Strange Observations – Combustible Materials in Structural Support

Continuing in a series of strange things that I have seen while consulting at hospitals…

So… I’m above a ceiling in a pre-assessment testing area and I see in the corner what appears to be a wood 2×4.

According to NFPA 220, construction types I and II cannot have combustible material in the structural components. (This hospital was a Type II (222).

This wood 2×4 is supporting an interior wall and the suspended ceiling.

You have to keep an eye on contractors while they are renovating your departments… they will do things like this that will eventually get you in trouble.

Non-Compliant Construction Type Above a Healthcare Occupancy

Q: I have an interesting one for you. We have an architect propose a construction type of Type V (111) for a 3-story building with the first-floor being Healthcare occupancy (a nursing home) and the upper 2 floors being Residential Board and Care occupancy (assisted living). There is a 2-hour floor ceiling assembly separating the nursing home and assisted living.

It is interesting to me because I am not aware that the LSC has ever allowed this in the past, but it appears to be allowed by the 2012 LSC in accordance with The 2012 LSC Handbook also gives a good description. What I am worried about is CMS and accreditation surveys. This is against everything that has been engrained in our brains and it could be a major issue. Have you seen this or heard of this before?

A: Yes… this is a very interesting case. I cannot recall that I’ve seen this before, mainly because the 2000 LSC did not allow this arrangement. It was not until the 2009 edition of the LSC that this was clearly permitted. And I agree, the Handbook for the 2012 LSC explains this very well. I recall a conversation that I had with a representative from NFPA years ago on this very subject and he assured me it was not permitted (we were under the 2000 LSC at the time). So, I agree with you… It goes against what we’ve been taught. But times change, don’t they!

Unless you have other regulations preventing this arrangement, I would say that the NFPA codes and standards would permit it, but please check with your state and local authorities to see if they have any problems with it. I would not be too concerned about a nursing home being cited by a CMS surveyor or an accreditation surveyor since they follow NFPA rather rigidly (or are supposed to), and since the 2012 LSC does permit it, the nursing home may make the case that it is permitted if the surveyor is considering citing them.

Personally, I think it is poor insight by the healthcare organization to do this, as they will never be able to expand their healthcare occupancy beyond the 1st floor, and maintaining that 2-hour fire-rated barrier is a special challenge for anyone, let alone a typical maintenance staff of a nursing home that is often under-manned, and not trained well on technical issues. I suspect over a period of time the 2-hour fire-rated horizontal barrier will be compromised and not maintained properly due to a lack of understanding.


Strange Observations – Part 45

Continuing in a series of strange things that I have seen while consulting at hospitals…

In a Type I or Type II construction type structure (which most hospitals are) you are not allowed to have any combustible structural supports, including wood coverings over floors.

Overhead lift equipment raises elevator equipment to this platform, which serves as an extended floor. Then they roll the equipment to the elevator machines. Wood platforms are not permitted.

Remember what I said… Equipment rooms are a huge source of non-compliance on safety issues. They are out-of-sight/out-of-mind and nobody is assigned to maintain them.

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.

Different Construction Types

Q: What is the allowed distance a non-sprinkled stick built building can be located beside a hospital?

A: Your question encompasses a couple of different issues. When you say “stick-built” building, I think of wood frame construction, which is Construction Type V (000) in accordance with the Life Safety Code and NFPA 220. Construction Type V (000) is not permitted in healthcare occupancies unless the hospital is only one story and is fully sprinklered.

So, let’s assume your hospital is more than one story and is at least Construction Type II (222), which is non-combustible construction with beams, columns, joists and floors fire rated at 2-hours. If you have an adjoining wood-frame building with Construction Type V (000), then it must be separated from the healthcare occupancy with a 2-hour fire rated barrier.

However, there is a caveat with this requirement. If the wood-frame construction building is separated by a minimum of 10 feet, and is not-connected to the building containing the healthcare occupancy, then a 2-hour fire rated barrier is not required. This 10-foot gap would act as a fire barrier is one building were to catch on fire.

This 10-foot gap is an interpretation based on section that requires 10-feet of the horizontal exterior of the building wall to be fire-rated where unprotected exterior walls of a stairwell connect to the building at an angle less than 180 degrees.

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.


Sprinklers in Existing Healthcare Occupancies

This may seem basic to some of you, but one of the problems in the healthcare facilities management industry is people don’t always have a good solid foundation of the basics. From time to time, I have a conversation with a client about challenges they are having in regards to installing sprinklers in their existing facilities. Frequently they ask me how they should enter their sprinkler project into the Joint Commission Statement of Conditions (SOC), Plan For Improvement (PFI) list. Eventually I get around to asking the question “Why are you installing sprinklers?” Now, don’t get me wrong, I’m a firm believer in sprinklers as they do save lives in the event of a fire, and I am all for hospitals and nursing homes retroactively installing them, but I want to make sure the client fully understands their options.

First of all, let’s make it very clear that the 2000 edition of the Life Safety Code (LSC) does not require existing healthcare occupancies to be protected with automatic sprinklers, unless the Construction Type or an approved equivalency requires it. Existing conditions is defined as the local authority having approved construction documents for new construction or renovation projects before March 11, 2003. Why March 11, 2003? Because that’s the date the Centers for Medicare & Medicaid Services (CMS) approved the 2000 edition of the LSC. There is a caveat to this issue, and that is the LSC has required new construction and renovation to be protected with automatic sprinklers since the 1991 edition, so if your organization was required to comply with the 1991 (and subsequent) edition(s), then new construction and renovation conducted since the time that edition was adopted by your authorities needs to be sprinklered. CMS went directly from the 1985 edition of the LSC to the 2000 edition on March 11, 2003. I know Joint Commission had adopted the 1994 and the 1997 editions prior to adopting the 2000 edition on March 1, 2003 (Yes, they adopted the 2000 edition 10 days earlier than CMS…), but I do not know if and when they ever adopted the 1991 edition.

Construction Type is a NFPA reference describing the general fire resistance of the construction materials used to build the facility, and the level of fire protection on key structural members of the building, as measured in hours. So, Construction Type II (222) which is the most common type  for hospitals, would be a building constructed with fire resistant materials (such as concrete, brick, stone, gypsum board, etc.) and has key structural members (such as load bearing walls, beams, joists, trusses, floor decks) with a 2-hour fire resistant rating. Generally speaking, the taller the building the greater the Construction Type must be. According to the existing healthcare occupancy chapter (19) in the LSC, some lessor Construction Types in existing constructions must be sprinklered. In some cases an equivalency will specify sprinklers in an existing condition in order to gain enough points to be successful. If you have any approved equivalencies, check them out to see if automatic sprinklers are a condition of their approval.

So, getting back to the client with the question about entering the sprinkler project into the SOC PFI list, I ask them “Why are you installing sprinklers?” If they say it is just a desire of theirs to have a fully sprinklered facility, then that is not a LSC deficiency, and they cannot enter that into their PFI list. The PFI list is reserved only for deficiencies with the Life Safety Code. Now, if they are installing sprinklers because they are renovating an area,or correcting a deficiency with their Construction Type, or need the points on an equivalency, then that is a life safety deficiency and the sprinkler project may be entered into the PFI list.

Confusing? That’s all-right, as it can be. Rome wasn’t built in a day, and everything a facility manager needs to know about the Life Safety Code is not learned by just reading a blog posting…. But it can help!


P.S. Be prepared for changes when the 2012 edition of the Life Safety Code is finally adopted (probably in 2014 or 2015). The new edition will require existing nursing homes to be fully protected with automatic sprinklers, and existing hospitals that are considered high-rise facilities to be fully protected with automatic sprinklers. A high-rise building is greater than 75 feet in height where the building height is measured from the lowest level of fire department vehicle access to the floor of the highest occupiable story. A penthouse mechanical room would not typically be considered an occupiable story.

Hot Work in Construction

In the last post that I made, I mentioned ‘Hot Work’ in construction sites in a hospital require special fire barrier protection, which is a 1-hour fire rated barrier from the floor to the deck above, between the construction and any occupied areas. This is found in NFPA 241 Standard for Safeguarding Construction, Alterations, and Demolition Operations (2000 edition), section 8.6.2. Now, Joint Commission does not enforce this level of protection, and all they require is flame resistant smoke-tight barriers that extend from the floor to the ceiling, mainly because the 2000 edition of the Life Safety Code only references the 1996 edition of NFPA 241, and not the 2000 edition of NFPA 241. The 1996 edition of NFPA 241 did not require the 1-hour barriers around ‘Hot Work’, only flame resistant smoke-tight barriers.

As a hospital facility manager, you need to be aware of this difference because many of the state agencies who survey on behalf of CMS will enforce NFPA 241 (2000) requirements. Here are examples of what ‘Hot Work’ can be:

  • Welding
  • Brazing
  • Soldering
  • Cutting with a torch
  • Grinding

It is suggested that you review your own policies on construction barriers and consider having 1-hour fire rated barriers whenever any ‘Hot Work’ is being done on a demolition, renovation, construction or remodel project.

There may be times when a service technician will need to use an open flame torch to solder or braze a fitting for a repair function. While this should be tracked and covered with your own ‘Hot Work Permit’ program, it is important to identify that it is not construction and 1-hour fire rated barriers are not required.

NFPA does not define ‘construction’ so I turned to the dictionary which says construction is: The act of putting together to form an assembly. So, remodeling something, or a renovation process appears to me to be construction and would require the 1-hour barriers for ‘Hot Work’. But repairs would not.

But my opinion does not count. Since NFPA does not clearly define what ‘construction’ is, the authorities having jurisdiction (AHJ) are the ones who get to make this determination. Don’t be caught by surprise: If you haven’t already done so, I suggest you contact you local and state AHJs and ask them what they require for fire barriers when you have ‘Hot Work’ in construction sites inside the hospital.

Construction in Hospitals

Construction in hospitals is so unavoidable, as it seems to go together like salt and pepper, but usually does not taste as good. You simply cannot renovate or remodel an area in the hospital without creating some sort of Life Safety Code deficiency. It’s a lot like cooking: You can’t make an omelet without cracking the egg! (Enough of the cooking references… My wife has me watching the Food Network too much!)

All of the authorities of jurisdiction (AHJ) know this, and they understand that at times, you will have to disable fire alarm and sprinkler systems; you will have to close exits and stairwells; and you will have to encroach upon the exit corridor width. Even the Life Safety Code (2000 edition) section discusses the need to have alternative life safety measures in place during renovation. While some accreditation organizations actually call it “Interim Life Safety Measures”, the concept is the same.

Alternative (or interim) life safety measures requires the organization to make an assessment of the proposed renovation to determine if there will be any deficiencies made of the life safety features.  If so, then the organization needs to decide what actions, if any, will be necessary to compensate for this deficiency. The Joint Commission requires that you place this decision process in the form of a policy with pre-determined plans of action already identified.

Other issues concerning construction are the barriers that separate the construction area from the occupied areas. Joint Commission only requires the barriers to be ‘smoke tight and flame resistant’, which can be accomplished with a certain type of flame resistant plastic sheeting. However, other AHJs, such as CMS and some state agencies, require compliance with NFPA 241  Standard for Safeguarding Construction, Alteration, and Demolition Operations, (1996 edition) which requires construction areas with ‘hot work’ to have 1-hour fire rated barriers as a separation from occupied areas. Hot work is defined as work involving open flame, grinding, cutting and welding. And, this 1-hour barrier needs to go from the floor to the deck above, unless it meets a horizontal surface that is also rated for at least 1-hour.

When the new 2012 edition of the LSC is finally approved by all of the AHJs, then NFPA 241 will include an exception that is not available in the 1996 edition. It will allow non-rated smoke tight barriers in lieu of 1-hour fire rated barriers provided there are active automatic sprinklers, which are properly installed, in the construction site. This will be a great savings for future construction projects.

If you are currently relying on the official position of The Joint Commission and only providing smoke tight barriers for construction sites, then you are exposed to other AHJ’s opinion that you need 1-hour fire rated barriers. At the very least, I suggest you call your state and local AHJs and ask them if they would accept the smoke-tight barriers. If so, then you don’t need to go the route of erecting 1-hour barriers. However, if they do require 1-hour fire rated barriers, then you will have time to change your policies to allow them for future projects.

Then everybody will be as happy as a clam (oops, there I go again.)

Understanding the Importance of Construction Types

The following article originally appeared in the February 2011 issue of Helathcare Life Safety Compliance 

Construction Types are among the most misunderstood features of life safety in hospitals today. The National Fire Protection Association (NFPA) defines Construction Type as the combustibility and fire resistance rating of the building’s structural elements, such as columns, beams, girders, trusses, arches, joists, floors (and floor assemblies), decks, roofs, and load-bearing walls.

Why is this so important for safety in a hospital? Fire resistance material on structural members of the building provides a certain safety factor. Without fire protection, the extreme heat from a fire may cause the structural members in the building to warp and collapse before the occupants can successfully evacuate the building.

Chapters 18 (for new construction) and 19 (for existing facilities) of the 2000 edition of the NFPA 101 Life Safety Code® (LSC) requires all hospitals to comply with a Construction Type listed in Table 18/ This table is based on NFPA 220 Standard on Types of Building Construction, and the hospital must comply with the Construction Type listed based on the number of stories and whether the building is protected with automatic sprinklers.

Construction Types are categorized into five different designations:

Type I: All structural members are non-combustible or limited combustible materials. Non-load bearing exterior walls are permitted to be non-rated. Non-combustible materials are obvious, such as concrete, cement block, brick, steel and so forth. Limited combustion materials are those that have a potential heat value that does not exceed 3,500 Btu/lb and either a) has a covering that does not exceed 1/8-inch with a material that has a flame spread rating not exceeding 50, or b) is made of materials that have a flame spread rating that does not exceed 25. Gypsum wall-board is commonly considered to be a limited combustion material, and is permitted to be used in Type I and Type II structural assemblies.

Type II: All structural members are non-combustible or limited combustible materials. This is the same as Type I, however, the difference between the two types is found in the hourly fire resistance rating designation. Type I and Type II construction is commonly found in most hospitals constructed since the 1950s.

Type III: Exterior walls are non-combustible or limited combustible and interior walls and structural members are dimensional wood frame. This type of construction typically has wood floor assemblies and/or a wood rafter roof.

Type IV: Exterior and interior walls are non-combustible or limited combustible and structural members are solid or laminated wood beam. This type of construction typically has heavy timber beams as part of the structural members.

Type V: Exterior and interior walls and all structural members are dimensional wood frame. This is the typical construction found in most homes and light commercial applications.

Each Construction Type found in Table 18/ of the LSC has a series of three numbers or letters enclosed by parenthesis. These numbers refer to specific fire resistance ratings of certain structural members of the building (see sidebar, page X):

  • § The first number refers to the fire rating of the exterior and interior load bearing walls.
  • § The second number refers to the fire rating of the columns, beams, girders, joists, and trusses.
  • § The third number refers to the fire rating of the floor assembly.

For Type IV construction, the letter “H” holds the second and third spots, indicating there is no fire rating for the heavy timber structural members. Although roof construction is not specified in the table in the LSC, NFPA 220 Table 3-1 does have a fire resistance designation for roof assemblies for each Construction Type, which frequently is less than that for floor assemblies.

Healthcare occupancies are permitted to have different Construction Types in the hospital, provided they meet the requirements for the number of stories and sprinkler protection according to Table 18/ in the LSC. The LSC does require a two-hour vertical barrier separating different Construction Types, however, unlike occupancy separation barriers in hospitals, which are also two-hour fire rated assemblies, horizontal barriers separating Construction Types are not permitted. This means only vertical barriers separating buildings with different Construction Types are allowed. However, some states and local authorities may have more restrictive requirements for Construction Types so a check with their requirements would be recommended. So, it is very important to know and understand what the Construction Type is in your hospital.

Construction projects are also a problem for those smaller hospitals that were intended to have additional stories added when the need becomes apparent.

“Our challenge came when we wanted to add another story to our building that had unprotected structural steel,” says a facility manager who requested anonymity.

Construction Type II (000) with sprinklers is permitted for a two-story facility, however it is not permitted for a facility with three or more stories.

“If you decide to add another story, then all of the unprotected structural steel on the lower floors need to have fire protection material added,” explains the second facility manager. Fire resistance materials for structural steel come in various forms. For years, hospitals were built with a lath and plaster ceiling assembly in the corridors and rooms that served as a fire rated barrier, thereby providing the required protection for the bare structural steel above the ceiling. Unfortunately, over time, the true purpose of the plastered ceilings was forgotten and sections were removed to add utilities, such as piping and air ducts, and the ceilings were often replaced with a suspended acoustical tile system that did not provide any fire resistance rating. This leaves the bare structural steel without the required fire resistance rating, and compromises the Construction Type.

“Our building over the past 58 years has been built and added onto several times,” says the first facility manager. “I find that I must climb up and around in the entire building envelope to discover what has been put in place.”

Another challenge lies in not knowing exactly what the Construction Type was supposed to be in the first place when the building was originally constructed. Original construction documents may not be available, and current rated wall drawings may be inconclusive. How can you be expected to maintain what you don’t know? This sentiment was offered by yet a third facility manager who also wished to remain anonymous.

“Not possessing accurate life safety drawings that define and designate each Construction Type is one of my greatest challenges. This creates confusion when it comes to understanding what fire safety features we are bound to install and maintain,” he explains.

This appears to be a common problem for many hospitals that is created when the building or addition is first constructed.

“When a new hospital is built, the general contractor provides training for the maintenance staff on the correct maintenance and operation of air handlers, pumps and other mechanical equipment,” says James Murphy, RA, NCARB, president of MRF, Ltd. in Western Springs, IL, and a consultant for The Greeley Company, a division of HCPro, Inc., in Danvers, MA. “But architects rarely provide training to the facility manager on the correct maintenance and operation of the rated wall system.”

Without knowledge in the form of drawings that clearly indicates the different Construction Types and the necessary separation barriers, hospitals are bound to make mistakes that alter the fire resistance rating of the structural support members.

New architects working on additions to the hospital may not be able to understand what the original architect was attempting to do without adequate rated wall drawings.

“Another major challenge is undoing years of maintenance and construction work that was performed without taking Construction Type requirements into consideration,” adds Murphy. “It is apparent that a good deal of time and expense will be spent correcting Construction Type violations that could have been easily avoided if the hospitals had adequate drawings.”

Understanding what your Construction Type is required to be, then analyzing what the conditions currently are keys to LSC compliance.

“Knowing your building Construction Type will make you an asset in LSC compliance while providing a safe environment for your staff and patients,” says Murphy.