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.

Wood-Frame Addition

Q: Years ago, our state health department approved an addition to a hospital that I supervise. The addition is wood framed, not sprinkler protected, and does not have the required 2-hour fire barrier separation (yes, I’m serious). Recently, sprayed-on fire proofing began to fall from the deck. After consultation, we’ve decided the best course of action is to add complete sprinkler protection to this area. This is a costly project and will take time for approval. What are your thoughts on implementing some sort of ILSM? There is no egress blocked, or obstructed, but this is an area where there are MRI machines and I believe the wood framing with no sprinkler and fire proofing issues can be a serious concern.

A: Wow… that is a serious problem. You did not say what your Construction Type is. Since it involves wood-frame, it has to be one of the following:

  • Type III (211) with sprinklers
  • Type IV (2HH) with sprinklers
  • Type V (111) with sprinklers

But you say it does not have any sprinklers? Yeah… that’s serious problem. And there is no 2-hour fire-rated vertically aligned barrier to separate this non-compliant construction type from the rest of the hospital? That means the rest of the hospital is also now non-compliant.

You absolutely need to assess this issue for ILSMs and document your assessment. The whole hospital is now out of compliance with the Life Safety Code regarding Construction Type (see Table of the 2012 Life Safety Code). When there is no proper 2-hour fire rated vertically aligned barrier separating different construction types, then the lesser construction type prevails, and the rest of the hospital is not permitted to have this type of construction type.

You need to get professional help. Contact your architect, or a different architect if the one you currently use got you into this pickle. Discuss this with your CEO and tell him/her that you have three serious issues that will require funds:

  • Reapply the failing fire-proofing
  • Install sprinklers in the addition
  • Create a 2-hour vertically aligned barrier to separate the different construction types.

Develop a plan and time-line to implement all of these changes and improvements, but you need to discuss this with your architect, and before you do any construction, you need to submit a plan to the state and local authorities for their review.

Please understand that if you fail to resolve these issues, your next survey could end up being a Conditional Level Finding, based on the seriousness of the deficiencies.

Sprinklers in Construction Areas

Q: My question is about removing ceiling tiles in a construction area, and not having adequate fire protection in a 6′ to 8′ high ceiling plenum. The suggestion had been made to turn the sprinkler heads up, but the water spray still will not reach 12 inches below the deck since the deck is very high. What would be considered an adequate solution besides erecting fire rated walls surrounding a construction area? Also, where in NFPA 13 does it mention the requirement for 12 inches below deck, and is there is a requirement to turn the existing sprinkler heads up?

A: NFPA 13-2010, section says the distance between the sprinkler deflector and the ceiling above must be based on the type of sprinkler and the type of construction. Section of the same standard says for standard pendant and upright type sprinklers, the minimum distance is 1 inch and the maximum distance is 12 inches between the sprinkler deflector and the ceiling. In your case, when the suspended grid and acoustical tile ceiling is removed for construction, the deck above now becomes the ceiling. If you have 6 feet of interstitial space above the suspended ceiling, that is more than 12 inches so the piping needs to extend upwards so the sprinkler deflector are within 12 inches of the deck. Make sure you install upright sprinklers… you cannot use pendant sprinklers in an upright position. There are exceptions and added requirements for ductwork, piping and ceiling-mounted obstructions.

The requirement to provide sprinkler fire-protection during a construction project comes from the NFPA 241-2009 standard on demolition and construction, required by of the 2012 Life Safety Code. If your construction project is not protected with sprinklers during the construction phase, then you must construct 1-hour fire-rated barriers between the construction project and the occupied areas of the facility. A fire-rated barrier that is 1-hour is typically steel studs with one layer of 5/8 gypsum board on each side with all seams taped and covered with joint compound, and any openings would have to be 45-minute fire-rated door assemblies with closer and positive latching hardware. If the construction area is protected with sprinklers, then the barrier is not required to be 1-hour fire-rated, but construction tarps and flame-retardant plastic sheeting would not be permitted. Actual non-rated walls would be required.

Also, if an area of the healthcare facility is already protected with sprinklers, and the area is undergoing construction/remodeling that requires the removal of the suspended grid and acoustical tile ceiling, then a fire watch is required to be enacted until such time the sprinklers are no longer impaired. A fire watch is now based on the CMS Final Rule published on May 4, 2016. A fire watch must be performed by a trained individual who has no other duties to continuously patrol the impaired area looking for unsafe fire conditions, and must have the ability to immediately contact the fire department if they spot a fire. Continuous means this person is in the impaired area and does not leave to use the restroom, take a break or for any other reason. This is based on NFPA 25-2011, section A.15.2(4)(b). This goes on for 24-hours a day until the sprinklers are back in service. Even if you used minimum-wage individuals that would cost the hospital $3,500 to $4,000 per week, because you would need 5 individuals. This money could be better used to either turn sprinklers up to within 12 inches of the deck, or install sprinklers at the beginning of the project.

Suite Wall Construction

Q: I cannot find anywhere in NFPA on the wall construction of a suite wall. We’ve been building them as a smoke wall but the code doesn’t say anything.

A: You are correct… the NFPA Life Safety Code 2000 edition does not address the construction of the suite walls… directly. However, it does have something to say about it, in a round-about manner.

A suite is nothing more than a room, albeit a very large room with many smaller rooms inside it; but nonetheless, the suite is a room. Sections 18/19.2.5 (of the 2000 edition of the Life Safety Code) discusses the arrangement of the means of egress and how it relates to rooms. In this section, the terminology that the Life Safety Code uses, includes ‘room’ and ‘suite’ interchangeably. This section also uses the term “Suite of rooms”, which further reinforces the concept that a suite is a room. So, the conclusion is: If a suite is a room, then it must be protected in the same fashion as a room.

Sections 18/19.3 (same 2000 edition) discusses the requirements for protection, and sections 18/19.3.6 discuss the needs to protect corridors. Sections 18/ says “Corridors shall be separated from all other areas by partitions…” So, what are the “other areas” that 18/ is talking about? Rooms. Or more to the point for our discussion: Suites. Sections 18/ discuss how the corridor walls are to be constructed; sections 18/ discusses the requirements for corridor doors; and so on.

So, the construction requirements for walls separating suites from the corridors is covered under section 18/19.3.6. But that does not cover the construction requirements for walls separating suites from other areas other than corridors; such as other suites; or other rooms that are not part of the suite; and so forth. The 2000 edition of the Life Safety Code is rather silent on that subject, so the authorities having jurisdiction (AHJ) pretty much made an interpretation, and decided that the construction of the walls separating a suite from areas other than the corridor, must be the same as the construction requirements for a corridor wall. Not all the AHJs, but the AHJs that are national accreditors on healthcare pretty much came to this conclusion on their own

This made good sense, to the point that, when the 2012 edition of the Life Safety Code was created, the Technical Committee decided that should be placed in the actual code itself; so they did. Take a look at section in the 2012 edition of the Life Safety Code:

“Suites shall be separated from the remainder of the building, and from other suites, by one of the following:

  • Walls and doors meeting the requirements of through
  • Existing approved barriers and doors that limit the transfer of smoke”Section through is the section on corridor wall construction.So, a short and sweet answer to your question is: The walls for a suite need to conform to the requirements for corridor walls.

Section through is the section on corridor wall construction.

So, a short and sweet answer to your question is: The walls for a suite need to conform to the requirements for corridor walls.

More on Temporary Construction Barriers

I received an email from a reader who described a problem with their temporary construction barriers. He told me the following:

During construction and renovation projects our hospital uses drywall for temporary construction barrier walls. Our contractors are very ruff on these walls and constantly put holes in them. Our contractors have asked us if they could begin using fire retardant plywood for our temporary construction barrier walls for purposes of increased durability. Our infection control department did not have any issues with this. Would the use of fire retardant plywood be acceptable to with the Life Safety Code to use as temporary construction barrier walls in our hospital?

Non-Negative Air Barrier Web 2This is one of those issues that everyone does not agree on. Some authorities having jurisdiction (AHJ) may permit it and some may not. But when offering advice on Life Safety Code compliance, one must consider what the actual language of the code and standards say, and any interpretations made by AHJs.

According to the NFPA codes and standards, fire resistant plywood is not an acceptable temporary barrier for construction. Take a look at of the 2000 LSC which requires compliance with NFPA 241 (1996 edition) during construction. Section 2-2 says the following:

“Only noncombustible panels or flame-resistant tarpaulins or approved materials of equivalent fire-retardant characteristics shall be used.”

Fire resistant plywood is not noncombustible and it is not flame-resistant tarpaulins, so it does not qualify on that account. Now, section 2-2 does say “approved materials of equivalent fire-retardant characteristics” would be permissible. The fire-resistant plywood would seem to comply with this statement, but the key word is “approved”. The fire resistant plywood would have to be approved by all the AHJs that regulate the healthcare facility. That would be the following:

  • The federal government (CMS)
  • The accreditation organization (i.e. Joint Commission, HFAP, DNV)
  • The state AHJ on design and construction
  • The state fire marshal
  • The local fire inspector
  • The insurance company

Getting one of those AHJs to accept the fire resistant plywood as being acceptable is possible; but getting all of the AHJs to accept this, is improbable. Even if 5 of 6 AHJs accepted it, the organization would still have to comply with the lone AHJ who would not accept it.

Another consideration that is much less flexible in interpretation is section of the 2000 LSC, which says:

“All interior walls and partitions in building of Type I and Type II construction shall be of noncombustible or limited combustible materials.”

Again, fire resistant plywood is neither noncombustible or limited combustible materials. Therefore, from this code section’s point of view, fire resistant plywood would not per permitted, even on a temporary basis, and even if it was ‘approved’ by an AHJ.

My advice to this individual is to stick with the steel studs and gypsum board temporary construction barriers because once the new 2012 LSC is adopted, the updated edition of NFPA 241 will require 1-hour fire rated temporary construction barriers (with 3/4 hour fire rated doors that self-close and positively latch) where the construction area is not protected with sprinklers; or NFPA 241 will require non-rated noncombustible (or limited combustible) temporary construction barriers where the construction area is protected with sprinklers. It is important to understand that the new NFPA 241 will no longer permit the flame retardant tarpaulins (i.e. flame retardant plastic visqueen).

I also suggest to this individual that he should find a way to impress upon the construction people that the temporary barriers must be properly maintained; or find construction people who will be glad to have your work and comply with your requirements.

Remember: Those construction people work for the hospital; not the other way around.


Temporary Construction Barriers

imagesPE2I5ORAI was a co-presenter in a recent HCPro webinar on the new 2012 Life Safety Code along with my good friend and colleague Jim Murphy, and I received quite a bit of feed-back after the session. In the webinar we covered many of the changes that may add to the work-load of the facility manager. In a handout, I summarized them as follows:

  • Annual fire door inspections
  • New stairwell identification signs
  • Certain wheeled equipment will be allowed to be left unattended in corridors
  • Existing high-rise hospitals will need to be fully sprinklered within 12 years of the adoption of the 2012 LSC
  • Changes to the NFPA 72 fire alarm system test report
  • Changes to temporary construction barriers

And that last item on my list (changes to temporary construction barriers) was the one that I received the most feed-back. It appears that this issue is catching facility managers off-guard, probably because not many organizations are actually discussing this change.

To be sure, no one knows how accreditation organizations and state agencies inspecting on behalf of CMS will actually enforce this issue. First, they have to be aware of this change and as mentioned, not many organizations are talking about it, so perhaps the accreditation organizations and state agencies are not aware of the new requirements.

The issue of temporary construction barriers is found in section 18/ of the 2012 LSC, and says:

The means of egress in any area undergoing construction, repair, or improvements shall be inspected daily for compliance with and shall comply with NFPA 241, Standard for Safeguarding Construction, Alterations, and Demolition Operations. is the chapter 7 requirement for marking the means of egress. The edition of NFPA 241 which is referenced by the 2012 LSC is the 2009 edition, and it says this about temporary construction barriers: Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.  Walls shall have at least a 1-hour fire resistance rating.  Opening protectives shall have at least a 45-minute fire protection rating.*  Nonrated walls and opening protectives shall be permitted when an approved automatic sprinkler system is installed.

A.   Construction tarps would not be considered appropriate barriers or opening protectives.

There are still some unknowns about this new requirement that are not clear yet:

  • Will flame retardant plastic visqueen be permitted as temporary nonrated walls when the construction area is protected with sprinklers? The portion that says “construction tarps” in NFPA 241 is found in the Annex section which is explanatory information and is not considered part of the enforceable standard.
  • Will accreditation organizations and state agencies allow a ‘grace’ period from the start of demolition until such time that the construction area is fully protected with sprinklers, without the need for 1-hour barriers? At times, it may take multiple days to demo the suspended ceiling before temporary upright sprinklers are installed.
  • Are the 1-hour fire rated temporary barriers only required where the construction area is contiguous to occupied means of egress areas (corridors), or are the 1-hour barriers required wherever the construction area is contiguous to occupied areas?

My advice: Start working now with your construction people to not only be aware of this new requirement, but to begin incorporating 1-hour temporary barriers in their projects. When the new 2012 LSC is finally adopted, you will be expected to be in full compliance with this, as well as all the new changes. Eventually, the accreditation organizations and the state agencies will explain what their expectations are.

For a copy of the handout that I made for the webinar, go to “Tools”, and click on “Changes the New 2012 Life Safety Code Will Bring”.

Changes with Construction Barriers When the New 2012 LSC is Adopted

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.

Plastic Barrier Web 2Construction and renovation in healthcare facilities is a necessary force that needs to be reckoned with. It is going to happen, and the facility is not going to be shut down in order to accommodate it. A complete renovation of a unit will require the removal of the patients and staff, while the area is under construction. To protect the rest of the occupants of the building from the construction activities, sections 18/ of the 2012 edition of the LSC has referenced compliance with NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Activities, 2009 edition. In previous editions of NFPA 241, non-flammable smoke-tight partitions were all that was required between the area under renovation, and the occupants of the building, which is typically what the accreditation organizations have been enforcing. The 2009 edition of NFPA 241 will now have these new requirements:

  • Temporary construction barriers must be erected to separate occupied areas of the building from those areas undergoing alterations, construction or demolition, when such operations are considered as having a higher level of hazard than the occupied portion of the building

One may think the issue of ‘higher level of hazard’ may be open for interpretation, but NFPA has defined a hazardous area as one that poses a degree of hazard greater than that normal to the general occupancy of the building. Most construction areas would qualify as hazardous areas, under this definition. Other requirements involving the temporary construction barriers:

  • The walls must have a 1-hour fire resistive rating, and the door assemblies (if provided) must have a ¾ hour fire rating.
  • Non-rated walls and opening protectives are permitted when an automatic sprinkler system is installed (construction tarps are not considered appropriate barriers or opening protectives)
  • Where sprinkler protection is to be provided, the installation must be placed in service as soon as practicable

In a construction area that does not have automatic sprinklers installed and placed in service, the temporary barriers must be 1-hour rated, which means non-flammable plastic sheeting will no longer be permitted. Walls meeting 1-hour fire resistive rating usually are constructed with steel studs, and ¾ inch gypsum board on both sides, taped and mudded, and sealed to resist the transfer of smoke. All openings in the walls must be ¾ hour fire rated self-closing, positive latching doors, mounted on fire-rated frames. The clearance between the bottom of the door and the floor covering cannot exceed ¾ inch. It is interesting that NFPA 241 says construction tarps are not permitted where the barriers are not required to be fire-rated. This would lead one to believe that the non-flammable plastic sheeting will no longer be permitted in healthcare occupancies for temporary construction barriers.

The standard says non-rated walls and doors are permitted where sprinklers are installed and operating. Since all new construction in healthcare occupancies has to include the installation of sprinklers, NFPA 241 now requires the sprinklers to be installed as soon as practicable. This usually means temporary upright sprinklers are installed and tested and placed into service, as soon as demolition is completed. Occupancy of the renovated area is not permitted until the fire-safety features are properly tested and inspected.