Q: I have an unattached building that houses a cardiac rehab/wellness center with office space. We are converting 4900 sq ft into a day care. It is separated from the wellness center by a 2 hr fire wall. The addition will be primarily open floor plan–non sleeping—day care. Egresses meet code amount and distances. It is not sprinkled and has no smoke detection. Do I have to sprinkle the building for a day care renovation? Ch 16 is confusing to me. Any insight?
A: The answer is “It depends…”. The description that you describe is a renovation in an existing building to house a new day-care occupancy. You indicate a 2-hour fire rated barrier between this new day-care occupancy and the wellness center, which is fine, however, a 1-hour fire rated barrier is all that the Life Safety Code (LSC) requires.
Since this qualifies as new construction, Chapter 16 of the 2000 edition of the LSC is the chapter that you need to comply with. Looking at 16.3.5, that paragraph does not specifically require sprinklers for new construction. All it says is, if you have sprinklers, they must be installed according to section 9.7.
But you must consider the Construction Type requirements for this new day-care occupancy. Take a look at 220.127.116.11, and especially table 18.104.22.168. This table identifies when sprinklers are required based on the level of exit discharge and the construction type of the building. One caveat of this table allows for NO sprinklers if the entire day-care occupancy is on the level of exit discharge. Does this sound like your situation?
22.214.171.124 also describes the need for smoke compartment barriers in certain situations when the day-care occupancy is located above the level of exit discharge. 16.3.4 also requires a fire alarm system installed according to section 9.6 and paragraph 126.96.36.199 requires smoke detectors in corridors, in front of stairwell doors, in lounges, recreation areas, and sleeping rooms.
As always, check with your local and state code officials for additional requirements.
Q. Is there a Life Safety Code requirement to post “No Smoking” signs on patient room doors where oxygen is being administered? Our Respiratory Care department insists on posting No Smoking signs on the door frame for every patient that is currently being administered oxygen.
A: Section 188.8.131.52 (184.108.40.206 for new construction) of the LSC requires compliance with NFPA 99 Health Care Facilities (1999 edition) where medical gas is being administered. Section 8-6.4.2 of NFPA 99 requires precautionary signs advising no smoking adjacent to doorways or walls where oxygen is being administered. However, the exception to this standard states that no smoking signs are not required in health care facilities where smoking is prohibited. Currently, The Joint Commission standards prohibit smoking in hospitals except for specific patient circumstances. If your organization permits patient smoking in specific circumstances, then the No Smoking signs will have to be installed where oxygen is being administered. Also, check your organization’s policies about no smoking signs. If a policy requires the No Smoking signs to be in place, then you must have them, regardless what exceptions NFPA 99 offers.
Q: Does the Life Safety Code specify if we have to lock up our sterile scalpels in the same way that our syringes are locked? I have looked everywhere on the Joint Commission website and in their standards but cannot find anything that would relate to this question. I even looked up on OSHA but they just discuss used syringes or scalpels where I am looking at how to store “clean” or sterile scalpels.
A: In regards to the sterile scalpels, I am not aware of any LSC or standard that says they must be kept under lock and key. But you raise a good point: If you lock up syringes, why not scalpels…?
The reason you lock up syringes is to keep them out of unauthorized hands. The Joint Commission would expect you to conduct an assessment to determine the probable risk of these syringes ending up in the hands of the wrong people. Even though they do not list scalpels specifically, an assessment is expected from both the safety perspective and the security perspective. You need to determine what the risk is of an unauthorized individual having access to the sterile scalpels and either harming themselves or others. If it is a medium or high risk, then locking them would be appropriate. If it is a low or non-existent risk, then locking them may not be necessary.
You get to decide on whetehr or not you lock them up based on your risk assessments. Once a risk assessment is made, I strongly recommend that it be reviewed and approved by your safety commttee. That way, a multi-disciplinary group has reviewed the assessment and either agree or disagree with the suggested outcome. It is also in the minutes of the meeting, which is proof positive that the assessment was conducted.
Q: What is the requirement in time that a fire alarm needs to be transmitted to the fire department? Our fire alarm communication automatic dialer takes nearly 3 minutes to transmit an alarm to the monitoring company, and we are concerned this is too long.
A: Section 19.3.4 (18.3.4 for new construction) of the LSC requires the fire alarm system in the hospital to comply with section 9.6, which in turn requires the fire alarm system to be installed, tested and maintained according to NFPA 72 National Fire Alarm Code (1999 edition). Section 5-220.127.116.11.4 of NFPA 72 requires the digital transmitter (automatic dialer) to communicate with the digital receiver at the monitoring company in no more than 90 seconds. NFPA 72 requires the transmitter to retry a minimum of 5 times and a maximum of 10 times if the dialer fails to communicate with the receiver. Each retry is only allowed 90 seconds as well. According to 5-18.104.22.168 and A.5-22.214.171.124 the time to transmit the alarm signal from the monitoring company (central station) to the local fire responding unit (fire department) also is 90 seconds. You may be cited by an AHJ if the signal transmission process takes more time than allowed.
Q: During a recent inspection, our fire marshal said the 5-year standpipe water-flow test is required to have at least 500 gallons per minute (GPM) at the roof. We are not aware of this, and cannot find this requirement in the Life Safety Code (LSC). Are we required to have a minimum of 500 GPM flow from our standpipe system on our roof?
A: NFPA 14 Standard for the Installation of Standpipe, Private Hydrant, and Hose Systems is the standard for the installation of standpipe systems. NFPA 14 requires a specific pressure (PSI) and gallons per minute (GPM) that must be met for new standpipe systems when the water is flowed at the hydraulically most remote location. Depending on which version of NFPA 14 you were required to comply with at the time of the installation, the requirement may differ.
The LSC specifies that you must maintain your standpipe systems according to NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. In regards to standpipe systems, it requires a flow test every 5 years at the hydraulically most remote location (usually the roof) to verify the water supply still provides the design pressures and flow requirements at the time of installation. NFPA 25 does not specify what pressures and flow you need to meet, just that you must meet what was required when the system was installed. NFPA 14 has different pressure and flow requirements based on the edition of the standard, and the classification of the standpipe system. Based on these parameters, it is entirely possible that you would have to meet a 500 GPM flow requirement. To be sure, determine what classification your standpipe system is and refer to the appropriate edition of NFPA 14 for the design requirements. This information may also be found on your original acceptance records.
Q: Our existing hospital has an old smoke control system [not associated with an atrium] that was originally designed to remove smoke from the hospital. This system was code compliant some years ago but this requirement was later [circa 1980] removed from the local building code. The smoke removal fan system was later abandoned and is no longer used as designed. The abandoned smoke control fan system is only within a small portion of the existing hospital. The hospital is considering removing it so it does not need to continue to maintain it.
A set of drawings would be produced and we would obtain the local building department approval prior to removal of the smoke control fan system. What other approvals should I obtain before proceeding with the removal of this system?
A: Chapter 18 (for new occupancy) of NFPA 101-2000 does not require engineered smoke control systems, and section 4.6.7 of the LSC does not require you to maintain a system that is not required by the new occupancy chapter. However, most state licensing regulations have additional requirements that are not part of the LSC, and you should check with your state authorities to see if they have a concern with this action. Check with your property insurance company as they may count of the engineering smoke control system in the calculation of your premium rate. You should also review all the equivalencies or variances granted by your AHJ, looking to see if the smoke control system was identified in their acceptance. If so, then you can not remove the smoke control system without re-addressing the issues identified in the equivalencies or variances.
Q: The hospital I work for recently completed its sprinkler upgrade and wants to reduce maintenance by removing some fire and smoke dampers in the walls. What is the procedure for removing fire and smoke dampers within these walls? May we just permanently prop-open the wall dampers and leave them in place or should those dampers be removed since they no longer function as fire safety devices.
A: First let’s look at the requirement for smoke and fire dampers. NFPA 101-2000 LSC, section 9.2.1 requires HVAC ductwork to comply with NFPA 90A, which specifies when fire dampers are required. Generally speaking, fire dampers are only required in 2-hour fire rated walls or greater, or in any fire rated vertical shaft wall. They are not required in 1-hour fire rated walls with fully ducted systems on both sides of the rated wall, and they are not required in non-rated walls. Therefore, in this situation, it is permissible to remove them.
Section 126.96.36.199 for existing construction (and section 188.8.131.52 for new construction) has an exception that says smoke dampers are not required in smoke compartment barriers with fully ducted HVAC systems in smoke compartments protected with sprinklers. Therefore, it is permissible to remove smoke dampers from fully ducted HVAC systems in smoke compartments protected with sprinklers.
Your question asks what the procedure is to remove these dampers. It has always been my position to actually remove the dampers entirely and repair the ductwork. This would be considered “best practice” as it eliminates the dampers from being mistaken for devices that are supposed to work and be tested. However, many Authorities Having Jurisdiction (AHJ) will accept a damper that is no longer required to be in the wall, to be disabled and secured in the open position. If you choose to go this route, I would suggest you add a sticker on the outside of the damper identifying that it is no longer in service and is disabled.
Q: We had a mock survey recently and the life safety surveyor indicated that the lab — because it is a hazard area — is required to have all the doors closed to corridors. He said approved hold-open devices don’t count. But we use approved hold-open devices on some of our lab doors. If we are sprinklered and we have door hold-open devices, are we are good to go?
A: Laboratories are required to be treated as hazardous areas if they contain flammable materials in quantities less than what would be considered a severe hazard (NFPA 101-2000 184.108.40.206 LSC). If the lab contains flammable materials in quantities considered to be a sever hazard, then they still need to be treated as hazardous rooms with fire rated walls (per NFPA 99). Any way you look at it, the door to the lab is required to have a closure and positive latching as a hazardous room door.
Section 220.127.116.11.6 permits any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure to be held open by an automatic releasing device that complies with 18.104.22.168.2. The automatic sprinkler system and the fire alarm system in your building must be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. This means if you have approved hold-open devices that are connected to the fire alarm system on the lab doors, and they release the door when the fire alarm system is activated, then you qualify to have these devices. The fact that your facility is sprinklered does not have any bearing on this subject.
It appears to me that your scenario of approved hold-open devices connected to the fire alarm system meets the requirements of Life Safety Code.
Q: Our nursing home facility has the required sprinklers inside the facility, but management wants to move boxes of charts to the back yard/parking lot area into a locked and secure metal storage building, which will be large enough to walk inside and store boxes on shelving built along the walls. Is it a requirement for on-site storage areas to have sprinklers?
A: Nursing homes are required to comply with the NFPA 101-2000 Life Safety Code (LSC), according to paragraph 483.70 of the CMS Conditions of Participation. An auxiliary structure to house records and paperwork is not required to be protected with automatic sprinklers, according to the LSC, provided it meets one of the following requirements:
- The structure is not physically attached in any way to the nursing home, or
- The structure is separated from the nursing home by a 2-hour fire rated barrier.
The new storage structure should be classified as a Business Occupancy or Storage Occupancy. Neither of these two occupancies has a requirement for the installation of automatic sprinklers for new construction. The Omnibus Budget Reconciliation Act of 1987 (OBRA) is the congressional mandate for nursing home reform, and the OBRA surveys focus on the level of care provided to each resident. This act does not address the requirement for automatic sprinklers in storage facilities. While automatic sprinklers are a wise investment for any facility, it does not appear that you would have to install them for the purpose of storing boxes of charts, under the current CMS requirements. As always, make sure you check with your local and state authorities for any requirement that they may have.
Q: How do I know which edition of the NFPA 101 Life Safety Code I should be following? I see you refer to the 2000 edition many times, but shouldn’t I follow the most recent edition?
A: In March, 2003, the Centers for Medicare and Medicaid Services (CMS) adopted the 2000 edition of the LSC, which was a significant improvement as previously they were still recognizing the 1985 edition. Subsequently, other accreditation organizations with deeming authority, such as The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP) and Det Norske Veritas Healthcare Inc. (DNV) have also adopted the 2000 edition and have stated they will wait until CMS adopts a more recent edition before they do so as well. CMS has indicated that they may adopt a more recent edition of the LSC as early as the year 2012.
There are other organizations that have adopted more recent editions of the LSC, such as the Veterans Administration (VA) and various state and local governments. Depending on your location and who your Authorities Having Jurisdiction (AHJ) are, you may have to comply with a more recent edition. If that is the case, you may petition The Joint Commission and CMS for permission to comply with a newer version.
Q: During some research in the area around our main security control room, we discovered that two of the walls are constructed with wood framing. Our facility is fully sprinklered and comprises of two-stories; however this section of the hospital is single-story. Does the wood framing need to come out or is it of such a limited quantity that it doesn’t matter?
A: The answer to your question is: It depends entirely on the construction type of your facility. If it is a Type I or a Type II construction, then this is a problem as wood framed interior walls are not permitted for Type I or Type II construction. If your facility is classified as Type III, Type IV or Type V construction, then the interior wood framed wall may be permitted based on the rating of fire protection on load bearing walls, columns, beams, trusses, and floor assemblies.
According to the Life Safety Code (LSC), paragraph 22.214.171.124 for existing construction (and 126.96.36.199 for new construction) refers to section 8.2.1, which is based on NFPA 220 Standard for Types of Building Construction. NFPA 220 goes into detail defining what each construction type is, and the required fire rating of the load bearing walls, columns, beams, trusses and floor assemblies. In the LSC, table 188.8.131.52 lists the approved construction types for existing construction, and table 184.108.40.206 lists approved construction types for new construction. Review the fire rating requirements for each construction type to determine if your hospital complies with any of them. If you determine that your facility complies with two different construction types, you will need to separate them with a 2-hour fire rated barrier.
If you determine that the construction type that you have does not permit the wood framed interior walls, here are some options to resolve this problem:
- Physically remove the wood frame walls and replace with non-combustible or limited combustible materials.
- For existing construction, re-classify this area as either Type III, Type IV or Type V construction (depending on how you meet the fire rating requirements) and constrct a 2-hour fire rated barrier separating the different construction types. However, it may not be feasible to upgrade existing walls in the facility to create a 2-hour fire rated barrier.
- If the removal of the interior wood framed walls is considered an unreasonable hardship, then an equivalency should be explored, such as a Fire Safety Evaluation System (FSES).
You need to manage this deficiency by assessing it for interim life safety measures (ILSM), and placing it on your Statement of Conditions PFI list.
Q: Is there a maximum time required for doors to automatically close? This question came up in a recent department meeting and we cannot find any code reference that specifies how quickly a door must close.
A: It depends if the door is a swinging type or sliding type. The LSC and NFPA 80 Fire Doors and Fire Windows (1999) does not specify the amount of time that a closure must close a swinging door, whether it be for a fire rated door or a non-fire rated door. However, section 4-4.1.1 and 4-4.1.2 of NFPA 80 requires horizontal sliding doors to have a delay of no more than 10 seconds in the initiation of the closing, and the average speed of the closing must be between 6 and 24 inches per second. I suggest you ask your local AHJ if they have a requirement other than NFPA that addresses this issue.
Q: In our hospital, we have smoke compartment doors in the corridor that are held open with magnetic hold-open devices. When the fire alarm system is activated, the magnetic devices release and the doors automatically close. Are we required to have smoke detectors located within 5 feet of these doors, even though the smoke compartments on either side of the doors are fully protected with smoke detectors?
A: The Life Safety Code (2000 edition) requires your fire alarm system to be in compliance with section 9.6 which further requires compliance with NFPA 72-1999 National Fire Alarm Code. Section 2-10.6 of the National Fie Alarm Code states that smoke detectors that are part of an open area protection system that is covering the room, corridor or enclosed space on each side of the smoke door and that are located and spaced according to NFPA 72-1999, section 2-3.4, shall be permitted to accomplish smoke door release service. Therefore, if your smoke detectors actually meet the spacing requirements found in 2-3.4 on both sides of the smoke door, then you do not need to have a smoke detector mounted within 5 feet of the door to release the door in the event of an alarm.
Q: We have a large hospital with over 1.5 million square feet. We are fully sprinkled and would like to remove our occupant use fire hoses. It has been determined that we will not use these fire hoses in the event of fire, and the local fire department will not use them either. I have asked the Fire Marshal in our city for a letter granting permission to remove them and he refused stating he cannot find a standard allowing a hospital to remove fire hoses. My question is: Do we need his blessing to remove the hoses or can we do so without his permission?
A: The Life Safety Code only requires standpipe systems for new high-rise hospitals, according to section 18.4.2 of the LSC. That refers you to section 11.8, where section 220.127.116.11 requires a Class I standpipe system for new high-rise buildings in accordance with section 9.7. Section 18.104.22.168 requires a standpipe system and a 2½ inch hose connection compliant with NFPA 14, to supply water for use by fire departments and those trained in handling heavy fire streams. Class I standpipe systems do not require the installation of fire hoses of any size or intended use.
For all other hospitals that are not considered new high-rise buildings, standpipe systems (and occupant use fire hoses) are not required by the LSC. Removing existing occupant use fire hoses constitutes an alteration of the building and/or fire safety equipment, and section 4.6.7 requires alterations to meet the requirements for new construction. Therefore, from a NFPA Life Safety Code perspective, the existing occupant use fire hoses could be removed since they are not required for either new or existing. However, that alone does not give you the authority or permission to remove them.
A local Authority Having Jurisdiction (AHJ), such as a city Fire Marshal has the responsibility to inspect your facility to all applicable codes, standards and ordinances. Your municipality may have higher standards than what is required by the Life Safety Code. My advice is to negotiate with the Fire Marshal and show them that the Life Safety Code does not require the occupant use fire hoses. In other words, it is far better to keep the fire hoses and test or replace them every 3 – 5 years than to upset the Fire Marshal and make an enemy. I think in the long run you will be better served to keep that person as a friend.
Q: Is it permitted to have a time clock in an exit stairwell of a hospital? My VP of Operations wants to install time recording stations in stairwells where employees will have to record their time. Our hospital is over 30 years old and is fully sprinklered.
A: Section 19.2.1 of the Life Safety Code (LSC) 2000 edition refers to Chapter 7 for means of egress requirements. Section 22.214.171.124.1(e) prohibits penetrations and opening into an exit enclosure (stairwell) unless it serves the stairwell. The addition of new time clocks would not meet the definition of “serving the stairwell”. If electrical cable, wires or conduit is needed to operate the time clock, then this section alones prohibits you from installing it in the stairwell.
If the time clock is a wire-less device then section 126.96.36.199.3 states that no open space within the stair enclosure may be used for any purpose that has the potential to interfere with egress. The annex section of the LSC explains an example of interference with egress is storage. Here is one way to look at this: If a person is inside the stairwell and standing in front of the time clock attempting to “punch” in or out, and it interferes with another person trying to exit, then that interferes with egress, and the time clock would not be permitted. This is basically a judgment call as to whether or not the time clock is interfering with egress, but the Authority Having Jurisdiction (AHJ) is ultimately the one who makes this decision. I suggest that you take a conservative approach on this issue. Discuss it with your local AHJ and your safety committee for their opinions.