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

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1 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 Schrumpf August 8, 2018 Expertly Engineering Safety From Fire 1

2 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

3 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.

4 LSC 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

5 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

6 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

7 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

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

9 Overview of Changes to NFPA 80, Spans two editions; 2007 and and 2016 Editions not discussed

10 Overview of Changes to NFPA 80, 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

11 New Chapter 20: Fabric Fire Safety Curtains Fire Curtain must be listed and labeled 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 Emergency Operation Must be operated by manual emergency operation, fusible link, and rate of rise heat detection above the stage

12 Maximum Clearance Under Doors The clearance under the bottom of a door shall be a maximum of ¾ in 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 in. 1999, clearances ranged from 3/8 in. to ½ in. depending on door and floor type

13 Clearance Tool

14 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 After the installation of a combination fire/smoke damper, an operational test shall be preformed Each damper shall be tested and inspected one year after installation

15 Care and Maintenance of Fire Doors and Windows Chapter 15 in 1999 Edition moved to Chapter 5 in 2007 Edition 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 Swinging Doors with Builders Hardware or Fire Door Hardware, need 1-11 items verified during inspection Horizontal Sliding, Vertical Sliding, and Rolling Doors, need 1-11 items verified during inspection

16 Door Inventory List

17 Specific Door Provisions Rolling Steel Doors: Chapter 11 in 2007, from Chapter 6 in RS doors shall be permitted to be mounted to steel members set in or against the wall as listed Access to any clearance between construction and RS door shall allow for required testing and maintenance 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

18 Specific Door Provisions (continued) Service Counter Doors: Chapter 13 in 2007, from Chapter 12 in 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

19 Floor Fire Door Assemblies and Ratings 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.

20 Installation of Vision Panel in New Doors Part of technical changes to 2010 Edition 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 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.

21 Repair of Doors and Windows Changes made in 2010 Edition (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 If repairs cannot be made with labeled component or parts obtained from the original manufacturer, the fire door assembly shall be replaced

22 Test Your Knowledge Fire Doors Door 1 Door 2 Door 3

23 Test Your Knowledge Fire Doors Door 4 Door 5 Door 6

24 NFPA 99, Health Care Facilities Code, 2012 Edition

25 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

26 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

27 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

28 K900 Health Care Facilities Code K-900 is a catch-all where no other K-Tag specifically addresses the deficiency

29 K901 Fundamentals Building systems meet Category 1-4 Category Definition 1 major injury or death 2 minor injury 3 no injury but can cause discomfort 4 no impact on patient care Formal risk assessment

30 K 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

31 K911 Electrical Systems K-911 is a catch-all where no other K-Tag specifically addresses the deficiency

32 K912 Electrical Systems Receptacles Grounding poles Pediatric areas - tamper resistant Patient care areas CFCI are listed

33 K913 Electrical Systems 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

34 K914 Electrical Systems 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

35 K915 Electrical Systems 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

36 K916 Electrical Systems Essential Electric System Alarm Annunciator Remote annunciator Battery powered Outside of room Observable Hardwired A centralized computer system cannot be used for this purpose

37 K917 Electrical Systems Essential Electric System Receptacles Distinctive color or marking

38 K918 Electrical Systems 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

39 Emergency Generator

40 K919 Electrical Equipment K-919 is a catch-all where no other K-Tag specifically addresses the deficiency

41 K920 Electrical Equipment Power Cords and Extension Cords Power strips Extension cords

42 K921 Electrical Equipment 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

43 K922 Gas Equipment K-922 is a catch-all where no other K-Tag specifically addresses the deficiency

44 K923 Gas Equipment Cylinder and Container Storage 3,000 cubic feet storage locations are designed, constructed, and ventilated in accordance with and > 300 but <3,000 cubic feet storage locations 300 cubic feet Cylinders handled with precautions as specified in Sign "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

45 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

46 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

47 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

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

49 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 oxygendispensing 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

50 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

51 K930 Gas Equipment Liquid Oxygen Equipment Storage and use of liquid oxygen in base reservoir containers and portable containers comply with sections through (NFPA 99)

52 K931 Hyperbaric Facilities All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99

53 K932 Features of Fire Protection K-932 is a catch-all where no other K-Tag specifically addresses the deficiency

54 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

55 QUESTIONS??

56 Future Questions. Join our LinkedIn Discussion Groups Life Safety Code Join the group and submit your questions or and submit anonymously Smoke Management Proposed Changes to the IBC Ask the Expert FAQ.Koffel.com

57 Questions? Sharon S. Gilyeat, P.E. Koffel Associates, Inc Ayrsley Town Blvd Suite 202 Charlotte, NC Follow us on LinkedIn Lauren E. Schrumpf Koffel Associates, Inc Ayrsley Town Blvd Suite 202 Charlotte, NC Expertly Engineering Safety From Fire 57