New Construction vs. Existing Construction

Q: Is there a specific date for construction that is a cut-off point between chapter 18 and chapter 19, or does chapter 19 always applies once the new construction is complete and occupied?

A: Yes…there is a specific date to determine the difference between using new construction occupancy chapters (i.e. chapter 18) or existing conditions occupancy chapters (i.e. chapter 19). For the purpose of the 2000 Life Safety Code, that date was March 11, 2003 because that is the effective date when CMS adopted the 2000 LSC. For the 2012 Life Safety Code, the date is July 5, 2016, as CMS explained in their Final Rule adopting the 2012 LSC:

“Buildings that have not received all pre-construction governmental approvals before the rules effective date, or those buildings that begin construction after the effective date of this regulation, will be required to meet the New Occupancy chapters of the 2012 edition of the LSC.”

July 5, 2016 is the effective date of the new 2012 LSC so anything approved by state or local building departments or if construction begins after July 5, it is considered “New Construction”.

Sprinklers in Construction Areas

Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the sprinklers in the area for eight weeks. The construction is located on the lowest level and is unoccupied with no patient care in the area (but there’s patient care in the building). With the sprinklers out of service 24 hours a day, is a fire watch required? We also are looking at using 1 hour barriers and 3/4 hour doors during that time. Do the barriers change anything with a fire watch? Thank you

A: Can’t you re-install temporary sprinklers in this construction area for the duration of the project? You will need to turn the sprinkler lines upward to within 12 inches of the deck and install upright sprinklers. It is imperative that you have sprinkler protection, otherwise you will need to conduct a fire watch, continuously for the 8 weeks there are no sprinklers.

Yes… a fire watch is required because you have impaired sprinklers. It doesn’t matter where the impaired sprinklers are located… if you have impaired sprinklers, you must do a fire watch. NFPA 25-2011 section 15.5(4) says where the sprinkler system is out of service for more than 10 hours in a 24-hour period, you need to conduct a fire watch. CMS has said in their Final Rule to adopt the 2012 Life Safety Code published May 4, 2016, that a fire watch is conducted continuously, without interruption. The designated individual who performs no other function, continuously walks the impaired area looking for fire and the potential for a fire to occur, without leaving the area. This means the individual may not leave the impaired area to use the restroom, take a lunch break or any other function unless he is relieved by someone else.

This ‘continuous’ fire watch must be conducted for the duration that the sprinklers are impaired … 8 weeks. Can you afford to have that many FTEs designated to do nothing else but a fire watch for 8 weeks? I would believe it would be less expensive if you would turn up the sprinklers and install upright sprinkler heads in the construction area.

The fire watch does not affect the rated barrier, but the 1-hour fire rated barrier is required to separate the construction area from the occupied area if there are no sprinklers in the construction area.

Temporary Construction Barriers

Q: Per NFPA 101 2012 edition: are plastic barriers (w/zippers) no longer acceptable around construction areas though the facility is fully sprinkled?

A: No… I wouldn’t say that. But the issue is being reviewed by NFPA Healthcare Interpretations Task Force (HITF) and a change may occur later this year.

Section 19.7.9.2 of the 2012 LSC says the means of egress of any area undergoing construction, repair, or improvements must comply with NFPA 241, which is the standard for safeguarding during construction operations. Section 8.6.2 of NFPA 241-2009 says temporary construction barriers are required to be 1-hour fire rated, with ¾ hour fire rated doors assemblies if the construction area is not full protected with sprinklers. 1-hour barriers are typically steel studs with 5/8 inch thick gypsum board on both sides, with all seams taped and mudded and all screws heads mudded. If the construction area is protected with sprinklers, then the temporary construction barrier is permitted to be non-rated, but construction ‘tarps’ are not permitted as the non-rated barrier. At this time flame retardant plastic sheeting (i.e. Visqueen) will be permitted as a temporary construction barrier where the construction area is fully protected with sprinklers.

However, this issue is being reviewed by HITF of the NFPA. At the June, 2016 meeting of HITF, the members discussed whether or not flame retardant plastic sheeting was acceptable or if it was the same as ‘construction tarps’. At that time there was not a clear consensus so no decision was made. The committee said they would review it again next year.

Unless your AHJ has specifically ruled on this issue, the HITF seemed to say that flame retardant plastic sheeting would be permitted when the construction area is fully protected with sprinklers. But, of course, that is not in writing so it is not official.

I would say continue to use flame retardant plastic sheeting until you learn otherwise.

Distance to a Storage Shed

Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any minimal distance that the out-building must be away from the protected facility?  The number that I keep hearing from people is 10 feet of clearance from the protected building but I have not been able to confirm that as a requirement or a best practice.

A: No… there does not seem to be a set number of feet for a non-compliant outbuilding that needs to be from a healthcare occupancy, written into the Life Safety Code. I was at a seminar recently where that question came up and the instructor admitted there was no definite set-back required. But… like everything else that is not definitive in the Life Safety Code, the AHJ can interpret (decide) what the set-back should be. I too have heard 10 feet is the distance a non-compliant building needs to be from a healthcare occupancy without a 2-hour fire rated separation. That is actually a sound interpretation, based on other Life Safety Code requirements. Take a look at section 7.2.2.5.2 and 7.2.2.6.3 of the 2012 LSC which discusses the need for a 10 foot section of wall to be 1-hour fire rated when the fire rated wall intersects with an outside barrier at an angle less than 180 degrees. While that does not specifically refer to a set-back of a non-compliant building, it does provide you with a distance to go on.

Construction Barrier Doors

Q: Does a door that accesses a construction site within a hospital need to have an automatic closer installed on the access door? What if the door is constructed within temporary drywall barriers?

A: The 2012 Life Safety Code references the 2009 edition of NFPA 241 which has changed from previous editions to require fire-rated barriers separating construction areas from occupied areas. The 2009 edition of NFPA 241 now requires all construction areas to be separated from occupied areas with 1-hour fire rated construction, which will include ¾ hour fire rated doors that are self-closing and positive latching. There is an exception in the 2009 NFPA 241 that allows non-fire rated barriers if the construction area is protected with automatic sprinklers, but the Annex section of NFPA 241 specifically says ‘construction tarps’ would not be permitted. It is unclear if using flame retardant plastic visqueen to separate construction areas from occupied areas would be permitted since the standard does not allow tarps. The NFPA HITF committee began to deal with this issue but failed to come to a consensus.

That means steel studs and gypsum board would still need to be used to separate construction from occupied areas, however if the construction area is sprinklered then the separation barrier would not be required to be 1-hour fire rated. The construction area would still be considered a hazardous area which requires a self-closing door.

Areas of Refuge

Q: We have an offsite business occupancy location and need to know what the requirements are for an area of refuge. I have not been able to identify any fire/smoke separations in this building. What would make a distinguishable area of refuge?

A: Areas of refuge are required when the occupancy chapters of the Life Safety Code say they are required. Since you said the offsite location is classified as a business occupancy, then according to section 39.2.2.12 of the 2000 Life Safety Code, an area of refuge complying with section 7.2.12 is required. One exception to that requirement is an area of refuge is not required if the entire building is protected with automatic sprinklers. So, here are the requirements (according to section 7.2.12) for areas of refuge, when it is required:

  • Areas of refuge are considered part of the means of egress
  • Areas of refuge must be accessible from the space they serve by an accessible means of egress (corridor)
  • Areas of refuge must have access to the public way, meaning they must have a direct exit to the outdoors
  • If stairs are involved in the means of egress from the area of refuge to the public way, the minimum clear width must be 48 inches (with some exceptions)
  • If an elevator is provided from an area of refuge to the public way, the elevator must be provided with Fire Fighter Service; the power supply must be protected from interruption from a fire occurring outside the area of refuge; the elevator shaft must meet smokeproof enclosure requirements
  • The area of refuge must be provide with a 2-way communication system with a central control point
  • The door to the area of refuge must be identified with a sign, stating “AREA OF REFUGE”
  • Instructions on how to summon assistance via the 2-way communication system, and written identification of the area of refuge location must be posted next to the 2-way communication system
  • Areas of refuge must be size to accommodate one wheelchair space of 30” x 48” per each 200 occupants served by the area of refuge, and still allow adequate width in the area of refuge (minimum 36 inches)
  • Areas of refuge that do not exceed 1,000 square feet, must be calculated that tenable conditions are maintained within the area of refuge for a period of 15 minutes when the exposing space on the other side of the separation creating the area of refuge is subjected to the maximum expected fire condition
  • Access to any designated wheelchair space in an area of refuge must not be through more than one adjoining wheelchair space
  • Each area of refuge must be separated from remainder of the story by a 1-hour fire rated barrier, and must resist the passage of smoke (existing barriers with a 30-minute fire rating are permitted)
  • Door assemblies in areas of refuge must have at a minimum, a 20-minute fire rating, and be self-closing or automatic closing, and positive latching
  • Where HVAC ducts are not prohibited in areas of refuge by other sections of the Life Safety Code, they must be provided with smoke-actuated dampers to resist the transfer of smoke into the area of refuge
  • The ‘AREA OF REFUGE’ signs must be located at each door providing access to the area of refuge; and wherever necessary to indicate clearly the direction to an area of refuge
  • ‘AREA OF REFUGE’ signs must be illuminated as required for ‘Exit’ signs where ‘Exit’ sign illumination is required
  • Tactile signs complying with CABO/ANSI A117.1 must be located at each door to an area of refuge.

So, what I see mostly in these requirements for an area of refuge is an enclosed stairwell that has an exit door to the outdoors. The stairwell enclosure must meet the above requirements for width, communication, signage, fire rating, etc., but that is where you will find your area of refuge. If the offsite location is a single story building and you do not have a vestibule that could serve as an area of refuge, then you will have to create one by adding fire barriers and such. Please check with your state and local authorities to see if they have other requirements concerning the area of refuge.

Sprinklers in Construction Projects

Q: We have a construction project that involves removing all of the ceiling tiles in the area. Do we have to relocate the sprinklers heads to within 12″ from the deck above? Do you have any guidance on what’s required for fire protection in the construction area?

A: If your organization is required to be in compliance with the 2000 edition of the Life Safety Code, then sections 18/19.7.9.2 requires compliance with the provisions of NFPA 241 Standard for Safeguarding Construction, Alteration and Demolition Operations, (1996 edition) during renovation and construction that includes a means of egress. The phrase ‘means of egress’ pretty much covers everything, so it would be a safe bet that NFPA 241 applies whenever any construction or renovation is underway. The 1996 edition of NFPA 241 does not require an active water-based sprinkler fire protection system to be installed and operating during the construction phase, but if there is one, it must comply with NFPA 13 Standard for Installation of Sprinkler System, which means sprinkler heads would have to be mounted within 12 inches of the deck if the suspended acoustical tile ceiling had been removed. The 1996 edition of NFPA 241 also only requires fire resistant and smoke resistant temporary construction barriers, rather than 1-hour fire rated barriers. Now, the 2012 edition of the Life Safety Code requires compliance with the 2009 edition of NFPA 241, which did undergo a change in regards to temporary construction barriers. The requirement for temporary construction barriers changed to be either 1-hour fire rated, or non-rated fire resistant if the construction area is fully protected with automatic sprinklers. Again, sprinklers are not mandatory, but if you have them, they must comply with NFPA 13. If the decision for temporary construction barriers is to go with 1-hour fire rated walls, then a ¾ hour fire rated door, which is self-closing and positive latching must be provided. To answer your question directly, I would say ‘No’, there is no requirement whereby you must relocate the heads to within 12 inches of the deck. However, if you do, it may save you with considerable expenses in other areas. If the area is properly sprinklered according to NFPA 13, then a fire watch would not have to be implemented, and the temporary construction barriers would not have to be 1-hour fire rated. This may become a significant expense which could be avoided. If this construction area is located underneath an occupied inpatient unit, then it makes much more sense to provide properly installed sprinklers in the construction project for added protection, which should reduce the risk of the renovation to the inpatients.

Contractors During a Survey

images[3]It has always been my belief that as the surveyor team walks in the front door of the hospital on the first day of the survey, all of the contractors should be walking out the back door. For the most part (and I do understand that there are exceptions), contractors should be sent away once you know there are surveyors in the house. Why? Because they will get you in trouble one way or another.

I recently received an email from a reader who shared this story:

During our triennial survey the life safety surveyor asked me how we knew that the fire alarm system signal was received by our monitoring company. I could not immediately answer the question, but we were lucky to have the service contractor in the building doing his quarterly testing and I suggested we ask him.

The service technician explained that the software in the fire alarm control system will indicate if the alarm is received by the monitoring company within the designated amount of time. I was quite happy with the service technician’s explanation until the surveyor said “Prove that it happened at least quarterly for the past 12 months”.

The service technician said nobody could prove it; we just have to take his word for it. [Wrong answer.] The surveyor asked “Don’t you call them by telephone to confirm they received the signal?” The service technician replied, saying “Well, would you trust me if I said I did call?”

The surveyor was correct to ask the questions that he/she did. The service technician was probably answering them to the best of his ability, but the real problem is the facility manager allowed the surveyor to enter into a conversation with a contractor. During a survey, the hospital staff should try and control the process as much as possible. By allowing a surveyor to ask questions of a contractor, the facility manager lost control of the situation and will suffer any consequences of what a contractor may say.

Contractors are not trained and educated in the regulatory requirements the same way the hospital staff is (or should be). The contractors may not even know or understand the significance of an accreditation survey, or worse, a CMS certification survey. Service technicians have a tendency to take an attitude that they know more about the system they are working on than the hospital does, and for the most part they do. Otherwise, the hospital would not hire them. But the service technician my not know what specific regulations that the hospital must comply with and therefore may say something to a surveyor that may get you in trouble.

I’m not saying you should not be transparent in your processes, but during a survey, you need to control as much as you can of the survey process. This is not unethical or wrong; it is just smart business. Let the surveyor go where he/she wants; let the surveyor ask questions all they want; but eliminate the potential “loose cannons” that are not very well educated on the survey process by sending them home during the survey.

Another reader sent me an email earlier this year explaining that on a day during the accreditation survey a roofing contractor set a pallet of roofing material right in the middle of the exit discharge of a staff entrance/exit to the hospital. Nobody from the hospital was aware that the roofing contractor was about to do that, but the surveyor noticed it as soon as it happened and it went into the survey deficiency report.

When I was a surveyor for The Joint Commission, I would purposely seek out contractors and ask them what training the hospital provided them on fire safety procedures. Ultimately, contractors are expected to know the same fire response procedures as the staff. Invariably they could not answer the question satisfactory and it would be cited in the survey deficiency report.

I know that in some situations you cannot send the contractors home for the duration of the survey, but it seems that a large percentage of them could. At the hospital where I worked as the Safety Officer, I asked the project management team to send the contractors away during the week of the survey (this was when the surveys were announced). The project managers thought that was a good idea, but we were over-ruled by the COO of the hospital, because he did not want the opening of the new renovated unit to be delayed. That ended up being a costly mistake. The hospital had a policy that every contractor had to receive basic safety orientation before they begin their work on the campus of the organization. Unbeknownst to the hospital, the general contractor brought in a sub-contractor to install flooring in one area, and they did not go through the safety training because the general thought it would be “okay” since the sub was only going to be there for one day. Sure enough, the surveyor found that one sub who had not received the safety training which lead to a finding on the survey deficiency report.

You need to control what you can, and sending the contractors away is the smart thing to do during a survey.

Fire Alarm Devices in Construction Areas

Q: Are we required to install fire alarm occupant notification devices and manual pull stations in construction areas? I couldn’t find anything in NFPA 72 or the Life Safety Code.

A: The 2000 edition of the Life Safety Code, section 3.4.1 requires the healthcare occupancy to be provided with a working fire alarm system, which would include construction areas as well. This would require you to install a temporary pull station every 150 feet and within 5 feet of the exits, and install occupant notification devices (strobes & chimes) in the construction area, or conduct a risk assessment for Interim Life Safety Measures (ILSM) and implement measures to compensate for the absence of pull station and occupant notification devices.  As mentioned in last week’s Q&A, section 4.6.10.1 allows construction areas to be compensated for not having a working fire alarm system with ILSMs. I would recommend that you install the temporary pull stations and occupant notification devices in all construction areas, rather than conducting ILSMs, as it provides a higher level of safety for the construction workers and patients. Manual fire alarm system pull stations will allow for a quicker activation of the fire alarm system should an emergency present itself. This results in a higher level of safety for the patients and staff. Also, what ILSM is adequate to compensate for not have an operable fire alarm system in constructions areas? I could think of a few:

  • Fire watches
  • Extra fire drills
  • Staff and contractor education
  • Daily surveillance

Based on my experience, contractors (in general) are poorly educated in hospital fire safety programs and are unreliable to perform surveillances and daily inspections. The extra fire drills have to be conducted in the area (or areas) where the deficiency occurs, so that means you have to do fire drills with the contractors, which is not an easy task. When you add in the cost of labor to perform the ILSM compensating requirements, I would say it is safer and more cost effective to have the temporary pull stations and occupant notification devices.

Storage of Combustibles During Construction

Q: We are renovating one of our patient sleeping suites in an existing area. Would it be permissible to stage construction materials (some of which will be combustible) in one of the vacant rooms in the suite?

A: When combustibles are stored in a room greater than 50 square feet, the room must comply with section 18/19.3.2.1 of the 2000 edition of the LSC in regards to hazardous areas. This means, if the room did not previously comply with the requirements for hazardous areas, then the room has to be upgrade with 1-hour fire rated walls that extend from the floor to the deck above, equipped with a ¾ hour fire rated self-closing positive latching door, and the room is required to be protected with automatic sprinklers. However, section 4.6.10.1 permits alternative life safety measures (some AHJs call this Interim Life Safety Measures, or ILSM) to be implemented to compensate when features of life safety are compromised during construction. Therefore, it is permissible to store combustibles in non-fire rated rooms on a temporary basis to accommodate construction activities, provided ILSM are implemented. Some suggested ILSM activities could include:

  • Daily surveillance looking for unsafe conditions in the rooms
  • Staff education, notifying staff in the area that combustibles are stored in a non-approved room
  • Extra fire drills in the area
  • Install a smoke detector in each room