The following Questions and Answers were previously published in the Healthcare Life Safety Compliance newsletter, and all answers were provided by Brad Keyes.
Q: Our facility is a freestanding ambulatory surgical center and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story building with multiple tenants. We had a state inspection recently and they asked us for documentation that we tested our fire and smoke dampers every 4 years. What are they looking for? We’ve been in the building for 13 years and no one has ever asked us about fire and smoke damper testing before.
A: Since it appears that the inspector is holding you accountable for compliance with the 2000 Life Safety Code, I will assume you need to comply with chapter 21, for existing ambulatory health care occupancies. Section 188.8.131.52 requires compliance with section 9.2 which in turns requires compliance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition. Section 3-4.7 of NFPA 90A requires the fire and smoke dampers to be tested once every 4 years. For clarification, CMS did issue an S&C memo on October 30, 2009 which permitted hospitals to change the frequency of fire and smoke damper testing to once every six (6) years, but this memo only applies to hospitals, and not to ambulatory health care occupancies. It is not unusual for authorities who inspect your building to fail to ask for certain documentation (such as test results of the fire/smoke dampers), and then at a later date, another authority will request that information. Just because the previous surveyors/inspectors did not ask to see this information, does not mean it was not required. This inspector is now holding your organization accountable to what has always been a Life Safety Code requirement.
Q: During a recent survey, the surveyor said a card reader on the stairwell door cannot be located on an adjacent wall or door frame, but it must be an integral part of the lockset itself. Is this true? They were talking about card readers on the stairwell side for re-entry to a floor.
A: Did the surveyor cite you for non-compliance? If not, surveyors sometimes say things that are misunderstood, especially if there is no citation. Doors not in the path of egress are permitted to be locked, and a re-entry door from a stairwell usually is not in the path of egress. As long as the re-entry door in the stairwell is not in the path of egress then I do not see any reason that what you describe would be a problem. The Life Safety Code would allow for a card reader device to unlock a stairwell re-entry door as long as the door is not in the path of egress. If the card reader is mounted in the stairwell on the door leading to a floor of the building (not a discharge door), then the card reader is not on the egress side of the door. There is nothing in the Life Safety Code, or in NFPA 80 Standard for Fire Doors and Fire Windows, (1999 edition) that would require the card reader to be mounted on the door leaf, rather than the on the wall near the door. Therefore, it is clear that the LSC permits card-access readers to be mounted on the wall near the door, since it is not a device or motion to operate the door. I cannot think of any situation that would require the card-access reader to be mounted on the door leaf, itself.
Q: We are a freestanding ambulatory surgical center (ASC) and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story building with multiple tenants. During a recent state inspection, I was asked where our smoke compartments are located. I know that we have a 2-hour fire barrier between us and the other suites on our level, but I am not aware that we have any designated smoke compartments. Do we need smoke compartments?
A: You did not mention how many patients are incapable of self-preservation at any one time, so I will assume it is at least 4 or more patients, since that is the threshold to decide if the ASC is required to comply with ambulatory health care occupancy requirements, or business occupancy requirements. Ambulatory health care occupancy smoke compartment requirements are found in section 184.108.40.206, which requires your ASC to be sub-divided into not less than two smoke compartments. However, there are some exceptions to this requirement:
- ASC facilities that are less than 5,000 square feet and are protected by an approved smoke detection system do not need to be sub-divided.
- ASC facilities that are less than 10,000 square feet and are protected throughout by an approved automatic sprinkler system do not need to be sub-divided.
- An area in an adjoining occupancy may be permitted to serve as a smoke compartment for the ASC facility, provided all of the following criteria is met:
- The separating barrier must be at least 1-hour fire rated, and have doors that are self-closing.
- The ASC facility is less than 22,500 square feet.
- Access from the ASC facility to the other occupancy is unrestricted.
So, to answer your question, based on the size of your ASC and whether it has smoke detection or sprinkler protection, it may not require a smoke compartment barrier. If a smoke compartment barrier is required, you might be able to utilize the 2-hour fire rated barrier between you and your neighbors, if you are less than 22,500 square feet and if there is unrestrictive access to the other occupancy.
Q: Where is the reference in the Life Safety Code that requires the doors to housekeeping or soiled utility rooms to be locked? I have a Risk Management director that tells me the code requires these doors to be locked.
A: There is no Life Safety Code requirement to lock housekeeping or soiled utility room doors. There is no Joint Commission, CMS or any other national authority that requires housekeeping or soiled utility room doors to be locked. Where hospitals get into trouble with CMS and the accreditation organizations on this issue is the failure to assess the risk to safety for patients and staff, when these doors are left unlocked. Each of the national authorities has a standard that requires hospitals to either identify safety and security risks in the environment, or their standard requires the hospital to maintain a safe environment for their patients. An unlocked utility room that contains a risk to the patients would certainly be suspicious to a surveyor that the environment may not be safe for the patients. A housekeeping room may contain cleaning supplies that could be considered dangerous to unauthorized individuals (such as children). If the door to the housekeeping room was left unlocked, then people could gain access to the hazardous items and hurt themselves or others. Likewise for soiled utility rooms, which by definition would have soiled linens which may be bio-hazardous. This does not mean all soiled utility rooms or housekeeping rooms need to be locked. They just have to be assessed for the safety or security risks associated with the contents of the rooms. In my encounters, most of the soiled utility rooms that I see in hospitals are unlocked. Only soiled utility rooms where children are prevalent are the ones that are typically locked. Now, on the other hand, most (if not all) housekeeping janitor’s closets that I see are locked, partly due to the hazardous cleaning chemicals stored in them, but also because Housekeeping doesn’t want their other supplies stolen. But, to be sure, there is no direct requirement in the LSC or in the accreditation organization standards to keep these doors locked.
Q: How many spare sprinkler heads are we supposed to have in stock at our facility? We had an inspection recently, and the fire marshal said we did not have enough spare sprinklers, but he did not say how many we are supposed to have, or where we can find that information.
A: Section 220.127.116.11 of the Life Safety Code (2000 edition) requires you to be in compliance with NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 edition, when the occupancy chapter requires fire protection sprinklers. Section 3-2.9 of NFPA 13 discusses the need and quantities for a supply of spare sprinkler heads. A minimum of 6 spare sprinklers is required for each type of sprinkler head that you have installed in the facility, when the total quantity of each type is less than 300. If you have between 300 and 1,000 sprinklers installed of the same type, then you must have at least 12 spare sprinklers in supply. And if you have over 1,000 sprinklers of the same type installed in your facility, then you must have a minimum of 24 spare sprinklers of that particular type. As you can see, different spare heads are required depending on their type, temperature rating and quantity installed. And, with each type of spare head that you have in supply, a special wrench used in the removal and installation of sprinklers must also be provided and kept in the cabinet. For an older facility that had their fire protection sprinklers installed in stages, you can imagine that there may be many different types, styles and temperature ratings of sprinkler heads installed. A supply of this magnitude often requires a full-size cabinet to store everything. The NFPA 13 standard does not say where you need to store these spare sprinklers and wrenches, but contractors often install a spare sprinkler box in the fire pump room. The only requirement for storage is the room cannot exceed 100°F.
Q: Is the Life Safety Surveyor a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and various areas of survey?”
A: No, the Life Safety Code Surveyor that the accreditation organizations use is not a mandate or a requirement by the Centers for Medicare & Medicaid Services (CMS), or any other arm of the government. It is more of an indication that evaluating the hospital’s compliance with the Life Safety Code requires specialized skills that previous surveyors simply did not have. In 2004, the Government Accountability Office (GAO) published a report that indicated The Joint Commission needed improvement in the assessment of hospitals for compliance with the Life Safety Code. To their credit, the Joint Commission agreed and decided to hire Life Safety Code specialists and make them surveyors and put them on the survey team. The new LSC surveyors began surveying in January, 2005, for hospitals with 200 beds or more, and it was a huge success. Hospitals actually liked being inspected by knowledgeable surveyors and in 2008 the LSC surveyors were expanded to survey all hospitals, including Critical Access hospitals. When Det Norske Veritas Healthcare, Inc. (DNV) started surveying hospitals in 2008, they immediately recognized the need for surveyors with specialized skills in the Life Safety Code and included them in their surveyor compliment. And Healthcare Facilities Accreditation Program (HFAP) has decided to include surveyors with life safety skills as well.
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 18.104.22.168 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 22.214.171.124 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 126.96.36.199, 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 188.8.131.52.3 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.