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Health Care Facilities and NFPA Standards: What’s New
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by Stan Oman, NAFED Technical Training Manager

On July 5, 2016, the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission adopted the 2012 editions of NFPA 101 and NFPA 99. Previously, the facilities under the jurisdiction of these groups had been following the 2000 editions of those standards. That means now there are twelve years of changes that health care facilities must deal with. Below is a list compiled from many sources with some of these changes we, as fire equipment dealers, have to deal with.

Means of Egress

  • Existing openings into exit enclosures from unoccupied mechanical rooms permitted, provided the room does not contain fuel-fired equipment, the room does not have any combustibles stored, and the entire building is protected with sprinklers. [NFPA 101, 2012,]
  • Electrically locked hardware allowed on egress doors, to be similar to mechanically locked doors. [NFPA 101, 2012,]
  • Existing dead-bolt locks are permitted on a door to a room serving not more than three occupants, provided it does not require simultaneous operations to unlock the door. [NFPA 101, 2012,]
  • Door assemblies separating an elevator lobby from an exit access are permitted to be electrically locked, provided the building is protected throughout by a fire alarm system (this does not mean fully protected with smoke detectors) and fully protected with sprinklers; the elevator lobby is protected with smoke detectors; a two-way communication system is provided for communication between the elevator lobby and a central point that is constantly staffed with capable, trained, and authorized individuals to provide emergency assistance; delayed egress locks and access-control locks are not permitted. [NFPA 101, 2012, and]
  • All fire door assemblies, including side-hinged swinging fire doors, must be tested and inspected annually (but this does not apply to smoke barrier doors). [NFPA 101, 2012,] NOTE: For those of you that want to carry out this requirement. NFPA 80, Standard for Fire Doors and Other Opening Protectives, calls for a person "with knowledge and understanding of the operating components of the type of assembly being subject to testing." Do you have this knowledge/training?
  • Locked doors now permitted where the specialized protective measures are required for the safety needs of the patient, provided the staff is capable of unlocking the doors, the entire locked space is fully smoke detected or there is a remote switch to unlock the doors in a constantly attended location on the unit (NOTE: a typical nurse station is not considered constantly attended), the door unlocks on a power failure or activation of the sprinkler system or by a smoke detection system, and the building is fully sprinklered. [NFPA 101, 2012,]
  • Horizontal sliding doors do not have to be side-hinged and break-away if they serve an occupant load fewer than ten people. [NFPA 101, 2012,]
  • Corridor projections are limited to 4 inches instead of 6 inches. [CMS Final Rule, May 4, 2016] NOTE: Fire extinguishers fall into this new change.

Sleeping Suites

  • Sleeping suites may be 7,500 square feet if the entire smoke compartment where the suite is located is protected with standard response sprinklers and smoke detectors; or if the entire smoke compartment where the suite is located is protected with quick response sprinklers, then smoke detectors are not required. [NFPA 101, 2012,]
  • Sleeping suites may be 10,000 square feet provided the patient sleeping rooms are arranged for direct supervision, the entire suite is protected with smoke detectors, and the entire suite is protected with sprinklers. [NFPA 101, 2012,]

Protection from Hazards

  • Soiled linen and trash rooms containing less than 64-gallon capacity containers no longer have to be considered hazardous areas. [NFPA 101, 2012,]
  • Residential cooking equipment used for food warming or “limited cooking” (e.g., staff break rooms) do not have to comply with NFPA 96 for exhaust hoods and are not considered a hazardous area. [NFPA 101, 2012,]
  • Small cooking areas that are limited to preparing meals for no more than thirty persons are permitted to be open to the corridor (with specific restrictions on how the cooking equipment is arranged and used). [NFPA 101, 2012,]

Residential Hoods with Residential Range

  • Kitchens no longer have to be considered hazardous areas if the cooking exhaust hoods are fitted with fire suppression systems. [NFPA 101, 2012,]
  • A change in use of a space in an existing healthcare occupancy does not have to meet new construction requirements for hazardous areas, provided the space does not exceed 250 square feet and the entire building is protected with sprinklers, but the space does have to meet the requirements for hazardous areas for existing conditions. [NFPA 101, 2012,]

Fire Alarm Systems

  • Off-site monitoring transmission equipment for fire alarm systems has to be tested annually, rather than quarterly. [NFPA 72, 2010, Table 14.4.5 (22), and Table (18)]

Sprinkler Systems

  • Water-flow switches may be tested semi-annually instead of quarterly. [NFPA 25, 2011,]
  • Electric-driven fire pumps are now permitted to be tested monthly rather than weekly for the no-flow test. Engine-driven fire pumps still have to be tested weekly. [NFPA 25, 2011,]
  • In sprinkler systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, a main drain test of at least one system downstream of the device must be conducted on a quarterly basis. [NFPA 25, 2011,]
  • Fire hose valves are now required to be inspected quarterly to ensure the caps are in place and not damaged; the hose threads are not damaged; the valve handles are present and not damaged; gaskets are not damaged; there are no leaks; there are no obstructions to the valves; and to ensure any restricting devices are in place. [NFPA 25, 2011,]
  • Fire hose valves sized 2 1/2 inches are required to be tested annually by opening and closing the valves (full flow of water is not required). [NFPA 25, 2011,] NOTE: This has been a requirement. Now surveyors are wanting to see that these valves are inventoried. These valves need to be tested by July 5, 2017.
  • Fire hose valves sized 1 1/2 inches are required to be tested once every three years by opening and closing the valves (full flow of water is not required). [NFPA 25, 2011,] NOTE: This has been a requirement. Now surveyors are wanting to see that these valves are inventoried. Even though this is a three-year requirement, these valves need to be tested by July 5, 2017. Then they are good for three years.
  • Annual fire pump flow tests still require the pump to be operated at a no-flow condition (churn), but it is no longer required to be 30 minutes. The length of time is not specified. [Deleted requirement, NFPA 25, 2011]
  • Once every five years, an internal inspection must be conducted of the sprinkler piping (non-metallic pipe excluded) at two locations: 1) at the end of one main (drain system and remove end cap) and 2) remove one sprinkler at end of branch line. If the presence of foreign material is found, then a thorough obstruction investigation (as described by NFPA 25) is required and must be conducted every five years thereafter. If slime is found, it must be tested for Microbiological Influenced Corrosion (MIC). [NFPA 25, 2011, 14.2]
  • Sprinkler impairments do not require fire watches until the sprinklers are impaired for 10 hours in a 24-hour period. [NOTE: This does not apply to fire alarm system impairments which remain at 4 or more hours in a 24-hour period.] [NFPA 25, 2011, 15.5.2] NOTE: If repairs cannot be completed in this time period the hospital needs to put into place their Interim Life Safety Measures (ILSM).
  • Fire watches are now required in order to have a designated individual who performs no other duties to continuously monitor the impaired locations, looking for fire, fire hazards, and situations that could develop into a fire situation. The individual must have ready access to portable fire extinguishers and the ability to promptly notify the fire department. [NFPA 25, 2011, A.15.5.2(4)(b) and CMS Final Rule, May 4, 2016]
  • Existing high-rise healthcare occupancies must be fully protected with sprinklers by July 5, 2028. A high-rise facility is one where the floor of an occupiable story is greater than 75 feet above the lowest level of fire department vehicle access. [NFPA 101, 2012,]

Building Services

  • Generator annual load test is only required for 90 minutes rather than 2 hours. The test starts at 50% load for 30 minutes and increases to 75% load for 60 minutes for a 90-minute continuous test. No longer is the generator required to operate at 25% load for 30 minutes. [NFPA 110, 2010,]
  • The weekly inspection of the emergency generator permits battery conductance testing in lieu of specific gravity testing when applicable and warranted. [NFPA 110, 2010,]
  • A fuel quality test must be performed annually on the fuel supply for the emergency power generator, in accordance with ASTM testing methods. [NFPA 110, 2010, 8.3.8]

Operating Features

  • Fewer restrictions on the display of combustible decorations: 20% of walls, non-fire rated doors, and ceilings may be covered with combustible decorations in un-sprinklered smoke compartments; 30% of walls, non-fire rated doors, and ceilings may be covered with combustible decorations in sprinklered smoke compartments; 50% of the walls, non-fire rated doors, and ceilings may be covered with combustible decorations in patient sleeping rooms having a capacity of not more than four persons in a sprinklered smoke compartment. [NFPA 101, 2012,]
  • Waste containers up to 96-gallon capacity for the disposal of clean waste (e.g., patient records awaiting destruction) are permitted outside of a hazardous room provided the container meets FM Approval Standard 6921, or equivalent. [NFPA 101, 2012,]
  • Temporary construction barriers are required to be 1-hour fire rated, with 3/4-hour fire rated door assemblies if the construction area is not fully protected with sprinklers. 1-hour barriers are typically steel studs with 5/8-inch thick gypsum board on both sides, with all seams taped and mudded and all screw heads mudded. If the construction area is protected with sprinklers, then the temporary construction barrier is permitted to be non-rated, but construction tarps are not permitted as the non-rated barrier. At this time (and until further notice) flame retardant plastic sheeting (e.g., Visqueen) will be permitted as a temporary construction barrier where the construction area is fully protected with sprinklers. [NFPA 241, 2009, 8.6.2]

NFPA 99, Health Care Facilities Code

  • The plastic wrapping used in shipping compressed gas cylinders must be removed before the cylinders are placed in storage. [NFPA 99, 2012,]
  • Walls surrounding compressed gas storage rooms containing 3,000 cubic feet (or more) of compressed gas and walls surrounding gas manifold rooms must be 1-hour fire rated, and doors in the 1-hour barriers must be 1-hour fire rated as well (3/4-hour fire doors not permitted). [NFPA 99, 2012,]
  • Electric heaters are not permitted in compressed gas cylinder storage areas or in gas manifold rooms. Only indirect heaters (i.e., steam or hot water) are permitted. [NFPA 99, 2012,]
  • All storage racks for compressed gas cylinders must be non-combustible; wooden racks are no longer permitted. [NFPA 99, 2012,]
  • Electrical devices (e.g., switches and outlets) are not required to be mounted 60 inches above the finished floor if there is adequate protection (e.g., wire cage) around the device. [NFPA 99, 2012,]
  • A centralized computer system is permitted to be used in lieu of one of the required master alarms for medical gas systems. [NFPA 99, 2012,]
  • Non-stationary medical gas booms and articulating assemblies utilizing flexible connectors for medical gas outlets in procedure rooms must be tested for leaks per the manufacturer’s recommendations every eighteen months. [NFPA 99, 2012,]
  • Circuit breaker panels serving Category 1 and Category 2 rooms must be limited to just authorized individuals and cannot be located in public access areas (new construction only). This means circuit breaker panels must be locked for Category 1 and 2 rooms. [NFPA 99, 2012,]
  • Operating rooms must be considered “wet procedure locations” unless a risk assessment conducted by the health care governing body (e.g., board of directors) determines otherwise. This means wet procedural locations need to be protected with ground-fault circuit interrupters or isolated power systems. [NFPA 99, 2012,]
  • Plumes created from medical procedures (laser and electrosurgical use) must be removed and discharged outdoors, returned or exhausted through HEPA filtration, or returned to the space by means of chemical and thermal sterilization. [NFPA 99, 2012, 9.3.9]
  • Written procedures are required for operating room and surgical suite fire emergencies. The procedures are to include alarm actuation, evacuation, and equipment shutdown, and for extinguishing drapery, clothing, or equipment fires. [NFPA 99, 2012,]
  • Fire exit drills must be conducted annually in operating rooms and surgical suite locations. [NFPA 99, 2012,]

Copyright NAFED 2017. Do not reuse without permission.

See also:
So You Want to Service Health Care Facilities
Fire Extinguisher Inspections at Health Care Facilities
more Calendar

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2018 Conference - St. Louis

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