Fire-Proofing Structural Steel

Q: Since our last survey we were introduced to an epoxy based intumescent fire proofing product to repair damaged areas of vermiculite fireproofing on our structural steel that had bare areas from years of wear. Two weeks-ago we had a “mock” survey by my corporate representative and while he seemed to like the application process, he is not sure that we could pass our survey when the real surveyors come. He suggested that we think about having it repaired with the vermiculite product. What do you think? Any help would be greatly appreciated.

A: This issue is not clearly understood among the different AHJs, let alone their surveyors. I can say that many surveyors would not know what they are looking at if you had mixed fire-proofing products on the same piece of structural steel.

But, to be sure, your representative who conducted the mock survey is correct: You cannot mix and match different types of fire-proofing material to repair missing fire-proofing on structural members of your building. While you will not find a specific code or standard that says this, it is an interpretation of the UL listings for fire-proofing structural members of the building. Simply stated; There is no UL listing that allows you to mix different UL listed products to form a contiguous fire-proofing protection on the structural member. If there is, I have not seen or heard about it.

So, heed the advice from your mock surveyor and only put back the same type of fire-proofing material that was originally applied. Sounds to me, that your mock surveyor should be a real surveyor for CMS or one of the accreditation organizations. He seems to know what he is looking at.

Contiguous Facilities

Q: If an inpatient in a hospital (healthcare occupancy) is taken into a building that is not a healthcare occupancy for say CT or MRI, does this building have to then meet the requirements in the Life Safety Code for a healthcare occupancy?

A: Perhaps… According to section 19.1.3.4.2 of the 2012 LSC, it says ambulatory care facilities, medical clinics, and similar facilities that are contiguous to healthcare occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. This is new for the 2012 LSC and was not found in the 2000 edition, so not everyone may be aware of this.

But the kicker is “inpatients who are capable of self-preservation”. The inpatient really does need to be capable of taking action for their own self-preservation without the assistance of others. To compound this further, CMS issued a correction to their Final Rule to adopt the 2012 Life Safety Code on June 30, 2016, that specifically says any facility that qualifies as an ambulatory healthcare occupancy (AHCO) must meet the requirements for AHCO regardless of the number of patients served. So, that means the MRI and possibly the CT units would have to qualify as AHCO because patients are often strapped into the unit and are not capable of self-preservation.

All healthcare occupancy inpatients, even if it is just one inpatient, that are brought into a contiguous facility that is not a healthcare occupancy for diagnostic or treatment purposes must be capable of self-preservation. Otherwise, it is not permitted.

Coded Words for Fire

Q: Our EP manager was discussing removing the code words like Code pink for a missing infant to missing child and the conversation about code red for fire came up. Someone in the conversation said there is a NFPA code requirement that “Code Red” must be in code form instead of saying “Fire”. I have not heard of this and haven not search yet. I wondered what your take is on this. Our FA system is programmed for voice that states “Code Red” and then the location.

A: Well… that ‘someone’ is actually correct… sort of.

Section 19.7.1.7 of the 2012 Life Safety Code actually does say “When drills are conducted between 9:00 pm and 6:00 am a coded announcement shall be permitted to be used instead of audible alarms.” So this section of the LSC does reference a code-word should be used to identify fire, such as ‘Code Red’.

But that requirement for a coded word for fire is only found in section 19.7.1.7 and is limited to a fire drill conducted without audible alarms between 9:00 pm and 6:00 am. Therefore, since the Life Safety Code does not prohibit it, the conclusion is you would be permitted to say ‘Fire’ instead of ‘Code Red’ when the fire alarm system is activated.

But is that in your best interest to do so? I am aware that there is a trend across the country to eliminate coded words for certain emergency announcements. Many coded words (i.e. ‘Code Pink’) are not used universally in all hospitals, and since healthcare staff is rather transient, the movement is to have announcements identify the actual emergency rather than using coded words. But the original intent in using ‘Code Red’ is to alert staff of a fire condition, yet not alarm visitors and patients un-necessarily, thereby causing a panic.

If it were my hospital, I would be an advocate to allow ‘Code Red’ to remain, but eliminating other coded words should be considered.

Strange Observations – Aisle Width

Continuing in a series of strange things that I have seen while consulting at hospitals…

This is an equipment room. It appears to be a water room of some sort as I see a water tank and some water filters. I also see boxes and ‘stuff’ blocking access into and out of this room.

The problem with this situation is the room does not have a clear aisle width. Even though this is an equipment room, you still must maintain a clear aisle width of at least 28-inches for existing conditions, and 36-inches for new construction.

Remember: The exit-access is not limited to the corridor. Every room has an exit-access, and the appropriate aisle width must be maintained in those areas. Section 7.3.4.1.1 and 7.3.4.1.2 of the 2012 Life Safety Code provides the standards that regulate the aisle width.

Generator and ATS Testing

Q: I am new in my position and I would like to know what the weekly generator inspection consists of? I also would like to know what the monthly generator inspection and transfer switch testing consist of?

A: Some of this depends on your accreditation organization. Not all AOs survey generators the same way. So I will provide you with what the Life Safety Code requires, with the understanding you need to check with your AO to determine if they have additional requirements. The following information is derived from NFPA 110-2010, which says the routine maintenance and operation testing program must be based on the manufacturer’s recommendations and instruction manuals (section 8.1.1):

Weekly Inspections:

  • Inspection per manufacturer’s recommendation
  • Storage batteries, including electrolyte levels or battery voltage, used in conjunction with systems must be inspected weekly and maintained in accordance with the manufacturer’s specifications. (8.3.7)
  • Emergency Power Supply Systems (EPSS), including all appurtenant components, must be inspected weekly. (8.4.1)

Monthly Inspections:

  • Maintenance of lead-acid batteries must include the testing and recording of electrolyte specific gravity, Battery conductance testing is permitted in lieu of the testing of specific gravity when applicable or warranted. (8.3.7.1)
  • Emergency Power Supply Systems (EPSS), including all appurtenant components, must be exercised under load at least monthly. (8.4.1)
  • Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods (8.4.2):
    • Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
    • Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
  • Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours (8.4.2.3).
  • Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized (8.4.2.4).

Annual Test:

  • A fuel quality test must be performed annually in accordance with ASTM D 975 Standard Specification for Diesel Fuel Oils.

3-Year Testing:

  • Level 1 EPSS shall be tested at least once within every 36 months (8.4.9)
  • Level 1 EPSS shall be tested continuously for the duration of its assigned class (8.4.9.1).
  • Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours (8.4.9.2).
  • The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested (8.4.9.3).

Automatic Transfer Switches:

  • Transfer switches shall be operated monthly (8.4.6).
  • The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position (8.4.6.1).

Circuit Breakers:

  • EPSS circuit breakers for Level 1 system usage, including main and feed breakers between the EPS and the transfer switch load terminals, shall be exercised annually with the EPS in the “off” position (8.4.7).
  • Circuit breakers rated in excess of 600 volts for Level 1 system usage shall be exercised every 6 months and shall be tested under simulated overload conditions every 2 years (8.4.7.1).
  • The routine maintenance and operational testing program shall be overseen by a properly instructed individual.

Last Day to Register for… Compliance One Presents Keyes Life Safety Boot Camp

TODAY IS THE LAST DAY TO REGISTER!

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel.

NOTE: CEUs will be awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Presented by:

Fire Drills

Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift?

A: Yes. According to section 19.7.1.4 of the 2012 Life Safety Code, fire drills in healthcare occupancies must include the transmission of a fire alarm signal and simulation of emergency fire conditions. The Annex explains that the purpose of the drill is to test and evaluate the efficiency, knowledge, and response of the healthcare personnel in implementing the emergency fire response plan. The purpose is to not excite or disturb the patients, so doors to patient rooms should be closed. Between the hours of 9pm and 6am, you still must activate the fire alarm system during a drill, but you have the option to silence any audible notification devices.

Smoke Detectors in Patient Restrooms

Q: Can I provide a smoke detector in an existing hospital patient restroom? The smoke detector was recommended by the hospital safety committee to avoid smoking in these rooms. Our patient restrooms have bathtubs but no showers. Some restrooms are protected by sprinkler systems and some are not. Some restrooms are provided with heat detectors, but of course, they do not activate during patient smoking. Even though the safety committee recommended changing to a smoke detector, I am afraid of false alarms from the high humidity a restroom can generate.

A: While the Life Safety Code and NFPA 72-2010 do not require smoke detectors to be installed in patient bathrooms, designers usually do not place them there for fear of nuisance alarms. But experience shows a smoke detector in a bathroom that has a toilet and a bathtub is not the same risk that a smoke detector located in a bathroom with a shower has. The shower will atomize water droplets to form high concentrations of water vapor and will more likely cause nuisance alarms. The bathtub and toilet would not raise the relative humidity much at all.

Try it and see how it works for you.

Strange Observations – Exit Enclosure

Continuing in a series of strange things that I have seen while consulting at hospitals…

This is not corridor, but rather an exit enclosure to a stairwell. There was a construction project in progress and to achieve a negative air pressure in the project area, the contractor cut a hole (twice) in the 2-hour fire-rated barrier for the exit enclosure to run the temporary flex duct to the exhaust fan.

Section 7.1.3.2.1 (10) of the 2012 LSC does not allow penetrations into and through an exit enclosure for this purpose, even on a temporary basis.

If you’re asking what the hospital should have done if this was their only option to create negative air for the project, I would say they could have set-up a HEPA filter negative air machine inside the project area, and discharge the air from the HEPA blower to an adjacent corridor. Not the best solution, but one that is far better than making penetrations into the exit enclosure.

There is also the issue of headroom which must be at least 7-foot 6-inches, according to section 7.1.5.1.

Door Lever Hardware

Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not “hook” passing clothing, straps, purses during emergency evacuations? I swear I remember this for healthcare occupancies from somewhere, but can no longer find it in the Life Safety Code.

A: No, the 2012 Life Safety Code does not require a return on door lever handles to prevent hooking clothing during egress. But my good friend Lori Greene (www.idighardware.com) tells me the return is only required by the California Referenced Standards Code, which says: Levers.  The lever of lever-actuated levers or locks shall be curved with a return to within 1/2″ of the face of the door to prevent catching on the clothing of persons during egress. Since this is not a requirement of the NFPA or ICC codes or standards, it would only apply in California.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel.

NOTE: CEUs will be awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by:

Fire Hose Valves

Q: Are we allowed to remove the 1½-inch fire hose valves in our hospital? The local fire department would not even have a means of using them?

A: Section 4.6.12.2 of the 2012 Life Safety Code does imply that you can remove the valves. This section says no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. Well, 1½-inch fire hose valves are not required in hospitals under new construction standards so the implication is you may remove them.

However, you really need permission from you AHJs in writing before you do. So, contact your local fire department, your state fire marshal, your state department with authority over hospital construction, your accreditation organization, and your liability insurance provider, and get it in writing from each before you remove the valves. If one of the five refuses to allow you to remove the valves, then you cannot regardless what the other AHJs say.

Closet Doors

Q: Are closet doors located inside a corridor considered corridor doors and do they have to meet life and safety codes referring to corridor doors?

A: It depends…. What does your Life Safety drawings say?

Section 19.3.6.3 of the 2012 LSC requires doors in the corridor to be positive latching. If the closet door is in the corridor wall then it must be positive latching. However, there may be a possibility that the corridor wall could run behind the closet, provided the back of the closet wall meets the requirements of 19.3.6.2 for construction of corridor walls.

But your Life Safety drawings need to specifically identify that the corridor wall runs behind the closet. If they do not, then the surveyor has no choice but to hold your closet doors compliant to 19.3.6.3 for positive latching corridor doors.

Strange Observations – Picture Hanging Device

Continuing in a series of strange things that I have seen while consulting at hospitals…

Apparently, sidewall sprinkler heads can also be used to hang pictures…. NOT.

[That was sarcasm…]

I admit I did not take this picture, but it was contributed to this effort by Tim Niemer… Thanks Tim.

Non-Compliant Construction Type Above a Healthcare Occupancy

Q: I have an interesting one for you. We have an architect propose a construction type of Type V (111) for a 3-story building with the first-floor being Healthcare occupancy (a nursing home) and the upper 2 floors being Residential Board and Care occupancy (assisted living). There is a 2-hour floor ceiling assembly separating the nursing home and assisted living.

It is interesting to me because I am not aware that the LSC has ever allowed this in the past, but it appears to be allowed by the 2012 LSC in accordance with 18.1.3.5. The 2012 LSC Handbook also gives a good description. What I am worried about is CMS and accreditation surveys. This is against everything that has been engrained in our brains and it could be a major issue. Have you seen this or heard of this before?

A: Yes… this is a very interesting case. I cannot recall that I’ve seen this before, mainly because the 2000 LSC did not allow this arrangement. It was not until the 2009 edition of the LSC that this was clearly permitted. And I agree, the Handbook for the 2012 LSC explains this very well. I recall a conversation that I had with a representative from NFPA years ago on this very subject and he assured me it was not permitted (we were under the 2000 LSC at the time). So, I agree with you… It goes against what we’ve been taught. But times change, don’t they!

Unless you have other regulations preventing this arrangement, I would say that the NFPA codes and standards would permit it, but please check with your state and local authorities to see if they have any problems with it. I would not be too concerned about a nursing home being cited by a CMS surveyor or an accreditation surveyor since they follow NFPA rather rigidly (or are supposed to), and since the 2012 LSC does permit it, the nursing home may make the case that it is permitted if the surveyor is considering citing them.

Personally, I think it is poor insight by the healthcare organization to do this, as they will never be able to expand their healthcare occupancy beyond the 1st floor, and maintaining that 2-hour fire-rated barrier is a special challenge for anyone, let alone a typical maintenance staff of a nursing home that is often under-manned, and not trained well on technical issues. I suspect over a period of time the 2-hour fire-rated horizontal barrier will be compromised and not maintained properly due to a lack of understanding.