There’s A New Form on the ‘Tools’ Webpage

Just a quick note to let you know there is a new form available to you for free, on the ‘Tools’ webpage called “Fire/Smoke Damper Test”. Due to multiple requests by readers, we’ve developed a simple template for you to use in documenting your fire damper and smoke damper test results.

Check out this and other forms and documents that are available for you at no cost to help maintain your facility to be Life Safety Code compliance.

Occupational Therapy Kitchens

Q: Do occupational therapy kitchens need to meet NFPA 96 standards? This unit will be a new build and will fall under business occupancy requirements, but the Life Safety Code for new business occupancies refers me back to 9.2.3, which refers me to NFPA 96.

A: Is the cooking equipment really ‘commercial cooking equipment’? For an occupational therapy kitchen, you would be using residential cooking equipment, would you not? Also, is the cooking equipment that is used for occupational therapy ever turned on…? Do they ever actually cook or bake anything on the stove?

If it were a healthcare occupancy, the answer is a no-brainer, since section 19.3.2.5.2 specifically says residential cooking equipment that is used for food warming or limited cooking does not have to meet the requirements of 9.2.3. While that section may have been written for food warming equipment in staff lounges, one could apply it towards occupational therapy kitchens as well.

But you may have a good case with sections 38/39.3.2.3 (3), which says something similar and exempts cooking equipment used only for food warming from having to meet section 9.2.3. There are a few other points that would prevent you from having to meet NFPA 96 requirements. According to NFPA 96-2011, section 1.1, it says the following regarding residential equipment:

  • 1.1.2 This standard shall apply to residential cooking equipment used for commercial cooking operations.

(You’re not using this residential cooking equipment for commercial cooking operations, so therefore, NFPA 96 does not apply).

 1.1.4* This standard shall not apply to facilities where all of the following are met:

(1) Only residential equipment is being used.

(2) Fire extinguishers are located in all kitchen areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

(3) The facility is not an assembly occupancy.

(4) The authority having jurisdiction has approved the installation.

(Make sure you comply with the above four items and you do not have to comply with NFPA 96.)

So, I think you have enough to go on to convince an AHJ that a NFPA 96 exhaust hood is not required for occupational therapy residential cooking equipment in business occupancies.

Smoke Dampers in Smoke Partitions?

Q: When comparing smoke dampers in smoke barriers vs smoke partitions, section 8.5.5.2 requires smoke dampers (with exemptions) for penetrations by ducts or air-transfer openings in a smoke barrier. Section 8.4.6.2 (smoke dampers in smoke partitions) only indicates air-transfer openings as required to have smoke dampers, with no mention of ducted openings, which we interpret to mean that ducted openings in a smoke partition do not require smoke dampers. However, we have been repeatedly told by mechanical engineers that smoke dampers are required for all ducts, transfer ducts, and air-transfer openings that pass through a smoke partition – which interpretation is correct?

A: It appears to me that your mechanical engineers are confusing smoke partitions with smoke barriers. To be sure, air-transfer openings are prohibited in corridor walls (which are smoke partitions) in healthcare occupancies, according to section 19.3.6.4.1 of the 2012 LSC. Also, section 19.3.7.3 (2) exempts smoke dampers in fully-ducted penetrations in smoke barriers, where the smoke compartments served by the smoke barriers are fully protected with Quick Response sprinklers. I do not see where smoke dampers are required in HVAC ductwork in smoke partitions.

Offsite Locations

Q: For clinics that are in a facility classified as business occupancy, is an ICRA required?

A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations that are considered hospital departments even if it is not classified as healthcare occupancy. For example, if a hospital has an offsite therapy unit in a local mall, the Environment of Care and Life Safety chapter requirements must apply to the offsite location, in accordance with the respective occupancy designation. This means, where the hospital is a healthcare occupancy, an offsite therapy unit would likely be a business occupancy, but the requirements found in the EC and LS chapters still apply at the therapy unit, but in accordance with business occupancy classification.

So, the requirement for an Infection Control Risk assessment (ICRA) is found in EC.02.06.05, EP 2 in the Hospital Accreditation Manual. The expectation is the hospital would conduct an ICRA at an offsite location when planning for construction as long as it is a hospital department. This concept of the Joint Commission standards applying at offsite locations is explained in the Overview to the EC and LS chapters.

Smoke Dampers in Corridor Walls?

Q: In regards to suite separations, section 18.2.5.7.1.2 of 2012 LSC requires walls separating suites to meet requirements for corridor walls, which have to be constructed to limit transfer of smoke. There don’t seem to be any requirements for smoke dampers in air transfer openings or duct penetrations through corridor walls – is this correct?

A: Well… you’re sort of correct. Corridor walls in fully sprinklered smoke compartments are required to be smoke partitions… not smoke barriers. The 2012 Life Safety Code does not require smoke dampers in HVAC ductwork that penetrate smoke partitions. But section 18/19.3.6.4.1 prohibits the use of air-transfer openings in corridor walls.

Tamper-Proof Screws in Psychiatric Unit

Q: Do all of the screw heads in a psych ward need to be tamper proof?

A: There is no specific code or standard that addresses screw heads in a psych unit, but CMS and the accreditation organizations have a standard that requires you to provide a safe environment for your patients and staff. Therefore, having a screw head in a psych unit that is not the tamper-proof style would likely be a citation by a surveyor because the environment is not considered safe by their point-of-view.

Temperature Range

Q: I work in the Central Processing department and yesterday they upped the temperature to 72 – 73 degrees in decontam and the clean side. I always thought it had to be a lot cooler than 72. Did this change recently?

A: According to the 2014 FGI Guidelines, the design temperature in Central Supply decontamination rooms is from 72° F to 78° F. This is the same design temperature range that was called for in the 2010 edition of the FGI Guidelines, but is a change from the 2006 edition which called for a range between 68° F to 73° F.

Now, design temperatures are just that… a target to aim for. There is no reason why you cannot have set-points on thermostats that are outside of the design temperature range provided the reason is documented in either a policy or a risk assessment.

Negative Air-Pressure

Q: I’m butting heads with our Infection Control group regarding holes in construction barriers. They have started requiring the contractors to make the construction sites negative air-pressure, which is fine, if they have access to the outside of the building. If there isn’t any way to vent to the outside they want to install filters in the construction barrier so they can exhaust filtered air into the corridors. Our construction sites are fully sprinkled so we are not required to have fire barriers but I can’t find anywhere in the code that it says they can put holes in the corridor walls to exhaust air through. I’m telling them that if they put holes in the barrier I might as well hang beaded curtains because we don’t have a smoke separation anymore. What do you think?

A: I guess it depends on the level of construction, demolition or renovation. I like the idea of poking a hole in the corridor wall and exhausting through a HEPA filter into the corridor to create a negative air pressure in the construction area. That is a common process where there is no access to the outdoors. I don’t see a problem with this… just make your ILSM assessments for a corridor that no longer resists the passage of smoke and keep that exhaust fan w/HEPA filter running 24/7. Don’t let them turn it off.  Sometimes, IC people don’t like the airflow into the corridor because it stirs up the air in the corridor. But if your IC people are okay with this, then that would be considered best practice. I think you’re over-reacting… The Infection Control people are correct on this one.

Sprinklers in Patient Room Lockers

Q: Are sprinklers required in patient room lockers for existing facilities?

A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be sprinklered.

Staff Sleep Room

Q: Within our X-ray department we have a room (7 1/2 ft. by10 ft.) that was our dark room for film reading years ago. We would like to make this a sleep room for staff that get called in. It has a sprinkler head; if we install a sounder base detector can we make this a sleep room and be compliant?

A: Sleeping with the old X-ray developing chemicals….? What a lovely thought.

Yes, I think you can convert this room to a staff sleep room. Your thought of putting in a smoke detector with an occupant notification device is good, but let’s look at the other items that may be needed.

First you need to confirm which occupancy chapter you need to comply with. Staff sleeping rooms is not covered under the Healthcare occupancy chapters, so you would consider “Lodging or Rooming Houses” occupancy or “Hotels or Dormitories” occupancy chapter. Reviewing the definitions of each, “Hotels or Dormitories” occupancy chapter is for 16 or more people, and “Lodging or Rooming Houses” occupancy chapter is for no more than 16 people. So, I would say that you need to follow “Lodging or Rooming Houses” occupancy chapter, and specifically, chapter 26 for new construction.

Section 26.3.4.5.1 of the 2012 Life Safety Code requires single-station smoke alarms must be installed in every sleeping room. So, according to this requirement, you would need to install a single-station smoke alarm, that has an annunciating device as you suggested. Some AHJs allow hospitals to install a building smoke detector in lieu of a single-station smoke alarm, but be aware not all AHJs see it that way.

Section 26.3.5.1 requires the sleeping room to be separated from the corridor by smoke partitions. So that means there cannot be any louvers in the door or walls.

Section 26.3.5.7 requires the door to the sleeping room to be self-closing (i.e. door closer) if the building is not fully protected with automatic sprinklers.

Section 26.3.6.1 requires the sleeping room to be protected with sprinklers, as you mentioned.

According to section 26.2.3.5.1, the door to the sleeping room cannot be locked against the means of egress. But section 19.2.2.2.4 covers that in depth and only allows certain exceptions to door locks. Keep in mind that section 7.2.1.5.10.2 does not allow the installation of deadbolt locks that are separate from the latch-set hardware.

As always, have this plan reviewed and approved by an architect and then obtain necessary approvals from your state and local authorities.

That should do it….