Fire Drills During a Pandemic

Q: As the world faces this pandemic, can fire drill requirements be suspended or replaced with staff education type in-services?

A: Fire drills are a mandatory requirement that is regulated by the federal government through the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation standards. At this time, there has been no communication from CMS to suspend any of the Life Safety Code requirements, including fire drills, during this COVID-19 crisis.

If (or when) CMS issues a formal communication announcing any suspension to their standards, that will be reported by my website, as well as by many other informational services, and your accreditation organization.

So, no – fire drill requirements cannot be suspended at this time.

Keys to Unlock Doors

Q: We have a Geri-Psych unit and the stairwells are locked on that unit. Back in 2009, you surveyed our facility and wrote in your findings, “The housekeeper person on the Geri-Psych unit does not have a key on her person to unlock the exit doors.” This is a battle that we are continually fighting. We need some ammunition! Can you please provide me with the code that would require them to have keys on their person (since common sense isn’t so common around here)?

A: Look at section of the 2012 LSC. It says staff can readily unlock the doors at all times. Housekeepers, maintenance, food service, physicians, nurses, therapists, etc., are all ‘staff’, and each one working inside the locked unit needs to be able to unlock the doors. Therefore, each staff member must have a key or device to unlock the doors on their person.

Ignoring Life Safety Code for Emergency Situations

Q: My hospital is preparing for COVID-19. I’m at odds with the clinicians who believe that the pandemic is a special situation, meaning that Life Safety Code can go by the wayside in order to be prepared to receive and care for contagious patients. For instance, clinicians have decided to move waiting chairs into corridors to provide what is considered “social distancing.” Another example is the plan to place plastic sheeting barriers in corridors so that the hospital can be split into a clean and dirty zone. What would be your recommendation for these situations? Can the Life Safety Code be ignored for emergency situations?

A: Yes, but only when the Emergency Response Plan is activated. You still must maintain a level of safety for staff, visitors, and patients, but that level of safety is a moving target when there is a disaster to accommodate. Having plastic sheeting in an exit access corridor is certainly a violation of the Life Safety Code, but it may very well be necessary when there is a disaster. This is a judgment call and one that should be addressed in the Emergency Response Plan and approved by the person in charge of the disaster response team, not the physicians.

You will not find this written in any standard that I am aware of, but is based on years of experience working with Centers for Medicare & Medicaid Services (CMS) and The Joint Commission.

How to Prepare for a Public Health Emergency

Yesterday, Compliance One Group shared an insightful video by Carrie Kotecki that discusses her thoughts on how healthcare organizations can prepare now to prevent a future public health emergency.

Click here to watch the video.


Disabling Corridor Door Closer

Q: Is it allowed to disable a corridor door’s closer by removing the arm in order to keep it open while working inside of the office in a healthcare facility? I know that propping the door open with a wedge is not an option; I was just wondering that if these doors were required to have closers on them due to being a corridor door.

A: No… it would not be acceptable to disengage the function of the closer, even if it is was not required by a code or standard. Section of the 2012 LSC says existing features of life safety obvious to the public if not required by a code or standard, must be maintained or removed. Now, there are exceptions. When you say ‘working in the office’, if you meant there was a construction project or a repair job in progress, then yes, you can disengage the closer in order to accommodate the work in progress. In a situation like that, you would assess it for Alternative Life Safety Measures according to section (some AHJs call this Interim Life Safety Measures or ILSMs). But if you mean the person whose office it is wants the closer disabled so they don’t have to deal with a door that closes automatically, then the answer would be no, it is not permitted. If the closer is not required on the door by the Life Safety Code, then I suggest you ask your state and local authorities to determine if you may remove the closer.

Fire Watch

Q: With regards to a fire watch, the code is specific about requiring one in an occupied building when a fire alarm system or suppression system is out of service for a prescribed period of time. This makes sense for head end shutdowns and other scenarios where entire buildings or significant portions of buildings are impacted. My question is what if you are only taking part of a “system” down? Meaning a small renovation that impairs 3 heads in a room because the ceiling grid and tile are removed for greater than 10 hours. This is not a “system”, only a part of one. Where does an AHJ draw the line? Is it possible that our ILSM and Fire Impairment Policy could allow for a certain number of heads, certain square footage or percentage of a smoke compartment to be impaired without the fire watch requirement (given that other ILSMs are in place)?

A: While the interpretation is not written down as to how many impaired sprinkler heads constitute a system, it is generally understood more than 2. While that number may fluctuate between surveyors, it would be fair to say all of the sprinkler heads inside one room that are impaired would require a fire watch. The logic is, if a fire started in the room, there is no fire suppression device to extinguish the fire if all the heads were impaired. Does not matter if the room only has 3 sprinkler heads.

To be sure, you should obtain a decision directly from your accreditation organization. But even then, the CMS state agency may not agree with what your AO says. It is best to be conservative and conduct the Fire Watch as long as the sprinkler heads are impaired. Besides, how long does it take to install upright heads within 12 inches of the deck in this room?

Ambulatory Suites

Q: Am I allowed to have a suite inside an area designated as an Ambulatory Occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated?

A: Yes… you are permitted to have a suite in an ambulatory health care occupancy. Look at section 20/ which permits suites in AHCO, but any suite over 2,500 square feet must have two remotely located doors from the suite. No… Suite boundary walls are not necessarily required to be 1-hour fire-rated. They are required to be equal to the fire-resistive rating of the corridor walls. For new construction, corridor walls would be a minimum of 1-hour fire rated barriers, unless one of the following exists:

  • Where exits are available from an open floor area
  • Within a space occupied by a single tenant
  • Within buildings that are fully protected with automatic sprinklers

For existing construction, there are no requirements for corridor walls, so therefore there are no requirements for suite boundary walls.

What to expect when we’re inspecting

Keeping your door inspection on schedule and on budget is a central focus of our projects. To achieve this goal, we need your help and preparation. While you don’t need a doula or inspection coach, here are some important points to help us help you.

Fire doors are located everywhere within your facility and we access all of them. Providing us with a good set of master keys and master swipe cards keeps our team moving and on schedule. The only exception is sensitive areas such as pharmacy and labor and delivery. Our team will always check in with your pharmacy staff and asked to be escorted while in that area. Labor and delivery areas also require check-in and often have alarmed doors and exits. Understanding who to call or how to defeat those alarms is a required part of your pre-door inspection checklist.

Staff Notification
In the days before our arrival, please email or notify your department heads of our purpose and process. You may want to follow with a phone call to departments such as security, emergency, surgery, and labor and delivery, as these are especially sensitive areas in your facility.

Our door inspectors occasionally encounter blocked fire doors. Each fire door must be opened and closed several times during the inspection process, which requires unfettered access. Please make a point to remove any obstacles such as shelving, couches, pallets, or anything else that would prevent us from completing your inspection.

Be Available
While we are at your facility, please be prepared to respond to any request for assistance. Sometimes even the best-made plans hit a roadblock that needs to be cleared. Providing our team with an easy communication method to contact you, such as cell phone, radio, or pager, will aid in resolving any encountered obstructions.

Understanding these important steps will ensure that your annual door inspection is delivered smoothly and without issue, allowing you to cut the cord on this project and move to your next.

ASC Smoke Detector Sensitivity

Q: We are a service contractor that is attempting to obtain a contract with a new client that is an Ambulatory Surgery Center. The ASC told us they never had their smoke detector sensitivity checked. We told them it was a CMS requirement to have the smoke detector sensitivity checked every 2 years, but they tell us they want us to check it every 5-years as that is what their current service contractor is telling them. How can they be in business for over 12 years and no one ever checked their smoke detector sensitivity? Have the NFPA standards changed regarding smoke detector sensitivity testing?

A: Ignorance, and a lack of understanding of the codes and standards. And a lack of enforcement by their AHJs…that’s how it could be missed for 12 years. This is not surprising. But to answer your last question: No, testing intervals have not changed in NFPA 72. Sensitivity of the smoke detectors has to be checked one year after installation, and then every other year thereafter. After the second required calibration test, frequency may extend to every 5 years provided the sensitivity tests indicate the devices have remained within its listed and marked sensitivity range.

Life Safety Drawings are the unappreciated hero

Life Safety Drawings (LSDs) are often an unappreciated hero of an accurate door inspection. Not having accurate LSDs cause the inspection of extra doors and their consequential costly repairs.

Let me explain.

Notice the blue barrier called out on the LSD as 1FSB. The legend defines this wall type as a 1-hour fire smoke barrier but look closely at how it’s used as it moves from the top of the example to the bottom.

The 1FSB begins as it crosses the yellow corridor. During this portion of the barrier, it is being used to separate smoke compartment and is referred to in NFPA 101 as a “smoke barrier”. Doors in a smoke barrier are not required to be fire-rated, are not required to have fire-rated hardware, and in occurrences when it crosses a corridor, do not require latching.

Now follow the barrier as is defines the left side of the EQUIP/STORAGE room. The room is a designated hazardous storage room and is surrounded on three sides by the orange “1FB” defined in the legend as a 1-hour fire barrier. For this segment of the 1 FSB, the barrier is both a 1-hour fire barrier and is part of the smoke barrier (separating smoke compartments). Doors in this room need to be at least 45-minute rated fire doors with appropriate hardware.

Further down the 1FSB crosses in front of a non-hazardous room where the doors are again not required to be fire rated.

Including doors that are not required to be fire doors in your fire door inspection is a costly mistake. Along with the extra inspection costs, you will also:

  • Maintain or add expensive latching hardware in cross corridor doors.
  • Add and maintain fire-rated hardware.
  • Maintain doors to strict edge gap standards.
  • Use expensive fire-rated gap repair products when doors cannot be shimmed into the standard.
  • Risk your fire marshal or accrediting organization forcing you to repair wrongly identified fire doors at an accelerated and inflated rate.

We have many customers who we have created Life Safety Drawings for. On almost every occasion, the customer had reduced their previous required fire door inventory. The following inspection and repair cost avoided with the new LSDs have more cover the cost of the new drawings.