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 new clinic integration program has made us look closely at the clinic’s life safety process. The clinic is classified as a business occupancy. Is the assessment for life safety compliance different than an acute care hospital?
A: While the clinic is classified as a business occupancy, the approach to a life safety assessment would be similar as conducting a life safety assessment for a healthcare occupancy (hospital), but you do not assess the clinic to the same set of standards as you would the hospital. Healthcare occupancies must comply with the core chapters of the 2000 Life Safety Code (LSC), which are chapters 1-4, and 6 – 11, and they have to comply with the occupancy chapters 18 and 19. Business occupancies likewise have to comply with chapters 1 – 4, and 6 – 11, but they have a different set of occupancy chapters to comply with; chapters 38 & 39. Chapter 38 is for new construction and chapter 39 is for existing construction. A facility is considered new construction if its construction plans and documents were approved by the local authorities after March 11, 2003. A facility is considered existing construction if its construction plans and documents were approved by the local authorities on or before March 11, 2003. Also, any renovation conducted in existing construction buildings on or after March 11, 2003 must comply with new construction requirements.
Why the date of March 11, 2003? Because that is the date that the Centers for Medicare & Medicaid Services (CMS) adopted the 2000 edition of the LSC. Assuming your clinics qualify for existing construction occupancy, you must assess the building for compliance with chapter 39. You will find that the life safety requirements are far less restrictive for business occupancies as compared to healthcare occupancies. Examples where there will be significant differences (and leniencies) in compliance, are:
- Construction Type (39.1.6)
- Overhead Rolling Fire Doors (22.214.171.124.7)
- Means of Egress Arrangement (39.2.5)
- Emergency Lighting (39.2.9)
- Hazardous areas (39.3.2)
- Fire alarm systems (39.3.4)
- Sprinkler systems (39.3.5)
- Corridor walls (39.3.6)
- Smoke compartments (39.3.7)
- Fire Drills (39.7.1)
- Fire Extinguisher Training (39.7.2)
While fire damper testing in healthcare occupancies enjoys a 6-year cycle, that is not the case in business occupancies, which requires a 4-year testing interval. You will have to research each issue individually to determine your level of compliance.
Q: During a recent survey, the life safety surveyor wrote a finding that my refrigerator and freezer walk-in coolers are not in compliance with the building having full sprinkler coverage. The walk-In coolers were installed prior to 1982, and two units do have sprinklers, but three do not. The state fire marshal reviewed us and said we’re okay. What do you think?
A: It appears to me that it is an issue of whether you’re taking credit for the building being fully sprinklered. If you have a certain Construction Type (see Table 126.96.36.199 of the 2000 Life Safety Code) that requires sprinklers; or you have equivalencies or waivers that requires the building being fully sprinklered; or if you have performed any renovation or alterations in the walk-in coolers since March 11, 2003; or if you have delayed egress locks located anywhere in the building, then yes, the walk-in coolers must be protected with sprinklers.
But if none of that has occurred and there is no apparent requirement for the smoke compartment where the walk-in coolers are located (or the entire building) is required to be sprinklered, then you should be okay. Keep in mind that it doesn’t matter that one of your authorities having jurisdiction (AHJ) approved this installation. If another AHJ disagrees, it is their privilege to enforce the codes and standards as they understand them; they are not bound by what the state fire marshal says. Installing dry-head type sprinklers in freezing environments is not that difficult, nor costly. I would consider upgrading and installing dry-heads.
Q: Where are main drain tests required to be done? This is a large medical facility with nine story towers. Several fire mains feed the various campus buildings. Is the main drain test required to be done only where the fire mains supply the system risers, or does it also need to be done on each floor at the riser as well? Would you please supply your rationale for your answer?
A: According to the 2000 edition of the Life Safety Code, main drain tests are regulated by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. Section 1-5 of NFPA 25 defines a main drain as the primary drain connection on the system riser and also is utilized as a flow test connection. Section 9-2.6 requires a main drain test must be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply and control valves. NFPA 25 does not adequately define what a ‘system riser’ is, so we turn to the Handbook for NFPA 13 Standard for the Installation of Sprinkler Systems which identifies a ‘system riser’ as the above ground horizontal or vertical pipe between the water supply and the mains (cross or feed) that contains a control valve (either directly or within its supply pipe) and a waterflow alarm device. A system riser is more than just a subset of the term riser, which is broadly defined as any vertical piping within the sprinkler system. As indicated by the definition, a system riser can be any aboveground pipe in a vertical or horizontal orientation installed between the water supply and the system mains that contain specific devices. By this definition it appears one could loosely define the locations of a main drain test to be conducted wherever there is a control valve and waterflow alarm switch. In a large multi-story facility such as yours, that would most likely require a main drain test at least on every floor, possibly more. The Accreditation Organizations (AOs, such as Joint Commission, HFAP and DNV) typically do not seek this level of compliance. Most of the AOs only expect main drain tests to be conducted at the base of the risers of the sprinkler system, not at every floor. However, depending on your state agency surveyors who conduct CMS validation surveys, it is very reasonable and possible that they will expect the main drain tests to be conducted at every floor. To continue with additional information, the purpose of a main drain test is covered in the Annex section A-9-2.6, which says main drain tests are used to determine whether there is a major reduction in waterflow to the system, such as might be caused by a major obstruction, a dropped gate, a valve that is almost fully closed, or a check valve clapper stuck to the valve seat. A large drop in the full flow pressure of the main drain (as compared to a previous test) normally is indicative of a dangerously reduced water supply caused by a valve in an almost fully closed position or other type of severe obstruction. After closing the drain, a slow return to normal static pressure is confirmation of the suspicion of a major obstruction in the waterway and should be considered sufficient reason to determine the cause of the variation. A satisfactory drain test (i.e., one that reflects the results of previous tests) does not necessarily indicate an unobstructed passage, nor does it prove that all valves in the upstream flow of water are fully opened. The performance of drain tests is not a substitute for a valve check on 100 percent of the fire protection valving. The main drain test is conducted in the following manner:
- Record the pressure indicated by the supply water gauge [Static Pressure]
- Close the alarm control valve on alarm valves
- Fully open the main drain valve
- After the flow has stabilized, record the residual (flowing) pressure indicated by the water supply gauge
- Close the main drain valve slowly
- Record the time taken for the supply water pressure to return to the original static (nonflowing) pressure
- Open the alarm control valve
Q: Our hospital has an offsite building for our cardiac rehab, physical therapy, and pulmonary rehab programs. It also houses our business office and some physician offices. The building is classified as a Business Occupancy. What are the requirements for storing oxygen cylinders in a non-rated storage room?
A: A business occupancy that provides services for cardiac rehab, physical therapy, and pulmonary rehab programs is considered to be a health care facility. Assuming you are either Joint Commission accredited, or receive federal reimbursement monies for Medicare or Medicaid services, you are required to comply with NFPA 99 (1999 edition) Health Care Facilities standard. According to section 1-2, NFPA 99 (1999 edition) applies to all health care facilities, and section 2-1 defines a health care facility where medical care is provided. Chapter 13 in NFPA 99 is the chapter for “other” health care facilities which are not hospitals, nursing homes and limited care facilities. Section 13-3.8 requires all gas equipment to conform to chapter 8. Section 8-3.1.11 lists the storage requirements for nonflammable gases greater than 3,000 cubic feet and quantities less than 3,000 cubic feet which are similar (but not the same) as those requirements for hospitals. For storage of quantities of nonflammable gas greater than 3,000 cubic feet, the requirements are the same as those for hospitals, which are found in section 4-188.8.131.52 of NFPA 99. However, for quantities less than 3,000 cubic feet, there is a difference in storing nonflammable gas in quantities of 300 cubic feet or less. Hospitals have the advantage of having a special dispensation granted by The Centers for Medicare & Medicaid Services (CMS), in the form of S&C Letter 07-10, published January 12, 2007. In this letter, CMS allows hospitals (but not medical offices or clinics) the advantage of following the 2005 edition of NFPA 99, which permits quantities up to 300 cubic feet of nonflammable gas to not be stored in any special rooms or areas. This exception for ‘up to 300 cubic feet’ is not found in the 1999 edition of NFPA 99. Therefore, your business occupancy must store all nonflammable gas cylinders in quantities from 0 to 3,000 cubic feet in accordance with section 8-184.108.40.206, which requires a specially designated room which has a door capable of being locked, and all oxidizing gases in this room must be separated from combustibles by 20 feet (or 5 feet if the room is protected with automatic sprinklers), or the oxidizing gases are to be stored in a flammable cabinet with a fire rating of at least 30 minutes.
Q: I cannot find a code reference that prohibits storage in the generator enclosure. Is there a specific reference for this in the 2000 edition of the Life Safety Code?
A: Sections 19.5.1 and 9.1.3 of the Life Safety Code (2000 edition) references NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, section 5-2.1, which requires the generator to be installed in a separate room for Level 1 installations, which applies to hospitals. NFPA 110 does require a minimum 2-hour fire rating or the generator must be located in an adequate enclosure located outside of the building capable of resisting the entrance of snow and rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, is permitted in this room. In addition, section 5-2.2 of NFPA 110 does not allow generators to be installed in the same room where normal electrical equipment service is installed. These two sections are being interpreted by many national authorities whereby absolutely nothing is allowed in the same room as the generator. The good news (if there is any), the most recent edition of NFPA 110 (2010 edition) does allow small repair parts, tools and manuals in this generator room, but that edition will not be part of our accreditation process until CMS adopts the 2012 edition of the Life Safety Code. So for now, we must comply with the 1999 edition of NFPA 110.
Q: If hazardous areas like a carpentry shop and a paint shop are combined in a separate building distant from hospital building, what can be an appropriate reference to determine the required fire and life safety measures? If this building is a single story and has HVAC ductwork, is it required to provide smoke compartmentation and fire dampers also?
A: It is apparent that the building you described does not house patients, so it could be considered business occupancy or industrial occupancy. It really depends on what else is in the building besides the carpentry shop and paint shop. For example, if this separated building also houses offices or general storage, then I could see it having to comply with business occupancy requirements. In business occupancies, hazardous areas which have a degree of hazard greater than that normal to the general occupancy of the building must be enclosed with 1-hour fire rated barriers, or protected with an automatic sprinkler system. These code references are found in the 2000 edition of the Life Safety Code, sections 220.127.116.11, and 8.4. However, if the separated building is not mixed with offices or general storage, and is only a carpentry shop and a paint shop, then you could classify it as an industrial occupancy. Section 40.3.2 does not require added protection of hazards in industrial occupancies as long as the hazards are not considered ‘high hazards’. A high hazard (another name for this is a ‘severe hazard’) is one in which quantities of flammable, combustible, or hazardous materials are present that are capable of sustaining a fire of sufficient magnitude to breach a 1-hour fire separation. According to NFPA 90A, 1999 edition, fire dampers are only required in fire barriers of 2-hour rating or greater, with the exception of a 1-hour fire rated vertical shaft, or if the HVAC duct is open ended (a return air plenum ceiling) on one side of a 1-hour fire rated barrier. Your question indicated the building is single story so it appears that a vertical shaft is not present. If the option of a 1-hour fire rated barrier is selected for the protection around the carpentry shop and paint shop in a business occupancy, and the HVAC duct is open at the fire barrier, then a fire damper would be required. Please check with your local and state authorities to determine if they have other requirements which may apply.
Q: We are going to prepare an action card for fire safety as part of our major emergency response plan. What information regarding fire safety would you suggest we include on the Emergency Response job action card?
A: Emergency response preparedness (i.e. Emergency Preparedness) involves many different aspects, including fire safety. In order to write a job action sheet (or job action card) for fire safety, I would suggest that you utilize your basic fire response plan for the internal portion of emergency preparedness. Many hospitals utilize the familiar acronym RACE to help remind their staff as to the organization’s fire response plan:
- R = Rescue anyone in harm’s way of the fire
- A = Activate the alarm by pulling the manual fire alarm station and dialing______
- C = Contain the fire by closing all the doors
- E = Extinguish the fire with portable extinguishers, OR Evacuate patients from the scene of the fire
For external fires, a job action sheet may include some (or all) of the following:
- Shutting down all of the fresh-air intakes for the hospital’s ventilation system.
- Placing boards on windows
- Taking pro-active action and wetting-down combustible portions of the facilities or grounds
- Possible relocating patients from one wing or area to another
- Emptying parking lots and garages which are close to the hospital
- Possible evacuation of hospital
- Re-directing traffic away from the hospital
- Controlling access to the Emergency Department
- Suspending shift change and proceeding to a 12 hour on/12 hour off rotation
Q: Are there any requirements to firestop penetrations in Information Technology (IT) closets and electrical rooms in business occupancies?
A: Only if the barriers surrounding the IT closets are designated as being fire rated on the life safety drawings, or by an authority. There is no Life Safety Code requirement to firestop penetrations in barriers surrounding IT closets simply because the closet serves IT equipment. Penetrations in fire rated barriers must be properly firestopped regardless what the barrier serve. I am not aware of a Life Safety Code requirement for IT closets to have fire rated barriers. But, perhaps, local or state authorities have regulations that may require it. You should check with them.
Q: Are there any special storage requirements for flammable liquids and flammable aerosol cans in the work area?
A: Yes, flammable liquids in all forms and capacities must be stored in compliance with section 18.104.22.168 of the 2000 edition of the Life Safety Code, which in turn requires compliance with NFPA 30, 1996 edition. According to NFPA 30, class IA flammable liquids are permitted to be stored outside of a protected cabinet as long as the container is not greater than 1 gallon. As long as the aerosol can is less than 1 gallon, you should not have a problem with keeping it in a regular cabinet. Once you reach an aggregate total of 5 gallons of class IA flammable liquids, then they need to be stored in a fire-rated cabinet.
Q: Are Interim Life Safety Measures (ILSMs) required in Business Occupancies due to construction or life safety code deficiencies? Do we have to conduct a fire watch in Business Occupancies?
A: Yes, interim life safety measures are required for any impairment to a life safety deficiency, regardless of the occupancy type. This is based on two specific requirements. 1) Section 22.214.171.124 of the 2000 edition of the Life Safety Code describes alternative life safety measures (which are the same thing as ILSM) as a general requirement for all occupancies. It is not specific for just healthcare occupancies. 2) Also, if you are Joint Commission accredited, the overview to their Life Safety (LS) chapter says section LS.01.02.01 on ILSMs is applicable to all occupancies.