Fire Drills in an ASC

images0XCM788RI spoke at an Infection Control conference last week in St Louis, sponsored by the Excellentia Advisory Group. There were 13 different presentations made but mine was the only one that was not traditionally an IC subject matter. I was asked to make a presentation on how the Life Safety Code relates to Infection Prevention in the Ambulatory Surgical Centers. At first, I was reluctant to accept this speaking engagement because I was not sure how I was going to draw the connection between compliance with the Life Safety Code and how it actually impacts the Infection Prevention program in an ASC. But, I did accept the invitation and I researched the LSC and came up with a what I think was an interesting presentation.

Keep in mind, my audience was a room full of RNs who typically do not have any Life Safety Code compliance experience. So, I decided to take the approach that compliance with the LSC is just basic patient safety compliance, and identified many of the requirements that surveyors would be looking for.

At the end of my presentation I had time to take a few questions. One lady asked if they had to activate the building fire alarm system when they conducted a fire drill. I replied that yes, technically they would, since section 20.7.1.4 of the 2012 LSC requires it. They said that is a problem since the ASC shares the building with other tenants who are not part of their healthcare network.

I replied that they had a few of options: 1) They could coordinate with all of the other tenants prior to the fire drill alerting them of the pending alarm. The other tenants could conduct their own drill at that time if they chose; or 2) They could investigate to see if the fire alarm control panel can bypass the occupant notification appliances in the other tenants during their drill; or 3) They could conduct a risk assessment that identifies the hardship involved in sounding the building fire alarm system and conduct the drill without activating the alarm. This would have to be reviewed and approved by the ASC safety committee, and possibly a surveyor would accept that.

I asked if they thought they could use one of those scenarios, and they thought #3 would be the only possible solution. I asked why, and they said there was a massage parlor directly above their ASC and they didn’t believe they could get the cooperation from them and all the other tenants so they could activate the fire alarm system when they conducted a fire drill each quarter. I replied that I thought they had a pretty good case for a risk assessment since nobody wanted to see clients from the massage parlor escaping down the stairs during a fire alarm.

Uhm… the strange things I see (or don’t see) in this business.

All-in-all, I thoroughly enjoyed my day at the conference and I got to meet many interesting people.

New vs. Existing Construction for Ambulatory Healthcare Occupancies

A reader asked me recently what the Life Safety Code differences were between a new construction ambulatory healthcare occupancy, and an existing construction ambulatory healthcare occupancy. I did not immediately know, so I took the time to research this and I was surprised to learn what the differences (or non-differences) were.

The differences between new construction and existing construction of ambulatory healthcare occupancies are not monumental, but rather subtle. According to the 2000 Life Safety Code, here are some comparisons:

Description Chapter 20 New Construction Chapter 21 Existing Construction
Construction Type No restrictions for 1 story facilities; Building of two or more stories limited to Type 1 (443), Type I (332), Type II (222), Type III (211), Type IV (2HH), Type V (111). Type II (000), Type III (200), and Type V (000) are permitted if the entire building is protected with sprinklers.  Same
Occupant Load 100 square feet/person Same
Special Locking Arrangements Only permitted on exterior doors Same
Clear Width of Corridor 44 inches Same
Travel Distance between room and exit 100 feet Same
Travel distance between any point in a room and exit 150 feet Same
Travel distance increased for sprinklered buildings 50 feet Same
Emergency Power from Generators as per NFPA 99 Required when general anesthesia or life-support equipment is used. Same
Hazardous Areas Must meet the requirements of 8.4 and be protected with sprinklers, or protected with 1-hour construction Same
Anesthetizing Locations Must be protected in accordance with NFPA 99 Same
Fire alarm systems Manually initiation required Same
Portable fire extinguishers Required Same
Sprinkler System Not Required Same
Corridors Openings in corridor walls such as mail slots and pass-through windows permitted in windows and doors provided the opening is not more than 20 square inches. The opening may increase to 80 square inches if the room is protected with sprinklers. No Restrictions/No Requirements
Subdivision of Building Space Ambulatory healthcare occupancies must be separated from other occupancies with 1-hour fire rated barriers with ¾ hour fire rated doors Same
Smoke Compartmentation The ambulatory healthcare occupancy must be divided in to not less than two smoke compartments. Facilities less than 5,000 square feet that are protected by a smoke detection system are exempt. Facilities less than 10,000 square feet and protected by sprinklers are exempt. Same
Smoke Compartment Size Not less than 15 square feet area (net) must be provided for every occupant in the ambulatory healthcare facility on either side of the smoke compartment barrier. Smoke compartments are limited to 22,500 square feet in size. Travel distance to reach a smoke compartment barrier doors must not exceed 200 feet. No Restrictions
Fire Drills Required quarterly on all shifts Same
Combustible decorations Prohibited, unless they are flame retardant Same
Portable Space Heating Devices Prohibited, unless the heating elements do not exceed 212°F and only used in non-sleeping staff and employee areas. Same

 

 

Outpatient Centers and Clinics

Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business?

A: The Life Safety Code defines different occupancies by the level of care and/or activities that take place in them. A hospital may have many different occupancy classifications, or it may have only one… it’s the organization’s decision. Here is a run-down on the most common occupancy classifications found in healthcare today, and their requirements:

Healthcare Occupancy

An occupancy used for purposes of medical care or other treatment where four or more persons are incapable of self-preservation; and provides sleeping accommodations for those patients.

Ambulatory Care Occupancy

An occupancy used for purposes of medical care or other treatment on an outpatient basis, where four or more persons are incapable of self-preservation, and does not provide sleeping accommodations.

Business Occupancy

An occupancy used for the transaction of business other than mercantile.

So, to answer your question, an outpatient center and clinic could very well be ambulatory care occupancy or it may be business occupancy; it all depends on what level of care and treatment is provided. It is permissible to have more than one occupancy in the same building, provide appropriate fire rated barriers separates the occupancies. A 2-hour fire rated barrier is required to separate a healthcare occupancy from any other occupancy, and a 1-hour fire rated barrier is required to separate different occupancies that are not healthcare.

There are distinct requirements for each occupancy, but the requirements are less for ambulatory care compared to healthcare, and they are even less for business as compared to ambulatory care. So there is an advantage to the organization if the clinic was classified entirely as business occupancy. However, you may not have 4 or more persons incapable of self-preservation in a business occupancy, so make sure you are in synch with that.

Also, CMS considers all ambulatory surgical centers (ASC) to be ambulatory care occupancies regardless of the number of patients incapable of self-preservation, and they also consider end stage renal disease (ESRD) dialysis centers to be ambulatory care occupancies if they are located on a floor other than the level of exit discharge, or if they are contiguous to a high-hazard occupancy. Be aware that in their proposed rule to adopt the 2012 Life Safety Code, CMS has indicated that they intend to classify facilities that have 1 or more patients incapable of self-preservation as an ambulatory care occupancy. Whether they will adopt that as a final rule is unclear, but you should be aware of the possibility.

 

Ambulatory Surgical Center Waiting Rooms

Q: Can an Ambulatory Surgical Center (ASC) have a waiting room that is shared with another physician’s practice that is not associated with the ASC, but is located in the same building?

A: No, it cannot. Section 20/21.3.7.1 of the 2000 Life Safety Code states the ambulatory health care occupancy must be separated from other tenants and occupancies with 1-hour fire-rated barriers. The ASC is located in an ambulatory health care occupancy and the physician’s practice is another tenant and is presumably located in a business occupancy. This separation between tenants and occupancies includes waiting rooms and areas.

In addition, the Centers for Medicare & Medicaid Services (CMS) S&C memo 10-20-ASC dated May 21, 2010, specifically states ASC must have waiting areas that are separate from other tenants and occupancies by 1-hour fire-rated barriers. The logic expressed in the CMS memo is patients occupying an ASC waiting area for the purpose of receiving treatment may not be capable of evacuating without assistance; therefore the ASC waiting area needs to comply with all of the fire safety requirements afforded to ambulatory health care occupancies. The CMS memo does say existing ASC that are cited to be non-compliant in regards to the waiting area requirements may submit waiver requests, but waivers will not be allowed for ASC classified as new construction facilities (designed or constructed prior to March 11, 2003). Please be advised that the CMS categorical waivers do not apply to this situation.

Ambulatory Surgical Center Mixed Occupancies

Q: We have an Ambulatory Surgical Center (ASC) located in a one story nonsprinklered building, and is separated from a physician’s office. The exit access from the ASC leads into a corridor which is within the physician’s practice. Since this corridor is not technically part of the ASC, is the ASC responsible for having the corridor wall opposite from the occupancy separation to be 1-hour fire rated?

A: You raise an excellent point: Once you leave the ambulatory health care occupancy and enter a different occupancy type, does the means of egress have to comply with ambulatory health care requirements? According to sections 20/21.1.2.2 of the 2000 edition of the Life Safety Code (LSC), the answer is yes. This section says all means of egress from ambulatory health care occupancies that traverse non-ambulatory health care spaces must conform to requirements of the LSC for ambulatory health care occupancies. The exception to this requirement would be if the barrier between the ambulatory health care occupancy and the contiguous occupancy qualifies as a horizontal exit, then the means of egress in the contiguous occupancy does not have to meet the more rigorous requirements for ambulatory health care occupancy, provided the means of egress is not through a high-hazard area. Horizontal exits are required to be 2-hour fire rated. So, how does this apply to you? If your ASC qualifies as new construction (built after March 11, 2003), then the means of egress in the physician area (outside of the ASC) must have 1-hour fire rated walls that extend from the floor to the deck above (unless they terminate at a ceiling that is also 1-hour fire rated); or if the building is protected with automatic sprinklers throughout; or the barrier between the ASC and the physician’s offices is a 2-hour fire rated horizontal exit. If the ASC qualifies as existing construction (built on or before March 11, 2003) then there are no requirements for the corridors, and what you currently have would be acceptable.

O2 Cylinders in Ambulatory Surgical Centers

Q: Since the Life Safety Code addresses ambulatory surgery centers in chapters 20-21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage of compressed gas cylinders?

 A: According to the CMS S&C-07-10 memo dated January 12, 2007, Ambulatory Surgical Centers (ASC) are included in the scope of that interpretation memo and ASC are required to abide by the 2005 edition of NFPA 99, section 9.4.3. This allows them the same advantage as hospitals with no storage requirements for 300 cubic feet and less of non-flammable compressed gas per smoke compartment. For storage of non-flammable compressed gas over 300 cubic feet and less than 3,000 cubic feet per smoke compartment, the ASC needs to comply with Chapter 13 of NFPA 99, section 13-3.8 which refers back chapter 8. Section 8-3.1.11.2 provides the requirements for storage of non-flammable compressed gas in quantities less than 3,000 cubic feet, which do not include 1-hour fire rated barriers. However, since the CMS S&C memo grants a special dispensation for ASC to follow the 2005 edition of NFPA 99, for 300 cubic feet and less of compressed gas, then they are the same as hospitals in regards to storage of compressed gas. According to the CMS S&C memo, cylinders in use are not to be counted as cylinders in storage. Therefore, they are not included in the calculation of cubic feet of compressed gas when considering storage requirements.  NFPA 99 requires full compressed gas cylinders to be segregated when stored with empty compressed gas cylinders.

Fire Damper Testing Frequencies

Q: Our facility is a freestanding ambulatory surgical center and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story building with multiple tenants. We had a state inspection recently and they asked us for documentation that we tested our fire and smoke dampers every 4 years. What are they looking for? We’ve been in the building for 13 years and no one has ever asked us about fire and smoke damper testing before.

A: Since it appears that the inspector is holding you accountable for compliance with the 2000 Life Safety Code, I will assume you need to comply with chapter 21, for existing ambulatory health care occupancies. Section 21.5.2.1 requires compliance with section 9.2 which in turns requires compliance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition. Section 3-4.7 of NFPA 90A requires the fire and smoke dampers to be tested once every 4 years. For clarification, CMS did issue an S&C memo on October 30, 2009 which permitted hospitals to change the frequency of fire and smoke damper testing to once every six (6) years, but this memo only applies to hospitals, and not to ambulatory health care occupancies. It is not unusual for authorities who inspect your building to fail to ask for certain documentation (such as test results of the fire/smoke dampers), and then at a later date, another authority will request that information. Just because the previous surveyors/inspectors did not ask to see this information, does not mean it was not required.  This inspector is now holding your organization accountable to what has always been a Life Safety Code requirement.

Smoke Compartments in ASC

Q: We are a freestanding ambulatory surgical center (ASC) and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story building with multiple tenants. During a recent state inspection, I was asked where our smoke compartments are located. I know that we have a 2-hour fire barrier between us and the other suites on our level, but I am not aware that we have any designated smoke compartments. Do we need smoke compartments?

A: You did not mention how many patients are incapable of self-preservation at any one time, so I will assume it is at least 4 or more patients, since that is the threshold to decide if the ASC is required to comply with ambulatory health care occupancy requirements, or business occupancy requirements. Ambulatory health care occupancy smoke compartment requirements are found in section 21.3.7.2, which requires your ASC to be sub-divided into not less than two smoke compartments. However, there are some exceptions to this requirement:

  1. ASC facilities that are less than 5,000 square feet and are protected by an approved smoke detection system do not need to be sub-divided.
  2. ASC facilities that are less than 10,000 square feet and are protected throughout by an approved automatic sprinkler system do not need to be sub-divided.
  3. An area in an adjoining occupancy may be permitted to serve as a smoke compartment for the ASC facility, provided all of the following criteria is met:
  • The separating barrier must be at least 1-hour fire rated, and have doors that are self-closing.
  • The ASC facility is less than 22,500 square feet.
  • Access from the ASC facility to the other occupancy is unrestricted.

So, to answer your question, based on the size of your ASC and whether it has smoke detection or sprinkler protection, it may not require a smoke compartment barrier. If a smoke compartment barrier is required, you might be able to utilize the 2-hour fire rated barrier between you and your neighbors, if you are less than 22,500 square feet and if there is unrestrictive access to the other occupancy.

Delayed Egress on Doors in Ambulatory Health Care Occupancies

safeplace-ob-door-sm[1]

A friend of mine was working on a project involving ambulatory health care occupancy, and they wanted to use a delayed egress lock on an interior door.  The 2000 Life Safety Code (LSC) limits special locking arrangements to exterior doors in ambulatory health care occupancy, but the 2012 LSC does not include that limitation.  They wanted to know what I would recommend.

Well, they are correct: The 2012 edition of the LSC did away with the limitations of the special locking arrangements found in section 7.2.1.6 of the LSC. Section 20/21.2.2.2 of the 2012 edition of the LSC now permits delayed egress locks on any door in the path of egress, where the 2000 edition of the LSC limited them to the exterior door.

I assumed that the individual who asked me the question was bound by the 2000 edition of the LSC, such as a Joint Commission accredited organization, or perhaps a CMS provider for Medicare. My initial thought is the organization would have to comply with the conditions of the 2000 edition of the LSC, and cannot take advantage of the more lenient 2012 edition until such time that edition is adopted by CMS and/or Joint Commission.

However, CMS did issue a categorical waiver to healthcare organizations to allow them to use many of the provisions of the 2012 edition of the LSC now, before the 2012 edition is actually adopted (which may be at least another 12 months away). I reviewed the CMS S&C memo 13-58 once again, and while CMS did state in one of their opening paragraphs that they have the authority to grant waivers for ambulatory surgical centers, they failed to do so in the body of their memo. They have a categorical waiver on doors to allow healthcare occupancies to use the more liberal 2012 LSC position on delayed egress locks, but that categorical waiver only applies to healthcare occupancies, and not ambulatory surgical centers, assuming the ambulatory health care occupancy my friend was referring to was an ambulatory surgical center.

Therefore, I concluded that the organization should (or must) comply with the 2000 edition of the LSC and only install special locking arrangements on exterior doors. Once the 2012 edition of the LSC is adopted, they can then install delayed egress locks on interior doors.

I also mentioned that if the facility in question is only accredited by The Joint Commission, and does not receive any funds from CMS as a Medicare or Medicaid provider, then they could contact the Standards Interpretation Group (SIG) at Joint Commission and ask them if they would accept a Traditional Equivalency to allow them to use special locking arrangements on interior doors of their ambulatory care occupancy. (The telephone number for SIG is:  630-792-5900, select option 6.) My guess is they will, provided the organization meets all the requirements for a traditional equivalency.

If the facility in question actually is part of a larger organization that does have a CMS control number (CCN), then I advised my friend that they have no choice by to comply with the conditions of the 2000 edition of the LSC.

My friend replied asking if they could request a standard CMS waiver to allow the organization to install the delayed egress lock on an interior door now, before the 2012 edition of the LSC is adopted.

My reply was yes, there is always the possibility for a waiver, but CMS will not accept a waiver request unless it is in response to a survey deficiency. In other words, the waiver process is not valid until someone representing CMS cites a deficiency.

As a safety professional, I would never recommend or advise a client to knowingly violate the current edition of the LSC, even though we know that issue will be viewed differently in a more recent edition. There is always the chance that CMS may not adopt the 2012 LSC, although I would be very surprised if they did not.

However, any organization may do what they want, and often times they disregard the advice of a safety professional, and violate the LSC, taking the risk that they will not get caught. In this case, it is understandable as the presumption is the 2012 edition will be effective within the next 12 months or so, and they may feel they will not have any surveys or inspections before then.

So… in summary: The waiver process is not available to them since they have not been cited for non-compliance with the LSC. And, as a safety professional I cannot advise them to violate the LSC. What they do after that is their own business, and risk.

I have some clients who ignore my advice, preferring to ask other safety experts until they find someone who agrees with the answer they want. Hey… it’s their hospital, not mine. I always advise clients to follow the current rules, regulations, codes and standards, but if they decide otherwise, then that’s on them.

Separation of Occupancies

Q: Do different occupancies have to be separated by fire-rated barriers both horizontally as well as vertically? We are considering installing a dialysis unit on the second floor of a medical office building and the CMS interpretive guidelines say it must be separated from other tenants on the same floor by a one-hour fire wall. Shouldn’t a horizontal barrier be required as well?

A: Yes, I would agree. The 1-hour fire rated separation that the Life Safety Code (2000 edition), section 20.1.2.1 requires does include horizontal separations as well as vertical. I agree with you that the interpretive guidelines do not clearly state horizontal separations, but the LSC does make the generic statement that the ambulatory care occupancy must be separated from other occupancies with 1-hour fire rated construction, and does not limit the separation to just vertical barriers.