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 184.108.40.206 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: The health care facility where I work needs additional privacy on the nursing floor from the rest of the building. I would like to know if we could mount a ceiling track across the beginning of the nursing hallway, with a lightweight privacy curtain that can be drawn open or closed as needed; or place two decorative lightweight free-standing folding screens placed at the entrance to the nursing hallway.?
A: Assuming the nursing hallway that you refer to is an exit access corridor; then no, neither option that you suggest would comply with the LSC. Section 220.127.116.11 of the 2000 LSC edition requires the corridor to be arranged to avoid any obstructions for the convenient removal of non-ambulatory patients. That means nothing may be placed in the corridor that could obstruct access, such as the screen. A curtain hanging down from the ceiling would not be permitted according to section 18.104.22.168, which could conceal the path to the exit. However, permanently installed side-hinged swinging privacy doors would be permitted and are often used in situations like the one that you described. The new barrier for the doors would not have to extend to the deck above and would be permitted to terminate at the ceiling. The doors and frame would not be required to be fire rated, and would not have to have positive latching hardware. Any changes to the facility should be reviewed by your state and local authorities.
Q: Can evacuation chairs be installed in stairwells?
A: The answer is… maybe yes and maybe no. Sorry, that’s not a direct answer, so please allow me to explain. Section 22.214.171.124.3 of the 2000 edition of the Life Safety Code says: “There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.” So, if we take the latter half of this requirement, it says we cannot place anything in the stairwell that could interfere with egress. Would hanging an evacuation chair on the inside wall of a stairwell interfere with egress? This is a question that is not directly addressed by NFPA, so that means the authorities having jurisdiction (AHJ) get to make that interpretation. My experience with many AHJs is they do not want anything hung on the wall on the inside of a stairwell where it could be an obstruction to those individuals trying to egress down the stairs. That means to me, that you would NOT be able to hang these evacuation chairs anywhere in the path of egress inside the stairs, no matter how wide those stairs are. However, not all is lost. If there is a landing at the very top of the stairwell that is open and not used as part of the path of egress, and there is no other items on the walls around this landing, such as a fire hose cabinet or fire extinguisher, then I could see that area being used successfully to hang an evacuation chair. The downside of this is the arrangement only seems to apply to the very top of the stairwell, and if you wanted to hang evacuation chairs on every landing in the stairwell, I don’t believe you would be able. Something else to think about: Even if one AHJ says it is okay to hang evacuation chairs inside the stairwell on every landing, I strongly suggest you do not do it. You may have as many as 5 or 6 AHJs that inspect your hospital for compliance with the Life Safety Code. Just because one AHJ says it is okay that does not mean all of the other AHJs have to abide by that decision.
Q: What are the testing frequencies for fire alarm panel batteries and where do you find this requirement?
A: The testing frequencies for batteries for fire alarm control panels (including notification appliance circuit extender panels, or ‘NAC panels’) are found in Table 7-3.2 of NFPA 72 (1999 edition). For years, batteries used in fire alarm systems have been sealed lead-acid type, and there are three (3) tests that need to be conducted:
- Charger Test (Annually)
- Discharge Test (Annually)
- Load Voltage Test (Semi-Annually)
The Load Voltage test is usually what trips up the fire alarm testing contractor, as they do not always return on a semi-annual basis to perform the load voltage test. This is not always the fault of the testing contractor, but more of a contract issue with the healthcare organization. Make sure you check the language of your contract to ensure the vendor is performing these tests at the allocated time frequencies. If you’re scoring this as a Joint Commission deficiency, non-compliant with Table 7-3.2 battery testing could be scored under one of the following:
- EC.02.05.05, EP 3
- EC.02.06.01, EP 26
- LS.02.01.34, EP 4
Be aware that Joint Commission, and many other authorities, will expect the semi-annual test conducted 6 months from the previous test, plus or minus 20 days. The annual tests must be conducted 12 months from the previous test, plus or minus 30 days. Make sure your contract stipulates these requirements and monitor their activity to confirm it.
Q: We have a situation in our Lab where they would like to purchase another incubator that requires additional CO2 gas. The problem is that we do not have a designated space for storing more than 1 H size cylinder. We have a space that is used to store flammable agents and is a two hour fire rated room with a fire suppression system, exhaust and the doors are equip with door closures. Very little amounts of flammable agents are stored in this room anymore. Could we use this room as our gas manifold room for the CO2 gas?
A: NFPA 99 (1999 edition), section 4-126.96.36.199(a)2 is the code reference where oxidizing gases used in a manifold system are not allowed to be stored with anything else. Though, in your example you want to create a manifold system for CO2, which of course is not an oxidizing gas. I do not see anything in NFPA 99 that would prevent you from using this room for the CO2 compressed gas manifold system. However, it would be best to have the flammable agents stored inside a fire-rated metal storage cabinet.
Q: Do emergency power generators have to be located in a room by themselves? We have a generator that is located in a mechanical room which is shared with an air-handler, condensate pumps and other equipment. This generator was installed in the 1970’s, but a consultant told us we had to relocate the generator to a 2-hour room where it can be located by itself.
A: NFPA 110 (1999 edition), section 5-2.1 says the generator must be installed in a separate room with a 2-hour fire rating, and no other equipment is permitted in the room. However, section 1-3 of the same standard says NFPA 110 only applies to new installations and existing systems are not required to conform to the standards, unless the authority having jurisdiction (AHJ) determines that nonconformity presents a distinct hazard to life. If the generator has been installed since the 1970’s and no AHJ has cited you for nonconformity, then I suggest it is safe to assume the AHJs that have inspected your facility do not have a problem with the arrangement. If an AHJ attempts to cite this situation for non-compliance with NFPA 110 (1999 edition) section 5-2.1, then I would make the case that it is not required to since this room was constructed long before NFPA 110 was in existence. NFPA 110 was first adopted in 1984 by NFPA, so it was not part of the Life Safety Code until probably the 1985 edition. Therefore, it may be assumed it met the standards that were in existence in the 1970′s when the building was constructed.
Q: I have a reception area that has a sprinkler head in the middle of a 2′x2′ ceiling tile and less than twelve inches from this sprinkler head the interior designer has placed a circle light that is flush to the ceiling tile. Doesn’t this violate the 18″ rule and the 24″ circumference rule?
A: No, what you described does not appear to be a problem. The 18 inch rule that you refer to is measured down (or vertically) from the sprinkler head deflector to a horizontal plane that extends from wall-to-wall in the space or room. If the light fixture that you described is truly flush mounted, and does not extend below the sprinkler head deflector, then I do not see a problem. I am not familiar with the 24 inch circumference rule that you are referring to. You do have the correct idea concerning ceiling mounted obstructions, though. The 2000 Life Safety Code refers to NFPA 13 (1999 edition) for compliance involving sprinkler installations, and Table 5-188.8.131.52 provides the minimum distances that a ceiling mounted obstruction is permitted to a sprinkler head, depending on the distance the obstruction projects below the sprinkler head. So, in your example, the Table does not permit any object that is ceiling mounted to project below the sprinkler head within the first 12 inches of the sprinkler head. Then for each additional 6 inches, the allowable distance that a ceiling mounted obstruction may extend below the sprinkler head increases. So, you have the right idea concerning ceiling mounted obstructions, you just didn’t have all the details.
Q: We are designing a retrofit for a dental office in an existing business occupancy building without a fire sprinkler system. The space we are remodeling was formerly a doctor’s office. We are adding a medical gas system with oxygen and nitrous oxide delivered from an “exterior” medical gas room. It is required to have a “sprinkler”. What kind of system can be added to meet the requirement for a “sprinkler”?
A: In regards to the dentist office you are referring to, is it a conclusion that your local, state or accreditation authorities require compliance with the NFPA 101 Life Safety Code? And if so, which edition would that be? If the dentist office is to be accredited by Joint Commission and will receive reimbursements from Centers for Medicare & Medicaid Services (CMS), then the answer is yes, compliance with the LSC is required and the edition would be the 2000 edition. If not, then other codes or standards may apply, based on local or state authorities. In regards to your comment that the exterior gas room requires a sprinkler, what code or standard reference are you referring to? Is this a local or state requirement? I do not see a NFPA 101 Life Safety Code (2000 edition) or a NFPA 99 Health Care Facilities (1999 edition) requirement for the storage room or a medial gas manifold room to be sprinklered, for business occupancy (or for healthcare occupancy for that matter). There are certainly requirements for this room, that are found under NFPA 99 (1999 edition), section 4-3.1.1, but sprinkler protection is not one of them. To answer your question, many AHJs permit isolated rooms to be sprinklered using domestic water, provided the supply is adequate and no more than 7 heads are piped from the domestic system. Water-flow switches and control valves connected to the fire alarm system are required. But since sprinklers are not required based on NFPA codes and standards, you would have to negotiate the use of domestic water from the authority requiring sprinklers.
Q: When will we know if CMS will adopt the 2012 version of the NFPA LSC book?
A: You will not have to worry about that… Nearly everyone will be writing about it and there will be public announcements made in every industry newsletter and blog across the country. First, CMS will publish an announcement of the rule change to adopt the 2012 LSC in the Federal Register; then membership organizations like ASHE will alert their members of the news; then accreditation organizations like Joint Commission will issue statements and press releases about the adoption; then industry newsletters and blogs (like this one) will be talking about it. It will not go un-noticed. The good news is CMS has already said in the 2013 spring Unified Agenda that they intend to propose a rule that will require compliance with the 2012 edition of the LSC; the bad news is we don’t know when they will issue the final rule. I suspect it will be at least another 6 – 12 months if not longer as CMS must first publish a proposed rule change in the Federal Register, then allow 60 days for public comment; then take the time to review and respond to all the public comments; then they will issue the final rule change to adopt the 2012 LSC, again in the Federal Register. The length of time between CMS reviewing the public comments and issuing a final rule could be 12 months or longer (based on the last time they adopted a newer edition of the LSC). I don’t expect the effective date for the adoption of the 2012 LSC to be until early 2015. The misconception that seems to be very common is the myth that Congress needs to approve the rule change to adopt the 2012 LSC, which is not true. Congress has 60 days to review the final rule and if they don’t like it, they can only challenge it through the federal court system. This is all based on the Administrative Procedure Act of 1946 that limits how federal agencies make changes to their rules. There have even been comments by industry experts that CMS should change the rule, to allow them to adopt a newer edition of the LSC without having to go through the due diligence process of proposed rules and public comments. That does not seem to be a good decision for the public, as then there would be no process for us to make comments on a proposed change to a newer edition of the LSC. All in all, the way they are doing it now is a good system. Not very fast, but what part of government is?