fire emergencies are usually an acceptable substitute in performing a fire drill, provided you still are able to make all of the evaluation and confirmations. However, that is not easy to do when you and your staff are responding to an actual alarm.

Sorry, but you still must perform the required amount of fire drills in your facility. And by the way, many accreditation organizations have changed the way they define time. The phrase ‘quarterly’ used to mean you could perform the fire drill anytime during the calendar quarter. Now, Joint Commission and HFAP will require you to perform a fire drill 3 months from the previous drill, plus or minus 10 days. That will require more planning and organization on your part.

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