Low Voltage Wiring

Q: We recently underwent a mock survey in preparation for a full survey soon. The Life Safety mock surveyor cited us for failure to cover low voltage junction boxes. We had differing opinions about the requirement. A member of our team feels that the NEC requirements do not apply in Montana. I was not able to verify that statement. My question is twofold: 1. What experience & opinion do you have about the treatment of low voltage under the same code as high voltage? 2. Are you aware of state (or other codes) which are less stringent taking precedence over more stringent codes?

A: You can never take a less stringent code or standard, over a more stringent code or standard. You always have to comply with the most restrictive requirement. And yes, the National Electrical Code (NEC) NFPA 70-2011 does apply at your facility, regardless if your state requires it or not. This is because you are required to comply with the 2012 Life Safety Code and sections 18.5.1 and 9.1.2 require that you to comply with NFPA 70-2011.

In regards to low-voltage electrical wiring NFPA 70-2011 has many different Articles, depending on the application. Article 300.2 (A) says the requirements in chapter 3 apply to all voltages 600 volts or less. Article 411 is a standard on low-voltage lighting systems operating on 30 volts or less. But Article 517.80 is the one that you will be interested in: It says in healthcare patient care areas, low voltage wiring for communication systems and fire alarm systems less than 120 nominal volts, have to have an equivalent level of insulation and isolation to that required for electrical distribution systems in patient care areas, but the Class 2 and Class 3 signaling and communication systems do not have to comply with the grounding requirements or with the mechanical protection requirements, including raceways.

So, according to the NEC, you are not required to cover low voltage wiring junction boxes… But I advise that you do. Most surveyors will not know be able to tell low voltage qualifying under Article 517.80 when they see it, and will likely cite you for non-compliance.

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.

There’s A New Form on the ‘Tools’ Webpage

Just a quick note to let you know there is a new form available to you for free, on the ‘Tools’ webpage called “Fire/Smoke Damper Test”. Due to multiple requests by readers, we’ve developed a simple template for you to use in documenting your fire damper and smoke damper test results.

Check out this and other forms and documents that are available for you at no cost to help maintain your facility to be Life Safety Code compliance.

Which Edition of FGI?

Q: My understanding is we should be following the 2010 FGI Guidelines because that’s what is recognized by the 2012 LSC that was adopted by CMS. But I have read where CMS and Joint Commission would allow hospitals to comply with the most recent edition of the FGI Guidelines, which is the 2014 edition. To confuse the issue further, our state has adopted the 2010 FGI Guidelines. What this boils down to is Table 7-1 on ventilation and if we should follow the 2010 edition or a newer one. Is my understanding correct or are we to follow the latest FGI guideline?

A: For most hospitals, compliance with the FGI Guidelines is more of a suggestion, than a requirement. The FGI Guidelines are not standards, but are guidelines on how to design your facility. According to the Interpretive Guidelines for CMS Condition of Participation §482.41(c)(4), it is clear that the design of the hospital must be made in accordance with a select standard or guideline. CMS allows you to choose which standard or guideline you follow, and provides suggestions for temperature and ventilation as directed by AORN, FGI, CDC and the like. It is also expected that you would follow state or local regulations as well, even if they are more restrictive than the national regulations.

Once designed and constructed, the temperature and ventilation requirements do not change in your facility when a newer edition of a standard or guideline is adopted. If you designed your ORs to the 2010 edition of the FGI Guidelines, then you only have to comply with the requirements of the 2010 edition for the life of the building, or until you conduct major renovation. Your facility does not have to retroactively comply with newer editions of the FGI Guidelines.

If your state has adopted the 2010 edition of the FGI Guidelines, and they require compliance with that edition, then that is the edition you comply with, even though CMS would allow compliance with the 2014 edition. The state’s requirements are more restrictive than CMS’.

As far as I can see, the 2012 Life Safety Code does NOT reference any edition of the FGI Guidelines, but NFPA 99-2012 does reference the 2008 ASRAE 170 publication on ventilation, which is the basis for Table 7-1 in the FGI Guidelines.

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.

Fire Hose Removal

Q: We have an email confirmation from the State Fire Marshal that approves of our removal of the occupant-use fire hoses in our hospital. What exactly do we have to do with this email?  Do we have to let any other AHJ know?

A: Depending on your accreditation organization (AO), you may have to ask for their permission as well. I do know that Joint Commission used to have a policy that requires hospitals to ask them for permission to remove the occupant-use fire hoses, but I do not believe HFAP or DNV has the same requirement.

Contact your AO and your local AHJ to see if they have regulations that require asking them for permission to remove your occupant-use fire hoses

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:

Occupational Therapy Kitchens

Q: Do occupational therapy kitchens need to meet NFPA 96 standards? This unit will be a new build and will fall under business occupancy requirements, but the Life Safety Code for new business occupancies refers me back to 9.2.3, which refers me to NFPA 96.

A: Is the cooking equipment really ‘commercial cooking equipment’? For an occupational therapy kitchen, you would be using residential cooking equipment, would you not? Also, is the cooking equipment that is used for occupational therapy ever turned on…? Do they ever actually cook or bake anything on the stove?

If it were a healthcare occupancy, the answer is a no-brainer, since section 19.3.2.5.2 specifically says residential cooking equipment that is used for food warming or limited cooking does not have to meet the requirements of 9.2.3. While that section may have been written for food warming equipment in staff lounges, one could apply it towards occupational therapy kitchens as well.

But you may have a good case with sections 38/39.3.2.3 (3), which says something similar and exempts cooking equipment used only for food warming from having to meet section 9.2.3. There are a few other points that would prevent you from having to meet NFPA 96 requirements. According to NFPA 96-2011, section 1.1, it says the following regarding residential equipment:

  • 1.1.2 This standard shall apply to residential cooking equipment used for commercial cooking operations.

(You’re not using this residential cooking equipment for commercial cooking operations, so therefore, NFPA 96 does not apply).

 1.1.4* This standard shall not apply to facilities where all of the following are met:

(1) Only residential equipment is being used.

(2) Fire extinguishers are located in all kitchen areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

(3) The facility is not an assembly occupancy.

(4) The authority having jurisdiction has approved the installation.

(Make sure you comply with the above four items and you do not have to comply with NFPA 96.)

So, I think you have enough to go on to convince an AHJ that a NFPA 96 exhaust hood is not required for occupational therapy residential cooking equipment in business occupancies.

Smoke Dampers in Smoke Partitions?

Q: When comparing smoke dampers in smoke barriers vs smoke partitions, section 8.5.5.2 requires smoke dampers (with exemptions) for penetrations by ducts or air-transfer openings in a smoke barrier. Section 8.4.6.2 (smoke dampers in smoke partitions) only indicates air-transfer openings as required to have smoke dampers, with no mention of ducted openings, which we interpret to mean that ducted openings in a smoke partition do not require smoke dampers. However, we have been repeatedly told by mechanical engineers that smoke dampers are required for all ducts, transfer ducts, and air-transfer openings that pass through a smoke partition – which interpretation is correct?

A: It appears to me that your mechanical engineers are confusing smoke partitions with smoke barriers. To be sure, air-transfer openings are prohibited in corridor walls (which are smoke partitions) in healthcare occupancies, according to section 19.3.6.4.1 of the 2012 LSC. Also, section 19.3.7.3 (2) exempts smoke dampers in fully-ducted penetrations in smoke barriers, where the smoke compartments served by the smoke barriers are fully protected with Quick Response sprinklers. I do not see where smoke dampers are required in HVAC ductwork in smoke partitions.

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:

Offsite Locations

Q: For clinics that are in a facility classified as business occupancy, is an ICRA required?

A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations that are considered hospital departments even if it is not classified as healthcare occupancy. For example, if a hospital has an offsite therapy unit in a local mall, the Environment of Care and Life Safety chapter requirements must apply to the offsite location, in accordance with the respective occupancy designation. This means, where the hospital is a healthcare occupancy, an offsite therapy unit would likely be a business occupancy, but the requirements found in the EC and LS chapters still apply at the therapy unit, but in accordance with business occupancy classification.

So, the requirement for an Infection Control Risk assessment (ICRA) is found in EC.02.06.05, EP 2 in the Hospital Accreditation Manual. The expectation is the hospital would conduct an ICRA at an offsite location when planning for construction as long as it is a hospital department. This concept of the Joint Commission standards applying at offsite locations is explained in the Overview to the EC and LS chapters.

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.

Strange Observations – Ceiling Gaps

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

Ceilings that contain smoke detectors and/or sprinkler heads have to resist the passage of smoke.

For ceilings that are constructed with acoustical tile and grid assembly, this can be challenging in electrical rooms, or IT rooms where there are a lot of penetrations.

Gaps between the ceiling tile and the conduit cannot exceed 1/8-inch.