Q: With regards to a fire watch, the code is specific about requiring one in an occupied building when a fire alarm system or suppression system is out of service for a prescribed period of time. This makes sense for head end shutdowns and other scenarios where entire buildings or significant portions of buildings are impacted. My question is what if you are only taking part of a “system” down? Meaning a small renovation that impairs 3 heads in a room because the ceiling grid and tile are removed for greater than 10 hours. This is not a “system”, only a part of one. Where does an AHJ draw the line? Is it possible that our ILSM and Fire Impairment Policy could allow for a certain number of heads, certain square footage or percentage of a smoke compartment to be impaired without the fire watch requirement (given that other ILSMs are in place)?
A: While the interpretation is not written down as to how many impaired sprinkler heads constitute a system, it is generally understood more than 2. While that number may fluctuate between surveyors, it would be fair to say all of the sprinkler heads inside one room that are impaired would require a fire watch. The logic is, if a fire started in the room, there is no fire suppression device to extinguish the fire if all the heads were impaired. Does not matter if the room only has 3 sprinkler heads.
To be sure, you should obtain a decision directly from your accreditation organization. But even then, the CMS state agency may not agree with what your AO says. It is best to be conservative and conduct the Fire Watch as long as the sprinkler heads are impaired. Besides, how long does it take to install upright heads within 12 inches of the deck in this room?
Q: Am I allowed to have a suite inside an area designated as an Ambulatory Occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated?
A: Yes… you are permitted to have a suite in an ambulatory health care occupancy. Look at section 20/184.108.40.206 which permits suites in AHCO, but any suite over 2,500 square feet must have two remotely located doors from the suite. No… Suite boundary walls are not necessarily required to be 1-hour fire-rated. They are required to be equal to the fire-resistive rating of the corridor walls. For new construction, corridor walls would be a minimum of 1-hour fire rated barriers, unless one of the following exists:
- Where exits are available from an open floor area
- Within a space occupied by a single tenant
- Within buildings that are fully protected with automatic sprinklers
For existing construction, there are no requirements for corridor walls, so therefore there are no requirements for suite boundary walls.
Keeping your door inspection on schedule and on budget is a central focus of our projects. To achieve this goal, we need your help and preparation. While you don’t need a doula or inspection coach, here are some important points to help us help you.
Fire doors are located everywhere within your facility and we access all of them. Providing us with a good set of master keys and master swipe cards keeps our team moving and on schedule. The only exception is sensitive areas such as pharmacy and labor and delivery. Our team will always check in with your pharmacy staff and asked to be escorted while in that area. Labor and delivery areas also require check-in and often have alarmed doors and exits. Understanding who to call or how to defeat those alarms is a required part of your pre-door inspection checklist.
In the days before our arrival, please email or notify your department heads of our purpose and process. You may want to follow with a phone call to departments such as security, emergency, surgery, and labor and delivery, as these are especially sensitive areas in your facility.
Our door inspectors occasionally encounter blocked fire doors. Each fire door must be opened and closed several times during the inspection process, which requires unfettered access. Please make a point to remove any obstacles such as shelving, couches, pallets, or anything else that would prevent us from completing your inspection.
While we are at your facility, please be prepared to respond to any request for assistance. Sometimes even the best-made plans hit a roadblock that needs to be cleared. Providing our team with an easy communication method to contact you, such as cell phone, radio, or pager, will aid in resolving any encountered obstructions.
Understanding these important steps will ensure that your annual door inspection is delivered smoothly and without issue, allowing you to cut the cord on this project and move to your next.
Q: In regards to the sensitivity testing of smoke detectors, I believe my fire alarm system is capable of complying with NFPA 72 for the sensitivity testing of smoke/heat initiating devices. For example: If we have a smoke detector that exceeds the expected sensitivity range it will send a trouble signal and the panel will show “dirty photo detector” and it will tell the device location. Additionally, we can run a complete report on all devices to show the current sensitivity value of each detector, this could be done on the alternating year frequency dictated by the code. I believe this meets NFPA 72-2010 requirements for sensitivity testing. Your thoughts, please.
A: I would agree with you. But when the surveyor asks for evidence that your smoke detector sensitivity was checked, what report do you show him? If you don’t print out a sensitivity report at least once every two years, you would have little to nothing to show them.
Q: I have a question on the requirement for the battery backup lighting inside the MRI suites. We are in the process of building two new MRI centers and I am receiving a lot of push back from the Project Engineer.
This engineering group specializes in MRI projects and they tell me they never install battery backup lighting and that NFPA 99 does not require battery backup lighting anywhere outside of an operating room. I was told to reference 220.127.116.11.11.2 of NFPA 99-2012 which specifically mentions operating rooms. My reply was that 18.104.22.168.11.1 does not specify only operating rooms so it is much broader in scope and since we use anesthesia in the MRI it would be required.
Before I stir up the pot anymore with the engineering firm I wanted to make sure that if Anesthesia is being used in the MRI room that emergency battery backup lighting should be in place.
A: Yes, you are correct. NFPA 99-2012, section 22.214.171.124.11.1 requires one or more battery-powered lighting units within locations where deep sedation and general anesthesia is administered. That includes MRI areas, Cath Lab areas, and of course, Operating Rooms and Procedure rooms. ICUs and NICUs would typically not be included.
Just because the project engineer from the contractor has never been told to install battery-powered lighting units before does not preclude the fact that it is a requirement and it is enforced by CMS and the Accreditation Organizations. The engineer is mistaken.
Q: We are a service contractor that is attempting to obtain a contract with a new client that is an Ambulatory Surgery Center. The ASC told us they never had their smoke detector sensitivity checked. We told them it was a CMS requirement to have the smoke detector sensitivity checked every 2 years, but they tell us they want us to check it every 5-years as that is what their current service contractor is telling them. How can they be in business for over 12 years and no one ever checked their smoke detector sensitivity? Have the NFPA standards changed regarding smoke detector sensitivity testing?
A: Ignorance, and a lack of understanding of the codes and standards. And a lack of enforcement by their AHJs…that’s how it could be missed for 12 years. This is not surprising. But to answer your last question: No, testing intervals have not changed in NFPA 72. Sensitivity of the smoke detectors has to be checked one year after installation, and then every other year thereafter. After the second required calibration test, frequency may extend to every 5 years provided the sensitivity tests indicate the devices have remained within its listed and marked sensitivity range.
Life Safety Drawings (LSDs) are often an unappreciated hero of an accurate door inspection. Not having accurate LSDs cause the inspection of extra doors and their consequential costly repairs.
Let me explain.
Notice the blue barrier called out on the LSD as 1FSB. The legend defines this wall type as a 1-hour fire smoke barrier but look closely at how it’s used as it moves from the top of the example to the bottom.
The 1FSB begins as it crosses the yellow corridor. During this portion of the barrier, it is being used to separate smoke compartment and is referred to in NFPA 101 as a “smoke barrier”. Doors in a smoke barrier are not required to be fire-rated, are not required to have fire-rated hardware, and in occurrences when it crosses a corridor, do not require latching.
Now follow the barrier as is defines the left side of the EQUIP/STORAGE room. The room is a designated hazardous storage room and is surrounded on three sides by the orange “1FB” defined in the legend as a 1-hour fire barrier. For this segment of the 1 FSB, the barrier is both a 1-hour fire barrier and is part of the smoke barrier (separating smoke compartments). Doors in this room need to be at least 45-minute rated fire doors with appropriate hardware.
Further down the 1FSB crosses in front of a non-hazardous room where the doors are again not required to be fire rated.
Including doors that are not required to be fire doors in your fire door inspection is a costly mistake. Along with the extra inspection costs, you will also:
- Maintain or add expensive latching hardware in cross corridor doors.
- Add and maintain fire-rated hardware.
- Maintain doors to strict edge gap standards.
- Use expensive fire-rated gap repair products when doors cannot be shimmed into the standard.
- Risk your fire marshal or accrediting organization forcing you to repair wrongly identified fire doors at an accelerated and inflated rate.
We have many customers who we have created Life Safety Drawings for. On almost every occasion, the customer had reduced their previous required fire door inventory. The following inspection and repair cost avoided with the new LSDs have more cover the cost of the new drawings.
Q: We have out-patient clinics classified as business occupancies. Are we required to have emergency egress lighting? If so what section of the 2012 or 2015 NFPA Life Safety Code outlines the requirement?
A: It depends. For new business occupancies section 126.96.36.199 of the 2012 LSC says emergency lighting shall be provided where any one of the following conditions exists:
- The building is three or more stories in height;
- The occupancy is subject to 50 or more occupants above or below the level of exit discharge;
- The occupancy is subject to 300 or more total occupants.
For existing business occupancies section 188.8.131.52 of the 2012 LSC says emergency lighting shall be provided where any one of the following conditions exists:
- The building is three or more stories in height;
- The occupancy is subject to 100 or more occupants above or below the level of exit discharge;
- The occupancy is subject to 1000 or more total occupants.
The emergency lighting must be installed in accordance with section 7.9, which discusses battery-powered emergency lights and those egress lights powered from generators. According to 184.108.40.206, new emergency power systems for emergency lighting shall be generator power, with a Type 10 (meaning no more than 10 seconds to transfer power), Class 1.5 (which means must provide emergency power for a duration of 90-minutes) and rated for Level 1 (which means the system shall be installed where failure of the equipment to perform could result in loss of human life or serious injury). Level 1 systems are described in NFPA 110 as rotating equipment energy converters powered by prime movers (i.e. generators). Existing condition emergency lights could be powered by battery-powered emergency lights.
Q: We are presently undergoing our 3-year licensure inspection by the Dept. of Health. One of the inspectors asked to see our air change records for the morgue. We have never completed air changes for the morgue. We use outside air and make sure the exhaust fan is working properly. So, should we be doing air change testing in the morgue? Also, do we need to do air change testing in all clean and soiled utility rooms in the hospital?
A: When your facility was designed and constructed, the HVAC system had to be designed to certain Air Changes per Hour (ACH). Depending when the facility was designed, the designer would use the AIA Guidelines (or as they are now called, the FGI Guidelines), or other state or local regulations as appropriate. You need to find out what those design ACH were at the time the facility was designed/constructed, or last renovated in that area.
It is important to understand that you do not have to meet the latest edition of FGI Guidelines; you just have to meet the edition at the time your facility was designed, or last renovated. It is important to also understand that you must comply with state and local regulations at all times.
So, let’s say the morgue was required to have 6 ACH at the time it was designed. You must maintain that 6 ACH for the life of the building, or until you renovate; then you would have to comply with new construction ACH for a morgue. The state inspector’s request is valid: How do you know you are maintaining 6 ACH if you don’t measure it from time to time? How often should you measure the ACH? The codes and standards do not say, so do a risk assessment and determine what is a valid number. Usually once per year is sufficient as long as you have historical data that shows the ACH rate was always in compliance.
You need to start measuring ACH rates in all areas where there was a design requirement for ACH.
Q: How does one handle a “Soiled Utility” room in an Ambulatory Healthcare Occupancy? If it is a small storage room without large volumes of flammable liquids, but perhaps containing soiled linens, are there any special fire protection features that need to be included?
A: Soiled utility rooms in ASCs are treated differently than they are in hospitals and healthcare occupancies. Where chapters 18 and 19 specifically identify soiled utility rooms as hazardous areas for healthcare occupancies, chapters 20 and 21 do not for ambulatory healthcare occupancies.
But chapters 20 and 21 refer to chapters 38 and 39 for “Protection from Hazards” and it does identify ‘storage rooms’ as a hazardous area and must comply with section 8.7. Section 220.127.116.11 requires the hazardous room (i.e. soiled utility room in ASC) to be protected in one of the following two ways:
- Enclosing the room with 1-hour fire rated barriers, that would include a ¾ hour fire rated door assembly that is self-closing and positive latching, or:
- Protect the room with sprinklers.
That’s what you need to do.
Q: Nursing staff has a tendency to stuff patient rooms that are not used as often with extra beds, furniture etc. Building does not have sprinklers on these patient floors so the concern is fuel load in a nonrated room. Is there a particular code I can cite to discourage this behavior?
A: Yes… Section 4.6.7 in the 2012 LSC says when you have a change in use (that’s what is happening… the patient room is not being used as a patient room anymore, but now is used as a storage room with combustible supplies), you need to comply with chapter 43. Section 18.104.22.168 (2) says when existing healthcare occupancies are fully protected throughout with automatic sprinklers, when you have a change is use in a room that does not exceed 250 square feet, the result is the room does not have to meet new construction requirements but is permitted to meet existing conditions for hazardous rooms. This is significant as the room where the extra beds and furniture are placed would not have to meet the more restrictive new construction requirements for adding sprinklers and making the walls become 1-hour fire rated barriers, with a ¾ hour fire rated door assembly. The room would only have to be sprinklered and the walls and doors made to resist the passage of smoke and the door be self-closing. But this is only permitted if the entire building is protected with sprinklers, and you say it is not. Therefore, you have no choice; you must reconstruct the former patient room to be 1-hour fire rated with a ¾ hour fire rated door assembly and install sprinklers in the room. This could cost you $10,000 – $20,000 per room depending on the current arrangement of the facility. This is an example of staff changing the use of a room or area without checking with facilities to see if it is permitted. Your best bet would be to complete the sprinkler installation in your building.
Q: Do you have to have smoke detectors in emergency electrical rooms or electrical rooms?
A: In a hospital? Only if you have an FSES equivalency that requires it, or the room is located inside an area under Specialized Protective Measure locks as described in section 22.214.171.124.5.2 of the 2012 LSC. Otherwise, there are no NFPA codes or standards that require it. But check with your state and local authorities to see if they have regulations that require it.
Often times smoke detectors are placed in locations based on designer preference.
Q: Section 19.3.7 of the 2012 LSC discusses smoke compartments in facilities that have greater than 30 sleeping beds per floor or building. If your facility is under 30 beds, but greater than 22,500 square feet, are smoke compartments required? Or can they be removed on the life safety plans?
A: No… They cannot be removed, because section 126.96.36.199 of the 2012 LSC says existing life safety features shall not be removed or reduced where such feature is a requirement for new construction. According to section 188.8.131.52 of the 2012 LSC, new construction requires it so you must maintain it for the life of the building.
Q: A question came up concerning NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never had an assessment done in the past but it is my understanding that it became a requirement in 2016. The CMS has established compliance requirements (K Tag) for risk assessment and its completion. Who would be the qualified personnel to perform this procedure and create a formal and documented risk assessment?
A: According to members of the Technical Committee who wrote the new Chapter 4 in NFPA 99-2012, the original intent was the risk assessment only applies to new construction. However, the way chapter 4 is written, it is not clear that the risk assessment is only applicable to new construction. CMS has instructed their state agencies who survey on their behalf to require all hospitals to have completed their NFPA 99 risk assessment for new as well as existing construction. Therefore, hospitals must conduct the risk assessment for new and existing conditions. These assessments are not difficult to do and only take a few minutes. There is no requirement to make a room-by-room assessment, but the intent is to assess the risk of the entire system if it were to fail and there were no back-up systems. It would stand to reason that most hospital systems would be Category 1 or Category 2. Anyone may conduct the assessment but would have to have knowledge of the risk assessment process and knowledge of the facility.
Q: Do we need to post the temperature ranges on the outside of our blanket and fluid warmers?
A: Well… no, I don’t believe you do. But the expectation is everyone using the blanket warmers will know what the maximum and minimum temperature settings are. This needs to be established and approved via policies, and staff needs to know the acceptable ranges.
So, one of the better ways of reminding staff what the acceptable ranges are is posting the temps on the warmer itself. It may not be a requirement and you don’t have to do it, but it may be considered ‘best practice’ to post the temps on the cabinets as a reminder.