Strange Observations – Exit Enclosure

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

This is not corridor, but rather an exit enclosure to a stairwell. There was a construction project in progress and to achieve a negative air pressure in the project area, the contractor cut a hole (twice) in the 2-hour fire-rated barrier for the exit enclosure to run the temporary flex duct to the exhaust fan.

Section 7.1.3.2.1 (10) of the 2012 LSC does not allow penetrations into and through an exit enclosure for this purpose, even on a temporary basis.

If you’re asking what the hospital should have done if this was their only option to create negative air for the project, I would say they could have set-up a HEPA filter negative air machine inside the project area, and discharge the air from the HEPA blower to an adjacent corridor. Not the best solution, but one that is far better than making penetrations into the exit enclosure.

There is also the issue of headroom which must be at least 7-foot 6-inches, according to section 7.1.5.1.

Strange Observations – Picture Hanging Device

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

Apparently, sidewall sprinkler heads can also be used to hang pictures…. NOT.

[That was sarcasm…]

I admit I did not take this picture, but it was contributed to this effort by Tim Niemer… Thanks Tim.

Strange Observations – Gypsum Patches

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

Holes in rated walls that are too large to be sealed with fire-rated materials, cannot be ‘fixed’ with a gypsum board patch, as shown in the picture.

However, there is a UL system W-L-0014 that does permit installing gypsum patches over holes in rated walls, but it requires an equal-sized patch on the opposite side of the wall, along with other requirements, such as 3-inch long screws with fender washers. The W-L-0014 system is part of the Hilti Firestop System library of listed products.

Fire Rated Barriers vs. Smoke Barriers

Q: Are doors in fire rated barriers also required to be listed and installed as a smoke barrier?

A: No… Fire rated barriers are not necessarily smoke barriers. They are two distinctly different barriers with different purposes. Now, if an organization wanted to combine the two purposes into one barrier, then that is acceptable as long as you meet the most restrictive requirements of each type of barrier. A fire-rated barrier requires fire-rated opening protectives (i.e. doors, windows). Fire rated door assemblies are required to have fire-rated doors and frames, self-closing devices, and positive latching. A fire rated barrier that is rated at 2-hours or greater must have fire dampers in any HVAC ductwork that penetrates that barrier.

A new construction smoke barrier is required to have walls constructed to 1-hour rating, but the doors and frames in the smoke barrier are not required to fire-rated. The doors are only required to be 1¾ inch thick, solid bonded, wood-core doors, or be of construction that resists fire for 20 minutes. Please understand that this does not mean the door has to be 20 minute rated; only be of construction that resists fire for 20 minutes. The door has to be self-closing but is not required to be positive latching. HVAC ductwork penetrating a smoke barrier must have smoke dampers, unless both sides of the smoke compartment barrier are protected with sprinklers. However, please understand this is an NFPA exception and the IBC does not recognize that, so your state or local authorities may not allow a smoke barrier without smoke dampers in the HVAC ductwork.

So, technically, a combination fire-rated barrier and a smoke barrier could be the same wall, but the requirements for both barriers need to be included.

Hot Patches on Fire Barriers

Q: In regards to penetrations through fire separations: Our latest survey from Joint Commission identified that “Hot Patches” (a piece of 5/8 sheet rock placed over a hole and the fire caulked around sheet rock) are not an effective way to seal a penetration. We just built a 90,000 square foot addition where builders used “hot patches”. Our district Deputy Fire Marshal states this is an acceptable method (not in writing). Your thoughts?

A: My thoughts…? I think the Deputy Fire Marshal is incorrect. He may accept them on behalf of the Fire Marshal office, but a ‘patch’ over a hole in a fire-rated barrier is not consistent with the UL listing of the way the fire-rated barrier was required to be built. The Joint Commission surveyor is correct. To maintain the UL listing of the fire-rated barrier, you would have to remove the section of gypsum board that has the hole from stud-to-stud, and cut in a new solid piece of gypsum board (without the hole of course) and secure it with the proper amount of screws, tape and joint compound as called for in the UL listing.

Just another example where one AHJ approves something, does not mean it is acceptable for another. The Joint Commission is not under any obligation to accept what the fire marshal says, and vice-versa… It is within the rights of the Deputy Fire Marshall to accept a ‘patch’ over a hole, but that is only for his review and approval. No other AHJ has to accept the fire marshal’s opinion and in this case, I believe the Joint Commission surveyor was correct in his observation.

Fire Barriers in Ambulatory Healthcare Occupancies -Part 2

 Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to install a fire barrier after the unit is constructed and if there are any other options. Your comments would be appreciated.

A: Well…. From a code standpoint, you may be obligated to have two different barriers:

  1. A 1-hour fire rated barrier to separate the ambulatory healthcare occupancy from other units that are not ambulatory healthcare occupancies (i.e. physician’s offices that would be classified as business occupancies). See sections 20.1.2.1 and 20.3.7.1 of the 2000 Life Safety Code.
  2. A 1-hour rated smoke compartment barrier to subdivide your ambulatory healthcare occupancy into two compartments. Exceptions to this requirement apply if your unit is less than 5,000 square feet and the unit is fully protected with smoke detectors, or if the unit is less than 10,000 square feet if the unit is fully protected with automatic sprinklers. See section 20.3.7.2 of the 2000 Life Safety code.

If you receive Medicare & Medicaid reimbursement funds then you are obligated to comply with these codes. However, CMS does allow you to apply for a waiver if compliance with the Life Safety Code is a hardship for the organization. You cannot apply for a waiver until you are first cited for a Life Safety Code deficiency by an accreditation organization or a state agency surveying on behalf of CMS. But there are no guarantees that CMS would grant approval of a waiver request for this deficiency. Even if they did, the waiver is only valid for 3 years then you have to be cited again and then you have to submit a waiver request again. At best, it is a temporary process… not a permanent solution. My suggestion is to make plans to resolve the deficiency as soon as possible and if you get cited in the meantime, you can always submit a waiver request as part of your Plan of Correction.

Fire Barriers in Ambulatory Healthcare Occupancies – Part 1

Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?

A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.

Ceramic Tiled Walls

Q: We have an old shower room that our administration wants to use for a maintenance workshop. In this room they will be storing paint and supplies. The walls and floors are lined with ceramic tiles. I read where ceramic tile has a fire-resistant rating. Would these ceramic tiled walls and floor comply with the requirement to have a fire-rated room for the maintenance workshop?

A: No. The Life Safety Code requires a new maintenance shop that stores paint to have 1-hour fire-rated walls, with doors that are ¾-hour fire rated, self-closing and positively latching. While ceramic tile may have some sort of fire resistance value, the actual walls and floors must comply with an approved assembly that is listed by an independent testing laboratory. The fact that the walls and floors are covered with ceramic tile does not meet this requirement. If you are unsure if your walls meet the 1-hour fire rating, I suggest you consult with a design professional to make sure.

Fire Protection of Equipment Rooms

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required and your answer decides who is correct.

A: According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have 2-hour fire rated barriers that protects the room from fire outside the room. Any 2-hour fire rated barrier is required to have 90-minute fire rated doors and frame and if there are any HVAC duct penetrations through the 2-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-minute fire damper. A boiler room is considered a hazardous area, and according to the 2000 edition of the LSC, sections 18/19.3.2.1, the hazardous area is required to be protected with 1-hour fire rated barriers if it is considered new construction, or 1-hour barriers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke resistant walls. All door openings in a 1-hour barrier are required to be ¾ hour fire rated, with fire rated frames. However, unlike the 2-hour barrier, a 1-hour fire rated barrier for a hazardous area is not required to have any fire dampers in a HVAC duct penetration, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire rated barriers (walls), however NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with 2-hour fire rated barriers in lieu of being protected with sprinklers. Therefore if the room does have fire rated barriers for any reason (including local or state building codes) then it would need fire dampers in the HVAC duct penetration if it is 2-hour fire rated or greater. Chiller rooms typically do not require fire rated barriers, unless the chillers are fuel-fired, then they would require the same protection as the boilers. As always, please check with your local and state authorities to determine if there are other regulations that may affect this situation.

Good Luck!

ILSM on Fire Door Replacement

Q: If renovation requires replacement of fire doors in multiple areas of the hospital, and must be completed in a short period of time, what would be appropriate interim life safety measures? This would cover multiple areas of the hospital.

A: Appropriate Interim Life Safety Measures (ILSM) for replacing multiple fire doors in a hospital all at the same time would be determined by hospital’s ILSM policy. According to Joint Commission’s standard LS.02.01.01, EP 3, the ILSM policy must include criteria for evaluating when and to what extent the hospital follows special measures to compensate for life safety risks. What this means is the hospital gets to decide what ILSM measures to implement for which life safety impairments, within reason. But, to directly answer your question, I would think the following measures should be considered for implementation:

  • Staff education:  Issue a memo to all departments that are affected by the fire door replacement, notifying them of alternative routes for exiting.
  • Temporary construction partitions: Fire retardant plastic sheeting needs to be installed to contain dust and dirt during the demolition and construction phase of the fire door replacement project.
  • Issue additional fire extinguishers: Place extra fire extinguishers in the project area and provide instructions to the construction workers on how to operate them
  • Daily surveillance: Daily surveillance to ensure the fire door project area is clean and free from debris should be performed, as long as the project is active.
  • Post signage: If the project to replace the fire doors blocks access through the egress corridor in that area, then signage should be posted indicating the nearest alternative exit.
  • Fire watch: If any portion of the fire alarm system or the sprinkler system is impaired for 4 or more hours in a 24 hour period due to the fire door replacement project, notification of the local fire department is required and a fire watch must be performed