Fire Suppression - VHA-Joint Commission Clarification Document - Effective 10-01-2023.docx

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 September 2023 Revision.

Effective Date: October 1, 2023 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.

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: 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 (2022 edition):

4.13.4 Temporary Construction Barriers

4.13.4.1 Barriers 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 have a higher level of hazard than the occupied portion of the building.

4.13.4.1.1 Barriers shall have at least a 1-hour fire resistance rating.

4.13.4.1.2 Opening protectives shall have at least a 45-minute fire resistance rating.

4.13.4.2 Barriers in buildings protected throughout with approved, automatic sprinkler systems that are not impaired in accordance with NFPA 25 shall be permitted to be noncombustible material, limited-combustible material, or fabric or plastic films meeting the requirements of 4.13.1.

4.13.4.3 In conjunction with the Fire Prevention Program, as an alternative to 4.13.4.1 and 4.13.4.2, a risk assessment shall be permitted to be performed to determine the required protective measures between an occupied portion of the structure and the portion of the structure undergoing alteration, construction, or demolition operations.

NOTE: The following text in italics is extracted from NFPA 101(2021), 19.7.9.3. VHA considers use of the protective measures in the text below to meet NFPA 241, 4.13.4.3 above (Option 3) without conducting a risk assessment.

For rehabilitation activities or preparation for rehabilitation activities of a duration not greater than 30 days that do not cause the classification of the construction area as a hazardous area as identified in NFPA 101, 19.3.2, flame-resistant plastic in accordance with NFPA 701, or equivalent, shall be permitted to be used to separate the construction area from the other spaces. (NFPA 101(2021), 19.7.9.3.)

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.

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.

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.

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 including:

-pressure supervisory indicating devices (including both high- and low-pressure switches), -water level supervisory indicating devices, -water temperature supervisory indicating devices, -room temperature supervisory indicating devices

Quarterly NFPA 72 (2010) Table 14.4.5 (15)(l)(2-5)

Annually NFPA 72 (2022) Table 14.4.3.2 (17)(10)(b,e,f,g)

Supervisory signal devices including:

-valve supervisory switches (tampers) Semiannually NFPA 72 (2010) Table 14.4.5 (15)(l)(1) Semiannually NFPA 72 (2022) Table 14.4.3.2 (17)(10)(a)

Supervisory signal devices including:

-other supervisory initiating devices.

Annually NFPA 72 (2010) Table 14.4.5 (15)(l)(7) Annually (See EP11) NFPA 72 (2022) Table 14.4.3.2 (17)(10)(d)

NFPA 72 (2010) Table 14.4.5 (15)(m) Semiannually NFPA 72 (2022) Table 14.4.3.2 (17)(11)

NFPA 72 (2010) Table 14.4.5 (15)(a)-(i) Annually NFPA 72 (2022) Table 14.4.3.2 (17)

NFPA 72 (2010) Table 14.4.5 (20) Annually NFPA 72 (2022) Table 14.4.3.2 (22)

NFPA 72 (2010) Table 14.4.5 (22) Annually NFPA 72 (2022) Table 14.4.3.2 (4)

Monthly (Electric) NFPA 25 (2011) 8.3.1.2 Weekly (Diesel) NFPA 25 (2023) 8.3.1.1 Monthly (Electric) NFPA 25 (2023) 8.3.1.2.

EP9

Sprinkler Systems Main Drain Test Test at each system riser.

Annually 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.

Annually Quarterly (where sole water source is through backflow preventer) NFPA 25 (2023) 13.2.2 & 13.2.2.2

NFPA 25 (2011) 13.7.1

Quarterly

NFPA 25 (2023) 13.8.1

EP11

Fire Pumps Tested Under Flow Fire Pump supervisory signal devices for “pump running” and “pump power loss” are tested.

Annually

NFPA 25 (2011) 8.3.3; 8.3.3.4

Annually

NFPA 25 (2023) 8.3.3, 8.3.3.14

NFPA 72 (2022) 23.8.5.9

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.

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.

NFPA 25 (2011) 6.3.1.1

Five Years

NFPA 25 (2023) 6.3.1.1

NFPA 96 (2011) 11.2.1

Semiannually

NFPA 96 (2021) 12.2.1

EP14

NFPA 12 (2011) 4.8.3.2

Annually

NFPA 12 (2022) 4.8.3.2

NFPA 12A (2009) 6.1

Semiannually

NFPA 12A (2022) 6.1

Other special systems per NFPA Standards

See NFPA 2001 (2012)

See NFPA 2001 (2022)

NFPA 10 (2010) 7.2

Monthly

NFPA 10 (2022) 7.2

NFPA 10 (2010), 7.3

Annually

NFPA 10 (2022) 7.3

EP17

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

Occupant Hoses have been removed from VHA facilities. See Issue 5 above.

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 (2022) 7.5.2 (Smoke Dampers) NFPA 80 (2022) 19.5. (Fire Dampers)

NFPA 90A (2012) 6.4.1

Annually

NFPA 90A (2021) 6.4.1

NFPA 80 (2010) 5.2.1

Annually

NFPA 80 (2022) 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.

Annually

NFPA 101 (2024) 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 orauto-closing) (8.8).

NFPA 101 (2012), 9.4.6.2

Monthly

NFPA 101 (2024), 9.4.6.2

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.

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.

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 theactivity

· 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 (2023): 4.3; 4.5;

NFPA 72 (2022): 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.

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

· 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)

· Summary of deficiencies covered by approved equivalency

· 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 (2024 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 (2024 edition), 7.1.3.2.1(9)(c) requires wiring for security and communications systems to be installed in metal conduit. NFPA 101 (2024 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.

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

(a) Low Frequency (LF) Exciter

(b) Infrared (IR) Beacon Issue 21. Time Frames: Time frames shall be as defined by the applicable standard or code. For instance, NFPA 25 (2023 ed) and NFPA 72 (2022 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

with a minimum of 54 months and a maximum of 66 months.

Not Defined

with a minimum of 30 months and a maximum of 40 months.

Not Defined

minimum of 9 months and a maximum of 15 months.

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

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 2024 edition of NFPA 101, 4.6.12.3, 4.6.12.4, and A.4.6.12.3).

Excerpt from NFPA 101 (2024) 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 subject to the annual fire door inspection and testing requirement of Chapter 8 or 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 and remain the same in subsequent editions. 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 text in the 2021 edition (18/19.7.1.4) and subsequent editions 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 (See Issue 29), 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 Commission will review those TLW requests for possible consideration. For additional details, see March 19, 2019 letter from TJC to Gerard R. Cox, MD MHA of the VHA attached to this document.

Issue 27. Inspections of Exit Signs: EC.02.05.07 EP1 states: “At least monthly, the hospital performs a functional test of emergency lighting systems and exit signs required for egress and task lighting for a minimum duration of 30 seconds, along with a visual inspection of other exit signs. The test results and completion dates are documented. (For full text, refer to NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012: 6.3.2.2.11.5)”. Section 7.10.9.1, which was the text that required exit signs to be inspected a minimum of every 30 days, was deleted from the 2021 edition of NFPA 101. Therefore VHA, is not required to conduct 30-day inspections of exit signs other than those exit signs that are provided with batteries as their sole emergency power source.

Issue 28. Soiled Linen and Trash Containers: LS.02.01.70 EP6 (Hospital) and LS.03.01.70 EP6 (Ambulatory Health Care) regulate soiled linen and trash receptacles larger than 32 gallons and requires them to be stored in a room protected as a hazardous area. The 2021 edition of NFPA 101 was changed (Section 7.5.7) and now only regulates soiled linen and trash receptacles larger than 64 gallons when those containers are not attended. Containers less than 64 gallons do not have to be located in a room protected as a hazardous area.

Issue 29. Breakers Labeled “Spare” in “Off” Position: The HITF June 7, 2022, Question #6, indicated that breakers labeled “spare” are permitted to be in the “on” or “off” position. However, VHA and TJC agree that breakers that are labeled “spare” must be in the “off” position.

Issue 30. Items Permitted to Touch Sprinkler Piping: A change to the 2023 Edition of NFPA 25, 5.2.2.2 has been made to clarify that sprinkler piping is not permitted to support non-system components.

NFPA 25, 2020 Edition:

5.2.2.2 Sprinkler piping shall not be subjected to external loads by material either resting on the pipe or hung from the pipe.

NFPA 25, 2023 Edition:

5.2.2.2 Sprinkler piping shall not be used to support nonsystem components.

There can, and will be, times when non-sprinkler system components will touch sprinkler system piping. As NFPA 25 (2023 edition) is now written, as long as those non-sprinkler system components are not supported by the sprinkler piping, the fact that they are touching the sprinkler piping does not violate the text nor the intent of NFPA 25.

General Note on Revisions: This document will be reviewed by the VHA and TJC annually, or upon revision of any NFPA Code or Standard referenced within this document. If any revisions to this document are made, a revised document will be issued with a new effective date.

Summary of Major Revisions

September 2023 Revision:

· Issue 14 was modified by updating the NFPA 241 reference from the 2019 to the 2022 edition and by addressing the use of plastic for minor short duration rehabilitation projects.

· Issue 16 was modified by updating the NFPA references, which resulted in no technical changes. Also incorporated TJC changes that included deleting EP7 and EP8 and modifying EP 1, 11, and 14.

· Issues 20 and 21 were modified by updating the code edition references, which resulted in no technical changes.

· Issue 22 was modified to update the annex text of A4.6.12.3 of the 2024 edition of NFPA 101.

· Issue 23a was modified to show that the changes made in 2021 remain applicable.

· Issue 25 was updated to reference the new issue 29, which differs with the HITF answer.

· Issue 29 was added to address breakers labeled as “spare”.

· Issue 30 was added to address non-system components touching sprinkler system piping based on a change to the 2023 edition of NFPA 25.

May 2021 Revision:

· Issue 1 was modified by deleting the reference to a specific edition of NFPA 101 with the understanding that VHA follows the most current edition of the codes and standards published by the National Fire Protection Association (NFPA).

· Changed the references from NFPA 101-2018 edition to the 2021 edition for issues 14 and 20. The change to reference the 2021 edition of the Life Safety Code did not result in any technical changes.

· Issue 16 was modified by updating the code edition references, which resulted in no technical changes.

· Issue 21 was modified to require the use of a frequency as defined in the respective codes and standards when the codes and standards have a definition for a frequency. Otherwise, the Joint Commission definitions from the accreditation manual will be used. Also, the time frame was changed and is to be measured from the event and not from the month when event occurred.

· Issue 22 was modified to reference the new Section 4.6.12.4 of the 2021 edition of NFPA 101.

· Issue 23a was added to coordinate fire drill requirements with the 2021 edition of NFPA 101.

· Issue 27 was added to clarify that monthly inspections of exit signs have been deleted in the 2021 edition of NFPA 101 and VHA will not be required to perform monthly inspections of exit signs.

· Issue 28 was added to clarify the change in the 2021 edition of NFPA 101 for regulating soiled linen and trash containers.

January 2020 Revision:

· Issue 4 was updated to remove the requirement to record the day of the monthly inspection for fire extinguishers.

· Issue 7 was modified to address using devices other than positive latching and documentation when using 5-lbf in lieu of latches to keep doors closed.

· Issue 9 Tracking inaccessible dampers was deleted.

· Issue 14 was updated to reflect the text of the 2019 edition of NFPA 241.

· Issue 16 was modified to add a new EP27 for monthly elevator testing and the previous EP27 was moved to EP28. References to code editions were updated. A note was added to EP28 for fire extinguisher annual maintenance.

· Issue 17 was updated to clarify requirements for interior finish materials for stairs and the term stairwells was changed to stair enclosures for consistency.

· Issue 18 Equivalency requirements were rewritten to comply with current TJC procedures. Only equivalencies that have been previously approved by TJC should be shown on the Life Safety Drawings. The March 19, 2019 letter from TJC to Gerard R. Cox, MD, MHA of the VHA that details equivalency requirements was added as an attachment.

· Issue 19 was revised to clarify that only TJC approved equivalencies are to be shown on the Life Safety Drawings.

Issue 24 was added to identify that VHA will follow NFPA 101 Board and Care Occupancy chapters as written in the current Life Safety Code edition.

· Issue 25 was added to clarify that interpretations from the HITF apply to accreditation surveys.

· Issue 26 was added to clarify that time limited waiver requests will be permitted for other than LS findings as identified in the March 19, 2019 letter from TJC to Gerard R. Cox, MD, MHA of the VHA. This letter has been added as an attachment.

August 2017 Revision:

· Changed the references from NFPA 101-2015 edition to the 2018 edition for issues 1, 14, 15, and 20. The change to reference the 2018 edition of the Life Safety Code did not result in any technical changes. The 2018 edition of the Life Safety Code has an effective date of September 4, 2017.

· Issue 2 was modified to show that the requirement for five-year flow testing of automatic standpipe systems is the same in the 2011 edition (CMS) and the 2017 edition (VHA) of NFPA 25. A five-year flow test for manual standpipe systems is not required in either the 2011 or 2017 edition of NFPA 25.

· Issue 7 deleted the positive latching provisions for power operated doors and horizontal sliding doors because the requirements in the 2012 edition and the 2018 edition of NFPA 101 are now the same. The permission for the use of roller latches in VA facilities was retained even though the use is not permitted by CMS.

· Issue 9 was modified to address the new PFI requirements that became effective in 2016. The six-year extension previously permitted for inaccessible dampers was deleted.

· Issue 13 was modified to remove the reference to a specific paragraph number in NFPA 101

· Issue 14 was modified to address the EP numbering changes in LS.01.02.01.

· Issue 16 was updated to show the differences in testing frequencies between CMS/TJC and VHA based on updated code references. EP 1, EP7, EP8, EP9, and EP25 show different requirements based on the different editions of the codes and standards referenced. EP25 was added that addresses testing of door assemblies. TJC/CMS requirements for EP25 are based on CMS S&C 17-38-LSC dated July 28, 2017). VHA requirements are based on the 2018 edition of NFPA 101.

· Issue 17 was updated to include the clarification information that was approved by George Mills in the email from George Mills to David Klein (VHACO) Wednesday, November 30, 2016 04:45 PM.

· Issue 18 was updated to provide clear direction for equivalencies based on the new Joint Commission SOC process that became effective in 2016.

· Issue 21 was added, which provides definitions of time intervals.

· Issue 22 was added to clarify that fire protection listing labels are permitted to remain on doors installed in locations where fire doors are not required. NFPA 101, 2018 edition, 4.6.12.3 states, “Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.” However, the annex note clarifies that if a door is not required by the Code to be fire protection-rated, it does not need to be self- or automatic-closing due solely to the presence of the label. Issue 22 further clarifies that the door does not have to comply with any requirements of NFPA 80.

· Issue 23 was added to clarify that quarterly fire drills are not required to be conducted at unexpected times. This clarification is in accordance with the HITF interpretation of June 2017.

June 2015 Revision:

· Issue 20 was expanded to permit the installation of Real Time Location System (RTLS) devices within exit enclosures, subject to specific restrictions. These devices are used for locating persons and equipment and the approved devices do not require penetrations of the fire rated enclosure for wiring. In addition, door security equipment and cameras that are part of a security system were added to the list of items permitted within exit enclosures.

February 2015 Revision:

· Issue 20 was added, which permits, under certain conditions, the installation within exit stair enclosures of wireless access point equipment and certain speakers. All of this equipment serves the exit enclosure, as required by NFPA 101, 7.1.3.2.1(10)(b). Permission for the installation of wireless access point equipment was originally granted in a separate email dated February 2010 and was added as part of Issue 20 to bring all items together in a single document.

October 2014 Revision:

· Changed the references from NFPA 101-2012 edition to the 2015 edition for issues 1, 3, 7, 14, and 15. The change to reference the 2015 edition of the Life Safety Code did not result in any technical changes.

· Issue 2 was modified to comply with the 2014 edition of NFPA 25 that requires all standpipes (including manual standpipes) to be flow tested every five years. Note: A proposal to change the 2017 edition back to the 2011 edition wording so that flow testing is only required for automatic standpipes has been submitted by the National Fire Sprinkler Association.

· Issue 3 was revised to be consistent with LS.02.01.34 EP2. The installation requirements for smoke detectors over the fire alarm control panel going back to NFPA 72-1999 and recent editions of NFPA 101 have changed with nearly every edition. For enforcement purposes, as a minimum for existing systems, VHA requires a smoke detector over the master fire alarm control panel when the master fire alarm control panel is in an area that is not continuously occupied. See also Issue 8 above for information on existing installations.

· Issue 13 was modified to reflect the fact that the 2015 edition of NFPA 101 now permits murals to disguise certain doors. NFPA 101 did not previously permit such murals on doors. The only change between the previous VA requirements and the current NFPA 101 requirements is 18.2.2.2.7(5) and 19.2.2.2.7(6) which state: “The location and operation of doors disguised with murals are identified in the fire safety plan and are included in staff training.”

· Issue 14 was modified to reflect that the 2015 edition of NFPA 101 now references NFPA 72 for impairments of fire alarm systems. Instead of 4 hours in a 24-hour period, NFPA 72 identifies 8 hours as the trigger point and NFPA 25 identifies 10 hours in a 24-hour period as the trigger point (see NFPA 72- 2013, 10.21.4, and NFPA 25-2014, 15.5.2(4)). The Joint Commission requirement for LS.01.02.01 EP1 would read: The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm is out of service for more than 8 hours or the sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building.

· Issue 16 was modified to update the testing frequencies to match those in the current NFPA codes and standards. Major changes included a new requirement to perform a flow test every five years on manual standpipes (EP12) and to change the testing frequency from quarterly to annual for all supervisory devices (EP1). Implementation options were also added to the issue. EP25 was deleted from the table as it only applied to deemed status facilities and not to VHA facilities.

· New Issues 17 through 19 were added. December 2011 Revision:

· Issue 3 was modified to comply with the 2012 edition of NFPA 101 to retroactively require a smoke detector above the fire alarm control panel in some cases.

· Issue 7 was expanded to add 7c and 7d, which address situations where other than positive latching doors are permitted for acute psychiatric settings (7c), and horizontal sliding doors (7d).

· Issue 9 was modified to clarify that at least one PFI entry is required on the eSOC. However, the facility has the option to individually identify all inaccessible dampers either on the eSOC or in a separate inventory.

· New Issues 11 through 16 were added. The original 10 issues were dated February 2010.

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