1k. Fire Protection Code Reviews.pdf

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Department of Veterans Affairs VHA DIRECTIVE 7712 Veterans Health Administration Transmittal Sheet Washington, DC 20420 February 10, 2017

FIRE PROTECTION CODE REVIEWS OF DELEGATED CONSTRUCTION

PROJECTS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive addresses the requirements for fire protection code reviews of VHA delegated construction projects.

2. SUMMARY OF MAJOR CHANGES: This directive clarifies the criteria for fire protection code reviews of delegated construction projects and establishes the VHA Authority Having Jurisdiction for fire protection code compliance and for the approval of fire and life safety equivalencies.

3. RELATED ISSUES: None.

4. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this directive. Questions related to this directive are to be directed to the Office of Occupational Safety, Health, and GEMS Programs (10NA8) at 202-632-7888.

5. RESCISSIONS: VHA Directive 2005-007, dated February 15, 2005 is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of February 28, 2022. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

David J. Shulkin, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publication Distribution List on February 14, 2017.

February 10, 2017 VHA DIRECTIVE 7712 i

CONTENTS

FIRE PROTECTION CODE REVIEWS

OF DELEGATED CONSTRUCTION PROJECTS

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. FIRE PROTECTION ENGINEERING REQUIREMENTS

7. REFERENCES

FIRE PROTECTION CODE REVIEWS

OF DELEGATED CONSTRUCTION PROJECTS

1. PURPOSE

This Veterans Health Administration (VHA) directive establishes the requirements for fire protection code reviews of VHA delegated construction projects with the goal of ensuring compliance with all applicable fire protection codes and standards. AUTHORITY:

Title 38 United States Code (U.S.C.) 7301(b), 40 U.S.C. 3312.

2. BACKGROUND

a. The Department of Veterans Affairs (VA) acts as its own building and fire protection official and Authority Having Jurisdiction (AHJ). Construction of facilities on Federal property is generally exempt from the requirements of local building codes and standards. In addition, construction projects on Federal property are generally exempt from code compliance reviews by local fire officials. Therefore, VA must have its own process to ensure that facilities are designed, renovated, and constructed in accordance with VA policy and the codes and standards adopted by VA.

b. VA is required to comply with national consensus codes and standards. VA general requirements addressing construction codes and standards are found in the Office of Construction and Facilities Management (OCFM) document Program Guide (PG) 18-3, Topic 1, Codes, Standards, and Executive Orders. Specific VA requirements for fire protection are found in the VA Fire Protection Design Manual. NOTE: Links to these and other referenced documents can be found in the References section of this directive.

3. DEFINITIONS

a. Change of Occupancy Classification. Change of occupancy classification means a change in the occupancy classification of a structure or portion of a structure.

b. Change of Use. Change of use means a change in the purpose or level of activity within a structure that involves a change in application of the requirements of the applicable code (e.g., Life Safety Code or Building Code).

c. Chief Engineer. For the purposes of this directive, the titles Chief of Facilities Management, Facility Manager, and other similar designations are synonymous with the title Chief Engineer.

d. Delegated Construction Projects. Delegated construction projects means construction projects that are managed in whole or in part by VHA (Veterans Integrated Service Network or VA facility). Management of project funds is at the VA facility level and funding could come from the Major, Minor, Clinical Specific Initiatives (CSI), or Non- Recurring Maintenance (NRM) programs, as well as other funding sources. Projects managed by staff of OCFM are not delegated construction projects.

e. Directives. Directives are concise documents of policy; mandatory procedures or operational requirements implementing policy are included in the appendices.

f. Modification. For the purposes of this directive modification means the new construction or reconfiguration of any space; the addition, relocation, or elimination of any door or window; the addition, relocation, or elimination of any load-bearing element; the addition, reconfiguration, or elimination of any system; or the installation of any additional equipment.

4. POLICY

It is VHA policy that independent third-party fire protection code reviews will be provided for delegated construction projects by qualified fire protection engineers, and that qualified fire protection engineers will be part of the design team for selected projects, in accordance with the requirements of this directive. The VHA Authority Having Jurisdiction for fire protection code compliance and for the approval of fire and life safety equivalencies is the Deputy Under Secretary for Health for Operations and Management (except as specified in paragraph 5.b.(2) of this directive).

5. RESPONSIBILITIES

a. The Under Secretary for Health. The Under Secretary for Health is responsible for appropriate resourcing and overall VHA compliance with this Directive.

b. The Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management is responsible for:

(1) Overseeing the development of VHA policy and programs to address safety and health issues.

(2) Serving as the VHA Authority Having Jurisdiction (AHJ) for fire protection code compliance and for the approval of fire and life safety equivalencies, except where the AHJ is otherwise established by Federal Regulations. NOTE: For a summary of community-based programs where the AHJ is established by Federal Regulations as other than the DUSHOM, see the Program Summary Matrix on the VHA Center for Engineering & Occupational Safety and Health Fire Safety Reference Library. This is an internal VA Web site that is not available to the public.

c. Assistant Deputy Under Secretary for Health for Administrative Operations.

The Assistant Deputy Under Secretary for Health for Administrative Operations is responsible for:

(1) Overseeing the implementation of VHA policy and programs to address safety and health issues.

(2) Ensuring that adequate funds are available to maintain a safe and functional environment for patients, visitors, employees, and volunteers.

http://vaww.ceosh.med.va.gov/01FS/Pages/SpecificTopics.shtml

d. Veterans Integrated Service Network Directors. Each Veterans Integrated Service Network (VISN) Director is responsible for:

(1) Establishing a written policy or written process to ensure that the requirements of this directive are met.

(2) Establishing a written policy or written process to monitor VISN and VA facility compliance with this directive. NOTE: One method of monitoring compliance is through the Annual Workplace Evaluation (AWE) process, which is conducted by VISN staff.

(3) Ensuring that the VISN Capital Asset Manager (CAM) or designee determines whether an independent fire protection code review is required for each project that is required to be entered into the Capital Assets Database and tracks the review and resolution of the review comments through the Capital Assets Database.

e. VA Facility Directors. Each VA facility Director is responsible for

(1) Establishing a written policy or written process to ensure that the requirements of this directive are met.

(2) Utilizing VA facility safety staff and others as needed to provide additional comments within their level of expertise to augment the third party fire protection code reviews. NOTE: Generally VA facility staff members do not meet the qualification requirements to perform fire protection code reviews and therefore their review would not meet the requirement under this directive for a third-party fire protection code review. However, VA facility safety staff members, such as the Safety Manager, Environmental (GEMS) Manager, and Industrial Hygienist (IH), might offer comments regarding facility-specific safety, environmental, and industrial hygiene operational issues. Operational issues include, but are not limited to, existing equivalencies;

coordination with facility Interim Life Safety Measures policy; door locking compatibility with existing facility locks; coordination with facility fire safety plans; asbestos and other IH considerations; facility spill plans, air pollutants permits, and other environmental considerations.

6. FIRE PROTECTION ENGINEERING REQUIREMENTS

a. Third-Party Fire Protection Code Review. For all delegated construction projects that involve a change of occupancy classification, change of use, or modification (see definitions) of any space, fire protection code review(s) shall be performed on the design by qualified fire protection engineer(s) who are not associated with the design team. A minimum of one review is required at or before the 95% document submission (referred to as “Design Development Submission” in PG-18-15, Volume C). NOTE: The criteria for requiring a third party fire protection code review are intentionally broad. In addition, complex projects should be reviewed at a stage earlier than the 95% submission so that significant review comments can be incorporated into the design without affecting project costs or schedule. Such projects will generally require more than one review.

b. Review Comments. All fire protection code review comments shall be responded to and resolved in a manner that is acceptable to the design team, the reviewer(s), and the Chief Engineer or designee (e.g., Contracting Officer’s Representative) responsible for managing the project. All fire protection code review comments and their resolution shall be documented in a permanent record as part of the project documentation. NOTE:

Documentation of the fire protection code review comments and their resolution is typically recorded in the Project Tracking Report (PTR) in the Capital Assets Database.

c. Design Team. Unless exempted by the VISN Director, qualified fire protection engineer(s) shall be part of the design team for all delegated Major and Minor construction projects, as well as for all other delegated construction projects that include the addition, reconfiguration, or elimination of a fire protection system. The fire protection engineer(s) shall provide the scope of services for project fire protection engineers specified in the OCFM document, Qualifications and Scope of Services for Fire Protection Engineer. This document is located in the Fire and Safety section of the OCFM Technical Information Library.

d. Qualifications. All fire protection engineer(s) involved in the review or design shall meet, as a minimum, the qualification requirements for project fire protection engineers found in the OCFM document, Qualifications and Scope of Services for Fire Protection Engineer. This document is located in the Fire and Safety section of the OCFM Technical Information Library. NOTE: VA staff members who are 803- or 804-series engineers, and who do not meet the referenced qualification requirements, might be qualified to perform third party fire protection code reviews.

e. Leases. Qualified fire protection engineer(s), who are not associated with the design team, shall perform fire protection code review(s) on drawings of the leased space for leases processed through a VISN or facility contracting officer. This shall occur as part of the leasing process and prior to signing the lease agreement.

f. Intent. The intent of these requirements is that facilities are designed, renovated, and constructed in accordance with VHA policy and the codes and standards adopted by

VA.

7. REFERENCES

a. 38 U.S.C 7301(b)

b. 40 U.S.C. 3312

c. Office of Construction and Facilities Management (OCFM) Technical Information Library, http://www.cfm.va.gov/til/index.asp)

d. OCFM PG-18-3, Topic 1: Codes, Standards, and Executive Orders, http://www.cfm.va.gov/TIL/cPro.asp http://www.cfm.va.gov/til/index.asp http://www.cfm.va.gov/TIL/cPro.asp

e. OCFM PG-18-15, Volume C: A/E Submission Instructions for Minor and NRM Construction Program Medical Center Projects, http://www.cfm.va.gov/til/aeDesSubReq.asp

f. OCFM Qualifications and Scope of Services for Project Fire Protection Engineer, September 2005 (or succeeding document), http://www.cfm.va.gov/til/spclRqmts.asp#FS

g. VA Fire Protection Design Manual, http://www.cfm.va.gov/til/spclRqmts.asp#FS

h. Chief Network Officer Memorandum, 'Construction Project Fire Code Compliance Process', November 15, 1996 http://www.cfm.va.gov/til/aeDesSubReq.asp http://www.cfm.va.gov/til/spclRqmts.asp#FS http://www.cfm.va.gov/til/spclRqmts.asp#FS