HEALTHCARE LIFE SAFETY COMPLIANCE - HCPro · Because water isn’t constantly flow-ing through them, sprinkler pipes are more apt to freeze during cold spells than regular water piping,

Because water isn’t constantly flow-ing through them, sprinkler pipesare more apt to freeze during coldspells than regular water piping,says George Wirsch, manager oftechnical services for Viking Corpo-ration, a sprinkler manufacturerbased in Hastings, MI.

“We’re dealing with standing water,not circulating water like a plumb-ing line,” Wirsch says of sprinklersystems. It is a common misconcep-tion to assume that because yourregular water pipes are okay, thesprinkler lines are also fine.

NFPA 25, Water-Based Fire > p. 2

How your facility carries out itsfire safety plan is among the topareas for surveyors to discuss in-depth during environment of care(EC) portions of an accreditationvisit.

And reports from the field indicatethat more than half of all noted cita-tions given by the Joint Commissionon Accreditation of HealthcareOrganizations (JCAHO) for EC standards are for fire safety–relateddeficiencies.

These conclusions come from sixmonths of data HLSC collected inan online poll of hospitals and

other facilities that the JCAHOtoured this year. The numberswere current as of September 15.The poll remains open and is up-dated frequently.

Headstrong this yearRespondents to our poll indicatethat 47% of the time, surveyorsdiscussed in detail the fire safetyplan under EC.5.10, making itamong the top four EC standardsto receive such high scrutiny. LifeSafety Code® (LSC ) complianceunder EC.5.20 was also a hot spot(see figure 1 on p. 5 more details).

Even before a government

Our online poll shows that fire safetynags facilities during 2004 surveys

—INSIDE—

Vol. 6 No. 10October 2004

Tips to avoid frozen sprinkler pipesCheck your settings and systems before winter

> p. 4

Winter is just around the corner,and even warm climates occasion-ally dip below 32 degrees Fahren-heit during this season. So it’sworth your while to double-checkthe conditions of sprinkler pipes.

Frozen sprinkler lines can rob yourbuildings of important protectionand cost your facility money torepair or replace.

Facility crews should judge frozenpipes as a potential problem thatis better solved during warmermonths, says Claude Baker Jr.,fire and life safety officer at theUniversity of Chicago Hospitals.

HEALTHCARE LIFESAFETY COMPLIANCE

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

FOR PERMISSION TO REPRODUCE

PART OR ALL OF THIS NEWSLETTER FOR

EXTERNAL DISTRIBUTION OR USE IN

EDUCATIONAL PACKETS, PLEASE CONTACT

THE COPYRIGHT CLEARANCE CENTER

AT WWW.COPYRIGHT.COM OR

978/750-8400.

Common problems

Review the rules for stairwellsigns and barrier penetrationsto avoid common citationsfrom the JCAHO. See p. 6

Compliance tips

You don’t need to submityour Statement of Conditionsduring the periodic performance review—so says the JCAHO. See p. 7.

Balance privacy and protection

Make sure you observe properclearances between cubiclecurtains and sprinklers. Seep. 8.

Questions and answers

We have had problems with visitors and patientswandering into a radioactivearea. Can we place a key-operated lock on thedoors? See p. 10.

Congratulations to MelissaBurik of Mercy Hospital

in Pittsburgh; Sandy Friedmanof Monongalia General Hospitalin Morgantown, WV; and DickLange of St. Joseph’s Hospitalin Marshfield, WI, who eachwon $25 for filling out our

recent reader survey.

Page 2 Healthcare Life Safety Compliance—October 2004© 2004 HCPro, Inc.

www.hcpro.com

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

Frozen pipes < p. 1

Protection Systems, requires an annual inspection of wet pipe systems before the onset of freezingweather (see paragraph 5.2.5).

The following are someguidelines to help you dealwith the risks of frozen sprin-kler pipes:

Look for places that cold air will findSure, it’s a good idea to check your sprinkler

pipes in areas that you know will frequently receiveblasts of chilly air, such as outer loading docks,garages, ambulance bays, and the main entrance toyour lobby. But there are plenty of other spots thatmay not be so obvious.

For example, check what Wirsch calls “blind spaces”—areas to which people have access but where theydon’t frequently stay, such as linen chutes or closets.Sprinkler pipes may run through these areas, anddepending on insulation and drafts, it’s possible forthese spots to drop below freezing temperatures.

Mechanical penthouses and elevator machine roomsmay also be risky areas for sprinkler pipe problemsif they aren’t well insulated or properly heated.

In the past, the University of Chicago Hospitals en-countered frozen pipes in an old ambulance bay

and an unheated outside stairway during a sustainedcold spell, Baker says. Subsequently, the facilitychose to protect those areas with dry pipe applica-

tions branched off the mainsprinkler system (more on drypipe systems later).

Also, if your facility has intersti-tial spaces—essentially subfloors

that house machinery or equipment but where peo-ple usually aren’t present—spot-check any piping,Wirsch says. In some situations, these spaces havetransfer grilles and, if a maintenance worker doesn’tclose exterior grilles, cold air can seep in.

Open transfer grilles also threaten facilities withattics. Nursing homes seem to have more atticsthan hospitals, and these attics can experiencefreezing temperatures, Wirsch says. Attics with transfer grilles or louvers need special attentionbefore winter. Facilities should designate some-one to check any attics before winter arrives.

Some nursing homes only employ one maintenanceperson, who typically has many duties, Wirsch says.A timely reminder may go a long way to protectingyour sprinkler pipes.

Attics may also have sprinkler pipes covered byinsulation, which is good. However, if someone or

It is a common misconception to assume that because your regularwater pipes are okay, the sprinkler

lines are also fine.

HLSC Subscriber Services Coupon Your source code: N0001

Name

Title

Organization

Address

City State ZIP

Phone Fax

E-mail address(Required for electronic subscriptions)

� Payment enclosed. � Please bill me.� Please bill my organization using PO # � Charge my: � AmEx � MasterCard � VISA

Signature(Required for authorization)

Card # Expires(Your credit card bill will reflect a charge to HCPro, the publisher of HLSC.)

� Start my subscription to HLSC immediately.

Options: No. of issues Cost Shipping Total

� Print 12 issues $249 (HLSCP) $18.00

� Electronic 12 issues $249 (HLSCE) N/A

� Print & Electronic 12 issues of each $311 (HLSCPE) $18.00

Sales tax(see tax information below)*

Grand total

Order online atwww.hcmarketplace.com and save 10%

Be sure to enter source code N0001 at checkout!

*Tax Information Please include applicable sales tax. Electronic subscriptions are exempt.States that tax products and shipping and handling: CA, IL, MA, MD, NJ,VA, VT, FL, CT, GA, IN, MI, NC, NY, OH, PA, SC, TX, WI. States that tax prod-ucts only: AZ, TN. Please include $21.95 for shipping to AK, HI, or PR.

Mail to: HCPro, P.O. Box 1168, Marblehead, MA 01945 Tel: 800/650-6787 Fax: 800/639-8511 E-mail: [email protected] Web: www.hcmarketplace.com

For discount bulk rates, call toll-free at 866/GO-HCPRO.

Page 3Healthcare Life Safety Compliance—October 2004 © 2004 HCPro, Inc.

www.hcpro.com


something has moved the insulation, it may exposethe pipes to cold air.

In general, NFPA 13, Installation of Sprinkler Sys-tems, requires sprinklers subject to freezing to eitherbe part of a dry pipe or preaction system (see sec-tion 8.15.3.1). However, NFPA 13 allows you to pro-tect small, unheated areas with systems that useantifreeze.

Also, you should wrap insulation coverings aroundwater-filled supply pipes, risers, and feed mains thatpass through open areas or cold rooms. Note thatNFPA 13 doesn’t include branch lines in this list.

Special steps for certain systemsIf a dry sprinkler system doesn’t protect your load-

ing dock, your facility may employ a common stepto maintain any wet system pipes: adding antifreezesuch as propylene glycol to the water in the pipes.

Generally, a 50% antifreeze-to-water ratio in thepipes is acceptable. The mixture helps avoid freez-ing, much like you see in your car’s radiator. Butmaintenance crews or reputable sprinkler contrac-tors need to inspect this mixture in September orOctober to make sure it’s appropriate, Wirsch says.Although the initial mixture might have been cor-rect, activity such as quarterly flow tests can some-times change the antifreeze mix.

Section 7.5 in NFPA 13 contains a host of details on the proper application of antifreeze solutions intoyour pipes.

Dry pipe systems may also need some upkeep inanticipation of colder weather. In particular, checkthat low-point drains do in fact drain out their water,he says. If the drains don’t work properly, watercould collect in them and freeze.

Section 7.2.5 in NFPA 13 provides general guidelinesfor protecting dry systems from freezing, whereasNFPA 25 requires you to empty low-point drainsbefore freezing weather sets in (see 12.4.4.3.3).

If your pipes freeze . . . Despite precautions, plenty of facilities will

encounter frozen sprinkler pipes. If it happens to you, your first calls should be to your insurancecarrier, fire department, and a reputable localsprinkler contractor to inform them of the problem.

The Life Safety Code requires facilities to institute afire watch if the sprinkler system goes out of servicefor more than four hours in a 24-hour period. Yourinsurance company may also require this step re-gardless of the amount of the time the system isdown, Wirsch says.

After the initial calls, take the system out of service.The sprinkler contractor can help you drain the sys-tem and thaw the ice. Once the system is down,crews should check for leaks and cracks in the pip-ing and sprinkler heads. Your facility’s disaster planmay have provisions for loss of heat, which wouldbe an appropriate spot to include responses tofrozen sprinklers.

A final thought: Make sure your as-built drawingsaccurately show the locations of sprinkler systempipes. “Have an up-to-date set of sprinkler plans forthe whole complex so someone knows where theseareas are,” Wirsch says.

Now it’s the 2005 LSC

As you may have noticed in recent issues, ourstories refer to the upcoming 2005 edition of theLife Safety Code (LSC ). Those of you familiar withthe NFPA’s code revision cycles may wonderabout the change, since prior issues of HLSCmentioned the 2006 LSC.

The NFPA shortened the cycle for the next LSCto tie it in with the revision cycle for NFPA 5000,Building Code. NFPA 5000’s healthcare chaptermimics the LSC in many ways, so the thinkingwas it made sense to parallel each of the docu-ment’s review periods.

The LSC will resume a three-year review cycleafter NFPA members vote on the 2005 edition,which means the next version will be in 2008.


www.hcpro.com


report released in July questioned how often sur-veyors caught LSC deficiencies in healthcare facili-ties, it was clear from our poll that emergencymanagement and fire protection spearheaded 2004EC concerns for the JCAHO.

No doubt part of this trend is because when the

JCAHO debuted its Shared Visions–New Pathways™program in 2004, it streamlined the building tourto focus more on LSC compliance. The 2003 nurs-ing home fires in Hartford and Nashville may havealso contributed to the attention.

Citations reflect that continued vigilance, as both re-quirements for improvement (formerly known asType I recommendations) and supplemental find-ings, show a strong life safety inclination.

For example, out of 43 requirements for improve-ment for various EC violations reported by respon-dents to our poll, 24 (56%) related to fire protectionin some way. Also, out of 38 EC supplemental cita-tions, 17 (45%) came from life safety issues.

Repeat offenders are revealingSome violations cropped up repeatedly, includingsuch common problems as clutter that impeded oncorridor widths, doors that didn’t close properly, andfire drill concerns.

But two other cited problems were surprising be-cause of how often respondents mentioned them:unsealed penetrations and a lack of stairwell signs.For ideas on how to stay on top of these potentialdifficulties, see the related story on p. 6.

The JCAHO also cited the following conditions:• Doors with louvers were in inappropriate areas • A facility didn’t post exit signs as required• Staff members didn’t observe the 18-in sprinkler

clearance along ceilings • Facilities didn’t inspect fire and smoke dampers

every four years • Workers didn’t secure oxygen tanks properly• Smoke detectors weren’t in required spots• A facility didn’t inspect two fire extinguishers• One site didn’t mark medical gas shutoff areas • A kitchen hood didn’t tie into the fire alarm

system• Stairways continued into the basement without

chains or barriers to block people from exitingdown there

• Items obstructed fire extinguishers

2004 surveys

The JCAHO’s engineering surveyorwill cost $3,500

Conforming with the Life Safety Code (LSC ) isabout to get more expensive for larger hospitalsaccredited by the Joint Commission on Accredi-tation of Healthcare Organizations (JCAHO).

When announcing an increase in survey feeseffective January 1, 2005, the JCAHO set a gen-eral increase for hospitals of $2,700 per survey.But the accreditor’s plans to bring in a specialengineering surveyor for hospitals with 200 ormore beds carries an additional price tag of$3,500. For affected hospitals, that brings thetotal survey increase to $6,200.

Currently, the average survey cost for large, full-service hospitals is $23,000.

The $3,500 fee likely covers not only the ex-pense of an engineer’s hours, but also the asso-ciated transportation and hotel costs, says StevenMacArthur, safety consultant for The GreeleyCompany, a division of HCPro, Inc., in Marble-head, MA.

JCAHO officials have made it clear they willscrutinize life safety issues more in future build-ing tours. “They don’t have people on staffwho can do this [LSC analysis], so they’ll haveto contract for this” by bringing in outside engi-neers, MacArthur says. On a related note, theJCAHO plans to introduce an installment billingoption in 2006 that will allow facilities to spreadtheir survey payments over their three-yearaccreditation cycles.

< p. 1


www.hcpro.com


Source: The figures come from information taken from HCPro’s online poll of 96 facilities surveyed by the Joint Commission on Accreditation of Healthcare Organizations in 2004. The above results are not scientific.

Other EC citations

Fire safety citations

No

Yes

Figure 2Percentage of EC requirements for improve-ment that dealt with fire protection:

Figure 3Did the surveyor review your SOC ?

44%

47%

41%

12%

44%

56%

15%

85%

0

10

20

30

40

50

60

70

80not discussed

somewhat discussed

heavily discussed

EC.5.50EC.5.40EC.5.30EC.5.20EC.5.10

Online poll results highlight fire safetyFigure 1Taken from information reported by our online poll respondents, this bar chart illustrates to whatdegree surveyors discussed fire safety requirements under the environment of care (EC) standards.

Explanation of the standards• EC.5.10—Managing fire safety risks and carrying out fire safety plans• EC.5.20—Complying with the Life Safety Code (LSC ) and Statement of Conditions (SOC )• EC.5.30—Conducting fire drills• EC.5.40—Testing, inspecting, and maintaining fire safety equipment and building features• EC.5.50—Protecting occupants if there are LSC deficiencies and using interim life

safety measures

52%

4%

34%

14% 18%

68%

20%

65%

15%

14%

52%

heavily discussed

somewhat discussed

not discussed


www.hcpro.com


Avoid Joint Commission fire safety citations

Check your stairwells and barriers for glitchesTwo life safety problems that frequently result incitations from the Joint Commission on Accreditationof Healthcare Organizations center on stairwell signsand unsealed penetrations. Let’s look at which LifeSafety Code (LSC ) requirements govern these issuesand ways to avoid deficiencies.

� Stairwell signsThe LSC mandates that healthcare facilities postidentification signs in stairs that serve five or morestories. The intent behind the provision is to alertoccupants and firefighters about important exitadvice as they enter a stairwell.

Specifically, paragraph 7.2.2.5.4 states that thesesigns must indicate the following information:• The story on which a person enters• Where the stairwell ends at both the top and

bottom, such as the roof and basement• Identification of the stair, such as “Stair No. 6”• The story and direction to the nearest exit

discharge

The last bullet is particularly helpful if the exit is upthe stairs, since many people naturally assume anexit is down a stairwell.

Facilities should post these signs in the stairwell 5 ftabove the floor and position them so people canview them with the stair door either open or closed.You also have the option to split the requiredinformation among two signs, says annex noteA.7.2.2.5.4.

On a related note, 7.2.2.5.5 requires directional signsat any stairwell landing where people will need totravel upward to an exit discharge. As a reminder, anexit discharge is the point where you leave a protect-ed exit, such as a stairwell. Exceptions to this provi-sion include signs already meeting 7.2.2.5.4, or if thedischarge is only one story above and is obvious.

� Unsealed penetrationsHoles in fire or smoke barriers—created by improp-erly running computer cables, plumbing, medical

gas lines, electrical wires, and other services—sub-vert the dependability of the walls.

If staff members, vendors, or contractors don’t properly seal these openings, facilities risk fire orsmoke escaping through the holes and endangeringlives.

Firestopping these holes involves restoring hourlyfire ratings to the barrier based on assemblies testedby a recognized laboratory, such as UnderwritersLaboratories, a product safety testing group in North-brook, IL. You restore barrier reliability by fillingpenetrations with a material classified by the testinglab that will maintain the rating.

The sealants come in forms such as caulks, putties,foams, or mechanical devices and are able to sealthe opening and withstand heat exposure.

In the LSC, paragraphs 8.2.3.2.4.2 and 8.3.6.1 discusshow to protect penetrations in fire and smoke barri-ers. The Statement of Conditions also mentions pen-etration protection.

Time-tested ideas to help you better control penetra-tions and follow-up sealing include the following:• Clearly label all barriers with their ratings to act as

warnings• Track your history of penetration work and focus

on problem spots that frequently arise• Ask your firestopping vendors to provide training

to staff members and contractors• Include requirements in the contract for vendors

to repair of all penetrated barriers • Issue barrier permits before any penetration work

begins• Conduct in-house firestopping inspections on

penetrations and sign off on final work beforeyou pay contractors or vendors

Sources: HLSC editorial advisors; 2000 LSC; Protect-ing penetrations: Tips to maintain your fire andsmoke barriers, a special report published by HCPro,Inc.

Check out these tips, which may make your life abit easier when completing the Statement of Condi-tions (SOC ). The advice comes from Dean Samet,CHSP, associate director of standards at the JointCommission on Accreditation of Healthcare Organi-zations (JCAHO):

No midpoint SOC reviewUnder the JCAHO’s Shared Visions-New Path-

ways™ program, facilities will need to complete amid-cycle self-assessment if they will receive accred-itation in July 2005 or later. These assessments,known formally as periodic performance reviews,allow JCAHO officials to look at how well a facilityfeels it complies with the standards.

Confusion has arisen regarding the role the SOCplays in a periodic performance review. Here’s thebottom line: “No SOC has to be submitted for re-view for the [periodic performance review],” saysSamet.

Further, you don’t need to fill out a completelynew SOC for every survey as long as you keepyour existing copy accurate and updated, he says.

That said, take heed of any renovation work or construction that took place in your facility sinceyou last completed your SOC. These alterationscan affect life safety compliance. Much of this issuecenters on the idea of the SOC as a “living docu-ment,” a term we examined in the June HLSC.

Part 3 is optionalIt appears some surveyors have browbeaten

facilities for not completing the life safety assess-ment (Part 3) in the SOC. The assessment is anoptional yet familiar checklist of various provisionsdesigned to show your compliance with the 2000Life Safety Code (LSC ).

However, you can’t receive a “requirement forimprovement” (formerly a Type I recommendation)if you haven’t completed Part 3, Samet says.


www.hcpro.com


A pair of SOC compliance hints to know about

If a surveyor attempts to cite you for not filling outthe life safety assessment, “that’s pure, unadulteratedpoppycock,” Samet says. Facilities facing this situa-tion should call him at 630/792-5759.

The instructions at the beginning of Part 3 clearlyindicate that the life safety assessment is just oneway to evaluate compliance with the LSC—in otherwords, it’s an optional tool, he says.

Facilities may choose to develop their own forms to review LSC compliance instead of using Part 3.On the flip side, surveyors are familiar with Part 3,so using your own approach may invite more scrutiny.

The only sections included in the SOC that youmust complete are Part 2 (basic building informa-tion) and Part 4 (plan for improvement).

Keep in mind that even if you answer all of Part 3’squestions, you haven’t completely evaluated yourfacility. Part 3 features some of the more commonrequirements of the LSC, but is isn’t a complete list.You must meet all of the LSC’ s requirements andother codes it references.

New SOC resource

HCPro, Inc., has just published a new tool tohelp with your life safety compliance efforts: TheStatement of Conditions (SOC ) Field Guide.

Intended as both a companion piece to our larger SOC Manual as well as a stand-aloneresource, the Field Guide presents only themost pertinent information you need to com-plete the SOC. And its compact size makes it a handy book to carry around as you inspectyour facility.

For more information or to order a copy, go towww.hcmarketplace.com/Prod.cfm?id=2729.

1.

2.


www.hcpro.com


Cubicle curtains are commonitems in healthcare facilities,

providing a semblance of privacy in exam areasand patient rooms. But the curtains’ widespreaduse also makes it easy to run into problems withsprinkler protection in these rooms.

In general, observe proper clearance distancesbetween sprinklers and cubicle curtains while alsoensuring that any mesh patterns along the upperportions of the curtains are appropriate. The cur-tains should withstand burning, too.

Let's start in the Life Safety Code (LSC ). In Chapters18 and 19 (new and existing healthcare facilities),paragraphs 18/19.7.5.1 mandate that cubicle curtainsbe flame-resistant. This characteristic must meet test-ing as required in NFPA 701, Methods of Fire Testsfor Flame Propagation of Textiles and Films.

You may find tags on your cubicle curtains that in-dicate they are made of a flame-resistant material.The curtain manufacturer can also fill you in onwhat materials it uses.

Annex notes A.18/19.7.5.1 remind you to checkout cubicle curtain requirements under NFPA 13,Installation of Sprinkler Systems. More on that in alittle bit.

When sprinklers are overhead . . .Meanwhile, paragraphs 18/19.7.5.1 also send youto 18/19.3.5.5, which require newly installed cubi-cle curtains in areas with sprinklers to comply withNFPA 13.

Existing cubicle curtains covered under 19.3.5.5don’t need to meet NFPA 13 requirements, butsince 18/19.3.5.5’s predecessors in earlier LSC edi-tions contained the same language, chances are atsome point your cubicle curtains did count asnewly installed items. Also, many regulators con-sider cubicle curtain obstruction a serious enough

issue to require retroactive application of NFPA 13.

In other words, it’s a good idea to check out NFPA13 even if your cubicle curtains are several yearsold.

It's a design issueThe concern about how sprinkler locations inter-mingle with cubicle curtain installations is well-founded, according to LSC annex notes.

Poor design of sprinklers and curtains “might ob-struct the sprinkler spray from reaching the fire ormight shield the heat from the sprinkler,” statesA.18/19.3.5.5.

Suggested options to accommodate cubicle curtainsin rooms with sprinklers include the following:• Hang the curtains 18 in below the sprinkler’s

deflector• Use curtains with a 1/2-in diagonal mesh or a

70% open weave top panel; the mesh shouldextend 18 in below the sprinkler

• Consult NFPA 13 for horizontal and vertical dis-tances for cubicle curtains and sprinklers—gener-ally, the greater the horizontal distance betweenthe sprinklers and the curtains, the more verticalclearance you need because of how water spraysdown from a sprinkler’s deflector

Also make sure to hang curtains with mesh panelsso sprinkler spray doesn’t have to penetrate morethan one panel, says Frederick Bradley, PE, prin-cipal at FCB Engineering in Alpharetta, GA. Ifwater has to get through more than one curtainmesh, the second curtain may block the spray’sintended pattern.

An incremental approachThe 2000 LSC references the 1999 edition of NFPA13. In that version, paragraph 5-6.5.2.3 and itsaccompanying table set minimum distancesbetween privacy curtains and standard pendent

Mesh sprinkler concerns, cubicle curtainsNFPA 13 requires curtains to accommodate sprinkler spray


www.hcpro.com


sprinklers, with the idea that you must meet longerhorizontal distances between these items with big-ger vertical clearances.

Here’s a summary of the calculations: If the sprin-kler’s deflector is 6 in or less horizontally alongthe ceiling from the curtain, you must have atleast a 3 in clearance from the bottom of thedeflector to the top of the curtain. This thinkingprogresses all the way to a 30-in horizontal dis-tance, which requires an 18-in vertical clearance.

These same figures are in the 2002 version ofNFPA 13, which is the most recent edition of thatstandard.

NFPA 13 switches, a bitHowever, some associated annex notes differbetween the editions of NFPA 13. In 1999, theannex note mentions that 1/2-in diagonal meshwould probably not severely obstruct sprinklerwater spray, and thus an authority might not need to apply the requirements of 5-6.5.2.3.

The annex note in the 2002 edition is tighter. Itstates that a 70% weave mesh is appropriate to fillthe 18-in clearance below the deflector, but saysnothing about ignoring clearance requirements.Again, the 2000 LSC points you to the 1999 edi-tion of NFPA 13, so that may buy you some con-siderations when it comes to cubicle curtains.Check with your authorities to be sure, though.

In addition, ambulatoryhealthcare facilities coveredunder Chapters 20 and 21 inthe LSC need to use flame-resistant cubicle curtains, butthe chapters don’t requirenewly installed curtains to comply with NFPA13. That said, in the bigger scope, if ambulatorysites installed sprinklers, they need to conformto NFPA 13.

We like your curtainsIt’s reasonable to anticipate that regulators willcheck how cubicle curtains interact with sprin-klers. For example, the Centers for Medicare &Medicaid Services (CMS) has specific provisionsfor inspectors to check these curtains.

In its most recent State Operations Manual, CMSprovides the following guidance for inspectors:• Check cubicle curtains for flammability• Where applicable, verify cubicle curtains have

the correct mesh opening size• If sprinklers are present in the room, ensure

that the curtains won’t block or interfere withthe sprinklers’ spray pattern

Also, in its fire safety survey report, the agencylists cubicle curtain flammability and sprinklerclearance concerns under item K74 (item K72 forambulatory surgical centers). These entries areinformally known as “K-tags.”

Stay compliant with cubicle curtainsThis chart synopsizes the requirements for cubicle curtains as they relate to sprinklers as found in theLife Safety Code (LSC ) and NFPA 13, Installation of Sprinkler Systems.

NFPA document

LSC (paragraphs 10.3.1,18/19.7.5.1, and 20/21.7.5.1)

LSC (paragraphs18/19.3.5.5)

NFPA 13 (paragraph 5-6.5.2.3)

Requirements

Cubicle curtains must be flame-resistant

New cubicle curtains installed in areas protect-ed by sprinklers must comply with NFPA 13

Facilities must observe minimum horizontaland vertical distances between privacy cur-tains and sprinklers

Settings

Hospitals, nursing homes, limited care facil-ities, and ambulatory healthcare facilities

Hospitals, nursing homes, and limited carefacilities

Hospitals, nursing homes, limited care facil-ities, and ambulatory healthcare facilities


www.hcpro.com


Each month, Jennifer Holloman and JamesLathrop of fire protection consulting firm KoffelAssociates, Inc., answer your questions about lifesafety compliance. HLSC’s editorial advisory boardalso reviews the Q&A column.

Locking restricted doorsRecently we have had problems with visi-tors and patients wandering into a radio-

active area within our cancer center. We restrictthe area to specific staff members. People canget into the area through a set of doors thatswing in opposite directions. These doors arenot located within a fire or smoke barrier andaren’t tied into the fire alarm system. The build-ing is a single-story business occupancy withoutsprinkler protection. Can we place a key-oper-ated lock on the doors? All staff members willcarry keys to unlock the doors.

Chapter 39 of the Life Safety Code (LSC ),which discusses existing business occupan-

cies, is the first location to look at to determine therequirements for locking arrangements in your building.

Paragraph 39.2.2.2.1 permits doors that comply withsection 7.2.1. In turn, 7.2.1.5.1 allows locks on doorsprovided they open from the egress side without theuse of a key, tool, or special knowledge or effort.

We assume that in your case occupants don’t needto pass through the radioactive area to reach an exitfrom the building. With that in mind, you can installhardware on the door that only locks it from thepublic side and allows free egress for staff membersfrom the restricted side. This is as simple as a com-mon privacy latch.

However, if occupants must pass through the re-stricted radioactive area to access an exit from the

building, you must take into account other require-ments. You could use access-controlled locking ar-rangements, but they probably wouldn’t meet yoursecurity needs, as they would allow the doors tounlock upon detection of an approaching person.

There are no LSC provisions that allow you to lock a door in the direction of egress all the time. Thecommon misnomer is that if a door unlocks uponloss of power, activation of the fire alarm system, oractivation of the sprinkler system, then it complieswith the LSC. This is not the case.

Unfortunately, in your situation, providing a key-operated lock on the door won’t comply with theLSC. Large signs and descriptions of the area asbeing restricted are methods to guard against wan-dering occupants. You may also discuss the situationwith your local authority to determine whether anequivalency, waiver, or other idea is possible.

Emergency power for elevatorsA consultant told me that the elevator thatserves my endoscopic surgery center does-

n’t comply with regulations because emergencypower doesn’t back it up. My practice is on thethird floor of an office building, and I lease myspace from the building owner. I have no controlover the elevator’s service. I have looked throughthe Life Safety Code (LSC ) and do not see whereit requires emergency power for elevators.Where is the consultant getting his information?

The LSC doesn’t require emergency powerfor elevators serving a building as you de-

scribe it—nor do American National Standard Insti-tute (ANSI) elevator requirements under ANSI A17.1(new elevators) and ANSI A17.3 (existing elevators).

However, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires

Q:

Q:

A:

A:

emergency power for at least one elevator underenvironment of care (EC) standard EC.7.20 in theComprehensive Accreditation Manual for Ambulato-ry Care (CAMAC ).

This is likely where the consultant takes his recom-mendation from, and based on that observation, we’llanswer your question from the perspective of seekingambulatory healthcare accreditation from the JCAHO.Although this emergency power provision is not com-monly known by facilities trying to gain accreditation,it isn’t a new JCAHO requirement.

Taking this knowledge to the building owner andhaving him or her provide the emergency power is another battle altogether. It is common to findambulatory care centers located in leased spaceswithin business occupancies that don’t meet ambu-latory healthcare requirements. Hopefully, the build-ing owner is willing to work with you.

If you haven’t already, obtain a copy of the 2004CAMAC from the JCAHO and review the standardsfor any additional features that you may need todiscuss with your building’s owner.

You may find that the owner is inflexible. In thatcase, contact the JCAHO and discuss the situation.There may be an equivalency that you can developfor the deficiency, which would allow you to re-ceive accreditation without emergency power foryour elevator.

Improperly constructed stairsWe just began a major renovation of ourhospital’s main lobby. While demolishing

an area, we realized that a section of the exist-ing stair, which serves five floors of the hospi-tal, was not properly enclosed. Upgrading thestair enclosure is not in the scope of the work.Can we just conclude that the stair is existingand therefore “grandfathered?”

You may find help within the Life Safety Code(LSC ) under one of the exceptions to para-

graph 7.1.3.2.1 (exit separations).


www.hcpro.com


Send us your questionsIf you have a question about life safety compliance,fire codes and standards, or the environment ofcare, pass it along to us and we’ll include it in oneof Healthcare Life Safety Compliance’s futureQuestions & 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] (put “Q&A”somewhere in the subject line)

�fax to 781/639-2982 (put your fax to the attention of Healthcare Life Safety Compliance)

Under exception 2, in buildings protected by sprin-klers, existing exit stair enclosures serving four ormore floors are permitted as long as they have atleast a one-hour fire resistance rating.

However, from your question it is unclear whetherthe entire stair or just a section of it is not properlyconstructed. You can use the above exception ifthe construction provides at least a one-hour rating.

If it does not, there are a few options. One is tocome up with an equivalency if you can provideother measures to ensure a comparable level of lifesafety, such as with plenty of exits in a buildingcompletely protected by sprinklers. If you providethose exits for the upper floors, you might be ableto deem this stairwell a convenience stair. As such, itwould then only need to meet a 30-minute rating forvertical openings (see the third item under 8.2.5.4).

If only a section of the stair was not properly con-structed, we suggest spending the extra time andmoney to fix it. The LSC references above still ap-ply, but the liability of not fixing a small section ofstair to ensure safety is much greater than the costto fix the problem. It is in the best interest of yourhospital to remedy such relatively small deficien-cies, especially when the area is already under renovation.

Q:

A:


www.hcpro.com


Healthcare Life Safety ComplianceEditorial Advisory Board

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

Joan Betzold, MEd, ABQAURPPresidentProfessional Services Consultants, Inc.Bel Air, MD

Frederick C. Bradley, PEPrincipalFCB EngineeringAlpharetta, GA

Michael Crowley, PEVice President, EngineeringManager

Rolf Jensen & Associates, Inc.Houston, TX

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

Kenneth Faulstich, PEChief Safety and Fire Protection EngineerDepartment of Veterans Affairs Washington, DC

Daniel J. O’Connor, PEVice President—Engineering Schirmer Engineering CorporationDeerfield, IL

Russell PhillipsPresidentRussell Phillips & Associates, LLCRochester, NY

Suzanne Perney, Publisher/Vice PresidentBob Croce, Group PublisherScott Wallask, Senior Managing Editor [email protected]

Healthcare Life Safety Compliance (ISSN 1523-7575) is published monthly by HCPro, Inc. 200 Hoods Lane, Marblehead, MA, 01945. Subscription rate is $249 for one year andincludes unlimited telephone assistance. Single copy price is $25. Periodicals postage paid at Marblehead, MA 01945 and other mailing offices. Postmaster: Send address changes toHealthcare Life Safety Compliance, P.O. Box 1168, Marblehead, MA 01945. Copyright 2004 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. Pleasenotify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance call781/639-1872 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 subscriber 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 addressabove. 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 FireProtection Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Information should not beconstrued as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final accept-ability 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 Boardmembers are not responsible for information and opinions that are not their own.

Contributing Technical EditorJames K. LathropVice PresidentKoffel Associates, Inc., Niantic, CT

Quick tipIn some cases, you can use fire alarm speakers for other announcements

➤

Your healthcare facility may use overhead speakersfor fire alarm notification. Under certain circum-stances, you may be able to use those same speakersfor other functions, too, and still stay compliant withNFPA codes and standards.

The place to start is NFPA 72, National Fire AlarmCode, says Robert Solomon, PE, chief building fireprotection engineer at the NFPA.

Paragraph 6.8.4.5 in NFPA 72 gets to the heart of thediscussion. The paragraph initially prohibits usingalarm speakers for any nonemergency purpose, butoffers two exceptions that might prove beneficial toyou:1. Occasional nonemergency announcements may

take place if a trained operator constantly stays ata fire command center or similar central spot inthe building

2. Nonemergency announcements or paging canoccur as long as the speakers and associated audio

equipment feature safeguards against tampering orreadjustment of essential alarm components, andthe equipment’s monitoring duties continue whilesomeone uses it for nonemergency purposes

This continual monitoring basically amounts to anoverride function in case a fire alarm goes off,Solomon says. He spoke during the July AmericanSociety for Healthcare Engineering’s annual confer-ence in Orlando.

Your authorities having jurisdiction need to approveeither of the above two exceptions if you choose totake advantage of them, according to NFPA 72.

Tampering becomes a concern if the overheadannouncements become too frequent and annoyemployees, an annex note in the Code explains.Some suggestions to reduce tampering risks includeinstalling vandal-resistant speakers and placing themin areas that are difficult for people to reach.

Robert Westenberger, CHFM-MCOConstruction Project ManagerAtlantic Health SystemMorristown, NJ

William Wilson, CFPSFire Safety CoordinatorWilliam Beaumont HospitalsRoyal Oak, MI

QuizQuizHEALTHCARE LIFESAFETY COMPLIANCEThe newsletter to assist healthcare facility managers with fire protection and life safety

1. (T) (F) The Life Safety Code® (LSC ) requires all existing cubicle curtains to comply with NFPA 13, Installation of Sprinkler Systems.

2. (T) (F) If you have a stairwell protecting five floors, the LSC allows the stairway to have a one-hour fireresistance rating as long as sprinklers protect the building.

3. (T) (F) It’s okay to put a key-operated lock on the egress side of a door.

4. (T) (F) Adding antifreeze to dry pipe sprinkler systems is one way to stop them from freezing.

5. (T) (F) The LSC requires stairwell signs that identify the level at which a person entered in all health-care facilities.

6. (T) (F) The Joint Commission on Accreditation of Healthcare Organizations will offer hospitals thathave more than 200 beds the option of adding an engineering surveyor to the survey team.

7. (T) (F) You can use fire alarm speakers for other paging at any time as long as the fire alarm overridesany other uses, according to NFPA 72, National Fire Alarm Code.

8. (T) (F) If a hospital’s fire alarm system goes out of service, the LSC requires the facility to institute afire watch within one hour.

9. (T) (F) Generally speaking, penetrations are mostly the result of medical gas lines running through bar-riers without proper sealing.

10. (T) (F) If your water supply lines aren’t frozen, your sprinkler pipes won’t be either.

Vol. 6 No. 10October 2004

Quiz questions October 2004 (Vol. 6, No. 10)

A supplement to Healthcare Life Safety Compliance

1. False. The LSC requires compliance with NFPA 13 for newly installed cubicle curtains.

2. True

3. False. The LSC doesn’t allow you to continually lock a door in the direction of egress.

4. False. You can’t add antifreeze to dry pipe systems because there is usually no water in the piping.

5. False. You only need to post these signs in stairwells that serve five or more floors.

6. False. Engineering surveyors will automatically join survey teams visiting hospitals with more than200 beds.

7. False. NFPA 72 provides a list of conditions under which nonemergency announcements may begiven over fire alarm speakers. Authorities having jurisdiction must also approve the arrangement.

8. False. The LSC requires a fire watch only if a sprinkler system will be down for more than fourhours in a 24-hour period.

9. False. The are many culprits behind penetrations, including gas lines, computer cables, plumbing,and electrical wires.

10. False. Sprinklers don’t frequently circulate water like regular plumbing lines; this circulation helpsward off freezing.

Copyright 2004 HCPro, Inc. Current subscribers to Healthcare Life Safety Compliance may copy thisquiz for use at their facilities. Use by others, including those who are no longer subscribers, is a violationof applicable copyright laws. ®Registered trademark, the National Fire Protection Association, Inc.

Quiz answers October 2004 (Vol. 6, No. 10)

Documents

HEALTHCARE LIFE SAFETY COMPLIANCE - HCPro · Because water isn’t constantly flow-ing through them, sprinkler pipes are more apt to freeze during cold spells than regular water piping,