36C25023Q0878.docx

SUBJECT*

Sources Sought Notice Northern Indiana Health Care System (NIHCS) Fire Evacuation Maps Planning

GENERAL INFORMATION

SET-ASIDE

Network Contracting Office 10 24 Frank Lloyd Wright Drive Lobby M, Suite M2200 Ann Arbor MI 48105

POINT OF CONTACT*

Contracting Officer Andrea J. McKinney Andrea.McKinney@va.gov 734-222-4362

No Phone Calls Accepted.

PLACE OF PERFORMANCE

ADDRESS

Department of Veterans Affairs

VA Northern Indiana Healthcare System

1700 East 38th Street

Marion IN

COUNTRY

DESCRIPTION

THIS IS NOT A SOLICITATION. This is a Sources Sought Notice only and is issued in accordance with Federal Acquisition Regulation (FAR) 10 Market Research, to conduct market research. Responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. This Sources Sought Notice is issued solely for information and planning purposes and does not constitute a solicitation or guarantee to issue a solicitation in the future. This Sources Sought Notice does not commit the Government to contract for any supply or service. All information submitted in response to this announcement is voluntary; the Government will not pay for information requested nor will it compensate any respondent for any cost incurred in developing information provided to the Government. Not responding to this Sources Sought Notice does not preclude participation in any future solicitation, if issued. This announcement is based on the best information available at this time and is subject to future modification.

The North American Industry Classification System (NAICS) Code is 561210 – Facilities Support Services.

Size standards in dollars - $47 Million

Product Service Code is H312 – Inspection – Fire Control Equipment.

Purpose and Objectives This Sources Sought Notice is issued by VISN 10, Network Contracting Office (NCO) 10 located in Ann Arbor, MI for the purpose of collecting information about Fire Evacuation Maps Planning for the Northern Indiana Health Care System.

The VA is seeking a contractor to provide for this requirement for a base contract and no option years.

A draft copy of the SOW is attached.

Places of Performance:

Responses:

Please submit your response in accordance with the following instructions:

a) Responses shall be no more than 10 pages in length.

a. Responses are due by 7/14/2023 at 12:00 PM EST.

b) Responses shall be submitted via email.

a. Emails cannot exceed 10mb

b. Subject line of the Email shall include this Sources Sought Notice Number – Firm Name – Indiana Fire Evacuation Maps Planning.

c. If your response contains proprietary information you will place “Proprietary Information” in front of the Sources Sought Notice Number.

d. No marketing materials are allowed as part of this Sources Sought Notice. The Government will not review any other information or attachments included in your submission that is not listed herein or exceeds the 10-page limitation.

c) Contractors Federal Supply Schedule Contract that carries the desired services

a. If you do not have a Federal Supply Schedule contract, you shall state “open market”

b. Provide the Schedule

c. Provide expiration date of your FSS Contract

d. Provide your GSA/FSS/SAC Contract Number

e. Provide the SIN for Electrical Maintenance Service

f. If any of the items are not on your GSA/FSS contract you will mark which items are open market.

d) Contractor Point of Contact to include:

a. Name

b. Title

c. Phone

d. Email

e) Company Information to include:

a. Name

b. Address

c. Unique Entity ID

d. Tax ID Number

e. Business Size

f. Provide how your company invoices for services in the commercial marketplace.

f) Business Size/Type Examples: Service-Disabled Veteran Owned Small Business (SDVOSB), Veteran Owned Small Business (VOSB), 8(a), Hub Zone Small Business, Women Owned Small Business (WOSB), Small Disadvantaged Business (SDB), Small Business, or Large Business.

a. All prospective Contractors are reminded that in accordance with FAR 4.11 they shall be registered in the System for Award Management (SAM) database and shall complete annual Representations and Certifications in SAM prior to any offer. SAM is located at http://www.sam.gov and consolidated the capabilities of CCR/FedReg, ORCA, and EPLS. There is no cost to use SAM.

b. FOR SDVOSB/VOSB ONLY: Please note that if responding as an SDVOSB or VOSB, your company must be registered and verified in the VetCert database, which is available at: https://veterans.certify.sba.gov/

c. Please include a copy of your VetCert certification with your response.

g) Contractor shall include 3 past contracts for the same or similar services. Contractor shall include at minimum:

a. Name of Company

b. Company POC

c. Company POC phone

d. Company POC email

e. Dollar amount of contract

f. Contract number

g. Period of Performance

h. Description of services provided

h) Contractor shall include any relevant comments about the attachments, if applicable.

i) Contractor shall provide a public price list/contract price list for the services described herein.

Sources Sought Notice Sources Sought Notice Contractor shall provide a detailed response to include your firm’s ability, capability, and responsibility to deliver the services presented in this Sources Sought Notice.

Sources Sought Notice

A.1 STATEMENT OF WORK

Evacuation Maps & Service Specific Written Fire Plans Statement of Work Veteran Affairs Northern Indiana Health Care Systems

SCOPE OF WORK:

The Department of Veterans Affairs Northern Indiana Health Care System (VANIHCS) to include South Campus in Marion Indiana, North Campus in Fort Wayne Indiana, and all Community Based Outpatient Clinics in Muncie, Peru, Huntington, Mishawaka Indiana including one location in Defiance Ohio that will require Evacuation maps in each building on all campuses, to include all life safety features such as fire extinguishers, AED’s, Emergency eyewash/ shower stations, primary & secondary evacuation in accordance with all NFPA, joint Commission, and 29 CFR 1910.39 (b) and (c). This project will also have service specific written fire plans for all services within VANIHCS utilizing the processes in place. In accordance with all NFPA and Joint commission standards for healthcare facilities. The purchase of 350 sign holders and 350 R.A.C.E. placards will be included in this project, all permanent sign holders shall meet all interior design guidelines (Attachment D), such size, length and width, locations throughout the facilities, and is subject to change with all updates from the time awarded to final product.

HOURS OF WORK:

A. Hours of Work for support are defined as standard hours Monday through Friday from 7 A.M. to 3:30 P.M. (EST) unless the COR or CO deem the work necessary, not including Federal holidays or Contractor Holidays or as otherwise arranged with the Contracting Officer Representative (COR).

B. The eleven holidays observed by the Federal Government are New Year’s Day, Martin Luther King Day, President’s Day, Memorial Day, Juneteenth National Independence Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day, and Christmas Day. Also, any other day declared by the President of the United States to be a national holiday.

SERVICE:

Number of Buildings There is a total of __12___ multi-level buildings on the Fort Wayne Campus

There is a total of __47__ multi-level buildings on the Marion Campus There is a total of 5 single story Community Based Outpatient Clinic located in Muncie, Peru, Huntington, Mishawaka Indiana. Also, to include one location in Defiance Ohio.

Evacuation Maps Contractor shall provide all necessary labor, supplies, transportation, equipment, and reports to use the materials provided to affix preapproved evacuation maps sign holders and place evacuation maps in holders in accordance with VA Signage Design guidelines. Contractors shall remove the old evacuation sign holders once new signs are in place. VA engineering staff will patch the walls and repaint all areas where signs have been taken down.

CAD drawings or Revit files can be issued upon request by our local engineering services. All final evacuation maps shall have electronic copies in CAD or reddit to be able to update in the future with floor plans, occupants, and life safety features by VANIHCS. Approval by COR & Engineering Services for all evacuation maps prior to manufacture.

The Contractor shall provide certification that each sign has been placed by utilizing the checklist document provided by the COR. If any areas are identified that are not on the report provided by the COR, the area needs to be reported to the COR immediately for inclusion on the checklist. We have included a 15% overage for sign holders that will be given to COR for any updates in the future or missed areas during project.

Evacuation maps shall include location on the map where you are located, primary exits (Red Arrow), secondary exits (Orange broken line arrow), fire extinguishers (RED ICON), manual pull stations (RED ICON), Stairs (Yellow), Elevators (Green), Egress Point (Red). These maps shall be installed per design guide, and any other conspicuous area deemed recommend relevant by fire protection engineer but shall be approved by Facility Interior design. These maps shall include room numbers that are legible and easy to identify by our Veteran and visitors. VA U. S. Department of Veteran Affairs shall be in the (Bottom Left) of the evacuation maps. Please see example below for reference. Note the example doesn’t have the room numbers listed but shall like to include.

Written Fire Plans Fire prevention plan includes the following elements, at a minimum:

- a list of all major fire hazards, proper handling and storage procedures for hazardous materials, potential ignition sources and their control, and the type of fire protection equipment necessary to control each major hazard

- procedures to control accumulations of flammable and combustible waste materials

- procedures for regular maintenance of safeguards installed on heat-producing equipment to prevent the accidental ignition of combustible materials

- the job title of employees responsible for maintaining equipment to prevent or control sources of ignition or fires

- the job title of employees responsible for the control of fuel source hazards.

Joint Commission (2020), TJC EC.02.03.01 EP 9, (Attachment A) requires fire response plan to describe specific roles at and away from the fire's point of origin.

Plans shall be written to be easy to read and understand so employees upon initial assignment to a job can understand the fire hazard to which they are exposed. Additionally, each employee shall be able easily able to review each part of the fire plan to self-protect if necessary.

VHA Directive 7717 (Attachment B) requires written policies or procedures-specific staff accountability/ responsibilities identified. Shall include:

Qualified individuals for shutting off room or zone oxygen Requirement to telephone fire department Qualified individuals to respond w/ special keys, equipment, tools as needed Individuals to control the operation of utility systems (sprinkler, fire pump, fire alarm, heating, ventilation, electrical, etc.)

Open locked doors & windows Person to meet w/ fire department

All written fire plans shall be provided in Word so updates and changes can be made. Please see attachment C, D for guidance on Format/ template.

PARTS:

Evacuation maps shall include location on the map where you are located, primary exits (Red Arrow), secondary exits (Orange broken line arrow), fire extinguishers (RED ICON), manual pull stations (RED ICON), Stairs (Yellow), Elevators (Green), Egress Point (Red). These maps shall be installed per design guide, and any other conspicuous area deemed recommend relevant by fire protection engineer but shall be approved by Facility Interior design. These maps shall include room numbers that are legible and easy to identify by our Veteran and visitors. VA U. S. Department of Veteran Affairs shall be in the (Bottom Left) of the evacuation maps. Please see example below for reference. Note the example doesn’t have the room numbers listed but shall like to include.

CAD drawings or Revit files can be issued upon request by our local engineering services. All final evacuation maps shall have electronic copies in CAD or Revit to be able to update in the future with floor plans, occupants, and life safety features by VANIHCS. Approval by COR & Engineering Services for all evacuation maps prior to manufacture.

This project can only be accomplished by a Fire protection engineer

There is a total number of __66____ sign holder in place at Marion Indiana campus, and a total number _200___ signs will need to ordered. Currently at the facility we have a total of 38 buildings currently without sign holders or evacuation maps.

There is a total number of ___74___ sign holder at Fort Wayne Indiana campus, and a total number _100__ signs will need to ordered. This campus has already completed a recent update to evacuation maps including locations of all life safety features, evac routes, etc...

All sign holders shall be ___18 Inches__ Width X __18 Inches Height, dimensions and to read, Evacuation Plan having a Warning notice Do Not Use Elevators in case of Fire or Other Electrical Emergencies. Use Marked Exits. The sign holder will need to be __Red____ in color. Additional double-sided tape will need used to appropriately affix the signs to the walls. These sign holders shall be placed at _63 Inches_ above the finish floor to the top of the sign per VA sign guide. All old sign holders shall be removed once new signs are in place. VA engineering staff will patch the walls and repaint all areas where signs have been taken down. Attached you will see the Veteran Affairs Signage Design Guide, December 2012.

PERFORMANCE LOCATION & MONITORING, DOCUMENTATION, & REPORTS:

The Contractor shall submit a comprehensive service specific written fire plan along with detailed evacuation maps specified requirements in fields Service & Parts. All signage shall comply with VA Design guide specifications. All reports shall be in proper formatting and approved by appropriate COR & local Engineering Services prior to manufacture. Any additional charges not included within this service contract shall have the prior approval of the Contracting Officer Representative before those costs are incurred. Any service and repair costs incurred without obtaining prior approval may be determined by the VA to be unauthorized work and the contractor shall bear the burden of such costs.

COMPETENCY/ TECHNICAL REQUIREMENTS/ DELIVERABLES:

This project can only be accomplished by a Fire protection engineer and shall be able to show proof of credentials.

SECURITY:

All employees of general contractor and subcontractors shall comply with VA security management program and obtain temporary VA badges. The employees of the general contractor shall obtain permission of the VA Human Resources, be identified by project and employer, and restricted from unauthorized access.

PLACE OF PERFORMANCE:

· VANIHCS, Marion Campus, 1700 E 38th Street, Marion, IN, 46953

· VANIHCS, Fort Wayne Campus, 2121 Lake Ave, Fort Wayne, Indiana, 46805

· VANIHCS, Muncie CBOC, 3401 N. Morrison Rd. Muncie, Indiana, 47303

· VANIHCS, Hoosier VA Clinic, 1496 W. Hoosier Blvd, Peru Indiana, 46970

· VANIHCS, St. Joe CBOC, 1540 Trinity Place, Mishawaka Indiana, 46545

· VANIHCS, Huntington CBOC, 2859 Northpark Ave, Suite 110, Huntington Indiana, 46750

· VANIHCS, Defiance CBOC, 800 N. Clinton St., Suite B, Defiance Ohio, 43512

Attachments Attachment A- Joint Commission Clarification Document

Attachment B- VHA Directive 7717

Attachment C- Fire Plan Template

Attachment D- VHA Interior Design Guide. See 10 14 00 Signage Specifications

See attached document: Attachment A- Joint Commission Clarification Document.

See attached document: Attachment B- VHA Directive 7717.

See attached document: Attachment C- Fire Plan Template.

See attached document: Attachment D- VHA Interior Design Guide. See 10 14 00 Signage Specifications.

See attached document: Attachment D- VHA Interior Design Guide. See 10 14 00 Signage Specifications 2.

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Attachment A-VHA-Joint Commission Clarification Document effective 1-May-2021 (Rev 0) (002).pdf

VHA-Joint Commission Clarifications, Effective Date May 1, 2021 Page 1 of 17

VHA-Joint Commission Clarification Document

Summary of Discussion Issues Related to VHA Implementation of The Joint Commission Environment of Care (EC) and Life Safety (LS) Standards

May 2021 Revision.

Effective Date: May 1, 2021

See end of document for summary of changes.

Issue 1. Life Safety Code Edition: VHA facilities are designed and inspected in accordance with the most current edition of the codes and standards published by the National Fire Protection Association (NFPA). The effective date of each code and standard is established by the NFPA Standards Council and is published in the front of each document.

Issue 2. Five-year flow tests: Five-year flow tests are required for automatic standpipe systems only, not for manual standpipe systems. If an existing standpipe system does not have an automatic water supply capable of providing 500 gpm at 65/100 psi at the most remote hose connection, it is a manual standpipe by definition, and it is not required to be tested. If an existing standpipe system has an automatic water supply (fire pump) that was designed to provide 500 gpm at 65psi/100psi at the most remote standpipe hose connection, it is required to be tested every five years to document that it meets the design criteria.

Due to the design criteria in the VA Fire Protection Design Manual, most VHA facilities with standpipe systems have manual standpipe systems that are part of a combined sprinkler/standpipe system, and therefore do not require a flow test every five years. For manual standpipe systems, it is intended that the fire department will provide the water supply necessary via the fire department connection to fight fires using the standpipe system.

Note: In 2016, the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) adopted the 2012 edition of the Life Safety Code, and Chapter 2 of the 2012 edition of the Life Safety Code references the 2011 edition of NFPA 25. The five-year flow test is required only for automatic standpipe systems in both the 2011 edition and the most current edition of NFPA 25. The requirements for CMS and VHA are now consistent.

Issue 3.

3a. Smoke detector above master fire alarm control panel: A smoke detector is required above the master fire alarm control panel when the master fire alarm control panel is in a space that is not continuously occupied.

3b. Requirement for the master fire alarm control panel to be located in a fire-rated enclosure: The master fire alarm control panel is not required to be located in a fire rated enclosure if the building is sprinklered.

Issue 4. Portable fire extinguisher monthly inspections: VHA will follow the requirements of NFPA 10 to document monthly inspections of fire extinguishers and where manual inspections are conducted, the month and year the manual inspection was performed and the initials of the person performing the inspection will be recorded.

Issue 5. Removal of occupant fire hoses: In 1985, VHA directed facilities to remove occupant fire hoses since VHA does not train nor expect occupants (staff) to fight fires with hoses. The Joint Commission acknowledges the VHA position that occupant fire hoses are to be removed and The Joint Commission will not require written documentation from the local fire department.

Issue 6. Portable space heaters: The specific portable space heater requirements in NFPA 101 are to be followed (i.e., portable space heater requirements apply to areas and not smoke compartments).

Issue 7. Roller Latches and Documentation of 5 lbf testing: Although CMS and TJC do not permit roller latches (Ref:

LS.02.01.30 EP13), VHA follows the current edition of NFPA 101, which allows devices capable of keeping doors fully closed against a force of 5 lbf to be used, including roller latches and self-closers. VHA facilities are permitted to use devices capable of keeping doors fully closed against a force of 5 lbf as permitted in NFPA 101, Chapters 18 and 19.

VHA-Joint Commission Clarifications, Effective Date May 1, 2021 Page 2 of 17

Where such devices are used, NFPA 101 does not require testing documentation of the 5 lbf and VHA facilities will not be expected to maintain 5 lbf testing documentation. VHA recognizes that if a door without a latch is not able to stay fully closed against a force of 5 lbf, then that door is deficient, but there is no requirement for documentation of periodic testing.

Issue 8. Enforcement of installation standards retroactively: VHA facilities are designed in accordance with the latest editions of the codes and standards at the time of design. The Joint Commission acknowledges that these editions could be earlier or later than the editions referenced by TJC, and in some cases, the requirements might be different.

While TJC references particular editions of NFPA installation standards, TJC will not enforce these installation standards retroactively.

Issue 9. Reserved

Issue 10. Use of standard Interim Life Safety Measure (ILSM) evaluations for typical deficiencies: Many deficiencies are typical and routine. The Joint Commission permits the use of standard ILSM evaluations and response plans for typical deficiencies.

Issue 11. Storage of evacuation chairs in stair enclosures: The Joint Commission does not permit evacuation chairs to be stored within exit enclosures.

Note: In stairs equipped with standpipes, The Joint Commission permits stretchers to be located in the spaces behind the standpipes provided that the stretchers are stored behind the standpipes and out of the means of egress and access to the hose valves is not compromised.

Issue 12. Penetration sealant materials: The Joint Commission has clarified that materials used to seal penetrations in fire/smoke barriers must be compatible with each other. In general, this means that materials from different manufacturers are not permitted to be used in the same penetration unless there is documentation to show that the materials are compatible.

Issue 13. Murals that disguise doors: Murals that disguise doors are now addressed in NFPA 101 and the VA will comply with the NFPA requirements.

Issue 14. Fire watch might not be required for scheduled (planned) construction activities that result in outages of sprinkler systems and/or fire alarm systems:

Summary:

For scheduled construction activities where the sprinkler system is taken out of service for more than 10 hours in a 24-hour period or the fire alarm system is taken out of service for more than 8 hours, if proper separation and appropriate ILSMs are in place, it is considered that no parties are left unprotected by the shutdown. Therefore, neither a fire watch nor evacuation is required. For details on proper separation and appropriate ILSMs, see the Discussion below.

Discussion:

The following is excerpted from The Joint Commission LS standards:

LS.01.02.01 The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.

EP1. The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital implements LS.01.02.01, EPs 2 –15 to compensate for increased life safety risk. The criteria include the assessment process to determine when interim life safety measures are implemented.

EP2. When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. (For full text, refer to NFPA 101 -2012:

VHA-Joint Commission Clarifications, Effective Date May 1, 2021 Page 3 of 17

9.6.1.6; 9.7.6; NFPA 25-2011: 15.5.2)

In the July 2009 Joint Commission EC News, the concept of scheduled and unscheduled activities is discussed, as follows:

A scheduled activity would be an event known to and under the knowledge of and control of organization staff, such as a construction project or servicing or upgrading the fire alarm system or sprinkler system. All other situations would typically be considered unscheduled activities, including a contractor stepping outside the defined boundaries of a contracted service or activity or staff covering an alarm near a cooking area.

For a scheduled activity, The Joint Commission permits ILSMs instituted as a result of the ILSM policy in EP1 to obviate the need for a fire watch that would be otherwise required by EP2.

NFPA 101 (2021 edition) states:

9.6.1.6 Fire alarm system impairment procedures shall comply with NFPA 72.

9.11.2 Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25.

Note: Since the 2015 edition, the Life Safety Code has referred to the requirements of NFPA 72, in which the time requirement is 8 hours. NFPA 101 has referred to the requirements of NFPA 25 since the 2012 edition of the Life Safety Code, where the time requirement is 10 hours in a 24-hour period. However, the concepts remain the same.

For scheduled construction activities where the sprinkler system is taken out of service for more than 10 hours in a 24-hour period or the fire alarm system is taken out of service for more than 8 hours, if proper separation and appropriate ILSMs are in place, it is considered that no parties are left unprotected by the shutdown. Therefore, neither a fire watch nor evacuation is required.

Proper separation means that, as a minimum, the temporary construction partition must be in compliance with NFPA 241 as well as LS.01.02.01, EP7.

NFPA 241 (2019 edition):

8.6.2 Temporary Separation Walls.

8.6.2.1 Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.

8.6.2.1.1 Walls shall have at least a 1-hour fire resistance rating.

8.6.2.1.2 Opening protectives shall have at least a 45-minute fire protection rating.

8.6.2.2 * Walls in 8.6.2.1.1 and opening protectives in 8.6.2.1.2 shall be permitted to be nonrated when an approved automatic sprinkler system is installed and operational.

LS.01.02.01, EP7 uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire. The need for these partitions is based on criteria in the hospital’s interim life safety measure (ILSM) policy.

In addition, the construction activities must be evaluated with respect to the facility ILSM policy, the ILSM evaluation must be documented, and ILSMs implemented as applicable in accordance with the evaluation.

VHA-Joint Commission Clarifications, Effective Date May 1, 2021 Page 4 of 17

Issue 15. Sprinklers in small closets (other than clothes closets and wardrobes): Some hose cabinets, hose closets, and electrical closets that are shallow in depth have not been provided with sprinkler protection. If these cabinets and closets did not have doors, the space would be protected by the nearby building sprinkler(s). Because doors are present, some inspectors have wanted sprinklers to be installed within the cabinet or closet. In line with NFPA 13 (see below), The Joint Commission will permit sprinklers to be omitted from these spaces provided that the space is small enough so that a person cannot reasonably enter the space (see photo for example).

NFPA 13 (2016 edition):

8.1.1(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure.

Please note that the Healthcare Interpretations Task Force (12-2008) and the 2021 edition of the Life Safety Code (18/19.3.5.10) have addressed the requirements for sprinklers within clothes closets and wardrobes.

Example of small closet for which The Joint Commission will permit omission of sprinklers.

VHA-Joint Commission Clarifications, Effective Date May 1, 2021 Page 5 of 17

Issue 16. EC.02.03.05 Summary of Inspection, Testing, and Maintenance (ITM) differences between The Joint Commission (TJC) and VHA: As of July of 2016, TJC standards are based on the 2012 edition of NFPA 101 and the codes and standards referenced therein (e.g., NFPA 72 (2010) and NFPA 25 (2011)), while VHA references the latest editions of NFPA codes and standards. The following table highlights differences as of the date of this document.

Frequencies are subject to change in accordance with the requirements in future editions of the codes and standards.

For ITM activities, the time required for implementation of a newly published code or standard could vary by facility. If ITM activities at a facility are contracted, the existing contract must be modified to incorporate any changed frequencies. Facilities might be able to amend an existing contract or might have to wait until a new contract is established to incorporate the changes. However, if a facility performs ITM activities using in-house staff, conversion to new frequencies might be accomplished more rapidly. It is the responsibility of each facility to document which edition of each code and standard the facility is using for ITM.

Table 1. Elements of Performance for EC.02.03.05 Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.

EP # Description Frequency (TJC/CMS) References as indicated in NFPA 101 – 2012 edition, Chapter 2 - Reference Publications.

Frequency (VHA) References per most current edition of the standard as of the date of this document.

EP1

Supervisory Signal Devices

1. pressure supervisory; pressure tank, pressure supervisory for a dry pipe (both high and low conditions), steam pressure

2. water level supervisory signal initiating device (see

EP7)*

3. water temperature supervisory (see EP8)* room temperature supervisory

*For items (2) and (3) above, VHA will use the criteria in EP7 and EP8, respectively

Quarterly NFPA 72 (2010) Table 14.4.5 (15)(l)

Annually NFPA 72 (2019) Table 14.4.3.2 (17)(10)(b-g)

EP2 Water Flow Devices and Valve Tamper Switches Semiannually NFPA 72 (2010) Table 14.4.5 (15)(l)(1) & (m)

Semiannually NFPA 72 (2019) Table 14.4.3.2 (17)(10)(a) & (17)(11)

EP3 Duct, Heat, Smoke Detectors, Pull Boxes, NFPA 72 (2010) Table 14.4.5 (15)(a)-(i)

NFPA 72 (2019) Table 14.4.3.2 (17)

EP4

Notification Appliances (Visual and Audio), Door Releasing Devices

NFPA 72 (2010) Table 14.4.5 (20)

NFPA 72 (2019) Table 14.4.3.2 (22)

EP5

Emergency Services Notification Transmission Equipment

NFPA 72 (2010) Table 14.4.5 (22)

NFPA 72 (2019) Table 14.4.3.2 (4)

EP6 Fire Pumps Tested (No Flow) Weekly (Diesel) NFPA 25 (2011) 8.3.1.1

Monthly (Electric) NFPA 25 (2011) 8.3.1.2

Weekly (Diesel) NFPA 25 (2020) 8.3.1.1

Monthly (Electric) NFPA 25 (2020) 8.3.1.2.

EP7

Water Storage Tanks (high and low level alarms) (when installed)

NFPA 25 (2011) 9.3.5

NFPA 25 (2020) 9.3.5

EP8

Water Storage Tanks (low water temperature alarms) (when installed)

Monthly (cold weather only)

NFPA 25 (2011) 9.3.3

Prior to heating season.

NFPA 25 (2020) 9.3.3

EP9 Sprinkler Systems Main Drain Test

Test at each system riser.

Quarterly (where sole water source is through backflow preventer) NFPA 25 (2011) 13.2.5 & 13.2.5.1

Test is only required at lead-in to a building.

Quarterly (where sole water source is through backflow preventer) NFPA 25 (2020) 13.2.3 & 13.2.3.2

EP10 Fire Department Connection Inspected

NFPA 25 (2011) 13.7.1

NFPA 25 (2020) 13.8.1

EP11 Fire Pumps Tested Under Flow

NFPA 25 (2011) 8.3.3

NFPA 25 (2020) 8.3.3

VHA-Joint Commission Clarifications, Effective Date May 1, 2021 Page 6 of 17

Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.

References per most current edition of the standard as of the date of this document.

EP12

Automatic Standpipe Systems Tested with Water Flow (See Issue 2 above)

Five Years

NFPA 25 (2011) 6.3.1.1

Five Years

NFPA 25 (2020) 6.3.1.1

EP13 Kitchen Extinguishing Systems

NFPA 96 (2011) 11.2.1

NFPA 96 (2017) 11.2.1

EP14

Gaseous extinguishing Systems (no discharge required)

N/A

N/A

EP15 Portable Fire Extinguishers Inspected Monthly

NFPA 10 (2010) 7.2

NFPA 10 (2018) 7.2

EP16 Portable Fire Extinguishers Maintained

NFPA 10 (2010), 7.3

NFPA 10 (2018) 7.3

EP17

Fire Hoses Hydrostatically Tested 5 years after installation and every 3 years after

5 years/3 years NFPA 25 (2011) Table 6.1.1.2

5 years/3 years NFPA 25 (2020) Table 6.1.1.2

NFPA 1962 (2018) 4.2.2

EP18 Smoke and Fire Dampers

1 year after installation, then:

Hospitals - every 6 years Others - every 4 years NFPA 105 (2010) 6.5.2 (Smoke Dampers) NFPA 80 (2010) 19.4. (Fire Dampers)

1 year after installation, then:

Hospitals - every 6 years Others - every 4 years NFPA 105 (2019) 7.6.2 (Smoke Dampers) NFPA 80 (2019) 19.5. (Fire Dampers)

EP19

Smoke Detection Shutdown Devices for

HVAC

NFPA 90A (2012) 6.4.1

NFPA 90A (2021) 6.4.1

EP20

All Horizontal & Vertical Rolling & Sliding Doors

NFPA 80 (2010) 5.2.1

NFPA 80 (2019) 5.2.4

EP25 Door Assemblies

Annually (fire doors)

NFPA 101 (2012): 8.3.3.1;

NFPA 80 (2010): 4.8.4; 5.2.1; 5.2.3; 5.2.4;

5.2.6; 5.2.7; 6.3.1.7 Note: CMS recommends that non-rated doors should be routinely inspected as part of the facility maintenance program.

NFPA 101 (2021) 8.3.3.3.1, 8.8

Fire doors are required to be inspected annually (8.3.3.3.1).

Doors in smoke barriers, doors in smoke partitions, and doors serving hazardous areas are also required to be inspected annually (i.e., doors that are required to be self or auto-closing) (8.8).

EP27

Elevators with firefighters’ emergency operations

NFPA 101 (2012), 9.4.6.2

NFPA 101 (2021), 9.4.6.2

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Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.

References per most current edition of the standard as of the date of this document.

EP28

Documentation of maintenance, testing, and inspection activities for Standard EC.02.03.05, EPs 1–20, 25 (including fire alarm and fire protection systems) includes the following:

- Name of the activity

- Date of the activity

- Inventory of devices, equipment, or other items

- Required frequency of the activity

- Name and contact information, including affiliation, of the person who performed the activity

- NFPA standard(s) referenced for the activity

- Results of the activity

Note: For additional guidance on documenting activities, see

NFPA 25 (2011): 4.3; 4.4;

NFPA 72 (2010): 14.2.1; 14.2.2;

14.2.3; 14.2.4.

Note: For additional guidance on documenting activities, see

NFPA 25 (2020): 4.3; 4.5;

NFPA 72 (2019): 14.6 & 7.8.2 (Figure 7.8.2)

Note: EP28 does not apply to fire extinguisher annual maintenance, which is permitted to be documented by using a tag with the month and year in accordance with NFPA 10.

Issue 17. Decorations in Fire Rated Stair Enclosures: Artwork painted directly on the walls or ceilings is permitted in stair enclosures. The following are not permitted in stair enclosures:

• Decorations and furnishings

• Artwork in frames

• Bulletin boards and message boards

• Posters and papers attached directly to the wall

Interior finish materials that meet the requirements of Chapter 10 of NFPA 101 are permitted to be installed in fire rated stair enclosures.

Note 1: In addition to the general requirements in Section 10.2.1, Chapter 10 of NFPA 101 has special requirements for textile, expanded vinyl, cellular plastic, foam plastic, and other materials when used as interior finish materials. Care must be taken to ensure that a candidate interior finish material meets these special requirements. Since advertising material might be misleading or incomplete, documentation of the actual laboratory fire test report should be obtained to verify that the requirements of Chapter 10 are met. If the laboratory fire test report is not readily available online, then a copy of the laboratory fire test report should be kept on file for those materials used as interior finish in fire rated stair enclosures.

Note 2: Textile wall and ceiling coverings and expanded vinyl wall and ceiling coverings meeting the requirements of Class A in accordance with ASTM E84 and located in a room or space protected by an approved automatic sprinkler system are permitted by NFPA 101. Therefore, these materials are permitted to be installed in a stair enclosure that is sprinkler protected in accordance with NFPA 13. In some cases, NFPA 13 only requires a sprinkler at the top and under the bottom landing of the stairs.

Issue 18. Equivalencies: Per current Joint Commission (TJC) policy, no new equivalencies will be accepted by TJC without having been cited during a Joint Commission Accreditation survey. Existing equivalencies approved by TJC that are shown on the life safety drawings will be reviewed and the compensating measures will be confirmed during survey and the deficiency for which the equivalency was issued will not be cited as a Requirement for Improvement (RFI). For additional details, see March 19, 2019 letter from TJC to Gerard R. Cox, MD MHA of the VHA attached to this document.

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Issue 19. Life Safety Drawings - Information required on the SOC Drawings:

• Identify if the building is sprinkler protected throughout or identify those areas of the building with sprinkler protection (fire extinguisher locations not required)

• Legend showing features of fire safety

• Fire barriers o If vertical enclosures are identified with fire barriers, they are not also required to be labeled as to their function (i.e., linen chute/HVAC shaft/elevator, etc.)

• Smoke barriers

• Hazardous Areas (as defined by NFPA 101, 19.3.2.1.5 and 21.3.2.1)

• Exits (exit sign locations not required to be shown)

• Suites, including the type (sleeping, patient care non-sleeping, non-patient care) and suite size (maximum suite size is per current edition of NFPA 101). Note: Suite identification is only to be provided for healthcare occupancies.

• Equivalencies Previously Approved by TJC (on drawings where the covered deficiencies are located) o Summary of deficiencies covered by approved equivalency o Summary of compensating measures for deficiencies

Note: The list above is mandatory; other features may optionally be included on the drawings. Exit sign and fire extinguisher locations are NOT required to be shown on the drawings.

Issue 20. Installation of Speakers and Cameras, as well as Wireless Access Point, RTLS, and Door Security Equipment within Exit Stair Enclosures:

NFPA 101 (2021 edition), 7.1.3.2.1(9)(b) permits penetrations into an exit enclosure assembly for electrical conduit serving the exit enclosure. Annex note A.7.1.3.2.1(9)(b) states, “…Penetrations for electrical wiring are permitted where the wiring serves equipment permitted by the authority having jurisdiction to be located within the exit enclosure.”

NFPA 101 (2021 edition), 7.1.3.2.1(9)(c) requires wiring for security and communications systems to be installed in metal conduit. NFPA 101 (2021 edition), 7.1.3.2.1(9)(j) requires wiring for fire alarm systems to be installed in metal conduit.

With respect to penetrations into an exit enclosure assembly, in accordance with NFPA 101, 7.1.3.2.1, penetrations that are properly protected in accordance with NFPA 101, 8.3.4 are permitted for conduit that serves:

(1) Speakers in the stair enclosure where those speakers are used for one or more of the following: public address systems, fire alarm voice communication systems, emergency communication systems, or speakers that are used in conjunction with a wellness program that encourages use of the stairs by patients or staff;

(2) Cameras that are part of a security system,

(3) Door security equipment such as magnetic locks, electronic door strikes, electronic door release buttons, and card readers, or

(4) Wireless access point equipment that allows for functionality within the stair enclosure such as emergency telephone communications, as shown in the photos below.

Speakers, cameras, and wireless access point equipment shall be located not less than 6 ft 8 in above the floor and shall not obstruct sprinklers. Only the speakers, cameras, and wireless access point equipment specifically listed above are permitted.

Items not requiring penetrations:

In addition to the speakers, cameras, door security equipment, and wireless access point equipment listed above, devices associated with a Real Time Location System (RTLS) are permitted to be installed within exit enclosures subject to the following:

(1) Each device is battery-operated and does not require a penetration of the exit enclosure for wiring.

(2) Each device has a maximum footprint area of 50 square inches and a maximum projection from the wall of

4 inches.

(3) The RTLS devices shall not obstruct sprinklers.

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The following are examples of RTLS devices that are permitted (see photos below):

(a) Low Frequency (LF) Exciter

(b) Infrared (IR) Beacon

Wireless Access Point Typical Installation

LF Exciter, typical example LF Exciter installed adjacent to elevator door

Typical examples of RTLS equipment

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IR Beacon, typical example IR Beacon installed on suspended ceiling

Typical examples of RTLS equipment

Issue 21. Time Frames: Time frames shall be as defined by the applicable standard or code. For instance, NFPA 25 (2020 ed) and NFPA 72 (2019 ed) have frequencies defined and the definitions of those frequencies are shown in the table below. Where a code or standard does not define a frequency or time frame, the time intervals established in The Joint Commission (TJC) accreditation manual, as shown below in the second column, will be used. For the purposes of complying with EC and LS standards, there is no penalty for conducting the activity more frequently than required.

Table 3. Time Interval Definitions Time Frame / Frequency Definition - TJC Definition – NFPA 25

Minimum and maximum time between events.

Definition – NFPA 72 Minimum and maximum time between events.

Five Years Not Defined Occurring once every 60 months with a minimum of 54 months and a maximum of 66 months.

Not Defined

Triennially (every 3 years, every 36 months, etc.)

Defined as 36 months from the last event, plus or minus 45 days

Occurring once every 36 months with a minimum of 30 months and a maximum of 40 months.

Not Defined

Annually (yearly, every year, every 12 months, etc.)

Defined as 1 year from the last event, plus or minus 30 days

Occurring once per year with a minimum of 9 months and a maximum of 15 months.

Once per year with a minimum of 9 months, maximum 15 months.

Semiannually (twice a year, every 6 months, etc.)

Defined as 6 months from the last event, plus or minus 20 days.

Occurring twice per year with a minimum of 4 months and a maximum of 8 months.

Twice per year with a minimum of 4 months, maximum of 8 months.

Quarterly (once a quarter, every three months, etc.)

Defined as every 3 months, plus or minus 10 days

Occurring four times per year with a minimum of 2 months and a maximum of 4 months.

Four times per year with a minimum of 2 months, maximum of 4 months.

Monthly (once a month, every 30 days, etc.)

Defined as 12 times per year, once per calendar month.

Occurring once per calendar month

Twelve times per year, once per calendar month.

Weekly (once a week, every week, etc.)

Defined as once per calendar week.

Occurring once per calendar week.

Fifty-two times per year, once per calendar week.

Daily (once a day, every day, etc.) Defined as once per calendar day.

Occurring every day Not Defined

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Issue 22. Labeled Fire Doors Installed Where Fire Doors Are Not Required: Labeled fire doors installed in locations where life safety drawings indicate that a fire door is not required do not need to comply with the requirements of NFPA 80. In addition, the label can remain on the door (based on the 2021 edition of NFPA 101, 4.6.12.3, 4.6.12.4, and A.4.6.12.3).

Excerpt from NFPA 101 (2018)

A.4.6.12.3: “…Where a door that is not required to be fire protection-rated is equipped with a fire protection listing label, it is not the intent of 4.6.12.3 to require such door to be self- or automatic-closing due merely to the presence of the label.”

Issue 23. Quarterly Fire Drills not required at unexpected times: While the CMS Life Safety Checklist (Form CMS- 2786R (10/2016)) requires quarterly fire drills to be conducted “at unexpected times” (reference Checklist Item K712), NFPA 101, 19.7.1.6 does not require fire drills to be conducted “at unexpected times.” Since VHA facilities are not deemed by TJC, VHA facilities are not required to conduct fire drills at unexpected times and VHA facilities are permitted to conduct fire drills on the same shift, during the same day, and during the same hour, as previous and subsequent quarterly fire drills. See HITF Interpretation June 2017.

Issue 23a. Fire Drills – neither transmission of an alarm off-premises nor activation of notification appliances during night shift required:

The requirements for fire drills were clarified in the 2021 edition of NFPA 101. There is no requirement for a signal to be transmitted to an off-premises location during a fire drill. The previous editions of NFPA 101 are confusing regarding the issue of the “transmission” of a fire alarm signal during a fire drill. This confusion centers around the term “transmission” which some have interpreted to mean that a fire alarm signal must be sent to an off-premises receiving location during a drill. This was previously addressed by the Healthcare Interpretations Task Force (HITF) (June 2014), which clarified that it is not the intent of the code to require a signal to be sent off-premises during a fire drill.

The new text in the 2021 edition (18/19.7.1.4) has eliminated the confusion by no longer using the term “transmission” in the code.

In addition, for a fire drill that is conducted between 9:00 pm and 6:00 am, the code (18/19.7.1.7) has been clarified and activation of the notification appliances, which includes the audible and visual notification appliances, is not required provided a coded announcement is used.

Issue 24. Standards for Behavioral Health Care: TJC has modified the Life Safety (LS) Standards for the Behavioral Health Care Accreditation Program by changing the Life Safety Code references from Chapter 26, Lodging and Rooming Houses and Chapter 28/29, Hotel and Dormitories to Chapters 32/33, Residential Board and Care Occupancies. These changes include elements of performance (EPs) in LS.04.01.20, LS.04.01.40, LS.04.01.50, LS.04.02.20, LS.04.02.30, LS.04.02.40 and LS.04.02.50. The references in the LS standards published by TJC are based on the 2012 Edition of NFPA 101 and some TJC requirements do not correspond to what is written in NFPA

101. In accordance with Issue 1 above, VHA will follow the requirement of the latest edition of NFPA 101 for Residential Board and Care Occupancies.

Issue 25. Healthcare Interpretations Task Force (HITF): VHA and TJC are voting members of the HITF. VHA and TJC will follow the interpretations rendered by the HITF unless an interpretation is superseded by the requirements published in an NFPA code or standard, or an interpretation differs with an issue specifically addressed in this document, in which case the requirements of the NFPA code or standard or this document will apply.

Issue 26. Time Limited Waivers: The Joint Commission will accept Time Limited Waiver (TLW) requests for all Life Safety (LS) related Requirements for Improvement (RFIs) and Environment of Care (EC) RFIs that link to NFPA

101. In addition, for those EC RFIs that link to NFPA 99 and where resolution will take longer than 60 days, the Joint…