the impact the reference standards in the 2012 edition of ... · •respiratory therapy •sources...

1Expertly Engineering Safety From Fire®

The Impact the Reference Standards in the 2012 Edition of NFPA 101® have on the Operation of Health Care Facilities: NFPA 80 and 99

Sharon S. Gilyeat, P.E.Lauren SchrumpfAugust 8, 2018

Introductions

• Sharon S. Gilyeat, P.E.• Director of the Koffel Associates, Inc.

Southeast Office• B.S. in Fire Protection Engineering from the

University of Maryland• Serves on multiple NFPA Technical Committees• Subject Matter Expert and instructor for CMS• 35 years industry experience

• Lauren E. Schrumpf• Fire Protection Engineer with Koffel Associates, Inc.

for 5 years • B.S. in Fire Protection Engineering from the

University of Maryland• Experience in healthcare surveys, plan reviews, and

general code consulting

CMS Adopts 2012 Edition of NFPA 101®,Life Safety Code®

The Centers for Medicare and Medicaid Services formally adopted

provisions of the 2012 Edition of NFPA 101, Life Safety Code,

effective July 5, 2016.

LSC 2000 - 2012

• Numerous changes over the last 12 years

• Many changes are beneficial to health care facilities

• Today’s focus is on some of the changes to the referenced standards

• In the spring NCHEA conference we focused on NFPA 13 and 72

Objective

• Provide an overview of the significant changes in the

Referenced Publications upon adoption of NFPA 101, Life

Safety Code, 2012 Edition (LSC)

⁻ NFPA 80, 2010 Edition

⁻ NFPA 99, 2012 Edition

NFPA 101 Referenced Publications

• NFPA 101 Chapter 2, Referenced Publications

⁻ Become part of the LSC, but only to the extent

called for within other chapters of the LSC

⁻ Where requirements differ, the LSC governs

⁻ Not the intent to continually upgrade existing

buildings

Limitations

• Not all Life Safety Code (LSC) reference standard changes will be discussed

• Chapter 2 contains many different publications

• Many “minor” changes might have a big impact on a specific situation

• Wording provided on slides is not always Code or Standard text, refer to reference standards for specific text

NFPA 80, Standard for Fire Doors and Other Opening Protection, 2010

Overview of Changes to NFPA 80, 1999-2010

• Spans two editions; 2007 and 2010

• 2013 and 2016 Editions not discussed

Overview of Changes to NFPA 80, 1999-2010

• 1999-2007

• No major changes - NFPA 80 returned to committee during the Fall 2002 revision cycle

• 2007

• New chapter on fabric fire curtains

• ITM of fire dampers

• Care maintenance and maximum clearance of fire doors

• New information on Floor Fire Door Assemblies and rating

• 2010

• Changes to glazing materials in vision panels

• Repair of windows and doors

• Operation of Chute Doors

New Chapter 20: Fabric Fire Safety Curtains

• Fire Curtain must be listed and labeled

• 20.2.2 gives label requirements

• When used in proscenium openings must extend a

minimum of 18 in. on each side of the opening, and a

minimum of 24 in. above the top of the opening

• 20.7.3 Emergency Operation

• Must be operated by manual emergency operation,

fusible link, and rate of rise heat detection above the

stage

Maximum Clearance Under Doors

• 4.8.4.1 The clearance under the bottom of a door shall

be a maximum of ¾ in.

• 4.8.4.2 Where the bottom of the door is more than 38 in.

above the finished floor, the maximum clearance shall

not exceed 3/8 in. or as specified by the manufacturers

label.

• Previously information found in Table 1-11.4 in. 1999,

clearances ranged from 3/8 in. to ½ in. depending on

door and floor type

Clearance Tool

Fire Dampers

• New to 2007, Chapter 19 on Inspection Testing and

Maintenance of Fire Dampers

• 19.2 Installation of Dampers, damper sleeves, opening

preparation, sleeve construction, and access

• 19.3.2 After the installation of a combination fire/smoke

damper, an operational test shall be preformed

• 19.4.1 Each damper shall be tested and inspected one

year after installation

Care and Maintenance of Fire Doors and Windows

• Chapter 15 in 1999 Edition moved to Chapter 5 in 2007 Edition• 5.1.5.2. Field Modification: In cases where this is desired, the

laboratory who listed the assembly shall be contacted and a description of the modification be presented. It is permitted only if the lab confirms it will not compromise integrity and fire resistance.

• 5.2 Fire Door Assemblies shall be inspected and tested not less than annually, Performance Based Option can be a means of compliance

• 5.2.4.2 Swinging Doors with Builders Hardware or Fire Door Hardware, need 1-11 items verified during inspection

• 5.2.5.2 Horizontal Sliding, Vertical Sliding, and Rolling Doors, need 1-11 items verified during inspection

Door Inventory List

Specific Door Provisions

• Rolling Steel Doors: Chapter 11 in 2007, from Chapter 6 in 1999• 11.1.2.3 RS doors shall be permitted to be mounted to steel

members set in or against the wall as listed• 11.3.5 Access to any clearance between construction and RS

door shall allow for required testing and maintenance• 11.4.2.2.2-11.4.2.2.3 Provisions for reopening door, or reclosing

on an obstruction• 11.5 Weather protection required for exterior RS doors

• Fire Shutters: Chapter 12 in 2007, from Chapter 10 in 1999• Only requirements echo those of swinging door, sliding doors,

and rolling steel doors

Specific Door Provisions (continued)

• Service Counter Doors: Chapter 13 in 2007, from Chapter 12 in 1999• 13.1.2 Types clarified: Swinging door panels, sliding

doors, or rolling steel doors• Installation Section removed

• Chute Doors: Chapter 15 in 2007, from Chapter 9 in 1999• Chute doors now have to be self-closing, rather than

just have an automatic closing operation like other swinging doors

Floor Fire Door Assemblies and Ratings

• 16.2.3 Floor Fire Door Assemblies shall be tested in accordance with the procedures described in NFPA 288 Standard Methods of Fire Tests of Floor Fire Door Assemblies Installed Horizontally in Fire Resistance-Rated Floor Systems.

• Annex D includes new information on listings and ratings for fire doors and windows

• D.4 mentions that listings are provided for Floor Fire Door Assemblies which are permitted to be used based on their hourly rating.

Installation of Vision Panel in New Doors• Part of technical changes to 2010 Edition• 4.4.3.1 For new wood doors, glazing materials in vision

panels shall be installed in labeled glass light kits or in accordance with the fire door listing

• 4.4.4 Fire protection glazing not exceeding 100 sq in shall be permitted in fire doors having a 3hr fire protection rating or in fire doors having a 1.5-hr fire protection rating for use in severe exterior fire exposure locations where glazing has been tested to NFPA 252 Standard Methods of Fire Tests of Doors Assemblies.

Repair of Doors and Windows

• Changes made in 2010 Edition• 5.2.15.3 (1) When a fire door or any part of it is

damaged to the extent it impairs the emergency function, the fire door and parts shall be repaired with labeled parts or parts obtained from the original manufacturer

• 5.2.15.3.1 If repairs cannot be made with labeled component or parts obtained from the original manufacturer, the fire door assembly shall be replaced

Test Your Knowledge – Fire Doors

Door 1Door 2

Door 3

Test Your Knowledge – Fire Doors

Door 4 Door 5 Door 6

NFPA 99, Health Care Facilities Code, 2012 Edition

NFPA 99 HEALTH CARE FACILITIES CODE UPDATE

• Objectives

• Review NFPA 99 CMS K-Tags in Form 2786R for health care occupancies

• Go over specific requirements and typical citations for K-Tags

• Content limited to all chapters but Chapter 5, Piped Medical Gas and Vacuum Systems

New vs. Existing

• Installation and construction requirements

• Operations

• Inspection, testing and maintenance

• Each chapter specifies what applies to new and what applies to existing in the chapter

K323 Anesthetizing Locations

• Zone valves and control• Alarm panels, visual and audible alarms• EES Critical Branch supplies• Task illumination• Fixed equipment• Select receptacles• Power circuits

• EES Equipment Branch supplies ventilation• Ventilation in accordance with ASHRAE 170

K900 Health Care Facilities Code

• K-900 is a catch-all where no other K-Tag specifically addresses the deficiency

K901 Fundamentals

• Building systems meet Category 1 -4

• Formal risk assessment

Category Definition

1 major injury or death

2 minor injury

3 no injury but can cause discomfort

4 no impact on patient care

K902 - 910 Gas and Vacuum Piped Systems • Not covered in depth in this presentation• K-902 is a catch-all where no other K-Tag specifically addresses

the deficiency• K-903 – Categories• K-904 – Warning systems• K-905 – Central supply system identification and labeling• K-906 – Central supply system operations• K-907 – Central supply system maintenance• K-908 – Central supply system inspection and testing• K-909 – Information and warning signs distribution piping• K-910 – Modifications

K911 Electrical Systems



• Receptacles

• Grounding poles

• Pediatric areas - tamper resistant

• Patient care areas – CFCI are listed


• Wet Procedure Locations

• Operating rooms considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body

• Protected by either isolated power or ground-fault circuit interrupters

• Written record of risk assessment maintained and available for inspection


• Maintenance and Testing Hospital-grade receptacles at patient bed locations where deep sedation or general anesthesia is administered

• Line isolation monitors

• Records are maintained

of required tests and associated repairs


• Essential Electric System Categories • Critical care rooms (Category 1) including all

rooms where electric life support equipment is required, served by a Type 1 EES

• General care rooms (Category 2) served by a Type 1 or Type 2 EES

• Basic care rooms (Category 3) not required to be served by an EES

• Type 3 EES life safety branch has alternate source of power for 1 1/2 hours


• Essential Electric System Alarm Annunciator Remote annunciator

• Battery powered

• Outside of room

• Observable

• Hardwired

• A centralized computer system cannot be used for this purpose


• Essential Electric System Receptacles

• Distinctive color or marking


• Essential Electric System Maintenance and Testing • Supply service within 10 seconds• Maintenance and testing of the generator and

transfer switches are performed in accordance with NFPA 110

• Written records of maintenance and testing are maintained and readily available

• EES electrical panels and circuits are marked and readily identifiable

Emergency Generator

K919 Electrical Equipment



• Power Cords and Extension Cords

• Power strips

• Extension cords


• Testing and Maintenance Requirements

• Tests for fixed and portable patient-care related electrical equipment (PCREE)

• Testing intervals established with policies and protocols

• Instructions and maintenance manuals available

• Record of electrical equipment tests, repairs, and modifications maintained in accordance with the facility's policy

• Personnel responsible receive continuing training

K922 Gas Equipment


K923 Gas Equipment

• Cylinder and Container Storage• ≥ 3,000 cubic feet storage locations are

designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3

• > 300 but <3,000 cubic feet storage locations• ≤ 300 cubic feet • Cylinders handled with precautions as

specified in 11.6.2• Sign "CAUTION: OXIDIZING GAS(ES) STORED

WITHIN NO SMOKING“

K924 Gas Equipment

• Testing and Maintenance Requirements • Anesthesia apparatus

• Defective equipment immediately removed

• Areas designated for servicing of oxygen equipment clean and free of oil, grease, or other flammables

• Manufacturer service manuals used to maintain equipment

• Scheduled maintenance program followed

K925 Gas Equipment

• Respiratory Therapy • Sources of Ignition smoking materials removed• When a nasal cannula is delivering oxygen outside of a

patient’s room, no sources of ignition are within in the site of intentional expulsion (1-foot)

• When other oxygen deliver equipment is used or oxygen is delivered inside a patient’s room, no sources of ignition are within the area are of administration (15-feet)

• Solid fuel-burning appliances is not in the area of administration

• Nonmedical appliances with hot surfaces or sparking mechanisms not within oxygen-delivery equipment or site of intentional expulsion

K926 Gas Equipment

• Qualifications and Training of Personnel

• Personnel are trained on the risk

• Facilities provide continuing education, including safety guidelines and usage requirements

• Equipment is serviced only by personnel trained in the maintenance and operation of equipment

K927 Gas Equipment

• Transfilling Cylinders • Transfilling of oxygen from one cylinder to another is in

accordance with CGA P-2.5, Transfilling of High Pressure Gaseous Oxygen Used for Respiration

• Transfilling of any gas from one cylinder to another is prohibited in patient care rooms

• Transfilling to liquid oxygen containers or to portable containers over 50 psi comply with conditions under 11.5.2.3.1 (NFPA 99)

• Transfilling to liquid oxygen containers or to portable containers under 50 psi comply with conditions under 11.5.2.3.2 (NFPA 99)

K928 Gas Equipment

• Labeling Equipment and Cylinders • Equipment listed for use in oxygen-enriched atmospheres• Oxygen metering equipment and pressure reducing regulators

are labeled "OXYGEN-USE NO OIL“• Flowmeters, pressure reducing regulators, and oxygen-

dispensing apparatus are clearly and permanently labeled designating the gases

• Oxygen-metering equipment, pressure reducing regulators, humidifiers, and nebulizers are labeled with name of manufacturer or supplier

• Cylinders and containers are labeled in accordance with CGA C-7

• Labeling is durable and withstands cleaning or disinfecting

K929 Gas Equipment

• Precautions for Handling Oxygen Cylinders and Manifolds

• Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen

• Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions

K930 Gas Equipment

• Liquid Oxygen Equipment

• Storage and use of liquid oxygen in base reservoir containers and portable containers comply with sections 11.7.2 through 11.7.4 (NFPA 99)

K931 Hyperbaric Facilities

• All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99

K932 Features of Fire Protection


K933 Features of Fire Protection

• Fire Loss Prevention in Operating Rooms • Periodic evaluations • When flammable germicides or antiseptics are employed

during surgeries utilizing electrosurgery, cautery or lasers: • packaging is non-flammable• applicators are in unit doses• Preoperative "time-out" is conducted prior the initiation of

any surgical procedure to verify:• application site is dry prior to draping and use of surgical equipment• pooling of solution has not occurred or has been corrected• solution-soaked materials have been removed from the OR prior to

draping and use of surgical devices

• Policies and procedures are established outlining safety

QUESTIONS??

Future Questions….

• Join our LinkedIn Discussion Groups• Life Safety Code

• Join the group and submit your questions or

• E-mail [email protected] and submit anonymously

• Smoke Management

• Proposed Changes to the IBC

• Ask the Expert • FAQ.Koffel.com

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Sharon S. Gilyeat, P.E.Koffel Associates, Inc.

2015 Ayrsley Town BlvdSuite 202

Charlotte, NC 28273704-280-8365

[email protected]

Lauren E. SchrumpfKoffel Associates, Inc.

2015 Ayrsley Town BlvdSuite 202

Charlotte, NC 28273704-280-8366

[email protected]

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