february 2008 vol. 10, no. 2 healthcare life safety...

proposed life safety standards (see the proposed standard

numbers for healthcare and ambulatory occupancies

on p. 3). William Koffel, owner of the consulting firm

Koffel Associates, Inc., in Elkridge, MD, participated in

the group.

“In virtually all instances, The Joint Commission is

merely looking for compliance with the NFPA require-

ments,” Koffel says. It’s “not imposing anything new.”

The intent of the new chapter—which basically re-

casts EC.5.20 and the Statement of Conditions (SOC) into

a series of stan-

dards—was not

to make technical

changes but rath-

er to format the

LSC’s requirements in a way that elevated their impor-

tance, he adds.

For hospitals, there are nine proposed standards with

101 EPs that surveyors will score.

“What we’ve identified [as standards] is a specific list

of things that The Joint Commission will be evaluating

you on,” Koffel says.

Future scoring will be a key area to watch

The Joint Commission, in its preamble to the field

review, indicates that it’s working on a new standards

scoring system, which hopefully will attempt to avoid

a sudden spike in adverse accreditation decisions based

on the sheer amount of new life safety EPs.

Under the current scoring setup, various LSC defi-

ciencies might result in one requirement for improve-

ment (RFI) under EC.5.20.

In the proposal, those same deficiencies, when con-

verted into multiple standards, might result in several

RFIs—or, conversely, might spread out and not aggre-

gate to an RFI at all, says Britton Berek, CCE, MBA,

IN THIS ISSUE

p. 5 Weigh your risksThere’s no strong guidance from The Joint Commission about what constitutes a reasonable completion date for plans for improvement.

p. 8 Means of egress debateDead-end corridor provisions benefit existing hospitals, but the Life Safety Code’s® (LSC ) flexibility dwindles for renovated areas.

p. 9 Cracking the CodeOur new column will delve into the technical background of healthcare requirements in the LSC and other NFPA standards.

p. 10 Questions & AnswersWe aren’t sure whether wooden wardrobe cabinets require sprinkler protection. Can you help?

p. 12 Quick tipThe NFPA allows visitors to view for free all current and some past versions of its codes and standards list.

Future life safety standards offer new guidance, but scoring remains a question

There are few, if any, new

life safety requirements to

deal with in the proposed

standards.

> continued on p. 2

February 2008 Vol. 10, No. 2

Healthcare Life Safety Compliance

In reviewing The Joint Commission’s (formerly

JCAHO) proposed life safety standards, two things

stand out:

1. There are few, if any, new requirements to deal with

2. The Joint Commission more explicitly outlines 2000

edition Life Safety Code® (LSC) requirements that sur-

veyors will score

The field review for the proposed standards closed

on January 22. After considering received comments,

the accreditor will issue a final version of the standards,

which is scheduled to go into effect in January 2009 as

part of a broader overhaul of all accreditation standards.

New standards will raise awareness

In 2007, The Joint Commission convened a small

group of industry representatives to help it create the

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

Healthcare Life Safety Compliance February 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.

Life safety standards < continued from p. 1

Editorial Advisory Board Healthcare Life Safety Compliance

Group Publisher: Bob Croce, [email protected]

Executive Editor: Julia Fairclough, [email protected],

781/639-1872, Ext. 3109

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 Engineer Aurora, CO

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

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 Safety & SecurityNorwalk Hospital Norwalk, CT

Robert Westenberger, CHFM-MCOConstruction Project Mgr.Atlantic Health System Morristown, NJ

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

Healthcare Life Safety Compliance (ISSN 1523-7575) is published monthly by HCPro, Inc., 200 Hoods Lane, Marble-head, MA, 01945. Subscription rate is $289 for one year and includes unlimited telephone assistance. Single copy price is $25. Postmaster: Send address changes to 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 sub-scription information, call customer service at 800/650-6787, fax: 800/639-8511, or e-mail: [email protected]. Occasion-ally, 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 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 Protec-tion Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is ex-pressed or implied. Information 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.

director of regulatory compliance for ARAMARK Health-

care in Downers Grove, IL.

The potential for an increase in RFIs worries facilities,

adds Berek, a former Joint Commission associate director

of standards, who also participated in creating the pro-

posed life safety standards.

As of early January, details of the revised scoring sys-

tem hadn’t been released. Several models have been pro-

posed, but Joint Commission officials haven’t approved

any of them yet, Berek says. The final scoring model will

be a key factor in how excited to get about the new life

safety chapter, he adds.

Part of the dilemma—and a reason for the shift to the

life safety standards—resides with the SOC’s current scor-

ing of LSC provisions, which differ from the scoring of

other standards in the accreditation manual. “The Life

Safety Code stuff . . . has it owns sub–scoring system with-

in the [full] scoring model,” Berek says.

At presstime, The Joint Commission hadn’t returned

our request for further comments about the proposal.

PFIs may associate even closer with ILSMs

The proposal also seems to more clearly tie interim

life safety measures (ILSM) into plans for improvement

(PFI), says Steven MacArthur, safety consultant for The

Greeley Company, a division of HCPro, Inc., in Marble-

head, MA. “I have a sneaking suspicion that the inter-

im life safety measures will be taking on an even greater

prominence as this moves forward,” he says.

PFI and ILSM compliance are in the crosshairs of sur-

veyors these days. Deficiencies in either area can lead to

automatic conditional accreditation under a Joint Com-

mission rule known as CON 04.

A series of nuances to note

Although the requirements in the proposed life safety

standards aren’t new, there are interesting points in the

proposal worth noting:

The introduction to LS.1.10 (complying with the

LSC) states that PFIs not completed within six

months after their projected completion date will

be out of compliance. This PFI deadline has not

shown up in any standards before, though Joint

Commission publications occasionally mentioned

it. “This is going to be a useful thing,” MacArthur

says of this addition.

LS.1.10, EP 3 notes that LSC deficiencies can be han-

dled through a 45-day work order program in lieu of

a PFI or equivalency.

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February 2008 Healthcare Life Safety Compliance Page �

© 2008 HCPro, Inc.


LS.2.20 (maintaining means of egress), EP 10 men-

tions that wall-mounted computers with self-retract-

ing keyboards are allowed to project up to 6 inches

into corridors (when retracted) if the halls are at least

6 ft wide.

LS.2.20, EP 17 includes a reference to the 2006 LSC by

allowing suites of patient sleeping rooms to go up to

7,500 square feet under certain conditions. This refer-

ence offers flexibility to facilities, Koffel says.

A footnote to LS.2.34 (maintaining fire alarm systems)

mentions The Joint Commission’s policy about manual

transmission of fire alarm signals in its May 2006 En-

vironment of Care News. Technically, only the standards,

online FAQs, and Joint Commission Perspectives provide

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➤

➤

official accreditation information. “Does this somehow

introduce EC News into the realm of ‘enforceable’ infor-

mation sources?” MacArthur says.

Also in LS.2.34, EP 2 refers to the 2002 NFPA 72,

National Fire Alarm Code. The 2000 LSC refers to the

1999 NFPA 72.

LS.2.50 (maintaining building services) mentions

fireplace requirements in three EPs.

LS.3.20 (maintaining means of egress in ambulatory

healthcare occupancies) allows hand gel dispensers in

corridors under certain conditions in EP 6. The 2000

LSC has no provisions for gel dispensers in ambulatory

settings.

➤

➤

➤

A rundown of The Joint Commission’s draft life safety standards

The Joint Commission’s proposed life safety chapter will

extract EC.5.20, which mandates compliance with the Life

Safety Code® (LSC), and will more clearly delineate asso-

ciated requirements. The proposal includes the following

standards.

Healthcare occupancies (i.e., hospitals and

nursing homes)

LS.1.10 (four EPs)—The physical environment complies

with the LSC and electronic Statement of Conditions (SOC)

LS.2.10 (nine EPs)—Building and fire protection features

minimize the effects of fire, smoke, and heat

LS.2.20 (30 EPs)—The facility maintains its means of

egress

LS.2.30 (24 EPs)—The facility provides and maintains

its fire protection building features

LS.2.34 (four EPs)—The facility provides and maintains

its fire alarm systems


its fire extinguishing systems

LS.2.40 (two EPs)—The facility provides and maintains

its special fire protection features (i.e., requirements for

windowless and high-rise buildings)


its building services

➤

➤

➤

➤

➤

➤

➤

➤

LS.2.70 (three EPs)—The facility provides and maintains

operating features

Ambulatory healthcare occupancies

LS.1.10 (four EPs)—The physical environment complies

with the LSC and electronic SOC

LS.3.10 (10 EPs)—Building and fire protection features

minimize the effects of fire, smoke, and heat

LS.3.20 (20 EPs)—The ambulatory facility maintains its

means of egress

LS.3.30 (19 EPs)—The ambulatory facility provides and

maintains its fire protection building features

LS.3.34 (six EPs)—The ambulatory facility provides and

maintains its fire alarm systems

LS.3.35 (nine EPs)—The ambulatory facility provides

and maintains its fire extinguishing equipment

LS.3.40 (two EPs)—The ambulatory facility provides

and maintains its special fire protection features (i.e.,

requirements for windowless and high-rise buildings)

LS.3.50 (two EPs)—The ambulatory facility provides

and maintains its building services

LS.3.70 (five EPs)—The ambulatory facility provides and

maintains operating features

Source: The Joint Commission.

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> continued on p. 4

Page � Healthcare Life Safety Compliance February 2008

© 2008 HCPro, Inc.


layout of Part 3 in the SOC. If you skim through Part 3

now, you’ll see it broken down by “units” within a

building, such as floors and compartments. The Joint

Commission’s task force took Part 3, reorganized it to

more closely follow the organization of the LSC, and

transformed the information into the proposed stan-

dards, Berek says.

Certain aspects of the SOC have been placed into the

standards or their rationale statements, which makes

the proposal more user friendly, he adds. For example,

the introduction to the proposed standards clearly de-

fines what an ambulatory occupancy is, whereas to find

that definition currently, one has to connect the dots

through the SOC’s instructions.

“There was a lot of information that was hidden in

the directions of [the SOC],” Berek says. Clarifying this

type of information represents an improvement in the

proposed standards, he adds. n

Questions remain about BMP’s advantages

As we reported in the January Healthcare Life Safe-

ty Compliance, the proposed standards appear to down-

grade the advantages of using the building maintenance

program (BMP).

The introduction to LS.1.10 mentions the BMP but

doesn’t talk about the 95% compliance rate current-

ly associated with this optional approach, nor does the

proposal offer any

scoring benefits.

Instead, specif-

ic EPs within the

standards note that

a BMP is an “ac-

ceptable method for managing” items that aren’t func-

tioning properly.

In a field review questionnaire, The Joint Commis-

sion asked participants about whether the BMP should

be optional, mandatory, or eliminated. It also asked

about whether the 95% rate should be higher or lower.

Further, the list of items covered under the BMP in

the draft expands to include penetrations in one-hour-

rated fire walls.

“It’s hard to say that the BMP is going away, what

with the consistent identification of the BMP as an ac-

ceptable method for managing the same items it always

has—with the exception of the added one-hour-rated

fire walls,” MacArthur says.

Part � in the SOC transitions to the standards

Many of the proposed standards and their EPs cross-

walk to Part 3 in the SOC, which is also known as the life

safety assessment.

Part 3 isn’t a mandatory part of the SOC but rather a

lengthy checklist of NFPA requirements to help deter-

mine your compliance with the LSC. However, many hos-

pitals use Part 3 because surveyors are familiar with it.

The layout of the proposed standards more close-

ly parallels the LSC’s requirements, compared to the

Life safety standards < continued from p. 3

Don’t forget to start using six-year testing for hospital dampers

As of January 1, The Joint Commission expanded re-

quired fire and smoke damper testing from every four

years to every six years. The change comes under EC.5.40,

which sets various inspection, testing, and maintenance re-

quirements for fire protection equipment.

The six-year provision only applies to hospital build-

ings that provide inpatient services, according to the

January Joint Commission Perspectives.

A reader asked us how the new testing frequency

would apply to a damper that was last tested in 2004.

Would he need to test that damper again in 2008 be-

cause the four-year testing was in effect at the time of

the last test, or would the six-year time span instead

apply for a 2010 test?

In such cases, go with the six-year frequency from

your prior damper test, says Elizabeth Zhani, a spokes-

person for The Joint Commission.

“With the new six-year allowance, the organization

can extend the damper inspection to 2010,” Zhani says.

The proposed standards

appear to downgrade the

advantages of using the

building maintenance

program.


© 2008 HCPro, Inc.


If you’ve developed plans for improvement (PFI) to

fix deficiencies, most life safety specialists will review

your submissions during a survey. Joint Commission

(formerly JCAHO) officials can also track your progress

through the accreditor’s electronic PFI system, in which

you must file your improvement projects.

Citations remain high under EC.5.20, which requires

compliance with the Life Safety Code® (LSC) and Statement

of Conditions (SOC), and PFI deficiencies have played a

part in this trend.

Under Joint Commission requirements, facilities must

respond to LSC deficiencies using one of the following

three methods:

1. Fix the deficiency quickly, usually through a 30- or

45-day work order program

2. Request an equivalency from The Joint Commission,

in which a facility can try to use other existing fire

protection features to offset the deficiency (e.g., sprin-

kler protection to offset excessive travel distance)

3. File a PFI to correct the problem

One of the biggest areas of PFI scrutiny centers on

timelines a facility gives to projects and its ability to

keep up with that schedule. When you submit a PFI to

The Joint Commission, you must include a proposed

completion date, and that starts the clock ticking on the

project.

If you miss a completion date by six months with-

out an approved extension from The Joint Commission,

your PFI and SOC are out of compliance, and your facil-

ity may be cited.

Make your case, says Joint Commission

Unfortunately, there’s no strong guidance from The

Joint Commission about what constitutes a reasonable

time frame for various PFIs. However, it’s safe to say that

you can’t use a one-time-frame-fits-all approach, says

David Klein, PE, chief fire protection engineer for the

U.S. Department of Veterans Affairs.

LSC and other criteria will shape PFI completion dates

Illustration by

David Harbaugh

“Note the similarities between Deep Throat and

The Joint Commission’s press office.”

For example, a five-year completion schedule for a

ward renovation to fix a host of LSC deficiencies might

be a reasonable time frame, Klein says.

Using the same period for a series of door latch re-

placements? “That’s not reasonable,” he says.

The Joint Commission leaves the determination in the

hands of facilities,

says spokesperson

Elizabeth Zhani.

“The Joint

Commission does

not have a rule on

this because each organization and its deficiencies are

unique,” Zhani says.

Given that Joint Commission surveys no longer come

at regular, three-year intervals and healthcare build-

ings tend to always have an LSC deficiency somewhere,

chances are you will need a consistent approach to PFI

completion dates, says Thomas Gardner, PE, FSFPE,

managing director of the Atlanta and Miami offices of

Schirmer Engineering Corporation.> continued on p. 6

“ Setting the time frames

on [PFIs] can be subject

to a number of different

criteria.”

—Robert Castaldo

Page � Healthcare Life Safety Compliance February 2008

© 2008 HCPro, Inc.


Joint Commission officials are satisfied if life safety de-

ficiencies are “identified and being worked on” through

PFIs, Gardner says.

“Setting the time frames on [PFIs] can be subject to

a number of different criteria,” says Robert Castaldo,

safety director at Massachusetts General Hospital in Bos-

ton. From Castaldo’s perspective, those criteria go be-

yond just LSC debates.

Weigh the seriousness of the problem

That being said, life safety issues are an important

component to determining PFI completion dates, says

Castaldo.

He says he tends to look at how serious the life safe-

ty deficiency is, as opposed to how long the work could

take to fix it.

For example, if a renovated unit needs a sprinkler re-

configuration to comply with the LSC, that would likely

place high on Castaldo’s priority list for a quick comple-

tion date. “That’s probably something that we would put

on a shorter timeline rather than a longer one” because

of the importance of sprinkler protection, he says.

On the other hand, imagine a facility has a stairwell

with risers that are a 1/2-inch too high. The problem

technically puts the stairwell out of compliance with

the LSC, yet people can still use the stairs, Castaldo says.

In that case, a PFI for the fix might have a long-term

completion date. “We’re probably going to take more

time to change something like that,” he says.

Here’s another example, courtesy of The Joint Com-

mission: Suppose a facility notes a 2-inch-wide hole in

a fire barrier and submits a PFI this year to fix the prob-

lem, with a June 2012 completion date.

“Without elaborating about why the corrective action

would not be done within a more reasonable time frame,

a Joint Commission surveyor would discuss this with the

organization, and it might result in the organization be-

ing scored,” Zhani says.

Gardner suggests an interesting approach: Use scope

and severity ratings from the Centers for Medicare & Med-

icaid Services (CMS) to guide your PFI timeline decisions,

as outlined on p. 7. The ratings, when completed in a ma-

trix, can help pinpoint deficiencies that hold more risk

and thus may require more complex fixes, Gardner says.

“That’s a great way to go to The Joint Commission and

say, ‘This is why I need more time,’ ” he adds.

CMS doesn’t recognize PFIs, though the agency does

require compliance with the LSC.

Think past life safety, too

Beyond strict LSC issues, Castaldo and Gardner also

consider the following factors when determining a PFI

completion date:

Money—Many PFIs will need a financial commitment

to complete, so funding within a given fiscal year fig-

ures into realistic completion dates

Leadership buy-in—If administrators in a facility want

to see a project wrapped up, an earlier PFI completion

date is likely, Castaldo says

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PFI completion dates < continued from p. 5

Don’t skip ILSM reviews during your PFI projects

Submitting a plan for improvement (PFI) should auto-

matically make you think about interim life safety measures

(ILSM), too.

Under EC.5.50, facilities must assess Life Safety Code® de-

ficiencies and consider whether any ILSMs would be appro-

priate safeguards.

“That’s a given” to evaluate ILSMs for PFIs, says David

Klein, PE, chief fire protection engineer for the U.S. De-

partment of Veterans Affairs. “We tell our people always to

do that.”

Prolonged PFIs may invite ILSM scrutiny from Joint Com-

mission surveyors. “If the organization is able to defend

an extended projected completion date, then there would

be an expectation that interim life safety measures would

be implemented” if necessary, says Elizabeth Zhani, a

spokesperson for The Joint Commission.


© 2008 HCPro, Inc.


Other regulators—In some cases, state license agen-

cies or others can drive the need to fix a deficiency,

which might necessitate a quicker completion date,

Castaldo says

Subsequent projects—A PFI might benefit from a lon-

ger timeline if another project that hasn’t started yet

will eventually affect long-term plans, Gardner says

There are “all kinds of parameters to consider,”

Castaldo says.

Defend timelines with your experience

So who makes the decision about PFI completion

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➤

dates? The Joint Commission doesn’t say. For Castaldo,

the answer is easy. “Who’s in the best position to say

what’s reasonable? In my opinion, it’s the managers for

the facility,” he says.

If life safety specialists or Joint Commission officials

take issue with a projected PFI completion date, they

will eventually talk to safety officers and facility direc-

tors, so managers must be able to build a case for the

timelines.

“The Joint Commission isn’t in the facility every day,”

Castaldo says. “They may not see all the parameters that

went into the decision-making” without talking to the

facility’s staff members. n

CMS approach may help you gauge your PFI timelinesThe following categories and matrix are based on how

inspectors from the Centers for Medicare & Medicaid

Services (CMS) evaluate Life Safety Code® deficiencies in

nursing homes.

However, the same approach may be useful in deter-

mining Joint Commission plan for improvement (PFI)

completion dates. Remember, CMS does not use or rec-

ognize PFIs.

The scope of a life safety deficiency reflects its pervasiveness throughout a facility:

Scope is isolated when the deficiency affects one

or a limited number of patients or employees and/

or a limited area or number of locations within the

facility

Scope is a pattern when the deficiency affects more

than a limited number of patients or employees and/

or the situation has occurred in more than a limit-

ed number of locations, but the locations aren’t dis-

persed throughout the facility

Scope is widespread when the problems causing the

deficiency affect many locations throughout the facil-

ity and/or represent a systemic failure that affected,

or has the potential to affect, a large portion of or all

patients or employees

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The severity of a life safety deficiency reflects the impact the deficiency has on the fire safety of an individual:

Level 1—No actual harm to a patient or employee,

with potential for minimal harm

Level 2—No actual harm to a patient or employee,

with potential for more than minimal harm that is

not an immediate jeopardy

Level 3—Actual harm to a patient or employee that

is not an immediate jeopardy

Level 4—Immediate jeopardy to a patient’s or em-

ployee’s health or safety, in which immediate cor-

rective action is necessary because the deficiency is

likely to cause serious injury or death

You can chart a deficiency’s scope and severity us-

ing the matrix below. Generally, the shaded boxes in the

matrix denote more serious situations. n

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Isolated Pattern Widespread

Level 4

Level 3

Level 2

Level 1

Sources: CMS and the Indiana State Department of Health.

© 2008 HCPro, Inc.


Healthcare Life Safety Compliance January 2008

Dead-end corridor provisions benefit existing hospitalsDead-end corridors can create headaches during ren-

ovations or new construction. The concern is that occu-

pants may go down a dead end during a fire only to find

out they can’t exit via that route and thus need to re-

trace their steps.

Dead-end travel distances often occur in elevator lob-

bies and pockets of rooms served by a hallway, according

to the NFPA’s 2000 Life Safety Code Handbook. The figure

below illustrates dead-end arrangements.

The Life Safety Code® (LSC) regulates dead ends through

its means of egress provisions:

Paragraph 7.5.1.6 mandates that facilities arrange exit

access such that there are no dead-end corridors, sub-

ject to further provisions in Chapters 12–42

Under 18.2.5.10, newly constructed healthcare occu-

pancies (i.e., hospitals and nursing homes) can’t have

dead ends longer than 30 ft

Under 19.2.5.10, existing healthcare occupancies can

keep dead ends if they are impractical to correct

The final bullet is tempered by annex note A.19.2.5.9,

which suggests that dead-end corridors shouldn’t exceed

30 ft, similar to newly constructed corridors. However,

annex notes aren’t mandatory portions of the LSC.

If an existing dead end goes beyond 30 ft, you need

to make a judgment call and likely need to contact your

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authorities to get their approvals. In the LSC, only exist-

ing healthcare space under Chapter 19 enjoys the open-

ended provision for dead-end corridor lengths.

This fact can make options tricky if a healthcare

space that has a dead-end corridor undergoes a major

renovation or changes occupancy. In such situations,

the reworked space generally must meet the require-

ments for new construction (see 4.6.7 and 4.6.11 in

the LSC).

For example, if a hospital renovates a wing, it must

observe 18.2.5.10 for a newly constructed healthcare

site, which limits dead ends to 30 ft. That could create

a problem if there were any longer dead ends prior to

renovation. n

Commonly confused terms

Common path of travel—An arrangement in which

occupants are able to travel in only one direction be-

fore reaching paths for two distinct exits

Dead end—An arrangement in which there is no path

of travel from a space or an arrangement in which a

person enters a corridor thinking there is an exit but

instead finds none and needs to retrace his or her steps

to an exit path

Source: Annex note A.7.5.1.6 in the Life Safety Code®.

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Dead-end corridors

Source: 2000 Life Safety Code® Workbook & Study Guide for Health Care Facilities, published by HCPro, Inc.


© 2008 HCPro, Inc.


Learn about emergency lighting provisions, which intertwine with NFPA �0 and ��

Each month in this column, a staff member at Koffel Associ-

ates, Inc., in Elkridge, MD, clarifies the code references behind

commonly misunderstood healthcare requirements. Fire protec-

tion engineer Jennifer Frecker authored this installment.

Welcome to our new column, Cracking the Code. At

the request of many readers, this monthly feature will

delve into the background of healthcare requirements

in the Life Safety Code® (LSC) and other NFPA standards.

The application of these requirements can be con-

fusing or have unexpected consequences. Through this

column, we hope to provide additional insight into the

exact code requirements for specific situations and tech-

nical information about the development of the require-

ments. We’ll provide code references in parentheses as

we describe each requirement.

Check out emergency light provisions

To kick things off, let’s discuss the requirements for

emergency lighting in ORs and other anesthetizing

locations.

Existing healthcare occupancies require emergen-

cy lighting for egress under section 7.9 of the LSC (LSC,

19.2.9). New healthcare occupancies require compli-

ance with 7.9 (LSC, 18.2.9.1), but these sites must al-

so meet an additional requirement: Buildings equipped

with or in which patients require the use of life sup-

port systems shall have emergency lighting equipment

supplied by the life safety branch of the electrical sys-

tem as described in NFPA 99, Healthcare Facilities (LSC,

18.2.9.2).

The construction and equipment requirements of

NFPA 99 only apply to new installations and aren’t ret-

roactive (NFPA 99, 1999 edition, 1-2). For Joint Com-

mission (formerly JCAHO) purposes, new occupancies

are those that had design plans approved on or after

March 1, 2003, according to the Statement of Conditions.

Note the role of emergency lighting

You must provide battery-powered emergency light-

ing units in all anesthetizing locations (e.g., ORs), and

the lighting must meet the requirements of NFPA 70, Na-

tional Electrical Code, section 700-12 (NFPA 99 3-3.2.1.2).

Batteries in the lighting units must be of a “suitable

rating and capac-

ity to supply and

maintain at not

less than 87.5% of

the nominal bat-

tery voltage of the

total lamp load associated with the unit for a period of

at least one and a half hours,” according to NFPA 70.

It isn’t the intent of NFPA 99 to have enough lighting

to continue surgical procedures when emergency lights

activate. Rather, the intent is to permit enough illumina-

tion to move around a room until the emergency gener-

ator begins to supply power.

Should emergency power supplies fail, the battery-

powered lighting will provide enough light for the

structured evacuation of patients and staff members

from the OR.

The Joint Commission requires hospitals to test all

battery-powered lights required for egress. These in-

clude a functional test at 30-day intervals for a mini-

mum of 30 seconds and an annual test for a duration of

90 minutes (EC.7.40, EP 3). These requirements apply

to the battery-powered emergency lighting provided in

all anesthetizing locations per NFPA 99.

The Healthcare Interpretations Task Force provided

information on November 16, 2004, stating that emer-

gency lighting in anesthetizing locations is only manda-

tory for new locations and that existing lights exempt

from NFPA requirements may be considered task light-

ing. Again, this applies to locations that were approved

prior to March 1, 2003. n

It isn’t the intent of NFPA ��

to have enough lighting to

continue surgical procedures

when emergency lights

activate.


© 2008 HCPro, Inc.


Each month, Jennifer Frecker and James Lathrop

of fire protection consulting firm Koffel Associates, Inc., in

Elkridge, MD, answer your questions about life safety com-

pliance. Our editorial advisory board also reviews the Q&A

column.

Sprinklers for wardrobe closets

We are in the process of renovating a patient

care unit within our hospital. Each patient room

has two wooden wardrobe cabinets that measure 2 ft

deep by 7 ft high by 3 ft wide. The ceilings are 1 ft

above the tops of the cabinets. In each room, a desk

for nurse charting separates the two cabinets. We

aren’t sure whether these cabinets require sprinkler

protection. Can you help?

This question is a common one for new construc-

tion as we see more and more cabinetry used in

patient care rooms for storage.

NFPA 13, Installation of Sprinkler Systems, applies to

this situation. However, NFPA 13 really didn’t address

your concern until the 2007 edition of the standard.

“Furniture, such as portable wardrobe units, cabi-

nets, trophy cases, and similar features not intended

for occupancy, does not require sprinklers to be in-

stalled in [it],” paragraph 8.1.1(7) in NFPA 13 states.

Annex note A.8.1.1(7) offers some additional

thoughts:

“Portable wardrobe units, such as those typically

used in nursing homes and mounted to the wall, do

not require sprinklers to be installed in them,” the

annex says. “Although the units are attached to the

finished structure, [NFPA 13] views those units as

pieces of furniture rather than as part of the struc-

ture; thus sprinklers are not required.”

Remember that annex notes are not mandatory

parts of the standard, but rather explanatory. Also, at

this point, The Joint Commission and the Centers for

Medicare & Medicaid Services (CMS) don’t recognize

the 2007 NFPA 13. However, wardrobe sprinkler pro-

tection isn’t mentioned in earlier editions of NFPA 13.

If your facility feels its wardrobes might be question-

able (i.e., it’s not obvious they are furniture), you may

want to request an opinion from The Joint Commis-

sion or CMS based on the 2007 NFPA 13.

Clear width for door isolation caddies

Our infection control nurse has been contemplat-

ing the purchase of a personal protective equip-

ment (PPE) door caddy for patients who are placed

on isolation precautions. The facility would stock

these caddies with PPE and replace bulky isolation

carts. However, my EC guy is telling me this is a no-

no. The plan was to hang these caddies on remov-

able hooks that do not physically alter the fire rating

of the door. We are being told that this is not allowed

because we are not fully sprinkler-protected. Our pa-

tient hallways have sprinklers, but the patient rooms

don’t. What gives?

Actually, there are several reasons why the door

caddies are a problem:

The caddies restrict the clear width of the corridor

door when hung on the corridor side of the door—

see paragraph 19.2.3.5 in the Life Safety Code® (LSC)

If the caddies are on the patient room side of the

door, they can also restrict the clear width of the

door if the door opens to a wall or other fixed ob-

ject by not allowing the door to open the full

width—again, see 19.2.3.5

➤

➤

&QuestionsAnswers

February 2008 Healthcare Life Safety Compliance

© 2008 HCPro, Inc.


The caddies restrict the clear width of the corridor if

the patient room door is closed, as most caddies do

not meet corridor projection exceptions—see the

exception to 7.3.2 in the LSC

Sprinkler protection doesn’t play a role in your di-

lemma. The clear width requirements in the LSC apply

to occupancies regardless of sprinkler protection.

Code requirements for candle warmers

I am trying to locate any requirements concerning

electrical candle warmers in nonpatient areas of

a hospital. Are they against the LSC? Can you give me

any information about this?

There is really nothing in the LSC that speaks di-

rectly to candle warmers, which are small electri-

cal appliances that allow you to heat candles from the

bottom without lighting them.

The only requirement that comes close is paragraph

9.1.2, which requires all electrical equipment to meet

the requirements of NFPA 70, National Electrical Code.

Having said that, any type of warming device in-

troduces some level of fire risk to the facility, and

as such, we strongly discourage its use. As the LSC

doesn’t specifically speak to this situation, we suggest

that your facility complete a risk assessment to deter-

mine the potential hazards associated with the use of

the device.

If you determine that the level of risk is acceptable,

then the facility has documentation to provide to au-

thorities should anyone question the use of a candle

warmer. Of course, the local authority or other entity

might not agree with your facility’s assessment and

still require the removal of the device.

Sprinkler protection exceptions in ORs

We are preparing design documents to renovate

our surgery department. As part of this project, we

➤ want to install sprinklers in the surgery rooms. There

are currently sprinklers throughout the department ex-

cept for the recovery area and the ORs. Our head of

surgery doesn’t want sprinklers in the ORs because of

concerns that patients might be exposed to dirty wa-

ter from a possible broken sprinkler head. Do any NFPA

standards exempt sprinklers from ORs?

No, there are no exceptions for sprinkler protec-

tion for ORs within NFPA codes and standards,

including NFPA 13.

The chance of a leak from sprinkler piping is far

lower than the chance of a leak in the domestic water

system due to the required levels of sprinkler testing

and the monitoring of the system. If you want to pro-

vide an added degree of assurance, you can install a

pre-action system. Pre-action systems require the acti-

vation of local smoke detection or heat detection prior

to releasing water into the sprinkler piping.

Pre-action systems are more expensive to install and

maintain than traditional sprinkler systems, but pre-

action equipment provides added assurance against a

leak or accidental discharge.

You could also install sidewall sprinklers if your

main concern is water leaking from overhead. n

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] (put “Q&A” in the

subject line)

Fax to 781/639-2982 (to the attention of Health-

care Life Safety Compliance)

➤

➤

➤

Send us your questions


© 2008 HCPro, Inc.


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Quick tip

You can read many NFPA codes online for freeAnyone who’s spent even a short amount of time try-

ing to keep track of various NFPA codes and standards

appreciates how many references there are.

The Life Safety Code® (LSC) can send you to many oth-

er documents—popular ones include NFPA 99, Health-

care Facilities, and NFPA 13, Installation of Sprinkler Systems.

Within the pages of this newsletter, we often note stan-

dard and code requirements beyond the LSC.

In an ideal world where costs are no concern, we

could all own copies of the necessary NFPA codes, either

in print, on CD-ROM, or via online access. But those

purchases could cost hundreds, if not thousands, of dol-

lars, and NFPA documents undergo updates every three

years or so.

We feel having the 2000 edition of the LSC in paper

or electronic format is a must for facilities directors and

safety officers in healthcare facilities, particularly because

The Joint Commission (formerly JCAHO) and the Cen-

ters for Medicare & Medicaid Services explicitly require

compliance with the 2000 edition.

Beyond the LSC, how big or small to make your NFPA

library is an individual choice.

Those of you who’d like to have more standards and

codes handy, but don’t have the time or funds to get them,

may find a particular feature of the NFPA’s Web site useful.

The NFPA allows visitors to view for free all current

and some past versions of its codes and standards list. The

files are read-only, meaning you can’t download the doc-

uments, nor can you cut and paste passages from them.

But just being able to click through a document’s table of

contents and read provisions on your computer screen is

a practical benefit.

Here’s how to access this feature, using NFPA 13 as an

example (you will need Java installed on your computer

to complete this process):

1. Go to www.nfpa.org

2. Under the Codes & Standards tab, choose “Document

list and code cycle information”

3. Choose NFPA 13

4. Scroll down to the heading, “Additional information

about this document’’—you’ll see options to view ei-

ther the 2007 or 2002 editions

5. Choose an edition and follow the instructions

The NFPA tends to post only the two most recent edi-

tions of any code; as such, most references contained in

the 2000 LSC aren’t available. Regardless, it’s still helpful

to dig into current code and standard requirements, es-

pecially if you need quick answers rather than strict code

interpretation. n

1. (T)(F) Plansforimprovement(PFI)involvingsprinklerretrofitshaveacapoftwoyearsforcompletion,accordingtoTheJointCommission.

2. (T)(F) Undertheproposedlifesafetystandardsfor2009,thebuildingmaintenanceprogramwillbecomeitsownscoredstandard.

3. (T)(F) Youdon’tneedtoprovidebattery-poweredemergencylightingunitsinnewanesthetizinglocations,asoutlinedinNFPA99,Healthcare Facilities.

4. (T)(F) SprinklerprotectionforwardrobeclosetshaslongbeenaprovisioninNFPA13,Installation of Sprinkler Systems.

5. (T)(F) Sprinklerprotectionandcorridorwidthrequirementshelpdeterminewhetheryoucanplaceanisolationprecautionscaddyonapatientroomdoor.

6. (T)(F) Theproposedlifesafetystandardsfor2009closelyfollowtheorganizationofChapter19inthe Life Safety Code®(LSC).

7. (T)(F) Existinghealthcareoccupanciescankeepdead-endcorridorsgreaterthan30ftlongifitisimpracticaltocorrectthem,accordingtotheLSC.

8. (T)(F) Whenitcomestocandlewarmersandportablespaceheaters,theLSCclearlyprohibitstheiruseexceptincertaincases.

9. (T)(F) TocompletePFIs,theCentersforMedicare&MedicaidServicesrequiresyoutousetheagency’sscopeandseveritymatrix.

10.(T)(F) Pre-actionsystemsrequiretheactivationofallsmokedampersinacompartmentpriortoreleasingwaterintothesprinklerpiping.

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

Vol. 10 No. 2February 2008

Quiz questions February 2008 (Vol. 10, No. 2)

A supplement to Healthcare Life Safety Compliance

1. False. TheJointCommissiondoesn’tassignspecifictimeframesforPFIcompletiondates.

2. False. Ifanything,theprogramappearstobedownplayed,asthereisnomentionintheproposedstandardsofscoringbenefitscurrentlyenjoyedbyfacilities.

3. False. Youmustprovidebattery-poweredemergencylightingunitsinnewanesthetizinglocations.

4. False. Wardrobesprinklerprotectionisn’tmentionedineditionsofNPFA13publishedbefore2007.

5. False. Sprinklerprotectiondoesn’tplayaroleinthisdebate,thoughcorridorrequirementsdo.

6. True

7. True

8. False. TherearenoprovisionsintheLSCthatdirectlynotecandlewarmers.

9. False. AlthoughthematrixmaybeagoodtooltohelpdevelopPFItimelines,theagencydoesn’trecognizePFIs.

10.False. Pre-actionsystemsrequiretheactivationoflocalsmokedetectionorheatdetectionpriortoreleasingwaterintothesprinklerpiping.

Quiz answers February 2008 (Vol. 10, No. 2)

Copyright©2008HCPro,Inc.CurrentsubscriberstoHealthcare Life Safety Compliance maycopythisquizforuseattheirfacilities.Usebyothers,includingthosewhoarenolongersubscribers,isaviola-tionofapplicablecopyrightlaws.®Registeredtrademark,theNationalFireProtectionAssociation,Inc.

february 2008 vol. 10, no. 2 healthcare life safety...

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