Jun 05 2014

Inaccessible Fire Dampers

Category: BlogBKeyes @ 5:00 am

Many of you may be familiar with the Joint Commission’s standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose to insert the damper into the Statement of Conditions Plan for Improvement (PFI) list with a 6-year projected completion date. Then the hospital does not have to resolve the inaccessible fire damper, and they will not be cited for not performing the required testing.

Well, no other accreditation organization (AO) or state agency surveying on behalf of CMS has that luxury. CMS has been very clear to all AOs: If you observe a deficiency, then you must cite it. AOs and state agency surveyors are not permitted to not cite a deficiency if they are presented evidence that a feature of the Life Safety Code is non-compliant. And an inaccessible fire damper on a PFI list is clear evidence that it has not been tested.

So, why does Joint Commission continue to allow their hospital clients to not test inaccessible fire dampers and permit them to place them on the PFI list if CMS does not allow this practice? It is my observation that the reason is mainly due to the fact Joint Commission has been operating as an independent authority since 1965 without having to meet CMS’s rules and regulations, until just recently (2009).

For the record, I like the Joint Commission PFI list and think it is a very good deal for hospitals. It provides the hospital an incentive to get out and find their deficiencies before a survey and manage a solution to them through the PFI list. Then a TJC surveyor will not cite them for the deficiency. It’s a win-win situation. Hospitals are motivated to conduct self-examinations of their facilities and find all the LSC deficiencies they can, which results in a safer environment for their patients. I wish all AOs and state agencies had that option. However, CMS is threatening to remove the feature from Joint Commission and if they succeed, then the fear is hospitals will not be pro-active and look for their own deficiencies, and sit back and wait to see if the surveyors will find them during the triennial survey.

Even if Joint Commission allows you to manage the inaccessible fire damper through the PFI list, that’s only good for a Joint Commission survey. You still need to make the damper accessible and then test it for all the other AHJs.

So, when a fire damper cannot be tested because it is inaccessible… you have little choice but to make the fire damper accessible and then test it. There is another option though; you may request a waiver during the Plan of Correction process, provided it is a significant hardship to the hospital. Waivers are much more difficult to get approved lately through CMS but it is the only other option to you.

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Dec 27 2013

PFIs on Inaccessible Fire Dampers

Category: BlogBKeyes @ 11:20 pm


There seems to be much discussion lately on how to manage the Joint Commission Statement of Conditions Plans For Improvement (PFI) on inaccessible dampers. Joint Commission has instructed healthcare organizations to write a PFI for inaccessible fire or smoke dampers, and place a projected completion date of 6 years on them.

I have been telling my clients to close the PFI out at the end of the 6-year cycle; examine the fire dampers again to see if anything has changed that now allows them to be accessible (and then test them); and if they are still inaccessible, write up a new PFI with a new 6-year projected completion date. I vaguely remember that Joint Commission initially wanted hospital to request another 6-year extension on PFIs for inaccessible fire dampers, but I think they soon realized their error as they would be over-whelmed with extension requests. Also, they typically only allow one extension per PFI, so after the first 12 years, would they grant another extension? I also remember them saying to just close out the PFI and write a new one.

I don’t have a copy of the 2007 EOC article on the PFIs for inaccessible fire dampers, but 7-year old information seems a bit old for me to trust. People and organizations change their mind in 7-years. If anyone has any doubt, they should contact the Standards Interpretation Group at Joint Commission directly and ask them. Their number is (630) 792-5900, select option 6.


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Apr 11 2012

Radiant Ceiling Fire Dampers

Category: BlogBKeyes @ 5:00 am

I recently received a message from an old friend in regards to the testing requirements for ceiling mounted fire dampers. It was his contention that the ceiling was just a simple acoustical tile and grid suspended ceiling and by itself was not 2-hour fire rated and therefore the ceiling mounted fire dampers were not required, nor did they have to be tested.

What he actually had was radiant ceiling fire dampers mounted in the supply and return HVAC diffusers in the ceiling. These devices are part of an UL listed floor/ceiling assembly such as G-235 or G-227, which brought back lots of bad memories for me.

The hospital were I spent most of my development career years had an addition they wanted to have built in the early 1970’s, and the succesful contractor offered millions $$$ in savings to the hospital if they could install a UL listed (approved by building codes and state regulations) G-235 floor/ceiling assembly, rather than the heavy-duty poured concrete beams and floors and decks that were specified. The hospital leaders at the time could only see $$$ saved in construction costs, and approved the bid.

The floor/ceiling assembly consists of unprotected steel bar-joists supporting a poured light-weight concrete floor that is thinner and has less psi density than a regular 2-hour fire rated concrete floor. The UL standard G-235 makes up the fire rating by having a special suspended ceiling consisting of a particular acoustical tile and grid system, complete with radiant fire dampers mounted inside the HVAC supply and return (or exhaust) diffusers, and all openings in the ceiling grid (such as light fixtures, PA speakers, etc.) had to be tented with a special insulating materials that resembled mineral wool. And, all the lay-in ceiling tiles had to be clipped.

It wasn’t long after the addition was opened for business that the hospital maintenance staff was either poorly trained or poorly supervised, but within 15 years or so, many of the special requirements of UL G-235 (such as the radiant ceiling fire dampers, the tenting and the special ceiling tiles) were removed and replaced with hospital standard materials, that did not comply with the UL listing. And most of the tiles were never re-clipped after lifting them out of the grid. Enter the state survey agency for HCFA (that’s CMS before it was called CMS) and they found all of the problems that 15 years of neglect created. The hospital wanted to restore the ceiling to UL G-235 standards, but soon found that UL withdrew the listing on G-235 and the state survey agency made the hospital adhere to UL G-227 which was similar, but more difficult.