HealtHcare life Safety compliance - HCPro there a national standard for fire watch requirements other than NFPA 241? October 2008 Vol. 10, No. 10 The newsletter to assist healthcare

Beware of fire door troubleWatch for latching and label deficiencies

In the September Healthcare Life Safety Compli-

ance, we wrote about fire barriers as a fundamental meth-

od of protecting facilities.

Fire barriers enclose a room, stairwell, or other space

with fire-rated construction. They also separate build-

ings of different construction types (e.g., a wall between a

hospital and an attached medical office building). Section

8.2.3 in the Life Safety Code® (LSC) runs down the general

provisions for fire barriers.

One concern not addressed in our previous article is

fire doors, which protect openings within fire barriers.

These doors generally must:

Be installed and maintained in accordance with NFPA

80, Fire Doors and Fire Windows

Be self- or automatic-closing and self-latching

Have a fire protection rating as outlined in 8.2.3.2.3.1

of the LSC

Feature a legible label on the door frame

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The need for a label isn’t merely for formality’s sake,

said Keith Pardoe, DAHC, CDC, director of education

and certification at the Door and Hardware Institute in

Chantilly, VA.

“Labels on doors and frames contain a lot of informa-

tion,” said Pardoe,

who spoke at the

NFPA’s World

Safety Confer-

ence in Las Vegas

in June. Labels in-

dicate the ratings of doors, their temperature rises, and

necessary hardware for the door.

Also, without a label, the rating of a fire door is techni-

cally void, which is an issue Joint Commission (formerly

JCAHO) surveyors and other inspectors will check on.

For that reason, authorities appreciate having a label

that can easily be seen and read on a fire door, said Jeff

Turcotte, vice president at Intertek ETL SEMKO in Box-

boro, MA, who also spoke at the NFPA conference.

Doors are used and abused

The most common type of fire door you’ll find in

healthcare facilities is a swinging door with builders’

hardware attached (i.e., door knob, hinges, etc.), said

Pardoe.

And that type of door encounters constant use: Peo-

ple might open and close it 1,000 times per day, subjecting

it to constant wear and tear.

Thus, NFPA 80 requires facilities to maintain fire doors.

That’s a problem in healthcare and other industries, be-

cause contractors and facilities crews haven’t historically

installed or maintained fire doors properly, Pardoe said.

The 2000 edition of the LSC references the 1999 edi-

tion of NFPA 80; Chapter 15 in NFPA 80 discusses mainte-

nance concerns. Note that the chapter applies to new and

Without a label, the

rating of a fire door is

technically void, which is

an issue Joint Commission

surveyors will check on.

> continued on p. 2

IN THIS ISSUE

p. 4 Life safety notebookA Joint Commission engineer offers thoughts on creating a life safety committee, expanded building tours, and new notes for your Statement of Conditions.

p. 5 State criticizes hospitalMinnesota investigators found a hospital didn’t follow its own policies on preventing surgical fires, which allegedly led to a patient being burned.

p. 6 Life safety violationsThe following deficiencies were noted at a facility during inspections by the Minnesota Department of Health.

p. 9 Cracking the CodeIn this month’s column, learn about the critical requirements applicable to limited access trash and linen chutes.

p. 10 Questions & AnswersIs there a national standard for fire watch requirements other than NFPA 241?

October 2008 Vol. 10, No. 10

The newsletter to assist healthcare facility managers with fire protection and life safety

HealtHcare life Safety compliance

Page 2 Healthcare Life Safety Compliance October 2008

© 2008 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

existing door installations, Pardoe said. The 1999 edi-

tion of NFPA 80 doesn’t mandate the frequency of fire

door inspections. However, the 2007 edition of NFPA

80, which has been retitled Fire Doors and Other Opening

Protectives, requires that these doors undergo annual in-

spections and testing.

Checklist can help you inspect

The most recent edition of NFPA 80 offers the follow-

ing list of 11 items to review during fire door inspections:

Fire door < continued from p. 1

A fire door or frame is free of open holes or breaks

in its surface

Any glazing and vision light frames are intact

A door, frame, hinges, hardware, and threshold are

secure, properly aligned, and in working order

No parts of a door are missing or broken

Door clearances meet limits referenced in sections

4.8.4 and 6.3.1

The self-closing device works properly

An inactive door leaf closes before an active one

Latches work properly

Auxiliary items allow a door to operate properly

There are no field modifications to the door, which

will void the door’s label

Gaskets and edge seals are present when required

Joint Commission life safety specialists are aware of the

above objectives, and during a survey they might confirm

that a sampling of fire doors complies with NFPA 80 (the

diagram on p. 3 illustrates typical deficiencies that affect

fire doors).

Certification trend is afoot

Although NFPA 80 doesn’t require certified individuals

to conduct fire door inspections, there is some movement

to promote the benefits of certification, Turcotte said.

Intertek is among several organizations developing in-

dependent, third-party certification criteria for fire door in-

spectors. Underwriters Laboratories is also exploring fire

door inspection certification, Pardoe said. As with any cer-

tification process, door inspections through an indepen-

dent review may give authorities more confidence that a

door is indeed up to specifications.

Beyond independent certification, consider these final

two suggestions for fire door monitoring:

Make the doors part of a formal maintenance

program

Encourage staff members to report potential door

problems to the facilities department n

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Editorial Advisory Board Healthcare Life Safety Compliance

Group Publisher: Bob Croce, [email protected]

Sr. Managing Editor: Scott Wallask, [email protected],

781/639-1872, Ext. 3119

Contributing Technical Editor: James K. Lathrop

Vice President

Koffel Associates, Inc.

Niantic, CT

James R. Ambrose, PEPrincipalCode Consultants, Inc. St. Louis, MO

Frederick C. Bradley, PEPrincipalFCB Engineering Alpharetta, GA

Michael Crowley, PESenior Vice President, Engineering ManagerRolf Jensen & Associates, Inc. Houston, TX

Joshua W. Elvove, PE, CSP, FSFPEFire Protection EngineerAurora, CO

A. Richard FasanoManager, Western OfficeRussell Phillips & Associates, LLC Elk Grove, CA

Brad Keyes, CHSPSafety ConsultantThe Greeley Company Marblehead, MA

Burton Klein, PE PresidentBurton Klein Associates Newton, MA

Peter LeszczakNetwork 3 Fire Protection EngineerU.S. Department of Veterans Affairs West Haven, CT

David MohilePresidentMedical Engineering Services, Inc. Leesburg, VA

Daniel J. O’Connor, PEVice President, EngineeringSchirmer Engineering Corporation Deerfield, IL

Thomas SalamoneDirector of Healthcare EC ComplianceAKF Engineers Yonkers, NY

William Wilson, CFPSFire Safety CoordinatorWilliam Beaumont Hospitals Royal Oak, MI

Healthcare Life Safety Compliance (ISSN: 1523-7575 [print]; 1937-741X [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA, 01945. Subscription rate is $289 for one year and includes unlimited telephone assistance. Single copy price is $25. Healthcare Life Safety Compliance, P.O. Box 1168, Marblehead, MA 01945. Copyright © 2008 HCPro, Inc. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax: 800/639-8511, or e-mail: [email protected]. Occasionally, we make our sub-scriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of HLSC. Mention of products and services does not constitute endorsement. Advice given is general and based on National Fire Protection Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Infor-mation should not be construed as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter or otherwise. Advisory Board members are not responsible for information and opinions that are not their own.

October 2008 Healthcare Life Safety Compliance Page �


Typical deficiencies affecting fire door performance

This diagram illustrates common deficiencies found on or near fire doors.

Improper gaps around the perimeter

of a door in its closed position

Open holes from old

hardware that has

been removed

Door latches that are

missing or don’t work

properly

Fire exit hardware

installed on a door

that isn’t labeled for

this hardware

A door propped open for

convenience

Painted over or missing fire door labels

Other potential deficiencies for fire doors include the following:

Improperly adjusted door closer

Auxiliary hardware (e.g., deadbolt) that interferes with a door’s function

Area surrounding a door assembly blocked by furniture, equipment, or boxes

Missing or incorrect fasteners, which could affect hardware function

Bottom flush bolts that don’t project a ½ inch into a strike plate

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Sources: Keith Pardoe, DAHC, CDC, director of education and certification at the Door and Hardware Institute, Chantilly, VA, and Fire

Safety in Healthcare Facilities (2000 edition), published by the NFPA. Illustration by HCPro, Inc.

Page � Healthcare Life Safety Compliance October 2008


Life safety notebook

Consider forming a life safety committee soonEditor’s note: We culled the following notebook items from

presentations by George Mills, FASHE, CEM, CHFM, senior

engineer at The Joint Commission, who spoke at the NFPA’s

World Safety Conference in June in Las Vegas and the Ameri-

can Society for Healthcare Engineering’s annual conference in

July in National Harbor, MD.

New committee idea raised

With the new life safety standards coming on January

1, 2009, it might be a good idea for facilities to take those

concerns beyond their traditional safety committees.

Mills suggested facilities establish a life safety commit-

tee to emphasize the new standards.

Members of the life safety committee would ideally

interact with the safety committee and the emergency

management committee (if one exists), he added.

However, The Joint Commission (formerly JCAHO)

doesn’t require a life safety committee.

Building tours might expand again

Mills proposed to Joint Commission leaders that hos-

pitals with 1.3 million square ft. or more of inpatient

area host life safety specialists for three days.

Currently, life safety specialists use the following

schedule:

Two days for hospitals with 750,000 square ft. or

more of inpatient area

One day for hospitals with less than 750,000 square

ft. of inpatient area

The change to three-day life safety tours could come

as early as this year if the plan is accepted, Mills said.

New mandates bookmarked for 2010

When The Joint Commission published its 2009 stan-

dards, its long-standing intent was to avoid complicating

the changes by adding a variety of new requirements. That

makes 2010 the next year new mandates will come into

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play. One of the topics up for discussion in 2010 is all

unannounced fire drills, Mills said. Currently, under

EC.5.30 (which will become EC.02.03.03 in 2009), fa-

cilities must conduct at least half of their drills unan-

nounced, meaning participants won’t be aware of the

exercises ahead of time.

If The Joint Commission moves to all unannounced

drills, it will be more in line with rules set forth by the

Centers for Medicare & Medicaid Services, Mills added.

BBI now notes state actions

Be sure to note a new section on the electronic State-

ment of Conditions’ basic building information (BBI) that

tracks whether a state or local government has imposed

life safety restrictions on your facility.

For example, during lengthy droughts, states might

ask facilities to forgo required flow tests for fire pumps,

Mills said.

The BBI now asks facilities managers to note any state

restrictions, and managers must explain these restrictions

in detail in the BBI’s additional comments section.

When a state or local government lifts a restriction, fa-

cilities should strive to complete any missed testing within

30 days or at the scheduled test frequency if that occurs

sooner than 30 days, Mills said.

Old firestopping needs a close eye

Facilities can continue to use older firestopping

material (e.g., mineral wool) to seal fire and smoke

barrier penetrations as long as the material remains

undisturbed.

Mineral wool isn’t a current firestopping techno-

logy, but if it’s intact and in good condition, it still

works, Mills said.

However, if mineral wool is removed or otherwise

in poor shape, facilities crews or contractors need to

fill the penetration with a current, approved firestop-

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State rebukes hospital about burned surgical patientStaff members failed to follow cautery and draping policies

Minnesota’s Department of Health found a hospital

didn’t follow its own policies on preventing surgical fires,

which allegedly led to a patient being burned during

surgery.

On June 24, a physician at Abbott Northwestern Hos-

pital in Minneapolis was preparing to put a pacemaker in

the patient’s chest and was using a cautery device. The

patient was under conscious sedation.

Flames appeared, burning the drapes, nasal cannula,

and the patient’s lip, nose, and left shoulder, according

to an investigation report provided by the state. Surgical

team members quickly removed the drapes and cannula

and extinguished the fire.

The physician completed the procedure, and the pa-

tient was subsequently transferred to the ICU before

eventually being released.

The state concluded the following:

The surgical team failed to follow Abbott Northwest-

ern’s surgical fire prevention plan by not properly

draping the patient to allow oxygen to vent away

from the patient’s face

The team didn’t adhere to the facility’s electrocautery

policy, which calls for placing cautery devices in hol-

sters when not in use during surgery

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“It is not within the scope of our work to determine

the cause of the fire, so we did not determine whether

the cauterizer provided the heat that started it,” says

Darcy Miner, director of compliance monitoring at the

Minnesota Department of Health. “We did note, however,

that hospital procedures were to holster the cauterizer

when not in use, and this was not done each time.”

The root of surgical fires is constant, as they require:

A fuel (e.g., draping material, gauze, or plastic)

Heat (e.g., from a cautery device or laser)

An oxidizer (e.g., pooled oxygen)

Oxygen doesn’t burn, but at certain concentrations

it promotes burning and can contribute to surgical fires.

“While we do not yet know definitively the cause of

this incident, it appears likely to be related to oxygen

pooling and [then] accelerating a spark from the elec-

tocautery equipment,” according to a statement from

Abbott Northwestern provided by Timothy Burke, PR

manager. Involved staff members received refresher ed-

ucation about preventing surgical fires, and the hospital

has stopped performing pacemaker procedures in the op-

erating room in question until better draping equipment

can be purchased. n

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Cause of a bassinet fire still undetermined

The investigation continues into a bassinet fire that in-

jured a newborn in January.

The infant was in an open-topped bassinet under a warm-

er and was using an oxygen hood when something ignited.

Nurses attending to the infant quickly extinguished the flames.

The March Healthcare Life Safety Compliance covered

the incident in detail.

The hospital hired ECRI Institute of Plymouth Meeting, PA,

a nationally known healthcare research firm, to look into

the causes of the fire. ECRI Institute is still reviewing the fire

and digging through past records of bassinet and warmer

incidents.

The infant survived the fire but suffered burns of varying

degrees on 17% of his body, according to a report provided

by the Minnesota Department of Health, which also investi-

gated the incident.

The state didn’t reach any conclusions about how the fire

started and it found the facility properly completed preven-

tive maintenance on the equipment prior to the incident.

State investigators took a full tour of the building during

the inspection and found several Life Safety Code® violations

(see “Life safety citations noted during a hospital inspection”

on p. 6). These violations weren’t related to the bassinet fire,

according to the report.

Page � Healthcare Life Safety Compliance October 2008


Life safety citations noted during a hospital inspection

The following life safety deficiencies were noted at Mercy

Medical Center in Coon Rapids, MN, during inspections by

the Minnesota Department of Health in January and February.

The state provided this information. Mercy Medical undertook

the solutions mentioned below, which the state included in

the inspection report. Noted NFPA references come from:

NFPA 13, Installation of Sprinkler Systems

NFPA 25, Inspection, Testing, and Maintenance

of Water-Based Fire Protection Systems

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NFPA 70, National Electrical Code

NFPA 72, National Fire Alarm Code

NFPA 99, Healthcare Facilities

Life Safety Code® (LSC)

K-tags refer to violation categories in the Centers for Med-

icare & Medicaid Services’ (CMS) Fire Safety Survey Report

(form CMS-2786). The deficiencies stem from section 482.41

of CMS’ Conditions of Participation.

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Problems K-tags NFPA references Solutions from hospital

Corridor wall not smoke tight

because of the presence of a

transfer grill

K17 LSC: 19.3.6.1,

19.3.6.2.1, and

19.3.6.5 (corridor

separation and

construction)

Removed the transfer grill and repaired the wall

Two out of 63 inspected stairway

doors didn’t latch properly

K20 LSC: 8.2.5.6 and

19.3.1.1 (protection

of vertical openings)

Repaired one of the doors in question (the other

door latched when the hospital retested it)

Monitoring door latching through a building

maintenance program*

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In three instances from February

2007 through January 2008, staff

members failed to pull the fire alarm

box or notify hospital security during

fire drills or an actual fire

K48 LSC: 19.7.1.1 (written

emergency plan)

Re-educated staff members in a birth center

about the need to pull the fire alarm and alert

security for all fires, even those quickly extinguished

Conducted a fire drill in a birth center

Held fire safety presentations before a leaders’

and employees’ forum

Required workers who didn’t attend the employ-

ees’ forum to view a DVD of the presentation

Published fire safety articles in the hospital’s

internal newsletter

Required employees to complete an electronic

training module about fire safety

Created a new exercise in the hospital’s online

annual competency training about the impor-

tance of pulling the fire alarm and alerting secu-

rity during a fire

Added a question to the fire drill debriefing form

asking whether staff members pull the fire alarm

and alert security during a fire

Began monthly audits of fire safety procedures

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Problems K-tags NFPA references Solutions from hospital

Revised new employee orientation to highlight

the importance of fire safety

Redistributed badge buddy safety cards with

information about various emergency responses

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Day shift fire drills during the prior

12 months all occurred between

9:16 a.m. and 10:16 a.m., instead

of at varied times

K50 LSC: 19.7.1.2

(quarterly fire drills)

The 2008 fire drill schedule reflects varied times

for drills

Safety manager stressed the importance of varied

drill times to staff members during two meetings

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A smoke detector wasn’t secured

to its base in one location

A smoke detector was improperly

placed within 3 ft. of an air diffuser

in one location

A fire alarm contractor noted four

smoke detectors had indicating

lights that didn’t work

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K52 LSC: 9.6.1.4

(fire alarm systems);

NFPA 70; NFPA 72

Attached the smoke detector to its base

Relocated the smoke detector to the required

distance from the air diffuser

Ordered and installed smoke detector indicating

lights

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Equipment in a basement blocked

a sprinkler controller for a preac-

tion system

Sprinkler was missing a deflector

in one location

A closet in a computer training

lab didn’t have a sprinkler in it

Ceiling tiles were missing in three

locations

A sprinkler hung more than

12 inches below the ceiling slab

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K62 LSC: 4.6.12 and 9.7.5

(sprinkler system main-

tenance and testing);

NFPA 13; NFPA 25

Cleared equipment blocking the sprinkler

controller

Monitored sprinkler access through hazard

surveillance rounds

Installed missing sprinkler deflector

Installed sprinkler in the closet

Replaced missing ceiling tiles

Corrected the distance the sprinkler hung

below the ceiling

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Emergency generators didn’t have

manual stop switches outside the

generator room

Emergency generators didn’t have

remote alarm panels outside the

generator room

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K106 NFPA 99 Approved a capital project request to install the

manual stop switches and remote alarm panels

Four elevators didn’t have the

required firefighter recall service

K160 LSC: 9.4.3.2

and 19.5.3

Approved a capital request to upgrade the elevators

to phase II firefighter recall service **

* The building maintenance program is a Joint Commission approach that CMS doesn’t recognize, although the program is a useful

maintenance tool.

** For more details about elevator recall requirements, see the January Healthcare Life Safety Compliance.



Retrofitting sprinklers will cost nursing homes $8�� millionAffected facilities have until August 2013 to get the work done

The five-year phase-in period established by the Cen-

ters for Medicare & Medicaid Services (CMS) for nursing

homes to install sprinklers has started a clock ticking for

a variety of work, all of which will cost hundreds of mil-

lions of dollars. CMS says 2,446 of the country’s 13,391

nursing homes do not have full sprinkler protection, ei-

ther because they lack equipment outright or only have

partial sprinkler coverage.

After hinting about the publication of the long-await-

ed nursing home sprinkler regulation in a press release

in June, CMS formally released the rule on August 13

in the Federal Register.

Rundown of the CMS rule

The provisions of the regulation include the following:

All nursing homes with sprinkler protection have un-

til August 13, 2013, to retrofit such equipment into

their buildings

All nursing homes must maintain, inspect, and test

their sprinkler systems in accordance with NFPA 13,

Installation of Sprinkler Systems, and NFPA 25, Inspec-

tion, Testing, and Maintenance of Water-Based Fire Protec-

tion Systems

As of August 13, 2013, CMS will no longer require

nursing homes to install and maintain battery-operat-

ed smoke alarms in resident rooms and common ar-

eas (e.g., dining, activity, and meeting rooms)

The last bullet about smoke alarms went into effect

in 2006 only for nursing homes without sprinklers or

hardwired smoke detection systems. The provision off-

set some of the risks those facilities shouldered without

sprinkler protection.

Phase-in needed for work

CMS believes the five-year phase-in period will give

nursing homes enough time to complete the following

activities necessary for sprinkler retrofitting:

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Allocating funds to pay for the work

Hiring a sprinkler system designer and installation

contractor

Ordering and purchasing sprinkler system

components

Completing necessary permits

Installing the equipment

“A five-year phase-in period balances our dual goals

of improved fire safety and feasibility,” CMS said in the

final rule.

The work will cost affected nursing homes $846.6

million during the phase-in period (see “Nursing home

sprinkler costs” below).

Some nursing homes will have difficulty obtaining

funds for the retrofits without financial assistance, said a

spokesperson for the American Health Care Association

(AHCA), which represents nursing, assisted living, and

disabled care facilities.

AHCA is supporting proposed federal legislation to es-

tablish a low-interest loan program for nursing homes in

need of help with sprinkler installation.

Sprinkler protection in nursing homes came under

scrutiny in 2003, when nursing home fires in Hartford,

CT, and Nashville killed a total of 31 residents and raised

questions about how well protected the residents were

before the fire. n

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Nursing home sprinkler costs

Nursing homes that need sprinklers: 2,446

Average cost for sprinkler system installation: $7.95 per

square foot

Average cost for a 50,000-square-foot nursing home to

install a full sprinkler system: $397,500

Average cost of a quarterly sprinkler inspection: $150

Average cost of an annual sprinkler test: $250

Source: The Centers for Medicare & Medicaid Services.

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NFPA 82 sets the rules for sprinklers and ratings related to your facility’s limited access chutes

Editor’s note: Each month in this column, the staff at fire

protection consulting firm Koffel Associates, Inc., in Elkridge,

MD, clarify the code references behind commonly misunder-

stood healthcare requirements. Fire protection engineer

Sharon Gilyeat, PE, authored this installment.

Waste and linen chutes transport material to central-

ized areas for collection, processing, treatment, or disposal.

There are numerous types of chutes, but the most common

type in healthcare facilities is the limited access, gravity-

type system, which we’ll focus on. People access this type

of chute through locked chute doors or locked service

opening room doors.

Linen chutes must be of the limited access type. Waste

chutes can either be limited access or general access, which

doesn’t require a locked chute door and is typical in apart-

ment buildings.

NFPA 82, Incinerators and Waste and Linen Handling Sys-

tems and Equipment, prescribes requirements for the con-

struction and protection of chutes in buildings. Section

9.5.2 of the Life Safety Code® (LSC), 2000 edition, requires

that all newly constructed chutes comply with NFPA 82

(1999 edition). Let’s summarize the critical requirements

applicable to limited access, gravity-type chutes.

Chute diameters set by NFPA 82

To start, you can construct gravity-type chutes of un-

lined steel, refractory-lined steel, or masonry (NFPA 82,

section 3-2). Waste chutes must have at least a 24-inch in-

side diameter (NFPA 82, 3-2.2.3). However, linen chutes

can’t have an inside diameter less than 20 inches.

Properly sized chute service openings help prevent

clogging by stopping someone from shoving large waste

containers or excessive quantities of waste into the chute.

With that in mind, NFPA 82 restricts limited access, grav-

ity-type chute loading doors to two-thirds of the cross-sec-

tional area of a waste chute (NFPA 82, 3-2.4.2).

Meanwhile, NFPA 82 requires that chutes open into

fire-rated rooms. However, it can be confusing to figure

out the required protection of the chute access room. Let’s

go back to the LSC, as 18/19.5.4.3 refer you to section 8.4,

which requires access rooms to either:

Have a one-hour rating with ¾-hour opening

protection

Have sprinklers

However, there’s another section to check in the LSC:

In newly constructed healthcare occupancies, soiled linen

rooms and trash collection rooms must have one-hour-

rated construction, regardless of sprinkler protection (LSC,

18.3.2.1).

Existing soiled linen and trash rooms can be protected

like a hazardous area, with either a one-hour rating or

sprinkler protection (LSC, 19.3.2.1).

Things get even muddier. NFPA 82 is more restric-

tive than the LSC and requires the access room to have

the same rating as the chute enclosure, which means any

chute more than three stories in height needs a two-hour-

rated access room with 1 ½-hour-rated opening protec-

tion (NFPA 82, 3-2.4.3).

When two codes conflict—such as the LSC and NFPA

82 in this case—facilities should obey the more restric-

tive rules. However, the NFPA 82 technical committee is

addressing this conflict for the 2009 edition of NFPA 82,

which will reduce the required rating to one hour.

Chutes might need sprinkler protection

Chutes must discharge or terminate in a fire-rated dis-

charge room, and the discharge room must have sprinklers

(NFPA 82, 3-2.6.2). Also, chutes must have sprinklers at

the top level, lowest inlet level, and alternate floor levels

(NFPA 82, 3-2.5.1). There is an exception from sprinkler

protection for lined masonry and metal chutes and listed

medium-heat chimneys that comply with NFPA 82. n

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&AnswersQuestions



Editor’s note: Each month, Jennifer Frecker and James

K. Lathrop of fire protection consulting firm Koffel Associ-

ates, Inc., in Elkridge, MD, answer your questions about life

safety compliance. Our editorial advisory board also reviews

the Q&A column.

Tracking various code editions

Is there a list that shows which years of which codes

are being used? How would an NFPA novice locate

such a document?

See Chapter 2 of the 2000 Life Safety Code® (LSC).

That chapter lists all of the LSC’s referenced docu-

ments and their editions.

There is also additional information on other docu-

ments in Annex B of the LSC. This is useful for con-

struction projects so that you can see what additional

requirements apply when using specific editions of

the LSC.

Finally, the American Society for Healthcare Engi-

neering publishes the Fire, Electrical, and Life Safety Com-

pendium, which is also helpful (go to www.ashe.org for

more information).

Occupancy rules for family sleeping rooms

We have a family sleeping area in the wing adja-

cent to our neonatal ICU. We have 20 family

sleeping rooms that are separated from the health-

care occupancy by two-hour fire-rated construction.

We have been told that this area is required to be

surveyed under The Joint Commission’s (formerly

JCAHO) Statement of Conditions (SOC) as a residen-

tial occupancy. What suboccupancy would this fall

under, and are there any different requirements

that we need to meet?

You are correct that the area you describe requires

an SOC. You would classify the area as a hotel and

dormitory occupancy because there are 17 or more

rooms. In this case, the corridor walls must be 30-min-

ute, fire-rated construction with 20-minute, self-closing

and self-latching doors. Remember that corridors and

doors can simply be smoke resistive in smoke compart-

ments with sprinklers, but the doors must still self-close

and self-latch.

Each sleeping room also requires a smoke alarm that

will alert occupants to any smoke in the area. See Chap-

ters 28 and 29 in the LSC for additional requirements.

National provisions for fire watches

Is there a national standard for fire watch require-

ments other than NFPA 241, Safeguarding Construc-

tion, Alteration, and Demolition Operations? What is your

recommendation for how often to perform fire watch-

es, what type of documentation to keep, etc.?

No, there is nothing in writing and it is up to inter-

pretation. Some people think a fire watch means

someone sitting in the area 24/7 with the sole job of

looking for fires and eliminating possible fire scenarios.

Other people think a security officer walking through

the area every hour or so is sufficient.

If there is any hot work (e.g., welding) in an area,

it is a good idea to have someone overlooking the pro-

cess and dealing with any sparks.

On the other hand, having someone sit in an empty

construction area at 3 a.m. to ensure that there is no fire

might be excessive.

Ultimately, it is up to you to develop a definition and

procedure for fire watches, and we suggest you ask your

authorities for their interpretations.

October 2008 Healthcare Life Safety Compliance Page 11


Paragraphs 9.6.1.8 and 9.7.6 set the provisions

for when fire watches are necessary. Annex notes

A.9.6.1.8 and A.9.7.6 offer further guidance about

what a person conducting a fire watch might need,

including the following:

Training in fire prevention and occupant notifica-

tion strategies

Knowing how to use a portable fire extinguisher

Understanding the fire safety risks involved with the

particular activity at hand (e.g., construction work)

Annex notes aren’t mandatory parts of the LSC, but

instead explanatory.

Xylene storage limits under NFPA ��

What is the maximum storage allowance for

xylene in a laboratory?

Paragraphs 18/19.3.2.2 of the LSC require labo-

ratories using flammable and combustible liquids

considered a severe hazard to meet NFPA 99, Health-

care Facilities (1999 edition).

Severe hazards in labs are quantities of flammable,

combustible, or hazardous materials that could sustain

a fire that would breach a one-hour fire barrier.

NFPA 99 imposes the following requirements:

Class I, II and IIIA liquids outside of safety cans and

cabinets can’t exceed 1 gal. per 100 square ft. The

total volume, including what is in safety cans and

cabinets, can’t exceed 2 gal. per 100 square ft. (See

paragraph 10-7.2.2 in NFPA 99.)

Transfers of flammable liquids from bulk stock con-

tainers must be done in flammable liquid storage

rooms meeting the requirements in NFPA 30, Flam-

mable and Combustible Liquids Code (see 10-7.3 in

NFPA 99).

Laboratories must comply with NFPA 45, Fire Pro-

tection for Laboratories Using Chemicals (see 10-1.2.1

in NFPA 99).

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NFPA 45 (2000 edition) calls for additional require-

ments for flammable liquid handling or storage. When

dispensing from larger containers to processors or small-

er containers under 7.2.2.6, take the following actions:

When dispensing 5 gal. or less, do so under a lab

hood or within an inside storage room designed

and constructed in accordance with NFPA 30

When dispensing 5 gal. or more, do so in a separate

facility or in an inside storage room designed and

constructed in accordance with NFPA 30

Section 4-4 of NFPA 30 (2000 edition) dictates the

design requirements for an inside storage room.

There’s often confusion about whether labs should

refer to NFPA 45 or 99.

Generally, medical labs should use NFPA 99 as a

starting point for lab provisions. From there, NFPA

99 further delineates requirements in labs, including

through NFPA 45.

Editor’s note: See the March 2007 Healthcare Life

Safety Compliance for more details on the differences

between NFPA 45 and 99.

All subscribers can access our electronic archives by

logging on to www.hcpro.com. If you don’t have a user-

name or password, call our customer service center at

800/650-6787. n

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If you have a question about life safety compliance,

fire codes and standards, or the EC, pass it along to us

and we’ll include it in one of Healthcare Life Safety

Compliance’s future “Questions & Answers” columns.

Send us your questions in writing by:

Mail to Healthcare Life Safety Compliance, 200

Hoods Lane, P.O. Box 1168, Marblehead, MA 01945

E-mail to [email protected] (include “Q&A” in the

subject line)

Fax to 781/639-2982 (send your fax to the attention

of Healthcare Life Safety Compliance)

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Quick tip

With holidays looming, monitor decoration risksSome of you may dread the start of the fall holidays

not because you don’t enjoy them, but because these

celebrations bring with them plenty of fire safety risks.

The Life Safety Code® (LSC) and The Joint Commission

(formerly JCAHO) address this matter. Paragraph 7.1.

10.2.1 in the LSC states that no furnishings or decora-

tions can block exits, access to and from them, or their

visibility.

Also, paragraphs 18/19.7.5.4 prohibit combustible

decorations in any hospital unless they are flame-re-

tardant. An exception allows combustible decorations,

such as photographs and paintings, if they are in limit-

ed quantities that don’t create a risk of fire developing

or spreading.

Meanwhile, The Joint Commission:

Requires compliance with the LSC under EC.5.20

(which will transition to the new life safety stan-

dards in 2009)

Discusses decorations under EC.5.10, element of

performance (EP) 5

EP 5 will disappear in the 2009 EC standards, likely

because the new life safety chapter will bring up deco-

rations under LS.02.01.70, EP 1.

This is a good example of The Joint Commission elim-

inating redundant provisions in its standards in 2009.

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Take a reasonable approach

When it comes to combustible decorations, “we don’t

want to go over the top here,” said David Hood, presi-

dent of Russell Phillips & Associates, LLC, in Fairport,

NY. Hood spoke during HCPro’s July audio conference,

“Conquer Your Next Life Safety Code® Survey.”

Hood has found that decoration policies need to

obey the LSC while also observing common sense.

For example, holiday greeting cards could clearly

catch fire if they are near a flame. However, two cards

taped to a door on a unit don’t really qualify as a risk

from combustible decorations, Hood said.

On the other hand, hanging 150 greeting cards on

a wall in a unit clearly violates the LSC because they

aren’t of limited quantity, he added.

Holiday decorations can also create the following

hazards:

Obstruction of sprinkler spray patterns

Use of electric lights or displays not approved by

a testing laboratory

Susceptibility to burning from displays that include

cut trees and wreaths, which may dry out

It also makes sense during the holidays to include

decorations on your hazard surveillance rounds. n

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Join Us in Dallas or Orlando for Upcoming Sessions of the Life Safety Code® Boot Camp – Hospital Version

Within Healthcare Life Safety Compliance’s pages, we’ve written about many life safety citations issued by the Centers for Medicare & Medicaid Services and The Joint Commission. And now, with The Joint

Commission’s new life safety standards debuting in 2009, it is more important than ever to understand the nuances of the Life Safety Code®. If you’re looking for in-depth help understanding the 2000 Life Safety Code’s provisions for healthcare occupancies, then register for one of two upcoming Life Safety Code Boot Camps:

HCProbootCamPs tm OctOber 2008

OrlandoNovember 10–12

DallasOctober 15–17

For full information about the Life Safety Code Boot Camp and to register, visit http://hcpro.com/url/1221 or call our customer service center at 877/207-4036. In either case, use source code MT74217A.

The two-and-a-half-day course agenda for the Life Safety Code Boot Camp is intensive and covers the following material:

General requirements for healthcare occupancies Why facilities use the Life Safety Code and how it ties into other industry codes Application of the Life Safety Code in healthcare occupancies Special definitions and classifications for healthcare occupancies, and mixed occupancies in healthcare Construction types and occupant load requirements Additions, conversions, and renovations

Means of egress requirements for healthcare occupancies Brief overview of means of egress components Brief overview of provisions for the number of required exits Arrangement of means of egress Provisions for lights and signs in egress routes

Protection feature requirements for healthcare occupancies Vertical opening protection Hazardous areas Interior finish Alarm, detection, and extinguishing systems Corridors Smoke compartments

Our instructors will also discuss requirements for building services, operating features, and ambulatory and business settings, and present an overview of alternative approaches to Life Safety Code requirements. n

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1. (T) (F) The three roots of a surgical fire are fuel, heat, and the procedure.

2. (T) (F) Fire doors must have legible labels or their ratings are void.

3. (T) (F) Corridors and doors can be smoke resistive in smoke compartments with sprinklers, but the doors must still be self-closing and self-latching.

4. (T) (F) The Life Safety Code® (LSC) prohibits combustible decorations in healthcare facilities.

5. (T) (F) NFPA 80, Fire Doors and Fire Windows, requires individuals who inspect fire doors to hold certification.

6. (T) (F) Staff members participating in fire drills should pull the fire alarm box during an exercise.

7. (T) (F) In the 2009 life safety standards, The Joint Commission requires facilities to establish life safety committees.

8. (T) (F) Facilities can continue to use all older firestopping material because of a grandfather clause.

9. (T) (F) Limited access trash and linen chutes feature locked chute doors or locked service opening room doors.

10. (T) (F) Nursing homes without sprinklers have until August 2009 to retrofit this equipment.

QuizQuizHealtHcare life Safety complianceThe newsletter to assist healthcare facility managers with fire protection and life safety

Vol. 10 No. 10October 2008

Quiz questions October 2008 (Vol. 10, No. 10)

A supplement to Healthcare Life Safety Compliance

1. False. The three roots are fuel, heat, and an oxidizer.

2. True

3. True

4. False. The LSC allows combustible decorations if they are flame-retardant and in limited quantities that don’t create a risk of fire development.

5. False. NFPA 80 doesn’t require certification for individuals who inspect fire doors.

6. True

7. False. The Joint Commission doesn’t require a life safety committee, although the agency’s senior engineer suggested such a committee is a good idea.

8. False. Facilities can continue to use older firestopping material only if the material remains undisturbed and is in good condition.

9. True

10. False. Nursing homes have until August 2013 to retrofit sprinklers if they don’t already have them installed.

Quiz answers October 2008 (Vol. 10, No. 10)

Copyright © 2008 HCPro, Inc. Current subscribers to Healthcare Life Safety Compliance may copy this quiz for use at their facilities. Use by others, including those who are no longer subscribers, is a viola-tion of applicable copyright laws. ® Registered trademark, the National Fire Protection Association, Inc.

Documents

HealtHcare life Safety compliance - HCPro there a national standard for fire watch requirements other than NFPA 241? October 2008 Vol. 10, No. 10 The newsletter to assist healthcare