Minnesota Health Care Engineers Association

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1 Minnesota Health Care Engineers Association Life Safety Code Potpourri Friday, May 1, 2015 Presenter: Bob Dehler, P.E., Engineering Program Manager, Minnesota Department of Health

2 Minnesota Department of Health Engineering Services Section - Bob Dehler, P.E. Minnesota Department of Health Engineering Services Section

3 Today s Topics Engineering Services Project Submittal Process Barriers in Healthcare Life Safety Plan Requirements Occupancies Suites Gift Shops Minnesota Department of Health Engineering Services Section

4 Engineering Services Project Submittal Process What do we need? Complete plan submittal form Plan review fee Full set of signed pdf plan Fully reviewed by submitter prior Full set of signed hard copies of plan Minnesota Department of Health Engineering Services Section

5 Engineering Services Project Submittal Process Plan submittal form Ensure construction type and cost included Cross reference project cost with fee schedule

6 Engineering Services Project Submittal Process Plan review fee Plan review fee correlated to construction cost Be very careful to get accurate cost and ensure it is in the range in the statute Sometimes revised submittals are sent in because cost is not in line with fee

7 Engineering Services Project Submittal Process PDF plan Full set of pdf plans Can submit: CD, thumb drive, to Have architect/engineer review set before submission to MDH. Many times sheet(s) not properly certified by licensed engineer or architect. Master plumbers and master electricians may not submit plans to MDH

8 Engineering Services Project Submittal Process Hard copy of plans Architect to review every sheet for proper certification

9 Engineering Services Project Submittal Process Failure to provide any one item will delay your project from being completely entered in our system Any time construction activity takes place in a healthcare facility, plans should be submitted for review and approval The main exception is interior finish replacement Remember, we review plans to help the facility. Not be a pain to the facility or engineer/architect Please do not send MDH all drawing changes throughout construction. Only changes that affect licensure and certification requirements. If a change is sent to MDH, additional plan review fees may be required

10 Barriers in Healthcare What is a smoke partition? Generally a building code term, not in chapter 18 or 19 Building code requires the smoke partition to extend from floor to deck above and life safety code allows termination at drop ceiling. Life Safety Code Corridor walls shall form a barrier to limit the transfer of smoke. Allows termination at drop ceiling. Life safety code requires all doors in smoke partitions to have closers and clearances must meet NFPA 80. Not an appropriate term on life safety plans.

11 Barriers in Healthcare Smoke barrier Wall that extends from outside wall to outside wall and floor to floor/roof. These barriers shall be continuous through all concealed spaces CMS is looking at this requirement and have found non-compliant smoke barriers to roof requires smoke barriers in healthcare to have a 1-hour rating and doors must be rated for 20 minutes or be constructed of 1-¾ solid wood. WARNING If your life safety plans call out 1 hour smoke barrier walls, you need rated doors in the openings, not just 1-3/4 solid wood doors

12 Barriers in Healthcare Fire resistance rating and fire barrier The time that materials or assemblies have withstood a fire exposure as established in accordance with the test procedure of NFPA 251, Standard methods of Test of Fire Endurance of Building Construction and Materials Fire barriers have one of the following fire resistance ratings: 2-hour fire resistance rating 1-hour fire resistance rating ½-hour fire resistance rating (lath and plaster or ½ gypsum on both sides of studs)

13 Barriers in Healthcare Limit the transfer of smoke Corridor walls in new healthcare must limit the transfer of smoke Corridor walls in existing healthcare that are protected with automatic sprinkler systems may limit the transfer of smoke Can end at lay-in ceiling (check building code) Doors must resist passage of smoke with positive latching. Max 1 undercut per Max door gaps from frame ¼ (non-sprinklered) and ½ (sprinklered) S&C 07-18

14 Barriers in Healthcare Smoke Wall? Term heard a lot. Not defined in building code or life safety code Fire Wall? Building code term not required in life safety code. A fire resistance rated wall with structural stability under fire conditions to allow collapse of the wall on either side without collapse of both sides

15 Life Safety Plan Requirements Building construction year, construction type and occupancy Areas of building sprinklered Locations of all hazardous areas Locations of all smoke barriers Suite boundaries with size (sf) and exiting Locations, size and exiting of designated smoke compartments Locations of chutes and shafts (ratings) Locations and direction of any horizontal exits Locations of all exits Other required elements from AHJ s

16 Example of Life Safety Plan

17 Occupancies Hospital and CAH life safety code occupancy classification may be classified as other occupancies other than healthcare S&C Letter explains the requirements for classification If mixed occupancy in one building (without proper separation) then most stringent occupancy classification applies An example could be assembly in healthcare may have more stringent exiting requirements

18 Occupancies Healthcare Occupancy Provide sleeping accommodations, Provide housing on a 24 hour basis and Patients mostly incapable of self preservation A CMS-certified hospital or CAH does not need to have four or more inpatients at all times in order to be classified as a Health Care Occupancy. Occupancy classification must be determined regardless of the number of patients served at a hospital s or CAH s component facility.

19 Occupancies Ambulatory Health Care Occupancy Does not provide sleeping accommodations, Facility does not provide housing on a 24 hour basis and Patients mostly incapable of self preservation (provides anesthesia services) Be aware that CMS does not consider whether or not a patient has been rendered incapable of taking action for self-preservation by the facility; rather, the only consideration is whether the patient is capable or incapable of self-preservation. CMS does not consider the number of patients treated when determining an AHC occupancy classification

20 Occupancies Business Occupancy Does not provide sleeping accommodations, Facility does not provide housing or treatment on a 24 hour basis, Facility does not provide anesthesia; and Patients are mostly capable of self-preservation A patient may be incapable of self-preservation due to many factors, including, but not limited to, age, physical or mental disability, medical or therapeutic interventions, medication reactions, etc.

21 Sweet! - I mean Suite Suites are essentially large rooms with rooms inside Benefits of suites include: Hallways in suites do not have to meet corridor requirements Park equipment or carts in suite hallway Latching of doors inside suite not required but exterior

22 Suites Common Features Suite perimeter walls and doors abutting all interior space should meet corridor wall and door requirements Hazardous areas may not be an intervening room. Unless whole suite is protected as hazardous Interior walls in suite do not need to extend to deck above but must be non-combustible or limited combustible Minimum hallway width is 36 inches clear (chapter 7) Max travel distance to exit; 150 feet is building is not sprinkled and 200 feet if building is sprinklered Constant staff supervision required in sleeping suites Doors in suites for treatment/exam must be 41.5 clear Generally, sleeping suites not appropriate for nursing homes

23 Suites Maximum suite size Sleeping Suite 5,000 square feet Non-Sleeping Suite 10,000 square feet

24 Suites Intervening rooms within suites Sleeping Suite You may not pass through more than 1 intervening room within the suite to reach the corridor Non-Sleeping Suite You may not pass through more than 2 intervening rooms within the suite to reach the corridor

25 Suites Max travel distance to corridor Sleeping Suite You must get to corridor within 100 feet (1 intervening room) Non-Sleeping Suite You must get to corridor within 100 feet (1 intervening room) or 50 feet (2 intervening rooms)

26 Suites Number of exits to corridor Sleeping Suite 2 remote means of egress required when suite is over 1,000 square feet Non-Sleeping Suite 2 remote means of egress required when suite is over 2,500 square feet

27 Suites Potential Issues Found Outside the Suite When Suites are Used Are new excessive dead end corridors created? Has the new suite blocked access to a required exit?

28 Suites

29 Suites

30 Suites

31 Suites

32 Suites

33 Suites

34 Gift Shops New Gift Shops Must meet NFPA 101, Gift shops that are used for the storage and display of combustibles in quantities considered hazardous must be protected as hazardous (1-hour construction). Basically considered storage room storing combustibles Gift shops not considered hazardous and having separately protected storage may be: Open to the corridor if the gift shop does not exceed 500sf. Separated from the corridor with non-fire rated walls

35 Gift Shops Who determines if the gift shop is a hazardous area? The Joint Commission The Center for Medicare & Medicaid Services (CMS) The state department of health The state fire marshal The local fire inspector The facilities insurance carrier The facility safety officer All of the AHJ s make their own interpretation if the gift shop is hazardous. If one AHJ determines that the gift shop is hazardous the gift shop must be protected with 1-hour construction

36 Gift Shops Most gift shops are full of combustibles, such as greeting cards, clothing, stuffed toys, packaging, plastics, etc. In order to avoid any issues for new construction, protect gift shop with 1-hour construction Granted, you could have a protected storage room but who moves combustibles from gift shop to storage room during times the gift shop is closed?

37 Thank you for having me here today

38 QUESTIONS

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