7712_D_2022-05-19.pdf

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Department of Veterans Affairs VHA DIRECTIVE 7712 Veterans Health Administration Transmittal Sheet Washington, DC 20420 May 19, 2022

FIRE PROTECTION CODE REVIEWS OF DELEGATED CONSTRUCTION

PROJECTS

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

2. SUMMARY OF MAJOR CHANGES: This directive:

a. Adds responsibilities for the Assistant Under Secretary for Health for Support and establishes them as the Authority Having Jurisdiction (AHJ) (see paragraph 5).

b. Adds responsibilities for the Executive Director, VHA Healthcare Environment and

Facilities Program; Director, Office of Occupational Safety and Health (OSH); Veterans Integrated Service Network Capital Asset Manager; and VA medical facility Chief Engineer (see paragraph 5).

c. Updates responsibilities for the Assistant Under Secretary for Health for

Operations (see paragraph 5).

3. RELATED ISSUES: VHA Directive 7701, Comprehensive Occupational Safety and Health Program, dated May 5, 2017.

4. RESPONSIBLE OFFICE: The Assistant Under Secretary for Health for Support (19) is responsible for the content of this directive. Questions related to this directive may be addressed to the Director, OSH, Office of Healthcare Environment and Facilities Programs (19HEF) at VHAOccSafetyandHealthAction@va.gov.

5. RESCISSIONS: VHA Directive 7712, Fire Protection Code Reviews of Delegated

Construction Projects, dated February 10, 2017, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of May 31, 2027. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

BY DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Deborah E. Kramer Acting Assistant Under Secretary for Health for Support mailto:VHAOccSafetyandHealthAction@va.gov

May 19, 2022 VHA DIRECTIVE 7712

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NOTE: All references herein to Department of Veterans Affairs (VA) and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on May 24, 2022.

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CONTENTS

FIRE PROTECTION CODE REVIEWS OF DELEGATED CONSTRUCTION

PROJECTS

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. FIRE PROTECTION ENGINEERING REQUIREMENTS

7. TRAINING

8. RECORDS MANAGEMENT

9. REFERENCES

FIRE PROTECTION CODE REVIEWS OF DELEGATED CONSTRUCTION

PROJECTS

1. PURPOSE

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

AUTHORITY: 38 U.S.C. § 7301(b); 40 U.S.C. § 3312.

2. BACKGROUND

a. The Department of Veterans Affairs (VA) acts as its own building and fire protection official and Authority Having Jurisdiction (AHJ). Construction of facilities on Federal property is generally exempt from the requirements of local building codes and standards. In addition, delegated construction projects on Federal property are generally exempt from code compliance reviews by local fire officials. Therefore, VA must have its own process to ensure that VA medical facilities are designed, renovated and constructed in accordance with VA policy and the codes and standards adopted by VA. NOTE: VA medical facilities include all facilities associated with a VA medical center campus including, but not limited to, childcare centers, boiler plants and leased facilities.

b. P.L. § 100-678, The Public Buildings Amendments of 1988, requires Federal agencies to comply with national consensus codes and standards. VA general requirements addressing construction codes and standards are found in the Office of Construction and Facilities Management (OCFM) Program Guide (PG) 18-3, Topic 1, Codes, Standards, and Executive Orders located at:

http://www.cfm.va.gov/TIL/cPro.asp. Specific VA requirements for fire protection are found in the VA Fire Protection Design Manual located at:

http://www.cfm.va.gov/til/spclRqmts.asp#FS.

3. DEFINITIONS

a. Authority Having Jurisdiction. AHJ is an organization, office or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation or a procedure.

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

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

d. Delegated Construction Projects. Delegated construction projects are construction projects that are financially managed in whole or in part by VHA (Veterans Integrated Services Network (VISN) or VA medical facility). Funding may http://www.cfm.va.gov/TIL/cPro.asp http://www.cfm.va.gov/til/spclRqmts.asp#FS come from the Major, Minor, Clinical Specific Initiatives or Non-Recurring Maintenance programs as well as other funding sources. Projects managed by OCFM staff are not delegated construction projects.

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

4. POLICY

It is VHA policy that independent third-party fire protection code reviews are provided for delegated construction projects by qualified fire protection engineers, and that qualified fire protection engineers are part of the design team for selected projects in order to ensure a safe environment for Veterans, visitors and staff. Except as provided in paragraph 5.b.(1), the VHA AHJ for fire protection code compliance and for the approval of fire and life safety equivalencies is the Assistant Under

Secretary for Health for Support.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for:

(1) Establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

(2) Serving as the VHA AHJ for fire protection code compliance and for the approval of fire and life safety equivalencies, except where the AHJ is otherwise established by Federal regulations. NOTE: For a summary of community-based programs where the AHJ is established by the Code of Federal Regulations as other than the Assistant

Under Secretary for Health for Support, see the Community Care Program Summary Matrix on the VHA Healthcare Environment and Facilities Programs Fire Protection website at: http://vaww.hefp.va.gov/fire-protection. This is an internal VA website that is not available to the public.

c. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the VISNs.

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

http://vaww.hefp.va.gov/fire-protection

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

d. Executive Director, VHA Healthcare Environment and Facilities Program.

The Executive Director, Healthcare Environment and Facilities Program is responsible for:

(1) Overseeing the VHA Occupational Safety and Health (OSH) program.

(2) Periodically assessing the VHA fire protection program for continued need, currency and effectiveness.

(3) Coordinating with the Assistant Under Secretary for Health for Operations, Veterans Integrated Services Network (VISN) Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address fire protection in a manner that meets the requirements of applicable Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

e. Director, Office of Occupational Safety and Health. The Director, Office of Occupational Safety and Health is responsible for:

(1) Supporting the Assistant Under Secretary for Health for Operations with the implementation and oversight of this directive.

(2) Collaborating with the Director, Office of Healthcare Engineering, in the development and distribution of guidance and directives related to fire protection compliance and standards for VHA-delegated construction projects.

f. Veterans Integrated Services Network Directors. Each VISN Director is responsible for:

(1) Ensuring that all VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

(2) Establishing a written process to monitor VISN and VA medical facility compliance with this directive and taking corrective action when non-compliance is identified. NOTE: One method of monitoring compliance is through the Annual

Workplace Evaluation process, described in VHA Directive 7701, Comprehensive Occupational Safety and Health Program, dated May 5, 2017, which is conducted by VISN staff.

(3) Ensuring that the VISN Capital Asset Manager (CAM) determines whether an independent fire protection code review is required for each delegated construction project that is required to be entered into the Capital Assets Database and that the review and resolution of the review comments are tracked through the Capital Assets Database. See paragraphs 6.a. and 6.b. for further information.

g. Veterans Integrated Services Network Capital Asset Manager. The VISN CAM is responsible for determining whether an independent fire protection review is required for each delegated construction project entered into the Capital Assets Database.

h. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Establishing a written process to ensure that fire protection code reviews are accomplished in accordance with the requirements of this directive and taking corrective action when non-compliance is identified.

(2) Utilizing VA medical facility safety staff and others as needed to provide additional comments within their level of expertise to augment the third-party fire protection code reviews. NOTE: For further information, see paragraph 6.d. Generally, VA medical facility staff members do not meet the qualification requirements to perform fire protection code reviews; therefore, their review would not meet the requirement under this directive for a third-party fire protection code review. However, VA medical facility safety staff members, such as the Safety Manager, Green Environmental Management System (GEMS) Manager and Industrial Hygienist (IH), might offer comments regarding facility-specific safety, environmental and industrial hygiene operational issues. Operational issues include, but are not limited to, existing equivalencies; coordination with VA medical facility Interim Life Safety Measure assessments described in VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017; door locking compatibility with existing facility locks; coordination with VA medical facility fire safety plans; asbestos and other IH considerations; and VA medical facility spill plans, air pollution permits and other environmental considerations.

i. VA Medical Facility Chief Engineer. NOTE: For the purposes of this directive, the titles Chief of Facilities Management, Facility Manager and other similar designations are synonymous with the title Chief Engineer. Each VA medical facility Chief Engineer is responsible for:

(1) Ensuring a fire protection engineer is part of the design team for delegated construction projects as described in paragraph 6.c.

(2) Ensuring that the third-party code review is performed by a qualified fire protection engineer as described in paragraph 6.d.

(3) Tracking and documenting the review and resolution of the fire protection code review comments in the Project Tracking Report in the Capital Assets Database.

6. FIRE PROTECTION ENGINEERING REQUIREMENTS

a. Third-Party Fire Protection Code Review. For all delegated construction projects that involve a change of occupancy classification, change of use or modification

(see paragraph 3 for definitions) of any space, f ire protection code reviews must be performed on the design by qualified fire protection engineers who are not associated with the design team. A minimum of one review is required at or before the 95% document submission (referred to as “Design Development Submission” in OCFM PG-

18-15, Volume C). NOTE: The criteria for requiring a third-party fire protection code review are intentionally broad. In addition, complex projects should be reviewed at a stage earlier than the 95% submission so that significant review comments can be incorporated into the design without affecting project costs or schedule. Such projects generally require more than one review.

b. Review Comments. All fire protection code review comments must be addressed and resolved in a manner that is acceptable to the design team, the reviewers and the

VA medical facility Chief Engineer or designee (e.g., Contracting Officer’s Representative) responsible for managing the delegated construction project. All fire protection code review comments and their resolution must be documented in a permanent record as part of the project documentation. NOTE: Documentation of the fire protection code review comments and their resolution is typically recorded in the Project Tracking Report in the Capital Assets Database.

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

Protection Engineer located at: http://www.cfm.va.gov/til/spclRqmts.asp#FS.

d. Qualifications. All fire protection engineers involved in the review or design must meet, as a minimum, the qualification requirements for project fire protection engineers found in the OCFM document, Qualifications and Scope of Services for Fire Protection

Engineer located at: http://www.cfm.va.gov/til/spclRqmts.asp#FS. NOTE: VA staff members who are GS-803- or GS-804- series engineers, and who do not meet the referenced qualification requirements, might be qualified to perform third-party fire protection code reviews.

e. Leases. Qualified fire protection engineers who are not associated with the design team must perform fire protection code reviews on drawings of the leased space for leases processed through a VISN or VA medical facility contracting officer. This must occur as part of the leasing process.

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

7. TRAINING

There are no formal training requirements associated with this directive.

8. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive must be managed as required by the National Archives and Records

Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

9. REFERENCES

a. 38 U.S.C § 7301(b).

b. 40 U.S.C. § 3312.

c. P.L. § 100-678, The Public Buildings Amendments of 1988.

d. VHA Directive 7701, Comprehensive Occupational Safety and Health Program, dated May 5, 2017.

e. VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017.

f. Community Care Program Summary Matrix. http://vaww.hefp.va.gov/fire-protection. NOTE: This is an internal VA website that is not available to the public.

g. OCFM Program Guide (PG)-18-3, Topic 1: Codes, Standards, and Executive Orders. http://www.cfm.va.gov/TIL/cPro.asp.

h. OCFM PG-18-15, Volume C: A/E Submission Instructions for Minor and NRM

Construction Program Medical Center Projects.

http://www.cfm.va.gov/til/aeDesSubReq.asp.

i. OCFM Qualifications and Scope of Services for Project Fire Protection Engineer.

http://www.cfm.va.gov/til/spclRqmts.asp#FS.

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

http://vaww.hefp.va.gov/fire-protection http://vaww.hefp.va.gov/fire-protection http://www.cfm.va.gov/TIL/cPro.asp http://www.cfm.va.gov/til/aeDesSubReq.asp