Q: The Joint Commission’s standard on Interim Life Safety Measures (ILSM) requires the hospital to implement ILSM for deficiencies to the Life Safety Code (LSC) when the deficiency cannot be immediately corrected. Please define the time-frame that they mean with the word “immediately”. Can the implementation of an ILSM wait until the Safety Committee approves it?
A: The implementation of an ILSM cannot wait for a committee’s review and approval. The intent of the word “immediate” suggests that the ILSM must be implemented as soon as it is determined the deficiency cannot be resolved the moment it is discovered. This means to me that you need to implement an ILSM the same day a deficiency is discovered.
Each hospital is required to have a written Interim Life Safety Measure policy that applies to situations when LSC deficiencies cannot be immediately resolved due to equipment failure, maintenance, or construction. Your policy should proactively identify the process in which you meet the 11 different prescriptive requirements found in the standard. By following your own policy, your staff should be able to determine which measure to implement based on the deficiency that was discovered. This implementation phase may be approved by someone in authority at your facility, but it should not be held up for approval by a committee. However, it is encouraged that all ILSMs be presented to your Safety Committee as evidence of your organization managing the life safety deficiency. This will foster general discussion which should be reflected in your committee’s minutes.
Be very conservative with the implementation of ILSMs. Failure to implement appropriate ILSMs can lead to an adverse decision at your next survey.
Q: We have a mechanical room in our hospital whose entrance door opens into the top of an exit stairwell. I was informed by a consultant that this arrangement is not permitted and we must create a vestibule so the mechanical room does not open directly onto the stairwell. Is this true? If so, is this our only option?
A: The requirement for the arrangement that you described is found in the Exits section of chapter 7 of the 2000 Life Safety Code. This chapter applies to both new occupancies and existing occupancies. Section 126.96.36.199.1(d) requires openings to exit enclosures (stairwells) to be limited to normally occupied spaces. A mechanical room is not considered by many authorities having jurisdiction (AHJ) to be normally occupied. Therefore, by this definition alone, your consultant is correct and your arrangement does not appear to meet the requirements of the Code.
However, you do have other options to building the vestibule. Later editions of the Life Safety Code address this exact issue and actually permit an opening into an exit enclosure from an unoccupied mechanical room space, provided it meets the following criteria:
- The space does not contain any fuel-fired equipment
- The space does not contain storage of combustible equipment
- The building is protected throughout by an approved automatic sprinkler system
If your mechanical space meets these conditions, it is my recommendation your organization submit an equivalency to the AHJ that has regulatory control over your facility. You should cite the change in chapter 7 of the 2006 edition of the Life Safety Code as your facility meeting an equivalent level of safety. This is an acceptable alternative to meeting this requirement, rather than constructing a vestibule which could be costly.
Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?
A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.
In new healthcare occupancy, section 188.8.131.52.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).
However, for existing healthcare occupancies, section 184.108.40.206.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception. When locks are permitted on egress doors, they must meet the requirements found in 220.127.116.11.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.
Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.
Q: Why are corridors within the business offices of our hospital permitted to be 44” rather than the 8’ that the rest of the hospital has to maintain? Our hospital is considered 100% existing healthcare occupancy, with no mixed or separated occupancies.
A: Section 18.104.22.168 of NFPA 101-2000 Life Safety Code refers to exit access corridor width in existing healthcare occupancies. Existing corridors wider than 4 ft. can’t be reduced to less than 8 ft. under 4.6.7. However, exception number 1 to 22.214.171.124 states that aisles, corridors and ramps in adjunct areas not intended for the housing, treatment or use of inpatients is permitted to be 44 inches in width. The definition of adjunct is something that is associated to another in a subordinate way. Therefore, aisles and corridors in a business office area which is not intended for the housing, treatment or use by inpatients is adjunct to the main exit access corridors found in the rest of the hospital, and permitted to be 44 inches wide.
Also, if the business office qualifies as a suite-of-rooms, exception number 2 of 126.96.36.199 allows an exemption to the corridor width requirement for suites-of-rooms that qualify under 19.2.5. Therefore, there are no requirements for corridor widths inside a suite, because by definition, there are no corridors.
For those hospitals that are mixed occupancies, you should follow that appropriate chapter in the Life Safety Code for corridor widths. The only exception to this is if the exit access corridor in the other occupancy also serves as an exit from a healthcare occupancy. Then you would need to meet the requirements of corridor width from the most restrictive chapter, which is usually the healthcare occupancy chapter.
Q: In the February issue of Healthcare Life Safety Compliance, I found your article on Interior Finish Requirements to be helpful, but it did raise a question for me. In most areas where carpet is installed, a 6″ banded carpet cove base is used in lieu of a rubber top set. Is this 6″ banded carpet base required to have a Class I or a Class A or B rating? The product is used in an existing healthcare occupancy, in sprinklered and non-sprinklered areas. Thank you.
A: The answer is Class A. Cove base by definition is applied to a vertical surface and is considered part of the wall. NFPA 101-2000 Life Safety Code, section 19.3.3 (for existing healthcare occupancies) discusses the many options for interior wall and ceiling finish, and states interior finishes must be in accordance with section 10.2. Normal interior finish on walls and ceilings are permitted to be Class A or Class B, and in some cases Class C. However, carpet is considered a textile, and the Code has specific requirements for textile wall coverings found in section 10.2.4.
The use of textiles as wall coverings is limited to Class A provided they are used in areas protected by automatic sprinklers. It is not permitted to be used in areas that are not protected with automatic sprinklers. Newly installed textiles as wall coverings must meet the requirements of NFPA 265-1998 Standard Methods of Fire Tests for Evaluating Room Fire Growth Contribution of Textile Wall Coverings. Please check with the manufacturer of the carpet for documentation of compliance with this standard.
188.8.131.52 allows existing wall and ceiling finishes to be Class A and Class B, and in rooms with sprinklers, Class C. However, this is only limited to those materials identified in 10.2.3 which does not include textile finishes. Therefore, you are limited to Class A textiles in areas protected by automatic sprinklers. Your question indicates that this product is used in non-sprinklered areas of the facility. It appears that you will have to remove the textile cove base in those areas.
Q: We currently have a Building Maintenance Program (BMP) that surveyors said was a good program during recent surveys. However, I’ve learned that the Joint Commission no longer offers scoring advantages for a BMP, and since this program requires quite a bit of time and resources, my VP wants us to discontinue it. Are there any advantages to continuing a BMP even though the surveyors no longer will offer scoring breaks?
A: The Overview of the Life Safety Chapter to the Joint Commission 2009 Hospital Accreditation Standards manual explains the changes to the BMP. You are correct when you say they no longer offer scoring advantages for a successful BMP. However, that is not a good reason to discontinue a BMP. There are many advantages with a BMP that should not be overlooked:· A successful BMP routinely conducts inspections of critical life safety features of the facility. This is a large part of a Life Safety Assessment, which you are still required to do. · Deficiencies found during a BMP should be immediately resolved, or if they are unable to be resolved immediately, then they can be managed through the Statement of Conditions Plan for Improvement (PFI) list. This allows management of a deficiency that may not otherwise be discovered until a survey.· A BMP provides education and staff knowledge of the building’s life safety features to those individuals who perform the inspections. This translates into pride and ownership by those individuals and will pay off in years to come.· A successful BMP provides confidence for the facility manager (and the VP) that the building is in compliance with the Life Safety Code, and is ready for an inspection. My advice: If you currently have a BMP, continue it. If you do not currently have a BMP, start one.
QUESTION: It has been stated that an organization is permitted to submit either a Traditional Equivalency or a Fire Safety Evaluation System for a deficiency to a life safety feature. How do we decide when to use which one and what is the difference between them?
ANSWER: A Traditional Equivalency is a basic three-step process:
- Identify the deficiency and reference the applicable NFPA 101 Life Safety Code paragraph.
- Propose an alternative solution to the problem; include drawings showing existing conditions and the proposed solution; identify the total cost of the solution, including the source and availability of the funds; and identify when the solution will be implemented.
- One of the following individuals needs to state in writing that the proposed solution meets the intent of the code, or creates an equivalent level of safety:
- A fire protection engineer
- A registered architect
- The local AHJ over enforcement of fire safety
A Fire Safety Evaluation System (commonly referred to as FSES) is a multiple page document that places numerical values to specific life safety features of your building. It is found in NFPA 101A, Guide on Alternative Approaches to Life Safety. This document provides alternative approaches to life safety based on the NFPA 101 Life Safety Code. It is intended to be used with the Life Safety Code, not as a substitute. The Life Safety Code permits alternative compliance with the Code under equivalency concepts where such equivalency is approved by the authority having jurisdiction.
After assigning a numerical value to specific life safety features based on questions in the FSES, a sore is derived in four basic equivalency functions:
- Containment safety
- Extinguishment safety
- People movement
- General safety
If the score equals 0 or greater in each of the basic functions, then the FSES demonstrates an acceptable level of safety, and the AHJ should approve it as an equivalency.
Anyone with intimate knowledge of your facility is permitted to conduct a FSES and special degrees and licenses are not required.
QUESTION: Are fire dampers required in ductwork when the duct penetrates the walls of the same room that house the air handler? These air handlers are equipped with duct detectors that shut the air handler system down and activate the alarm system.
ANSWER: It depends on the fire rating of the wall. NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems is very clear on this issue. Fire dampers are only required in the following situations:
- When the duct penetrates a 2-hour fire rated barrier
- When the duct penetrates any fire rated vertical shaft
- When a duct terminates at a 1-hour (or greater) fire rated barrier but the airflow continues through the barrier into an open air plenum ceiling space
The need for a fire damper is a result of the fire rating of the wall. The room that you describe (air handler room) is not necessarily a hazardous room by definition, unless you also have fossil fuel-fired devices (gas-fired boilers, incinerators, water heaters, etc.). If the walls of this room are not required to be fire rated, then the ductwork does not require fire dampers.
Perhaps you are thinking about smoke dampers in regards to air handlers. Smoke damper are required to be installed in air handler systems that have a capacity greater than 15,000 cubic feet per minute. The purpose of these smoke dampers is to isolate the air-handling equipment, including the filters, from the remainder of the system in order to restrict the circulation of smoke. There are exceptions to this smoke damper requirement on air-handler units: A). on air handlers that are located on the floor that it serves and only serving that floor, and: B). When the air handler unit is mounted on the roof and only serves the floor immediately below the roof.
In these situations, the smoke dampers are not necessarily required to be mounted in the wall of the air-handler room, but just in the ductwork at the discharge of the air-handler. Remember: The purpose of the smoke dampers is to isolate the air-handling equipment from the remainder of the ductwork distribution system.
A client of mine contacted me last week and wanted to know if they could temporarily store combustibles in a patient room that is currently under renovation. Apparently the suite where the patient room is located is undergoing a facelift, involving wall coverings and floor coverings, and the patients have been relocated.
I don’t know if my answer was what they wanted to hear, but I informed them whenever combustibles are stored in a room greater than 50 square feet, the room must comply with section 184.108.40.206 of the 2000 edition of the LSC. The reason we need to follow chapter 18 instead of chapter 19 is by placing combustibles in storage in a patient room, we are now changing the use of the room, and a change in use requires compliance with chapter 18.
Section 220.127.116.11 requires all new construction to be sprinklered and Table 18.104.22.168 requires rooms that are over 50 square feet but no more than 100 square feet to have a self-closing door. For combustibles stored in a room exceeding 100 square feet the room must be sprinklered (per 22.214.171.124), have 1-hour fire rated barriers, and have a 3/4 hour fire rated self-closing, positive latching door.
What if the patient room is over 100 square feet and is not constructed to 1-hour fire rated standards, do you have to spend thousands of dollars to modify the room for temporary storage? I say no, you don’t. That’s what section 126.96.36.199 on Alternative Life Safety Measures (or Interim Life Safety Measures as some AHJs call them) is for. Conduct a risk assessment of the combustibles temporarily stored in the patient room and compare the results with your policy on ALSM (or ILSM). Implement whatever compensating measures are needed according to your policy, and document the assessment.
Make sure you do what your policy says you will do, and document all actions, and you should be OK.
Today, I was reviewing a Fire Safety Evaluation System (FSES) equivalency request on behalf of AOA/HFAP, and the requester wanted an equivalency for an interior discharging exit stairwell, because it did not discharge into an exit passageway, but discharged into a common corridor.
I sent the requester an email asking if the stairwell qualified for the three (3) conditions on Section 7.7.2 of the 2000 edition of the LSC where no more than 50% of the exit stairwells may discharge on the level of exit discharge and not have to comply with exit passageway requirements.
Their reply said no, it did not, because the stairwell discharge was positioned in such a way that the occupants would not be able to see the exit when they discharged from the stairwell.
Well, that’s not what is required by the standard. Provision #1 of 7.7.2, reads:
“Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit (stair)”
The provision says “…such way is readily visible…” it does not say the exterior (or exit) of the building is visible., but the ‘way’ to the exit is visible. This actually is a common mistake, and one that I remember making when I still worked in a hospital. It wasn’t until I was preparing an equivalency request myself and I sent it to a good friend of mine for review before I sent it to Joint Commission, and he informed me that I didn’t need to ask for an equivalency because the stairwell discharge (the one in the picture, above) qualified for the provisions under 7.7.2.
So, what did I do in regards to the equivalency request today? I denied it, of course. I informed them that the interpretation that AOA/HFAP has is there is no Life Safety Code deficiency, and therefore, there is no need for an equivalency.
Q: Regarding a recent question on access-control locks, you said the egress side of the door is required to have motion sensors and a wall-mounted “Push to Exit” button. Does it make any sense to have a card-swipe reader on the egress side of an access controlled door? Wouldn’t the motion sensor on the egress side be over-riding the card swipe reader? (Or is that the point you are trying to make?).
A: You are exactly correct… That is the point. A card swipe reader on the egress side of a magnetic-locked door is totally unnecessary, since a motion sensor and a “Push to Exit” button are required in accordance with 188.8.131.52.2 of the 2012 LSC. If you do not have the motion sensor and “Push to Exit” button then you are non-compliant. It does not make any sense to have a card-swipe reader on the egress side of a properly installed access-control lock. The card-swipe reader is indeed, pointless.
Q: Our hospital has an outpatient clinic attached via a hallway and connected to the hospital directly. When I am in the out-patient clinic you cannot hear the fire alarms going off in the hospital. Do the systems need to communicate? They are currently on 2 different systems.
A: No… the two systems are not required to communicate with each other unless the expectation is for staff at one location is to respond to fire alarms in the other location. However, it may be practical for the alarm to communicate in each other’s building, in some fashion. There may be key individuals (i.e. engineering staff, management staff, and executives) who may be in one location and if the alarm is activated in the other location, they should know about it. But this can also be accomplished using two-way radios or pagers.