Qualifications for Fire Damper Testing

Q: Do the NFPA standards for fire damper testing require the testing to be performed by a certified vendor/specialist or can it be performed internally by our engineering staff?

A: According to NFPA 80-2010, section 19.4 addresses the issues for testing fire dampers. While I do not see any restrictions in the standards regarding qualifications of the person conducting the fire damper test, the general understanding in other NFPA standards is the person should have knowledge and understanding of the operation of the equipment, which can be provided at the time of the test/inspection. So, to directly answer your question: No, fire damper testing does not have to be conducted by a certified vendor/specialist and may be conducted by your own staff. Although you did not ask, here is a summary of what NFPA 80-2010 requires for fire damper testing:

  • Each damper shall be tested and inspected 1 year after installation.
  • The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
  • All tests shall be completed in a safe manner by personnel wearing personal protective equipment.
  • Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required.
  • If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped.
  • The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.
  • The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.
  • The damper shall not be blocked from closure in any way.
  • The fusible link shall be reinstalled after testing is complete.
  • If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating.
  • All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of the inspector, and deficiencies discovered.
  • The documentation shall have a space to indicate when and how the deficiencies were corrected.
  • All documentation shall be maintained and made available for review by the AHJ.
  • Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105-2010, Standard for Smoke Door Assemblies and Other Opening Protectives.

Battery Charging Room

Q: Are there any Life Safety Code requirements for a battery charging room, such as HVAC pressurization and air changes per hour (ACH) rates? These rooms are where I charge my EVS floor machines.

A: I guess it would depend on how the room is interpreted in regards to its function. According to the 2014 FGI Guidelines, which references the ASHRAE 170 table, a janitor’s closet must be negative, have 10 ACH, the air in the room must be exhausted to the outdoors, you cannot have a room HVAC that recirculates air, and there are no design requirements for humidity and temperature.

If the room is hazardous material storage (which sounds more like it), the room would have to meet the same requirements as listed above, with the added requirement that there is 2 ACH of outdoor air.

But those are for new construction. For existing conditions, you would have to comply with the FGI or AIA requirements in effect at the time of the design of the room.


Fire/Smoke Damper Drawings

Q: A California Life Safety Code surveyor enforcing the 2012 edition of the LSC asked for a map of all of the smoke and fire dampers in the building (skilled nursing home) and threatened a deficiency if one could not be produced. I have been searching for the 2012 LSC and cannot find any such reference to this specific requirement. I have not heard of this before. Can you shed any light on this matter?

A: Yes, I can understand the surveyor’s request, although threatening you with a citation seems a bit much.

The surveyor’s position is: How can you effectively maintain all of your fire/smoke dampers if you do not know where they are located? Having them documented on a drawing is logical in that you can then properly maintain the dampers. Without having them documented on a drawing, the chance is great that you would miss one or more dampers and they would not be tested.

But, to be sure, there is no standard that requires you to have drawings showing the locations of all fire/smoke dampers. But if you provide a test report that says you tested 25 dampers, how do you know where these 25 dampers are located, and you don’t have more than 25, and you got them all tested? I can see the surveyor could cite you with a finding that would read something like this: “The organization failed to provide evidence that all fire and smoke dampers were properly tested.”

But I don’t approve of surveyors making threats… that is just unprofessional.

Fire Extinguishers

Q: What are the rules for fire extinguishers in elevator mechanical rooms? Is it good enough to have the extinguisher outside the room in the hallway?

A: Yes… Based on NFPA codes and standards, there is no requirement to have an extinguisher inside the mechanical room, as long as there is an extinguisher within the maximum travel distance for the classification of the extinguisher and the capacity of the extinguisher. It is permitted to have an extinguisher outside of the elevator mechanical room.


EM Lights in MRI

Q: I have a question on the requirement for the battery backup lighting inside the MRI suites. We are in the process of building two new MRI centers and I am receiving a lot of push back from the Project Engineer.

This engineering group specializes in MRI projects and they tell me they never install battery backup lighting and that NFPA 99 does not require battery backup lighting anywhere outside of an operating room. I was told to reference of NFPA 99-2012 which specifically mentions operating rooms. My reply was that does not specify only operating rooms so it is much broader in scope and since we use anesthesia in the MRI it would be required.

Before I stir up the pot anymore with the engineering firm I wanted to make sure that if Anesthesia is being used in the MRI room that emergency battery backup lighting should be in place.

A: Yes, you are correct. NFPA 99-2012, section requires one or more battery-powered lighting units within locations where deep sedation and general anesthesia is administered. That includes MRI areas, Cath Lab areas, and of course, Operating Rooms and Procedure rooms. ICUs and NICUs would typically not be included.

Just because the project engineer from the contractor has never been told to install battery-powered lighting units before does not preclude the fact that it is a requirement and it is enforced by CMS and the Accreditation Organizations. The engineer is mistaken.


Air Changes in the Morgue

Q: We are presently undergoing our 3-year licensure inspection by the Dept. of Health. One of the inspectors asked to see our air change records for the morgue. We have never completed air changes for the morgue. We use outside air and make sure the exhaust fan is working properly. So, should we be doing air change testing in the morgue? Also, do we need to do air change testing in all clean and soiled utility rooms in the hospital?

A: When your facility was designed and constructed, the HVAC system had to be designed to certain Air Changes per Hour (ACH). Depending when the facility was designed, the designer would use the AIA Guidelines (or as they are now called, the FGI Guidelines), or other state or local regulations as appropriate. You need to find out what those design ACH were at the time the facility was designed/constructed, or last renovated in that area.

It is important to understand that you do not have to meet the latest edition of FGI Guidelines; you just have to meet the edition at the time your facility was designed, or last renovated. It is important to also understand that you must comply with state and local regulations at all times.

So, let’s say the morgue was required to have 6 ACH at the time it was designed. You must maintain that 6 ACH for the life of the building, or until you renovate; then you would have to comply with new construction ACH for a morgue. The state inspector’s request is valid: How do you know you are maintaining 6 ACH if you don’t measure it from time to time? How often should you measure the ACH? The codes and standards do not say, so do a risk assessment and determine what is a valid number. Usually once per year is sufficient as long as you have historical data that shows the ACH rate was always in compliance.

You need to start measuring ACH rates in all areas where there was a design requirement for ACH.

Storage in Patient Rooms

Q: Nursing staff has a tendency to stuff patient rooms that are not used as often with extra beds, furniture etc. Building does not have sprinklers on these patient floors so the concern is fuel load in a nonrated room. Is there a particular code I can cite to discourage this behavior?

A: Yes… Section 4.6.7 in the 2012 LSC says when you have a change in use (that’s what is happening… the patient room is not being used as a patient room anymore, but now is used as a storage room with combustible supplies), you need to comply with chapter 43. Section (2) says when existing healthcare occupancies are fully protected throughout with automatic sprinklers, when you have a change is use in a room that does not exceed 250 square feet, the result is the room does not have to meet new construction requirements but is permitted to meet existing conditions for hazardous rooms. This is significant as the room where the extra beds and furniture are placed would not have to meet the more restrictive new construction requirements for adding sprinklers and making the walls become 1-hour fire rated barriers, with a ¾ hour fire rated door assembly. The room would only have to be sprinklered and the walls and doors made to resist the passage of smoke and the door be self-closing. But this is only permitted if the entire building is protected with sprinklers, and you say it is not. Therefore, you have no choice; you must reconstruct the former patient room to be 1-hour fire rated with a ¾ hour fire rated door assembly and install sprinklers in the room. This could cost you $10,000 – $20,000 per room depending on the current arrangement of the facility. This is an example of staff changing the use of a room or area without checking with facilities to see if it is permitted. Your best bet would be to complete the sprinkler installation in your building.

NFPA 99 Risk Assessment

Q: A question came up concerning 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 their state agencies who survey on their behalf 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 take 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.

Blanket Warmers

Q: Do we need to post the temperature ranges on the outside of our blanket and fluid warmers?

A: Well… no, I don’t believe you do. But the expectation is everyone using the blanket warmers will know what the maximum and minimum temperature settings are. This needs to be established and approved via policies, and staff needs to know the acceptable ranges.

So, one of the better ways of reminding staff what the acceptable ranges are is posting the temps on the warmer itself. It may not be a requirement and you don’t have to do it, but it may be considered ‘best practice’ to post the temps on the cabinets as a reminder.

Air Pressure Relationships

Q: We have operating rooms with two doors, one that is adjoining to the sterile corridor and one to the common corridor in the Surgery department. We monitor the common corridor continuously through our building automation system (BAS). We do not monitor the sterile corridor. Is there a requirement to monitor the sterile corridor continuously or daily?

A: The standards on monitoring and logging are weak on ventilation requirements and not well defined in many cases. But the expectation is your organization will be monitoring and logging certain environmental parameters regarding operating rooms, such as:

  • Air-pressure relationship to surrounding areas;
  • Humidity levels;
  • Temperature levels

For new construction, CMS and the accreditation organizations recommend compliance with industry standards such as FGI Guidelines, AORN, CDC, and the like when other state or local regulations are silent. For existing conditions, most accreditation organizations have standards that require you to maintain ‘appropriate’ pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity, based on the edition of the design standards used at the time of design… if you know when that was, and what document was used for the design.

Many organizations don’t have that information available to them. When that is not known, most surveyors will lean on what is currently required for temperature, humidity, and air-pressure relationships. The FGI Guidelines require a positive air-pressure relationship to surrounding areas for operating rooms. That would include all areas, including the sterile OR corridor. I believe CMS and the accreditation organizations would expect you to monitor the air-pressure relationship between the operating room and all other areas, including the sterile corridor. There is no requirement to monitor this on a continuous basis, but should be conducted prior to every case.