Dec 09 2016

Incorrect Interpretations on Smoke Door and Fire Door Testing

Category: BlogBKeyes @ 12:00 am
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I just found out yesterday that CMS is teaching their state agency LS surveyors that smoke barrier doors need to be tested in healthcare occupancies. This interpretation of the 2012 Life Safety Code from CMS is incorrect, but your state agency on behalf of CMS may be expecting you to do this.

Yes… section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested. But that conflicts with the occupancy chapter for healthcare and section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing). Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies.

Now… you may have a state agency that believes differently. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but ultimately they are an authority and if they say you have to test smoke doors, then you have to test smoke doors.

But it is not required in healthcare occupancies according to the 2012 LSC.

Also, CMS has instructed their state agency LS surveyors that healthcare occupancy doors in 7.2.1.15.1 must be tested, even if they are not fire-rated doors. This also is incorrect. The doors identified in 7.2.1.15.1 do not apply to healthcare occupancies so they are exempt from having to be tested. Only doors in assembly occupancies and residential board & care occupancies need to comply with 7.2.1.15.1.

But be aware: If you have areas of your healthcare facility that qualify as assembly occupancy, even if you do not declare that area as assembly occupancy, then you must comply with 7.2.1.15.1 and test those doors. This would include doors in assembly occupancies that:

  • Have panic hardware or fire-rated hardware;
  • Are located in an exit enclosure;
  • Are electrically controlled egress doors;
  • Delayed egress, access-control, and elevator lobby locked (per 7.2.1.6).

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May 04 2016

I’m Sorry…

Category: BlogBKeyes @ 12:00 am
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Dear Readers…

In a recent post I made a comment that architects are making errors and causing facility managers headaches by calling for 20 minute fire-rated doors in smoke barriers. I was wrong to have said that. While NFPA allows non-rated 1.75 inch thick solid-bonded, wood core doors in smoke barriers; the IBC does not.

Architects have to design the facilities to meet not only NFPA requirements, but often times they have to design to meet IBC requirements as well. The most restrictive requirement must be met, and the IBC requires 20-minute fire rated doors in smoke barriers.

My comment was rather derogatory towards architects, and for that I do apologize. I was allowing my frustration with poorly designed hospitals regarding suites-of-rooms to over-shadow my objectivity with the smoke barrier door issue. I will attempt to be more understanding and fair in the future.

Be assured that this website is intended to discuss NFPA codes and standards as it relates to healthcare facilities, and does not attempt to discuss or reference any other codes or standards. This is because once the facility is constructed, the facility manager is under siege with inspections from multiple authorities that hold them accountable to NFPA codes and standards; not the IBC.

Thank you….

Brad Keyes

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Nov 13 2014

Use of Fire and Smoke Doors During a Fire Drill

Category: BlogBKeyes @ 6:00 am
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I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with:

The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/19.7.1.1 of the 2000 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary. Section 4.7 of the same code also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what you are referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who you are referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/19.7.1.3 of the 2000 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standards (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that a ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4th floor ICU, you do not want all 1200 workers to rush up to the 4th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped you with your question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If you are really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.

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Jul 31 2014

Smoke Compartment Barrier Door Gaps

Category: BlogBKeyes @ 6:00 am
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Smoke compartment barrier doorsI want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor doors that are not fire-rated or used in a smoke compartment barrier are permitted to have gap clearances up to ½-inch in smoke compartments that are protected with sprinklers. In this memo they have conflicting points; the subject line of the memo stated: “Permitted Gaps in Corridor Doors and Doors in Smoke Barriers”, but in the content of the memo they say “This information does not apply to doors in smoke barriers, which have other requirements.”

Click on this link to access this CMS memo:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/CMS1198675.html?DLPage=1&DLFilter=07-18&DLSort=3&DLSortDir=ascending

To be clear, the maximum gap for the proper clearance of smoke compartment barrier doors is 1/8 inch; not ½ inch, and it is not dependent on whether or not the smoke compartment is sprinklered. Sections 18/19.3.7.6 of the 2000 LSC references section 8.3.4 of the same code and the Annex section of 8.2.4.1 says the maximum gap for smoke compartment barrier door clearances is 1/8 inch.

The CMS memo addressed corridor doors that are not fire-rated or located in a smoke compartment barrier. Corridor doors are those doors which separate a room or an area from the corridor. Can a corridor door also be a fire-rated door or a door in a smoke compartment barrier? Yes, certainly; and in those situations the more restrictive requirements must apply.

The bottom line: Doors in smoke compartment barriers must not have gap clearances that exceed 1/8 inch per the 2000 LSC. The CMS S&C memo 07-18 only applies to non-fire-rated corridor doors that are not located in a smoke compartment barrier.

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