Missing Ceiling Tiles Impair Sprinklers

Q: We have a medical office building attached to the hospital using a 2-hour fire-rated separation. Two questions: 1) Our 8th floor is under renovations for a new auditorium and is not always occupied in that area. They have suppression, but also the whole ceiling grid is now open with the tiles removed. Does this require a fire watch? Am I correct in saying either they have to turn the sprinkler system upright to 12-inches from the decking or conduct a fire watch? 2) Our lobby is under renovation and the majority is ceiling tiles but also in the middle it opens up to the 2nd floor. They put up a flame retardant plastic sheeting barrier on the sides but not the ceiling which extends to the 2nd floor. This is also not under negative pressure as there are patients walking throughout. Is this a problem?

A: Yes… you’ve got a problem. When you remove the ceiling tiles from an acoustical grid and tile ceiling, the sprinklers are now impaired. You must conduct a continuous fire watch which requires a qualified trained individual to patrol the impaired area constantly and that person cannot do any other work, and must stay in the area until the impairment is resolved or he is relieved by another individual.

The sprinklers must be within 12-inches of the deck to no longer be considered impaired, and the sprinkler heads must be the correct orientation (upright vs. pendant). Since the construction area is not protected with sprinklers, the temporary separation barrier must be 1-hour fire rated with all openings ¾-hour fire rated doors that self-close and latch. The 1-hour barrier used is typically steel studs with 5/8-inch gypsum board on each side that is taped, mudded and the screw heads covered.

Patient Room Numbering System

Q: In our hospital the nurses found the architectural room numbers too confusing and wanted all patient care rooms to be in numerical order, so about 15 years ago they inserted paper numbers under the placards (for example one room will be C159 with an insert of 110). What are the codes for room numbers and labeling? Where can I find references?

A: The Life Safety Code does not provide much direction on room numbering. But NFPA 99-2012 section 5.1.11.2.1 does say medical gas shutoff valves must be identified (i.e. labeled) with the room that they serve. So, make sure the room numbers on the door match up with the room numbers on the labels for the medical gas shutoff valves.

If you are saying each room has two different numbering systems marked on the door, then that is certainly confusing to an outsider and would likely lead to a finding by a surveyor.

Other than that, I suggest you check with your state or local AHJs to determine if they have any requirements concerning this issue.

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UPDATE: After this posting was published, I received the following reply from a reader:

In addition to the Medical Gas references, just a quick friendly comment to supplement the post regarding Patient Room Numbering, at least in the State of Florida: NFPA 99-2012 section 7.3.3.1 and 7.4.3.1 Nurse Call Systems; and FGI Guidelines 2.1-8.3.7 Call Systems, all address the issue of communication of patient staff calls for assistance and information, medical device alarms, and patient safety and security alarms. The code requires annunciation of each call in several locations including the nursing station of the associated nursing unit. If the staff must learn alternative room numbers that are not annunciated over the system, this will most definitely generate a survey deficiency that will need to be corrected immediately. It is best practice for both the design professionals preparing the original plans, the life safety officer and/or consultant surveying the facility, and the AHJ reviewing plans and/or conducting regular surveys to require that the physical wayfinding room/bed location numbers posted agree with the Nurse Call System annunciation. 

While I agree with the reader’s comment, it is important to understand that any finding by a surveyor would be based on an interpretation of NFPA 99-2012, section 7.3.3.1, as there is no specific standard that requires the nurse call annunciation to agree with the actual room numbers. Authorities are permitted to make this interpretation based on section 4.6.1.1 of the 2012 Life Safety Code.

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

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.

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.

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.

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.

Hand Washing Sinks

Q: We have a relatively new Infection Control team.  They are performing rounds and having mock surveys with a nurse-consultant that cites issues from the 2014 FGI in areas that are much older.  The issue comes in when we are required to install new sinks (dirty, clean and a hand washing) in existing spaces.  We are a mixed hospital, some new that has to meet 2014 FGI due to new renovations.  What are your thoughts on the older areas that have not been renovated?  I am working with a design professional to see how he would design a space for the number of sinks and what reference he should use.  If it is simple and best practice to install them, I am all for it but some of the renovations come with a significant space or capital impact.  I am not sure if this is something you can help guide with or not.

A: According to Joint Commission’s standard EC.02.06.05, EP 1, the FGI Guidelines (2014 edition) is only used when planning for new, altered, or renovated spaces. Tell the nurse-consultant surveyor she is mistaken. She cannot apply a new guideline to an existing condition.

Now… if there was a requirement to have hand-washing sinks in the room at the time the room was designed or renovated, then she is correct and the sinks need to be installed. But if she plays that card, then she needs to provide evidence that there was a regulation (state, local, or otherwise) that required the sink at the time the room was designed and constructed.

Risk Assessments

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk level on the impact to patients/staff assuming the item being assessed would not be available or functional? We are performing a risk assessment on facility systems and medical equipment and are wondering what the standard is in the approach.

A: It sounds like you’re referring to the NFPA 99-2012 risk assessment for building system categories. If so, then the assessment is conducted with the assumption of the worst-case scenario, whereby the systems being evaluated fail and back-up systems (i.e. emergency power generators) fail as well. According to section A.4.1 of NFPA 99-2012, the category definitions apply to equipment operations and are not intended to consider intervention by caregivers or others. Also, the Introduction to Chapter 4 in the NFPA 99-2012 Handbook, the authors say:

“Each system must be evaluated for its impact on both the patients and the caregivers if the system should fail. Based on the worst-outcome scenario of a failure’s impact, the system is assigned a category. The chapter on that system the describes the requirements for the selected category.”

Be aware that the chairman of the Technical Committee who wrote this new chapter 4 for NFPA 99-2012 told me the intent was for the risk assessment to be on new equipment only, and existing equipment was exempted. However, chapter 4 of NFPA 99-2012 does not say that, and CMS is requiring all certified hospitals to have this risk assessment conducted on existing equipment as well as new. So, I recommend to my clients to do the assessment (it only takes a few minutes) on all existing and new equipment until such time CMS changes their minds.