Clarifications Part 5

I continue my series on clarifications of surveyor findings that I have written for a client.


Clarification for LS.02.01.10, EP 9

LS.02.01.10, EP 9: The spaces around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material.

Surveyor finding:

In the 6th floor utility room the 4 inch vertical wiring conduit and a one inch wall conduit were not sealed with fireproofing material.

In the Main Building there was a conduit penetration in the hallway by room xxxxx.

In the Main Building there was a conduit penetration by room xxxx.


Who: The Director of Facilities is responsible for the implementation and compliance of the life safety management program at XYZ Hospital.

What: Compliance with the NFPA 101 Life Safety Code (2000 edition) is the objective and mission of the Facilities Department. The Safety Management Plan clearly identifies the mission to provide a safe and secure environment, which includes compliance with the Life Safety Code. The Facilities Department conducts routine and non-routine inspections and surveillance throughout the facility, identifying safety and security related issues that need to be resolved. These inspections are documented and reported to the health system’s Safety Committee for their review and consideration.

When: The Safety Management Plan is reviewed annually and presented to the health system’s Safety Committee for their approval. As recently as November 1, 2013 the Safety Management Plan was reviewed and approved by the Safety Committee along with the annual evaluation of the plan. The annual evaluation of the Safety Management Plan was found to be effective, based on quantitative criteria.

How: The Safety Management Plan, and the statement that the facility will be maintained in accordance with the Life Safety Code, is shared with all members of the health system through the intra-net, Safety Manuals [is this true?], and through direct conversations with key leaders in the organization.

Why: As an organization that has thousands of feet of fire & smoke rated barriers and corridor walls, we feel that 4 situations of unsealed conduit penetrations is not a true reflection of our overall compliance rate. Since this element of performance is designated as a ‘C’ element, we conducted an audit on all of our fire & smoke rated barriers, and our corridor walls in our facility prior to the survey. The sample size chosen for this audit is 2,954 wall-units for fire & smoke rated barriers, and 2,750 wall-units for corridor walls. This represents 100% of all the fire & smoke rated barriers and 100% of all the corridor walls in the hospital.

A wall-unit is an inspection of the fire & smoke rated barrier, or the corridor wall, whereby the maintenance technician lifts a ceiling panel and examines the wall to the left and to the right for unsealed penetrations. This represents the barrier (or wall) being inspected approximately every six (6) feet.

The audit on the fire & smoke rated barriers was conducted in May, 2013, and the audit on the corridor walls conducted in September, 2013. These audits were conducted as part of our ongoing Building Maintenance Program (BMP), which were no more than 6 months prior to the survey. The walls and barriers were inspected for:

  • Unsealed penetrations
  • Conduit sleeves      penetrating the wall but were not sealed
  • Gaps and holes
  • Completion of construction      to the deck above

The results of these two audits found 2,930 compliant fire & smoke rated wall-units (out of 2,954 total fire & smoke rated wall units), which represents a 99.18% compliance rate, and 2,737 compliant corridor wall-units (out of 2,750 total corridor wall units) which represents a 99.52% compliance rate.

Therefore, since our audit of this ‘C’ element demonstrates a compliance rate greater than 90% prior to the survey, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under LS.02.01.10, EP 9, and consider this standard to be ‘Compliant’.


Result? The accreditor accepted this clarification. The success of this clarification is based on an audit that the hospital had done prior to the survey, that demonstrated more than 90% compliance. The audit option for clarifications is only allowed to be used on ‘C’ category EPs.

If you’re keeping track, the score is:   Accepted 2: Not Accepted 3