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 18.1.3.5. 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.

 

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by:

Exit Discharge

Q: I could not find in the 2012 Life Safety Code if there is a specific width requirement for a sidewalk as an exit discharge.

A: You are describing the exit discharge, and that is regulated under section 7.7.1.1 of the 2012 LSC, which says yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

Since the LSC does not specify what the width of the exit discharge should be, it is up to the AHJ to decide. When the building was designed and constructed, those dimensions would have been approved by the AHJ with authority over construction.

But it is mentioned in the NFPA handbook to the 2012 LSC that the exit discharge should be at a minimum wide enough to accommodate the calculated load of people using the exit discharge, so the dimensions used for the interior egress could be expected to be used for the exterior exit discharge. And remember, according to 7.1.6.2, the exit discharge must be level without an abrupt change in elevation greater than ¼ inch, so that means a smooth walking surface is required.

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.

Strange Observations – Conflicting Signage

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

What we have here is conflicting signage. The ‘Exit’ sign is saying “Hey, in an emergency come this way”. And the sign on the door says “Hey, don’t you dare enter”.

This is a conflict, and you cannot do anything to discourage anyone from using an exit.

The sign on the door has to go.

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by:

Strange Observations -Disabled Latches

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

Boy… I bet you’ve never had this problem at your facility, eh?

[Sarcasm]

This is why you need to do frequent rounds (i.e. weekly, if needed) to spot these trends and nip it in the bud.

Healthcare staff will frequently tape over a latch on a door or on a strike on the frame to make it easier to gain access to a utility room.

Marked Fire/Smoke Doors

Q: We are reviewing fire policy, and are wondering if it is a Life Safety Code requirement to have fire and smoke barrier doors labeled as such? By this I mean a sign or sticker on the face of the door stating: “smoke barrier” or “fire barrier”?

A: No… there is no Life Safety Code requirement to post signage on smoke barrier doors or fire-rated door assemblies, identifying them as such. I do not see any CMS or Accreditation Organization requirement to do so, either. However, it’s not a bad idea as long as the signage meets the limitation of NFPA 80 for fire-rated door assemblies. I have seen hospitals identify their smoke barrier doors, that helps their staff be aware of the smoke compartment locations. I think that works well for many organizations. Please check with your state and local authorities to determine if they have any requirements.

 

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively presented by:

Smoke Dampers in Corridor Walls?

Q: In regards to suite separations, section 18.2.5.7.1.2 of 2012 LSC requires walls separating suites to meet requirements for corridor walls, which have to be constructed to limit transfer of smoke. There don’t seem to be any requirements for smoke dampers in air transfer openings or duct penetrations through corridor walls – is this correct?

A: Well… you’re sort of correct. Corridor walls in fully sprinklered smoke compartments are required to be smoke partitions… not smoke barriers. The 2012 Life Safety Code does not require smoke dampers in HVAC ductwork that penetrate smoke partitions. But section 18/19.3.6.4.1 prohibits the use of air-transfer openings in corridor walls.