Apr 23 2018

Corridor Obstruction for Construction

Category: BlogBKeyes @ 12:00 am

Q: Can an existing 8-foot wide corridor be reduced in width to 4 feet by temporary construction barriers?

A: Yes, but you will need to conduct an assessment for Alternative Life Safety Measures (or Interim Life Safety Measures as one accreditation organization calls it). All of the AHJs understand there will be times when you will need to have non-compliance with the Life Safety Code during periods of construction, maintenance, or emergency repairs.

It is understandable that you will need to build a ‘bump-out’ in an existing corridor of an occupied unit, in order to conduct demolition, and reconstruction, which will obstruct the required width of the corridor during the period of construction. The Life Safety Code already has considered this situation and section of the 2012 LSC permits buildings to be occupied during periods of construction provided that ALSMs (or ILSMs) are in place.

So, when you know that the corridor needs to be obstructed for the purpose of construction, you assess the situation for ALSM (ILSM) and you follow what your ALSM (ILSM) policy requires you to do. For a corridor obstruction, it is likely that you would be required to do:

  • Staff education on the obstruction, informing them of alternative routes for exiting
  • Daily inspections, looking for accumulation of debris, supplies or other items
  • An additional fire drill in the affected area to ensure staff understands that an alternate route for exiting is required

There may be other measures that need to be implemented, such as additional education, or additional fire-extinguishment devices. Once the assessment is conducted, it must be recorded and available for review by surveyors.

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Mar 23 2018

Interim Life Safety Measures

Category: BlogBKeyes @ 12:00 am

Q: At our hospital, we had numerous fire dampers that failed their 6-year test. What ILSM measures for that many dampers would you recommend putting in place?

A: You are correct in saying ILSM assessment needs to be made for deficient fire dampers. Many hospitals get into trouble over that and forget to do that, so I’m glad to hear that you are on top of that. What I see some of my clients do for defective fire dampers is to make an ILSM assessment that states “No compensating measures are required”. I would not recommend that, but it appears that will be accepted by some accreditation surveyors. I would recommend at the minimum “Staff Education” as a compensation measure for an ILSM assessment. Send a memo to the staff in the area of the defective fire damper instructing them in the case of a fire, the fire dampers may not operate correctly until you get them repaired. They should take into account the location of the defective fire dampers when determining which direction they will evacuate (if needed).


May 02 2012

Temporary Storage in Patient Room

Category: BlogBKeyes @ 5:00 am

A client of mine contacted me last week and wanted to know if they could temporarily store combustibles in a patient room that is currently under renovation. Apparently the suite where the patient room is located is undergoing a facelift, involving wall coverings and floor coverings, and the patients have been relocated.

I don’t know if my answer was what they wanted to hear, but I informed them whenever combustibles are stored in a room greater than 50 square feet, the room must comply with section of the 2000 edition of the LSC. The reason we need to follow chapter 18 instead of chapter 19 is by placing combustibles in storage in a patient room, we are now changing the use of the room, and a change in use requires compliance with chapter 18.

Section requires all new construction to be sprinklered and Table requires rooms that are over 50 square feet but no more than 100 square feet to have a self-closing door. For combustibles stored in a room exceeding 100 square feet the room must be sprinklered (per, have 1-hour fire rated barriers, and have a 3/4 hour fire rated self-closing, positive latching door.

What if the patient room is over 100 square feet and is not constructed to 1-hour fire rated standards, do you have to spend thousands of dollars to modify the room for temporary storage? I say no, you don’t. That’s what section on Alternative Life Safety Measures (or Interim Life Safety Measures as some AHJs call them) is for. Conduct a risk assessment of the combustibles temporarily stored in the patient room and compare the results with your policy on ALSM (or ILSM). Implement whatever compensating measures are needed according to your policy, and document the assessment.

Make sure you do what your policy says you will do, and document all actions, and you should be OK.


Jan 26 2012

Construction in Hospitals

Category: BlogBKeyes @ 6:00 pm

Construction in hospitals is so unavoidable, as it seems to go together like salt and pepper, but usually does not taste as good. You simply cannot renovate or remodel an area in the hospital without creating some sort of Life Safety Code deficiency. It’s a lot like cooking: You can’t make an omelet without cracking the egg! (Enough of the cooking references… My wife has me watching the Food Network too much!)

All of the authorities of jurisdiction (AHJ) know this, and they understand that at times, you will have to disable fire alarm and sprinkler systems; you will have to close exits and stairwells; and you will have to encroach upon the exit corridor width. Even the Life Safety Code (2000 edition) section discusses the need to have alternative life safety measures in place during renovation. While some accreditation organizations actually call it “Interim Life Safety Measures”, the concept is the same.

Alternative (or interim) life safety measures requires the organization to make an assessment of the proposed renovation to determine if there will be any deficiencies made of the life safety features.  If so, then the organization needs to decide what actions, if any, will be necessary to compensate for this deficiency. The Joint Commission requires that you place this decision process in the form of a policy with pre-determined plans of action already identified.

Other issues concerning construction are the barriers that separate the construction area from the occupied areas. Joint Commission only requires the barriers to be ‘smoke tight and flame resistant’, which can be accomplished with a certain type of flame resistant plastic sheeting. However, other AHJs, such as CMS and some state agencies, require compliance with NFPA 241  Standard for Safeguarding Construction, Alteration, and Demolition Operations, (1996 edition) which requires construction areas with ‘hot work’ to have 1-hour fire rated barriers as a separation from occupied areas. Hot work is defined as work involving open flame, grinding, cutting and welding. And, this 1-hour barrier needs to go from the floor to the deck above, unless it meets a horizontal surface that is also rated for at least 1-hour.

When the new 2012 edition of the LSC is finally approved by all of the AHJs, then NFPA 241 will include an exception that is not available in the 1996 edition. It will allow non-rated smoke tight barriers in lieu of 1-hour fire rated barriers provided there are active automatic sprinklers, which are properly installed, in the construction site. This will be a great savings for future construction projects.

If you are currently relying on the official position of The Joint Commission and only providing smoke tight barriers for construction sites, then you are exposed to other AHJ’s opinion that you need 1-hour fire rated barriers. At the very least, I suggest you call your state and local AHJs and ask them if they would accept the smoke-tight barriers. If so, then you don’t need to go the route of erecting 1-hour barriers. However, if they do require 1-hour fire rated barriers, then you will have time to change your policies to allow them for future projects.

Then everybody will be as happy as a clam (oops, there I go again.)

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