Q: A state surveyor cited us for not doing a monthly fire pump automatic transfer switch (ATS) test. We are doing a weekly churn test and an annual fire pump flow test that includes switching over the ATS. I was not aware that this had to be done monthly.
A: Yes… NFPA 110-1999, section 6-4.5 requires all transfer switches in Level I and Level II systems (hospitals typically have Level I systems) to be tested monthly. The state surveyor is correct. I find that it is not uncommon for some hospitals to overlook the ATS serving the fire pump. I guess they don’t always see that it is part of the Level I emergency power supply system. Out-of-site is out-of-mind!
Q: In the past our hospital has used different brands of fire caulk on the same fire wall assembly. The fire caulk is two different brands and different colors and surveyors have stated that we cannot have “mixed” caulk. Where in the Life Safety Code does this say we cannot mix fire caulks?
A: There is no specific Life Safety Code reference that speaks to this, but the surveyors are correct. It has more to do with the UL listing of the fire-stop assembly where the mixed fire caulks are used. A proper fire-stop system is an assembly and must comply with the UL listing that it was tested to. For example; to seal a penetration in a fire-rated wall, the UL listing will identify what type of fire caulk to use, what material it is permitted to be used on (i.e. gypsum board or cement block), and how to apply it. The UL listing is typically specific to the brand of fire caulk material used. This is because the manufacturers pay to have Underwriter’s Laboratory test the assembly and the resulting UL listing is specific to their brand of fire caulk. There is no UL listing for when you mix the different brands of fire caulk on the same assembly. Will it work? Most likely it will, but it does not meet the UL listing of that particular assembly. This is why there is a movement in the industry to have the installers who install fire-stop materials be certified to do so. Education is needed so the installers fully understand how to properly apply the products.
Q: Are surgery rooms considered to be patient sleeping rooms or non-sleeping rooms? In reference to allowable suite sizes, what is the maximum area of the suite?
A: Surgery rooms are definitely considered non-sleeping rooms. A sleeping room is a room designed and constructed for patient sleeping. Surgery rooms are not designed and constructed for patient sleeping. And by the way, (you didn’t ask, but….) neither are sleep labs. A sleep lab sleeping room is not a patient sleeping room, but is an exam room, and can qualify to be classified as business occupancies. Since it is a non-sleeping area, a surgery suite is permitted to be 10,000 square feet in size. However, if you had a patient sleeping suite, the 2000 Life Safety Code limits the size to 5,000 square feet. The 2012 Life Safety Code does permit patient sleeping suites to extend to 10,000 square feet but specific additional requirements have to be met. There are CMS categorical waivers that would allow a hospital to utilize the 2012 edition pertaining to patient sleeping suites.
Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to install a fire barrier after the unit is constructed and if there are any other options. Your comments would be appreciated.
A: Well…. From a code standpoint, you may be obligated to have two different barriers:
- A 1-hour fire rated barrier to separate the ambulatory healthcare occupancy from other units that are not ambulatory healthcare occupancies (i.e. physician’s offices that would be classified as business occupancies). See sections 220.127.116.11 and 18.104.22.168 of the 2000 Life Safety Code.
- A 1-hour rated smoke compartment barrier to subdivide your ambulatory healthcare occupancy into two compartments. Exceptions to this requirement apply if your unit is less than 5,000 square feet and the unit is fully protected with smoke detectors, or if the unit is less than 10,000 square feet if the unit is fully protected with automatic sprinklers. See section 22.214.171.124 of the 2000 Life Safety code.
If you receive Medicare & Medicaid reimbursement funds then you are obligated to comply with these codes. However, CMS does allow you to apply for a waiver if compliance with the Life Safety Code is a hardship for the organization. You cannot apply for a waiver until you are first cited for a Life Safety Code deficiency by an accreditation organization or a state agency surveying on behalf of CMS. But there are no guarantees that CMS would grant approval of a waiver request for this deficiency. Even if they did, the waiver is only valid for 3 years then you have to be cited again and then you have to submit a waiver request again. At best, it is a temporary process… not a permanent solution. My suggestion is to make plans to resolve the deficiency as soon as possible and if you get cited in the meantime, you can always submit a waiver request as part of your Plan of Correction.
Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?
A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.
Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.
A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section 126.96.36.199 of the 2000 edition of the LSC requires compliance with section 9.6. Section 188.8.131.52 requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.
Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors. Is this permitted?
A: Actually, dead-bolt locks with a thumb-turn on the inside would be permitted on restroom doors, provided the doors to the restrooms are not positive latching. Restroom doors are not required to latch, therefore the larger restrooms rarely have positive latching hardware. Section 184.108.40.206.4 of the 2000 Life Safety Code© says doors in the means of egress are not permitted to have more than one action to operate the door. If the door had a latch-set and a dead-bolt lock then that would not be permitted since it takes two actions to operate the door (unlock the dead-bolt and turn the latch-set). But since the bathroom door does not require a latch-set, then a dead-bolt lock that can be unlocked from the egress side would be permitted.
Q: There appears to be many different ways a hazardous room is maintained: If it is sprinklered, does it have to be 1-hour rated? If it is existing construction, does it have to be sprinklered? What rules apply if there is a lay-in ceiling? What are the basic requirements for a hazardous room?
A: A hazardous room in a hospital includes a room larger than 50 square feet used for the storage of combustible supplies. How many combustible supplies are needed to make it a hazardous room? Not much, but it is a judgment call by the surveyor. If the room is designated ‘existing conditions’ (created prior to March 11, 2003) then there are two options on how it has to be maintained:
- If there are no sprinklers in the room, then the walls need to be one-hour fire rated and extend from the floor to the deck above, and the door to the room needs to be ¾-hour fire rated, self-closing and positive latching.
- If there are sprinklers in the room, then the walls only have to be smoke resistant, and extend from the floor to the ceiling, as long as the ceiling also resists the passage of smoke. The door to the room may be non-rated, but must be self-closing and positive latching.
If the room is designated ‘new conditions’ (created on or after March 11, 2003) then there is only one option for the room: The room must be sprinklered, and the walls must be one-hour fire rated and extend from the floor to the deck above, and the door must be ¾-hour fire rated, self-closing and positive latching. Also, if the supply room was originally constructed to ‘new conditions’, but before March 11, 2003, it cannot be down-graded to ‘existing conditions’, but must be maintained as ‘new conditions’. Any ceiling that has sprinklers or smoke detectors must be maintained to resist the passage of smoke. This is because smoke and heat will migrate above the ceiling if there are cracks, voids or missing tiles, and the detectors and sprinklers may not activate properly.
Q: Why does the escutcheon plate on a sprinkler need to be required when the ceiling is not rated and the corridor walls extend to the deck? If a basement can have sprinklers and no ceilings why are the sprinklers on the floors above required to have these plates when the ceiling is not rated?
A: The escutcheon plates are required on sprinkler heads which are mounted in ceilings to fill the gap between the head and the ceiling. Many times a sprinkler installer will use a hole saw larger than necessary to make the opening for a sprinkler head. Any gap over 1/8 inch must be sealed, so the escutcheon plate serves as a gap sealer and as an attractive trim plate. Without sealing this gap, heat and smoke will rise up above the ceiling and activation of the sprinkler head (and smoke detector, if so equipped) will be delayed. They are very important, and an easy deficiency for a surveyor to find.
Q: We have an old dark room that was converted into an air handler room. What’s the requirement for a door to this room?
A: It all depends where this former dark room is located. First of all, what is the occupancy designation for the building or area where this air handler is located? If it is business occupancy and the air handler does not include a gas-fired furnace, then it is very likely that no door is actually required to this room. However, if the building or area is designated as a healthcare occupancy, then it depends whether or not the room opens up onto a corridor. In healthcare occupancies, all corridors must be separated by walls and doors from all other areas. Now, there are some exceptions to this requirement, but an air handler room will not qualify for any of these exceptions. If the former dark room/air handler room does not open onto a corridor, but opens onto another room, then it is likely that a door would not be required, provided the air handler room does not contain anything to make it a hazardous room, such as fuel-fired equipment, or storage of combustibles of flammables. If the air handler room somehow qualifies as a hazardous room (see sections 220.127.116.11 of the 2000 edition of the LSC) then the room will need to be protected with automatic sprinklers, and the walls will be required to be 1-hour fire rated, and the doors will be required to be ¾-hour rated, self-closing and positive latching. All of that would be required even if the room does not open onto the corridor. If the air handler room is not considered to be a hazardous area, and the room opens onto a corridor, then the door is only required to resist the passage of smoke, or if the corridor is located in a non-sprinklered smoke compartment then a substantial door such as 1¾ inch thick, solid-bonded, wood-core door, or be of such construction to resist fire for at least 20 minutes. Notice it did not say the door had to be 20-minute fire rated. That is a common misunderstanding.