Hole in the Wall

Q: I have a surgery suite that had a hole punched into the wall by the door knob. Is there anything in LSC that states ” if a hole is made in a surgery wall the drywall needs to be replaced from stud to stud”, not just repair the hole?

A: No… The LSC does not concern itself with the way the walls are repaired. When it comes to walls, the LSC only concerns itself with identifying which walls must be smoke resistant, fire-rated, or smoke rated. The UL listings for the walls will determine how the wall is constructed, and repairs to the wall must follow the same UL listing.

Now, if the wall with the door knob hole is only required to be smoke resistant, then you can seal the hole with any type of patch that makes the wall resistant to the passage of smoke. But if the wall is fire-rated, or is required to be a 1-hour rated smoke barrier, then you must excise the hole from stud to stud, insert a new piece of gypsum board, and screw, tape and apply joint compound in accordance with the UL listing for that wall.

I’m sure your Infection Control practitioner would have a lot to say about a hole in a wall in surgery.

Penetrations in Corridor Walls

Q: Our life safety drawings identify the corridors in our hospital as being smoke partitions. My question is do wall penetrations above the dropped ceiling need to be sealed with a fire caulk like products used in 1 and 2 hour walls?

A: According to the Life Safety Code, a hospital corridor wall is required to be meet two-different standards, based on whether or not the smoke compartment where the corridor is located is fully protected with sprinklers. If protected with sprinklers, then the corridor wall is permitted to be smoke resistant (not-fire-rated) and extend from the floor to the deck, or from the floor to the ceiling if the ceiling also resists the passage of smoke. Be aware, however, that where NFPA recognizes that a suspended grid and tile ceiling does resist the passage of smoke, the IBC does not.

The other corridor wall requirement is where the smoke compartment is not fully protected with sprinklers, then the corridor wall must be 30-minute fire-rated and extend from the floor to the deck above. There is no exception to terminate at the ceiling if the ceiling resists the passage of smoke. NFPA describes a 30-minute fire-rated wall as steel studs with one layer of gypsum board on one side.

Since you state your corridor walls are smoke partitions, then the question is, do they have to extend all the way to the deck or do they qualify to terminate at the ceiling provided the ceiling also resists the passage of smoke? Since these are smoke partitions and not fire-rated barriers, you would be permitted to use non-rated, non-combustible caulk to seal any penetration, in lieu of using fire-rated materials.

Suite Boundary

Q: We have a suite inside of a smoke compartment. We are trying to find out if the dividing wall needs to be the same as the 1-hour smoke barrier.

A: According to section of the 2012 LSC, the boundary of a suite has to meet the requirements for corridors. This means, if the smoke compartment is not fully protected with sprinklers, then the corridor walls must be 30-minute rated, smoke-resistant, and extend from the floor to the deck above. If the smoke compartment is fully protected with sprinklers then the corridor walls only have to be smoke-resistant and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke. Therefore, the suite perimeter walls would have to be the same as the corridor walls.

It is possible however, that one wall can serve two purposes, so the suite wall could also be a smoke barrier as long as the wall meets the requirements for both purposes.

Keep in mind that a suite is nothing more than a room, although it is a large room with a lot of smaller rooms inside. Therefore, all corridor entrance doors into the suite must positively latch, and the path of egress cannot take you from a corridor into a suite to get to an exit.

Carpet on Corridor Walls

Q: I have a nursing home that is over 20 years old that has carpet on the corridor walls below the handrails. I am been told that this carpet must be removed. I am not able to find any information on the 20-year old carpet that gives the flame spread rating. What are my options other than removing it?

A: It depends on who is telling you to remove the carpet and why. If you were cited by a state surveyor or an accreditation organization, ask them to please identify the standard and reason for the citation. They should be able to identify the precise standard, code, or regulation why the carpet needs to be removed.

I suspect the violation comes from of the 2012 Life Safety code where existing interior finish materials have to be Class A or Class B on corridor walls, which would require a flame spread rating between 0 – 75, and a smoke development rating of 0 – 450.

If you cannot prove that the flame spread rating and smoke development rating of the carpet falls within these parameters, then you have no choice but to remove the carpet from the walls. After 20 years… it’s time for an upgrade.

Poly Vinyl Mural on Fire Doors and Walls

Q: Is it permissible to completely cover a fire rated door in a hospital with a polyvinyl picture/mural? Also, is it permissible to cover a fire rated wall, from floor to ceiling in hospital with the same product?

A: No. You are not permitted to cover a fire-rated door with anything. Period. The reason why is, whatever is placed on the door will likely change the fire-resistive characteristics of the door and may likely allow the door to not last as long as it is designed.

Assuming the mural is newly installed, a poly-vinyl picture mural on the walls of the hospital may be permitted if it meets the requirements for interior finish. Class A interior finish is permitted on walls, and Class B is permitted in rooms where the capacity does not exceed four persons. A Class A material has a flame spread rating of 0 -25, and a Class B materials has a flame spread rating of 26 – 75.

Ask your supplier/vendor to provide the interior finish classification or the flame spread ratings to determine if you are compliant.

No Longer Needed Overhead Rolling Fire Door

Q: We have an existing overhead rolling fire door acting as a curtain-window between a phlebotomy area and the egress corridor that is no longer needed (like to those found in Pharmacy areas to the corridor). It is currently connected to the fire system for release and also has a fusible link. We want to disconnect it from the fire system, keep it closed, and drywall the window area so that it does not appear it was ever there. The question arose, can this be done, or do we need to go through the cost to physically remove it. It is viewed by some that once it was in place it must always be tested and inspected unless completely removed. However, I see this as being similar to walling off a dumbwaiter with “2 hr. shaft-wall” when it is no longer needed. We have been allowed to do this by our state agency. What do you think?

A: I think your analogy is apt for this situation. According to sections 4.5.8 and of the 2012 LSC, whenever a device is required for code compliance, it must be continuously maintained. But, if you close-up the opening in such a way that complies with new construction requirements, then the over-head rolling fire door is no longer needed. So, boxing in the device and abandoning in place would be acceptable.

And, according to section of the 2012 LSC, existing life safety features obvious to the public, if not required by the code, must be either maintained or removed. Well, if you box-up and cover the overhead rolling fire door (and it is no longer required), then it is no longer obvious to the public and can be removed.

While my personal choice would be to remove the overhead rolling fire door if it is no longer needed and used, your plan to cover it up would be acceptable as long as it is no longer needed.

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.

Labeling Walls with Fire Rating

Q: Is there an NFPA code requirement for labeling fire / smoke rated walls above ceiling and if so what is it?

A: No… there is not a NFPA code or standard requirement to label the walls above the ceiling. But I’ve been told there is an IBC requirement, but I cannot provide you with any confirmation of that. I’m not a big fan of labeling the walls above ceiling with their hourly ratings, or even whether or not they are fire-rated walls or smoke barriers, etc. The reason why; it often can be labeled incorrectly… then what does a surveyor do if the walls are labeled one way and the LS drawings show something different? It creates confusion and opens the door for a finding by the surveyor. If you don’t have to do it, I suggest you do not.

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 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.

Fire Rated Walls and Barriers

Q: Are fire rated walls the same thing as fire rated barrier? And are smoke compartment barriers actually fire rated walls?

A: As it has been explained to me, a fire rated wall is used to subdivide a building into separate areas and they extend from an outside wall to another outside wall, and from the floor of the lowest level up through the roof of the highest level. A fire rated wall is structurally self-sufficient and acts as a block in the event a fire develops on one side, to prevent the fire from spreading to the other side. Fire rated walls are specified by building codes, and are not addressed by the Life Safety Code for healthcare occupancies. On the other hand, a fire rated barrier is not a fire rated wall, and are used extensively in healthcare occupancies. A fire rated barrier extends from the floor to the deck above. Examples of a fire rated barrier would be the walls surrounding a hazardous room; a vertical shaft (such as a stairwell or elevator shaft); and a separation between different occupancies or construction types. All opening in fire rated walls and fire rated barriers (such as doors, dampers, access panels, etc.) must be fire rated and equipped with fire rated frames and hardware. To be sure, smoke compartment barriers are not fire rated barriers; however they are similar. The barrier itself is constructed with fire rated materials however the doors in the smoke compartment barriers are not required to be fire rated, nor are they required to have positive latching hardware. They only have to self-close. Smoke compartment barriers are required to extend from the floor to the deck above. Another barrier that you may need to know about are smoke resistant barriers, which have no fire rating, but are required to extend from the floor to the deck above, and resist the passage of smoke. Corridor walls in a non-sprinklered smoke compartment are required to be smoke resistant barriers.