Wall-Mounted Cabinets Project More Than 4-Inches

Q: We previously built personal protective equipment (PPE) cabinets that are permanently mounted to the wall. These cabinets protrude in to the hallway 5-inches. The previous NFPA guidelines allowed 6-inch projections so we were within the limits. Now, the new NFPA 2012 decreased that projection allowance to 4-inches. Since these are isolation cabinets, are they allowed to stay in the hallway?

A: Well… you’re not quite correct…

The 2012 LSC actually does permit 6-inch projections into corridors. See section 19.2.3.4 (2). What has changed is the CMS Final Rule to adopt the 2012 Life Safety Code and the 2012 NFPA 99 Health care Facilities Code, where CMS said they will enforce the ADA requirements of a maximum corridor projection of 4-inches.

And this does apply to existing conditions where the removal of barriers to accessibility are readily achievable. So, since CMS adopted the 2012 LSC on July 5, 2016, this 4-inch maximum corridor projection rule does apply to new and existing conditions. And no, the cabinets are not allowed to stay in the corridor just because they are isolation supply cabinets.

You do have a few options:

  • Look into converting the area where your PPE cabinets are installed to be a suite-of-rooms, which eliminates the corridors and the 4-inch rule goes away;
  • Consider not doing anything and when (or if) you get cited, apply for a waiver based on ‘financial hardship’;
  • Remove the cabinets.

Smoke Door Testing?

Q: The Joint Commission standard for annual door testing states “The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested”. The Joint Commission also references NFPA 105 (smoke doors). Would this include all smoke barrier doors?

A: It appears you have an older copy of the Joint Commission standards. In January, 2019, the standard in which you refer has been changed to specifically identify the need to inspect and test fire door assemblies. Their note to this standard says nonrated doors including smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.

It is the position of CMS and all accreditation organizations that non-rated doors in smoke barriers (barriers that separate smoke compartments) do not have to be inspected on an annual basis.

Here is why: Even though section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested, that conflicts with the occupancy chapter for healthcare. 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 an AHJ 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.

Generator Load Bank Tests

Q: Do generators for healthcare need to be load-bank tested annually if they meet the 30% nameplate load requirement during each monthly test?

A: No. Load bank testing is only required when any monthly load test fails to achieve 30% of the nameplate rating of the generator. Then, an annual load bank test is required of 50% load for 30 minutes and 75% load for 60 minutes. A 3-year 4-hour test is required, and the load is a connected load from the facility and must reach a minimum of 30%. A supplemental load may be used if the connected load cannot reach 30%.

Life Safety Drawings

Q: The hospital where I work is leased, and the landlord is not a healthcare architect and pushes back on everything. My need is to have the life safety plan drawings updated to reflect proper boundaries and identification of the smoke compartments, hazardous areas, door assembly ratings, suites with sleeping or non and size, etc, etc.. Is there a standard or code which prescribes “requirements” or at least the expectation for what types of info should be on the LS plan?

A: Yes…. Every accreditation organization has some sort of standard or requirement that sets expectations regarding Life Safety drawings. Ironically, neither NFPA or CMS has any standard that requires Life Safety drawings yet the state agencies surveying on behalf of CMS will expect that you have an accurate set of Life Safety drawings.

Life Safety drawings are considered operational documents (not unlike a management plan or a policy) and I could see where a landlord is not responsible for providing operational documents for you at no charge. I suggest you contract with your own favorite architect to create these LS drawings, because a reluctant landlord will do you a lousy job at best.

Joint Commission’s standard identifies their minimum requirements for Life Safety drawings:

  • Identify areas of the building that are sprinklered
  • Identify locations of hazardous areas
  • Identify locations of all fire-rated barriers
  • Identify locations of all smoke-barriers
  • Identify the locations of all suites and identify the size of each suite in square footage
  • Identify the location of smoke compartments
  • Identify the locations of all chutes and shafts
  • Identify locations under approved waivers or equivalencies

Annual Fire Pump Test

Q: Is it required to dropped power to your electric driven fire pump while it is running to ensure it starts back up and continues to run on emergency power?

A: If you are referring to the annual fire pump flow test, the answer is yes. Section 8.3.3.4 of NFPA 25-2011 requires a simulated power failure while the pump is operating at peak capacity (150% of nameplate capacity) and confirm that the fire pump continues to operate at peak capacity under EM power. This means a second set of pitot readings are necessary while the pump is operating on EM power at peak capacity. Check with your contractor who conducts this test. Surprisingly, many contractors who perform the annual fire pump test fail to include this procedure.

Clothes Iron

Q: Our facility is a nursing home. I have been asked a question if a resident can have a clothes iron in their room? I said no and would check on it. What do you think?

A: While there is not a specific code or regulation preventing a nursing home resident to use a clothes iron, it does present a specific hazard since it can get very hot. If you allowed it, a surveyor could likely cite you for an unsafe environment, which does seem logical. But if you allowed the resident to use the clothes iron with supervision by one of your staff, that would seem to be acceptable (at least by me). Whatever you decide to do, you should have a policy and/or risk assessment on it.

Non-Sprinklered Elevator Control Room

Q: In a physician’s clinic that is claimed to be fully protected with sprinklers, the building elevator control room is not sprinklered. Must I install or can I leave it that way?

A: A Business Occupancy building that is fully protected with sprinklers provides you with the ability to meet certain options in the LSC that allows you to take advantage of certain features, such as:

  • Delayed egress locks would be permitted
  • Less restrictions on egress capacity factors
  • Exits permitted to discharge through the interior of the building
  • Less restrictions on hazardous areas
  • Less restrictions on interior finishes
  • Increased travel distances

According to NFPA 13-2010, the standard for sprinkler installation, there are very few exceptions to not installing sprinklers, and allow the building to still be considered fully sprinklered:

  • 2-hour fire-rated barriers around an electrical room
  • Clean agent suppression system installations

However, the 2012 Life Safety Code does have an exception specific to elevator machine rooms. Section 7.14.4.2 says sprinklers shall not be installed in elevator machine rooms serving occupant evacuation elevators, and such prohibition shall not cause an otherwise fully sprinklered building to be classified as non-sprinklered. This is one situation where the Life Safety Code trumps NFPA 13 on the installation of sprinklers.

The 2012 Life Safety Code Handbook continues to provide insight on this prohibition:

The presence of sprinklers in the elevator machine room would necessitate the installation of a shunt trip for automatically disconnecting the main line power for compliance with ASME A17.1 Safety Code for Elevators and Escalators, as it is unsafe to operate elevators while sprinkler water is being discharged in the elevator machine room. The presence of a shunt trip conflicts with the needs of an occupant evacuation elevator, as it disconnects the power without ensuring that the elevator is first returned to a safe floor so as to prevent trapping occupants.

So, no… you should not install sprinklers in the elevator machine rooms.

Sprinkler System Exceptions

Q: Are there any exceptions in NFPA 13 for smoke detectors in lieu of sprinklers in areas such as radiology rooms or other high tech equipment rooms and still be considered “fully sprinklered”?

A: No. There is an exception in Section 8.15.10.3 of NFPA 13-2010 that allows electrical rooms not be sprinklered, and the building can still be considered fully sprinklered, provided the room is dedicated to electrical equipment only; only dry-type electrical equipment is used; equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations; and no combustible storage is permitted in the room.

And, you can install clean agent suppression systems in lieu of wet sprinklers and the building is still considered fully sprinklered, but there are no exceptions allowing smoke detectors in lieu of sprinklers in any type of room, and still consider the building “fully sprinklered”.

Parking Garage Underneath Healthcare Occupancy

Q: Can you have a parking garage under a health care occupancy/patient sleeping areas, that does not have smoke separations but does have a 2-hour fire rated barrier between the floors? This is a project in the planning stages. Currently the floor serves administrative offices and will be converted to a patient floor.

A: I am not aware of any reason in the Life Safety Code that would prevent you from having a parking garage underneath a healthcare occupancy, provided you have the proper 2-hour fire rated separation barrier. A parking garage is required to be a Storage occupancy according to 3.3.188.15 of the 2012 LSC, so there must be a 2-hour fire-rated barrier separating the parking garage and the healthcare occupancy.

Section 18.3.7.2 (5) is clear that open-air parking structures protected throughout by a sprinkler system does not have to be subdivided into two or more smoke compartments. Since it is new construction, the entire hospital, including the parking garage, would have to be fully sprinklered. Also, the parking garage would have to be the same construction type as the healthcare occupancy.

As always, check with your state and local authorities to see if they have more restrictive regulations.

Downgrading Fire-Rated Door Assemblies

Q: My boss has hired an outside company that has advised him to rip fire rating labels off of doors and frames that we have maintained properly for decades. We do have automatic sprinklers in all areas. It does not feel appropriate to simply downgrade hazardous rooms, corridors, and elevator lobbies. My boss refuses to contact the AHJ and will only refer to his outside company. Is this appropriate and something I can sign my name too? Thank you for any information.

A: Well… maybe yes and maybe no.

All fire rated doors must be inspected based on 2012 LSC section 4.6.12.3 and 8.3.3.1, regardless if they are located in a fire-rated barrier or not. So, if your facility has a fire-rated door installed in a barrier (i.e. a corridor wall) that is not a fire-rated barrier, then the door assembly still has to be tested and inspected even though it is not located in a fire-rated barrier.

If you have a lot of these situations, then it can be costly to test and inspect fire-rated doors where you don’t have to, so the easy solution is to remove the fire-rating label from the door and frame. If you do that, then you don’t have to test and inspect the doors as they are no longer fire-rated assemblies. But you must be very cautious before you take such action and make doubly-sure that the door assembly is no longer needed to be fire-rated.

But you said something in your question that disturbs me… You said: “It does not feel appropriate to simply downgrade hazardous rooms, corridors, and elevator lobbies.” This statement is very troubling as you are not permitted to downgrade features of life safety that were required at the time of design or construction, unless it is a change with new construction standards. So, here is a possible scenario that may apply to your facility: When your facility was originally constructed, it was required to have all hazardous rooms be 1-hour fire-rated and fully protected with sprinklers. Today, that same room is now considered ‘existing conditions’ by definition since the 2012 LSC was adopted in July 5, 2016, and your facility was constructed prior to that date. According to the 2012 LSC, existing conditions hazardous rooms are permitted to be 1-hour fire-rated or sprinklered; not both. But section 4.6.12.2 of the 2012 LSC says no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. The 2012 LSC still requires sprinklers and 1-hour fire rated hazardous rooms, so you are not permitted to down-grade the fire-rated doors to a hazardous room just because it now qualifies as existing conditions.

You have every reason to be questioning this strategy. I suggest you and your boss contact your AHJs for guidance, or at least get some decent advice from a consultant. This outside company that you refer to… are they a qualified Life Safety company to be offering advice like this?

Some AHJs will not allow any down-grading of fire-rated door assemblies even if the doors are not required to be fire-rated, so make sure you check with them before removing any labels.

NFPA 99 Risk Assessment

Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never had an assessment done in the past but it is my understanding that it became a requirement in 2016. The CMS has established compliance requirements (K Tag) for risk assessment and its completion. Who would be the qualified personnel to perform this procedure and create a formal and documented risk assessment?

A: According to members of the Technical Committee who wrote the new Chapter 4 in NFPA 99-2012, the original intent was the risk assessment only applies to new construction. However, the way chapter 4 is written, it is not clear that the risk assessment is only applicable to new construction.

CMS has instructed the accreditation organizations and the state agencies who survey on the behalf of CMS to require all hospitals to have completed their NFPA 99 risk assessment for new as well as existing construction. Therefore, hospitals must conduct the risk assessment for new and existing conditions. These assessments are not difficult to do and only takes a few minutes.

There is no requirement to make a room-by-room assessment, but the intent is to assess the risk of the entire system if it were to fail and there were no back-up systems. It would stand to reason that most hospital systems would be Category 1 or Category 2. Anyone may conduct the assessment, but would have to have knowledge of the risk assessment process and knowledge of the facility.

Portable Fire Extinguishers

Q: In regards to fire extinguisher inspections… when the annual fire extinguisher maintenance is done, say in June, does the monthly fire extinguisher inspection still need to be completed?

A: Yes. According to NFPA 10-2010, there are distinctly different requirements for the annual maintenance and the monthly inspection. Typically, the annual maintenance does NOT include the actions required for monthly inspections, although there is no reason why the same person could not perform both duties during the annual maintenance process.

Annual Maintenance requires the following to be confirmed:

  • A thorough examination of the following:
    • Mechanical parts of all extinguishers
    • Physical appearance
    • Components of electrically monitored systems
    • Hoses on wheeled-type extinguishers completely uncoiled and examined for damage
  • Tamper seals on rechargeable extinguishers must be removed and replaced with new seals
  • For extinguishers that require a 12-year hydro-static test, once every 6-years the extinguisher must be emptied and subjected to an internal examination
  • A verification collar must be installed on the outside of the extinguisher, underneath the valve after an internal examination
  • CO2 hose assemblies must have a conductivity test

Monthly Inspection requires the following to be confirmed:

  • Location in designated place
  • No obstruction to access or visibility
  • Pressure gauge reading or indicator in the operable range or position
  • Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
  • Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
  • Indicator for non-rechargeable extinguishers using push-to-test pressure indicators

So, you can see an annual maintenance activity does not meet the requirement for a monthly inspection, but there should be no reason why the same person could not perform both duties.

Deactivating a Magnetic Lock

Q: When deactivating a magnetic lock but leaving it in place, what is the exact/excepted wording used noting that this magnetic lock is no longer in use?

A: What you are saying is not compliant with section 4.6.12.3 of the 2012 LSC which says existing life safety features obvious to the public, if not required by the LSC, shall be either maintained or removed.

If you want that maglock out of service, you must remove it since it is obvious to the public. 

 

Sprinklers in Lieu of Smoke Detectors

Q: We are seeking to reduce activation of smoke heads contained in our construction areas. In your opinion, if the construction area has existing sprinkler coverage or if new active sprinklers are installed in the construction area, would it be acceptable to remove the smoke heads in this space? In other words, are sprinklers a proper substitute for smoke heads?

A: No… sprinklers are never an acceptable substitute for smoke detectors, because sprinklers do not sense the presence of smoke. Conversely, smoke detectors are never an acceptable substitute for sprinklers because they do not extinguish a fire. However, if the smoke detectors are not required by code or regulation, then they can be removed without any alternative life safety measures applied.

According to 4.6.10.1 of the 2012 Life Safety Code, only deficiencies of required features of life safety necessitate alternative life safety measures (ALSM), also known as Interim Life Safety Measures (ILSM). However, be aware that not all surveyors will likely understand this and they may cite an organization for impaired smoke detectors even if the smoke detectors are not a required feature of life safety.

It is not uncommon for designers to over-install smoke detectors and place them in areas where they are not required. But if the smoke detectors are required, and you desire to remove them for construction purposes (not a bad idea) then you will have to assess them for ALSM and likely implement a fire watch, which can be very costly since it is now required to have a continuous fire watch. Replacing the smoke heads with heat detectors still does not change the result. If the smoke detectors are required then a heat detector is not an acceptable substitute.

Air Handler Unit

Q: Can we have a fan unit installed in a clean supply room? We have a room where an air handler unit is installed for cooling another equipment room. The unit is in the open and clean supplies are near it. Is this a violation of a code or standard?

A: Sounds like the room is now a mechanical room with clean supplies in it. As far as the Life Safety Code goes, and any referenced NFPA standards, I don’t see a problem. You must maintain 36-inches clearance around the equipment and have clear access to the unit. All electrical connections need to be enclosed (inside junction boxes, etc.).

If the clean supplies are combustible, then the room must be constructed to be a hazardous room. Check with your state and local AHJ to determine if they have any other requirements.