Smoke Detectors During Construction

Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space that does not involve the use of a fire watch. We are looking at multiple sensor detectors, but the initial comment we received from our vendor is that they are sometimes triggered by dust. In your opinion, would changing the smoke detectors to heat detectors be an acceptable solution in a construction space? If the space has an active sprinkler system, in your opinion, would it be acceptable to simply remove these smoke heads? Any thoughts you can provide would be greatly appreciated.

A: Changing the smokes to heats is not an acceptable solution to prevent a fire watch, because heats do not sense the presence of smoke. But perhaps you are making this more difficult than it has to be. The code only requires a fire watch for required fire alarm devices that are impaired. Are the smoke detectors in the construction area required? If so, then you need to do the fire watch if you remove the detectors, or suffer through many false alarms.

But if they are not required devices, then you can remove the smoke detectors and not have to do a fire watch. Section of the 2012 LSC specifically says a fire watch is for required fire alarm systems out of service.

One may be surprised to learn that in the typical hospital, there are very few locations that a smoke detector is required to be installed:

  • In areas open to the corridor as described in section of the 2012 LSC
  • In areas containing fire alarm control panels (including NAC panels) that are not continuously occupied as described in of the 2012 LSC
  • Near doors that are held open that must close on a fire alarm activation as described in NFPA 72-2010, section
  • Elevator recall for fire-fighter’s service as described in NFPA 72-2010, section 21.3

There are other situations where smoke detectors may be required, but those requirements are stipulated on optional design factors, such as on-call sleeping rooms, specialized protective measure locks, and equivalencies.

Therefore, if you have smoke detectors in an area that is under construction, and these smoke detectors are not required, then you may remove the detectors without having to perform a fire watch.

Gaps in Ceilings

Q: I am looking for the 1/8-inch gap reference for ceiling tiles. If the ceiling has broken tiles, or misaligned tiles, or gaps greater than 1/8-inch caused by anything (such as data cables temporarily run up through the ceiling), then I see that the surveyors will cite this. Is that actually written in the NFPA codes and standards anywhere? Is the 1/8-inch gap rule “real”? Does it use the 1/8-inch measurement anywhere? If so, where? If not, where does it come from?

A: No, there is no direct statement in the LSC that says gaps greater than 1/8-inch are prohibited, but ceilings containing smoke detectors and sprinklers must form a continuous membrane and any sizable gap in this membrane would allow smoke and heat to rise above the ceiling which would delay the activation of the detector or sprinkler, thereby causing an impairment.

Since the size of the gap must be quantifiable, and NFPA does not say how big the gap has to be before it is a problem, authorities having jurisdiction have ‘borrowed’ the 1/8-inch gap concept from NFPA 80 regarding the gap between a fire door and the frame. Authorities having jurisdiction are permitted to do this as section of the 2012 Life Safety Code says the authority shall determine whether the provisions of the LSC are met. This means, when the Life Safety Code is not clear on a subject, the authorities have to make interpretations in order to determine compliance.

Toaster Ovens

Q: I was having a discussion regarding toaster ovens use in healthcare and the frequency of fires was a factor for not favoring them. We have a few on campus and my research finds nothing in our policies or elsewhere specifically banning them from use. I see the requirements in the LSC regarding residential vs. commercial equipment requirements but no equipment is listed along these lines as not allowed. Can you share your knowledge on this subject?

A: Toaster ovens are not prohibited… but they are considered a perceived risk by many (if not most) authorities because they can be set to 450 degrees and they will not automatically shut-off, and potentially set something on fire. Therefore, you need to decide if you want to permit them in your facility. If so, conduct a risk assessment that identifies mitigating actions to reduce the perceived risk of these devices. If not, then remove them from the building.

Aerosol Can Storage

Q: Our nursing home just completed a state survey and while we were not cited we were “warned” that all aerosols are to be put into fireproof cabinet. The metal cabinets and toolboxes we have them in currently are not adequate. We use metal toolboxes on housekeeping carts to store one can of each cleaning product we use. The surveyor said these would have be logged in and out daily from fireproof cabinet. Is this an actual NFPA requirement?

A: This is not a Life Safety Code requirement. I’m always suspicious when I hear a surveyor ‘warns’ a facility about an alleged issue rather than actually cite them. In this day and age of the CMS dominant mantra of “If you see it, cite it” mentally, I have to question why didn’t the surveyor actually cite it. One reason could be that it is not a violation of any code or regulation, but it is a surveyor preference. Perhaps the surveyor is using his/her authority to cajole the facility into doing something that is actually not required. Would the facility be safer if all aerosols are stored in a fire-rated cabinet? Perhaps, but if it is not a requirement then the ends have to justify the means.

You didn’t say what was in the aerosol cans; are the contents flammable? According to NFPA 30-2012 flammable liquids are permitted to be stored in their original containers up to 1-gallon in size, and you do not need special containment (i.e. fire-rated cabinet) until the aggregate total of the stored product (per smoke compartment) reaches 5 gallons. To me, aerosol cans placed on a housekeeper’s cart would not be considered in storage – they would be considered in use. However, there are other aspects to consider: Are the cans of aerosol products on the housekeeper’s cart safe from unauthorized individuals (i.e. children, dementia patients)? If not, then that may be a valid reason to place them inside a storage container.

I’m not telling you to NOT follow the surveyor’s advice, but I am saying the warning is not based on Life Safety Code or other NFPA requirements. Perhaps it is based on state or local regulations. If you haven’t already done so, ask him/her to cite the code or standard that requires the storage requirements. If there is an actual code or standard that requires it, then we learned something. But if there is not an actual code or standard that requires it, then the surveyor will back down and admit it is a recommendation or preference.

GFCI Receptacles

Q: Where can I find the requirements for ground-fault circuit interrupters (GFCI) protection in the dietary/kitchen area of a nursing home? I thought it was 6′ within a water source. But when I look in the 2011 NEC it does not say that. The way I read it, it is everywhere in the kitchen/dietary that is 110v. What is your thought, and where can I find the clarification?

A: According to NFPA 70-2011, section 210.8, says:

All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(A)(1) through (8) shall have ground-fault circuit interrupter protection for personnel.

(6) Kitchens— where the receptacles are installed to serve the countertop surfaces

(7) Sinks — located in areas other than kitchens where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink

Section 210.8 does apply to healthcare facilities so NFPA 70-2011 does require GFCI receptacles in kitchens in healthcare facilities.

Surveyors will often use section 210.8 in assessing GFCI compliance in healthcare occupancies.

Tamper-Resistant Receptacles

Q: My question involves childproof outlets in healthcare. Where are they required and where in the code does it discuss not using snap-in covers?

A: According to NFPA 70-2011, Article 517.18(C), tamper-resistant receptacles are required in pediatric locations of health care facilities (i.e. hospitals, physician offices, therapy areas, etc.) including patient rooms, bathrooms, playrooms, activity rooms, and patient care areas of designated pediatric locations. As an option, the receptacle may use a listed tamper-resistant cover. The listing would have to be from an independent testing laboratory, such as UL, ETL, or the like. In essence, wherever an unattended child could be, you would have to have tamper-resistant receptacles.


ASC Waiting Area

Q: I am looking at a hospital facility with an Ambulatory Surgery Center in an existing building that is a Business Occupancy and construction type – II (222). We are working to separate the Ambulatory Surgery Center from the other business in the building with a two-hour fire rated partition. The waiting area, which is adjacent to the lobby/elevator area is enclosed by glass. Can we leave the waiting area out of the Ambulatory Surgery Center and make the separation behind the waiting area? This would be just separating the Ambulatory Surgery rooms and recovery area from the rest of the building (i.e. enclosed by a two-hour fire-rated wall).

A: No… I believe you are not permitted to do that. Actually, the LSC does not address this, but the CMS Conditions for Coverage (CfC) does address this. According to CMS Conditions for Coverage §416.44(a)(2), the ASC must have a separate recovery room and waiting area.

The Interpretive Guidelines for §416.44(a)(2) says this about waiting rooms:

The ASC is required to have both a waiting area and a recovery room, which must be separate from each other as well as other parts of the ASC. They may not be shared with another healthcare facility or physician office. (See the interpretive guidelines for §416.2 concerning sharing of physical space by an ASC and another entity.)

While the CfC does not specially say the waiting area must be inside the fire-barriers surrounding the ASC, if the waiting area was outside of these boundaries the surveyors could conclude that the waiting area is shared with other another healthcare facility or physician office.

I suggest you make sure the waiting area is inside the fire-rated barrier separating the ASC from the other entities.

Annual Testing & Balance of HVAC Systems

Q: Do you know if the ambulatory health care facilities are required to do an annual Test and Balance of the HVAC system?

A: No… I am not aware of that requirement. As far as I know, there is no standard for ambulatory healthcare occupancies (ASC) and healthcare occupancies (hospitals) to conduct annual TAB for their HVAC systems.

Now, having said that, the accreditation organizations and the CMS certification agencies do require you to demonstrate compliance with certain ASHRAE ventilation requirements in critical areas, such as operating rooms. But there is no actual standard that says you have to conduct annual TAB on the HVAC systems.

I suspect your accreditation organization and state agency who surveys on behalf of CMS will expect you to have documentation that your HVAC systems in your critical areas of the ambulatory healthcare occupancy is in compliance. An annual TAB report should be sufficient for that purpose.

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 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.


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 and 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, 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 of the 2012 Life Safety Code.