Attachment B - Fire Safety Drupal.pdf

Research Laboratory Safety Guidebook Volume 1:

Managing Chemical Safety

Fire Safety Guidebook

Published by

VHA Healthcare Environment and Facilities Programs (HEFP) http://vaww.hefp.va.gov/ i

Table of Contents

PREFACE

Disclaimer Statements ................................................................................... xi

Executive Summary ...................................................................................... xii

Acknowledgements ..................................................................................... xiii

Acronyms and Abbreviations ...................................................................... xiv

1. Public Law

1.1. Federal Fire Safety Act of 1992

1.1.1. Evaluation Summary

1.1.2. Discussion

1.1.3. Reference

1.1.4. Enclosures

2. VA Policy

2.1. Construction Process

2.1.1. Evaluation Summary

2.1.2. Discussion

2.1.3. References

2.2. Project Review for Fire Code Compliance

2.2.1. Evaluation Summary

2.2.2. Discussion

2.2.3. References

2.3. Construction/Renovation Activities

2.3.1. Evaluation Summary

2.3.2. Discussion

2.3.3. Frequently Cited Annual Workplace Evaluation (AWE) Findings

2.3.4. References

2.3.5. Enclosure

2.4. Fire Plans

2.4.1. Evaluation Summary

2.4.2. Discussion

2.4.3. Frequently Cited AWE Finding

2.4.4. Reference

ii

2.4.5. Enclosure

2.5. Fire Drills

2.5.1. Evaluation Summary

2.5.2. Discussion

2.5.3. References

2.6. Fire Investigation Program

2.6.1. Evaluation Summary

2.6.2. Discussion

2.6.3. References

2.6.4. Enclosures

2.7. Fire Incident Reporting

2.7.1. Evaluation Summary

2.7.2. Discussion

2.7.3. Reference

2.8. Smoking and Supplemental Oxygen Use

2.8.1. Evaluation Summary

2.8.2. Discussion

2.8.3. References

2.9. Hot Work Program

2.9.1. Evaluation Summary

2.9.2. Discussion

2.9.3. References

2.9.4. Enclosures

2.10. Carbon Monoxide Detectors in Quarters

2.10.1. Evaluation Summary

2.10.2. References

2.11. Index of VA Policy Documents

2.11.1. Discussion

2.11.2. Reference

3. VA Guidance

3.1. Equivalencies

3.1.1. Evaluation Summary

3.1.2. Discussion

3.1.3. When Established

iii

3.1.4. Who Approves

3.1.5. VA Approval Process

3.1.6. Joint Commission Approval Process

3.1.7. VA Submittal Requirements

3.1.8. Need for Separate VA Equivalency

3.1.9. Term of VA Equivalencies

3.1.10. Template and Approved VA-Wide Equivalencies

3.1.11. References

3.1.12. Enclosures

3.2. Domiciliaries (DOMs)

3.2.1. Evaluation Summary

3.2.2. Discussion

3.2.3. Frequently Cited AWE Findings

3.2.4. References

3.2.5. Enclosures

3.3. Community Residential Care Programs, Homeless and Other External Inspections

3.3.1. Evaluation Summary

3.3.2. Discussion

3.3.3. References

3.3.4. Enclosures

3.4. Hoptels Occupancy Classification

3.4.1. Evaluation Summary

3.4.2. Discussion

3.4.3. Frequently Cited AWE Findings

3.4.4. References

3.4.5. Enclosures

3.5. Fisher Houses

3.5.1. Evaluation Summary

3.5.2. Discussion

3.5.2.a. Background

3.5.2.b. Fisher Houses with 16 or More Guest Bedrooms

3.5.2.c. Fisher Houses with 7, 8, or 9 Guest Bedrooms

3.5.3. References

4. Building Features iv

4.1. Compartmentation

4.1.1. Evaluation Summary

4.1.2. Discussion

4.1.3. Frequently Cited Annual Workplace Evaluation (AWE) Findings

4.1.4. References

4.1.5. Enclosures

4.2. Multiple Occupancies

4.2.1. Evaluation Summary

4.2.2. Discussion

4.2.3. References

4.3. Vertical Openings

4.3.1. Evaluation Summary

4.3.2. Discussion

4.3.3. References

4.4. Hazardous Areas

4.4.1. Evaluation Summary

4.4.2. Discussion

4.4.3. Frequently Cited AWE Findings

4.4.4. References

4.4.5. Enclosure

4.5. Interior Finishes

4.5.1. Evaluation Summary

4.5.2. Discussion

4.5.2.a. Corridors, Exits, and Room Interiors

4.5.2.b. Interior Finish Walls and Ceilings

4.5.2.c. Trim and Incidental Finish, Bulletin Boards, Posters and Paper43

4.5.2.d. Textile, Expanded Vinyl, Cellular, or Foamed Plastic

4.5.2.e. Interior Floor Finish

4.5.3. References

4.6. Corridors

4.6.1. Evaluation Summary

4.6.2. Discussion

4.6.2.a. Corridor Walls

4.6.2.b. Corridor Doors

4.6.2.c. Areas Open to the Corridor v

4.6.2.d. Corridor Clutter - Equipment and Fixed Furniture

4.6.3. Frequently Cited AWE Findings

4.6.4. References

4.6.5. Enclosures

4.7. Smoke Barriers

4.7.1. Evaluation Summary

4.7.2. Discussion

4.7.3. Frequently Cited AWE Findings

4.7.4. References

4.7.5. Enclosures

4.8. Egress

4.8.1. Evaluation Summary

4.8.2. Discussion

4.8.2.a. General

4.8.2.b. Number of Means of Egress

4.8.2.c. Arrangement of Means of Egress

4.8.2.d. Discharge from Exits

4.8.2.e. Illumination of Means of Egress and Emergency Lighting

4.8.2.f. Exit Signs

4.8.2.g. Maintenance of Means of Egress

4.8.2.h. Special Locking Arrangements

4.8.3. Frequently Cited AWE Findings

4.8.4. References

4.8.5. Enclosures

4.9. Other Building Services

4.9.1. Smoke Control Systems

4.9.1.a. Evaluation Summary

4.9.1.b. Discussion

4.9.1.c. Reference

4.9.2. HVAC

4.9.2.a. Evaluation Summary

4.9.2.b. Discussion

4.9.2.c. References

4.9.3. Elevators

4.9.3.a. Evaluation Summary vi

4.9.3.b. Discussion

4.9.3.c. Frequently Cited AWE Findings

4.9.3.d. References

4.9.3.e. Enclosures

4.9.4. Trash and Linen Chutes

4.9.4.a. Evaluation Summary

4.9.4.b. Discussion

4.9.4.c. Frequently Cited AWE Findings

4.9.4.d. References

4.9.4.e. Enclosure

4.9.5. Commercial Cooking Equipment

4.9.5.a. Evaluation Summary

4.9.5.b. Discussion

4.9.5.c. Cooking Equipment in Health Care Occupancies, Including

Community Living Centers

4.9.5.d. Frequently Cited AWE Finding

4.9.5.e. References

4.9.5.f. Enclosures

5. Contents, Furnishings and Special Fire Hazards

5.1. Special Fire Hazards

5.1.1. Evaluation Summary

5.1.2. Discussion

5.1.2.a. Flammable and Combustible Liquid Storage

5.1.2.b. Ammonium Nitrate (Fertilizer)

5.1.2.c. Spray Painting Booths and Operations

5.1.2.d. Oxygen Storage

5.1.3. Frequently Cited Annual Workplace Evaluation (AWE) Findings

5.1.4. References

5.1.5. Enclosures

5.2. Hand Sanitizers

5.2.1. Evaluation Summary

5.2.2. Discussion

5.2.2.a. Applicable Code References

5.2.2.b. Clearances from Electrical Outlets and Switches

5.2.3. Frequently Cited AWE Findings

vii

5.2.4. References

5.2.5. Enclosure

5.3. Parking Structures and Repair Garages

5.3.1. Evaluation Summary

5.3.2. Discussion

5.3.2.a. Parking Structures

5.3.2.b. Repair Garages

5.3.3. References

5.4. Furnishings

5.4.1. Evaluation Summary

5.4.2. Discussion

5.4.2.a. Draperies, Curtains and Decorations

5.4.2.b. Patient Privacy Cubicle Curtains

5.4.2.c. Upholstered Furniture

5.4.2.d. Mattresses

5.4.2.e. Decorations

5.4.2.f. Common Fire Tests for Furnishings

5.4.2.g. Soiled Linen or Trash Collection Receptacles

5.4.3. References

5.5. High-Value Equipment

5.5.1. Evaluation Summary

5.5.2. Discussion

5.5.3. References

5.6. Mobile Shelving System

5.6.1. Evaluation Summary

5.6.2. Discussion

5.6.3. References

5.6.4. Enclosure ................................................. Error! Bookmark not defined.

5.7. Audiometric Booths

5.7.1. Scope

5.7.2. Discussion

5.7.3. Reference

5.8. Portable Space Heating Devices

5.8.1. Evaluation Summary

5.8.2. Discussion

viii

5.8.2.a. NFPA 101 (2012 Edition)

5.8.2.b. The Joint Commission (2012 Hospital Accreditation Standards)97

5.8.3. Frequently Cited AWE Findings

5.8.4. References

5.8.5. Enclosure

6. Fire Protection Systems and Equipment

6.1. Fire Alarm Systems

6.1.1. Evaluation Summary

6.1.2. Discussion

6.1.2.a. Where Required

6.1.2.b. Smoke Detection

6.1.2.c. Compliant Installations

6.1.2.d. Inspection, Testing and Maintenance

6.1.3. Frequently Cited Annual Workplace Evaluation (AWE) Findings

6.1.4. References

6.1.5. Enclosures

6.2. Sprinkler Systems

6.2.1. Evaluation Summary

6.2.2. Discussion

6.2.2.a. Where Required

6.2.2.b. Compliant Installations

6.2.2.c. Types of Systems

6.2.2.d. Types of Sprinklers

6.2.2.e. Inspection, Testing, and Maintenance

6.2.3. Frequently Cited AWE Findings

6.2.4. References

6.2.5. Enclosures

6.3. Standpipes

6.3.1. Evaluation Summary

6.3.2. Discussion

6.3.2.a. Where Required

6.3.2.b. Compliant Installations

6.3.2.c. Inspection, Testing, and Maintenance

6.3.3. References

ix

6.3.4. Enclosure

6.4. Water Supply Systems

6.4.1. Evaluation Summary

6.4.2. Discussion

6.4.2.a. Water Supply Systems

6.4.2.b. Sources

6.4.2.c. Flow and Pressure Requirements

6.4.2.d. Testing

6.4.2.e. Distribution System Valves

6.4.2.f. Hydrants Discussion

6.4.2.g. Storage Tanks Discussion

6.4.2.h. Fire Pumps Discussion

6.4.3. References

6.5. Fire Protection Systems (Excluding Water)

6.5.1. Evaluation Summary

6.5.2. Discussion

6.5.2.a. Carbon Dioxide

6.5.2.b. Halon

6.5.2.c. Dry and Wet Chemical Systems

6.5.2.d. Clean Agent System

6.5.3. References

6.5.4. Enclosures

6.6. Portable Fire Extinguishers

6.6.1. Evaluation Summary

6.6.2. Discussion

6.6.2.a. Where Required

6.6.2.b. General

6.6.2.c. Extinguisher Class

6.6.2.d. Location

6.6.2.e. Inspection and Maintenance

6.6.3. Frequently Cited AWE Findings

6.6.4. References

6.6.5. Enclosure

7. Fire Fighting Services x

7.1. Community Fire Department

7.1.1. Evaluation Summary

7.1.2. Discussion

7.1.3. References

7.1.4. Enclosures

7.2. Community Fire Department

7.2.1. Evaluation Summary

7.2.2. Discussion

7.2.3. References

7.2.4. Enclosures

7.3. VA Fire Department

7.3.1. Evaluation Summary

7.3.1.a. The VA Fire Department (VA Manual MP-3, Part III, Chapter 4)140

7.3.1.b. The VA Fire Department Staff (MP-3, Part III, Chapter 4)

7.3.2. Discussion

7.3.2.a. Mutual Aid Agreements

7.3.2.b. Non-Fire Activities

7.3.3. References

7.3.4. Enclosures

Enclosures xi

Disclaimer Statements Endorsement

Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government. The views and opinions of authors expressed herein do not necessarily state or reflect those of the U.S. Government and shall not be used for advertising or product endorsement purposes.

Hyperlinks

The appearance of external hyperlinks does not constitute endorsement by the

Department of Veterans Affairs (VA) of the linked websites or the information, products, or services contained therein. For other than authorized VA activities, the Department does not exercise any editorial control over the information you may find at these locations. All links are provided with the intent of meeting the mission of the Department and the VA website. Please let us know about existing external links that you believe are inappropriate and about specific additional external links that you believe should be included.

Liability

With respect to documents available from this server, neither the U.S.

Government nor any of its employees makes any warranty, expressed or implied, including the warranties of merchantability and fitness for a particular purpose, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately-owned rights.

Reference from this website or from any of the information services sponsored by

VA to any non-governmental entity, product, service, or information does not constitute an endorsement or recommendation by VA or any of its employees. We are not responsible for the content of any “off-site” websites referenced from the

Veterans Health Administration (VHA) Healthcare Environment and Facilities

Programs (HEFP) website, electronic media, or printed media.

Guidance

HEFP guidebooks are “best practice” resources designed to assist VA professionals implement and enhance HEFP programs; the guidebooks do not constitute official policy or an interpretation of published statutes or regulations.

Disclaimer Statements have been reviewed by the Department of Veterans Affairs

Office of General Counsel.

xii

Executive Summary This guidebook is provided as a reference source for the implementation of a Fire

Safety Program within the Veterans Health Administration (VHA). The guidebook discusses administration, built environment, fire-fighting services and Joint

Commission requirements.

Chapters 1, 2 and 3 discuss administration. They are a compilation of public laws, Department of Veterans Affairs (VA) policy and guidance related to fire safety.

Chapters 4, 5 and 6 discuss the built environment. They include information on building features and building contents, as well as operational and equipment requirements. Chapter 7 provides information on fire fighting service requirements. There are some references to The Joint Commission requirements throughout the guidebook, but the reader is directed to the EOC Guidebook for detailed information on The Joint Commission requirements.

The codes, standards and regulations referenced in this guidebook were current at the time of publication. However, codes, standards and regulations are revised on a regular basis. It is VA policy that, unless specifically indicated otherwise, the most recent edition of each code and standard is to be followed.

This guidebook can be accessed from the VHA Healthcare Environment and

Facilities Programs (HEFP) website, and questions can be directed to 314-894-

6100.

VHA policy documents (directives, circulars, information letters, etc.) typically include an expiration date. Prior to the expiration date, such documents are generally re-issued with a new expiration date, or the information is incorporated into a different policy document and given a current date. Occasionally, when

VHA policy documents expire, they are not re-issued nor incorporated into a different current document. Such expired documents that address fire protection or life safety issues should be considered best practices guides. Legacy documents can be found on the HEFP website.

https://vaww.hefp.va.gov/guidebooks https://vaww.hefp.va.gov/guidebooks xiii

Acknowledgements A special thank you is extended to the Fire Safety Professional Advisory Group

(PAG) who developed this guidebook, and to management at their respective

Veterans Integrated Service Networks (VISNs) and medical centers for their support.

Jeffery Belczak, VISN 2 Safety & Fire Protection Engineer, Syracuse, NY

Keith Cretsinger, Accreditation Manager, James H. Quillen VAMC, Mountain

Home, TN

Sue Ellen Myers, Safety Manager, Charles George VAMC, Asheville, NC

HEFP Publishing Staff

Lesley Luscri, Technical Information Specialist, St. Louis, MO

Meagan Sedivy, Media Manager, St. Louis, MO

Copyright Acknowledgements

Copyrighted documents used in this guidebook were reproduced with permission for VA use only.

The Viking Corporation 210 N Industrial Park Road Hastings, MI 49058

The American xiv

Acronyms and Abbreviations Acronym/

Abbreviation

Definition

A/E Architect/Engineer

ABHR Alcohol-Based Hand Rub

AC Alternating Current

ACU Ambulatory Care Unit

ADHC Adult Day Health Care

ADUSHOM Assistant Deputy Under Secretary for Health for

Operations and Management

AHJ Authority Having Jurisdiction

ANSI American National Standards Institute

ASME American Society of Mechanical Engineers

ASTM American Society for Testing and Materials

AWE Annual Workplace Evaluation

BBI Basic Building Information

BMP Building Maintenance Program

CAMH Comprehensive Accreditation Manual for Hospitals

CAP College of American Pathologists

CARF Commission on Accreditation of Rehabilitation Facilities

CBOC Community Based Outpatient Clinic

CEOSH Center for Engineering & Occupational Safety and Health cfm Cubic Feet per Minute

CFR Code of Federal Regulations

CHFM Certified Health Care Facility Manager

CLC Community Living Center

CMS Centers for Medicare & Medicaid Services xv

CNG Compressed Natural Gas

CNH Community Nursing Home

CO Carbon Monoxide

CO2 Carbon Dioxide

CP Chemically Pure

CPVC Chlorinated Polyvinyl Chloride

CRC Community Residential Care

CTC Canadian Transport Commission

DACT Digital Alarm Communicating Transmitter dB Decibel dBA Decibel Adjusted

DC Direct Current

DD Duct Detector

DOL Department of Labor

DOM Domiciliary

DOT Department of Transportation

DUSHOM Deputy Under Secretary of Health for Operations and

Management

EC Environment of Care (as it relates to standards)

ECRI Emergency Care Research Institute

EOC Environment of Care e-PFI Electronic Plan for Improvement eSOC Electronic Statement of Conditions

EP Elements of Performance

EPA Environmental Protection Agency

F Fahrenheit

FBI Federal Bureau of Investigation xvi

FEMA Federal Emergency Management Agency

FFSA Federal Fire Safety Act of 1992

FM Factory Mutual

FPETOOL Fire Protection Engineering Tool

FSES Fire Safety Evaluation System

GEC Geriatrics and Extended Care

GEMS Green Environmental Management System

GPD Grant and Per Diem gpm Gallons per Minute

HAS Hospital Accreditation Standards

HBPC Home-Based Primary Care

HCFC Hydrochlorofluorocarbons

HCHV Health Care for Homeless Veterans

HD Heat Detector

HFC Hydrofluorocarbons

HITF Health Care Interpretations Task Force

HVAC Heating, Ventilation and Air Conditioning

IBC International Building Code

ICU Intensive Care Unit

IDIQ Indefinite Delivery/Indefinite Quantity

IDLH Immediately Dangerous to Life and Health

IL Information Letter

ILSM Interim Life Safety Measure kg Kilogram kj Kilojoule lbf Pounds of Force

LD Leadership xvii

LED Light-Emitting Diode

LNG Liquid Natural Gas

LS Life Safety

LSC Life Safety Code®

MCM Medical Center Memorandum

MFAB Manual Fire Alarm Box

MFH Medical Foster Home

MH RRTP Mental Health Residential Rehabilitation Treatment

Program mm Millimeter

MRI Magnetic Resonance Imaging

N Newton

NFPA® National Fire Protection Association®

NHCU Nursing Home Care Unit

NRC National Response Center

NRM Non-Recurring Maintenance

OCFM Office of Construction & Facilities Management

OPC Outpatient Clinic

OR Operating Room

OSH Occupational Safety and Health

OSHA Occupational Safety and Health Administration

PAG Professional Advisory Group

PD Photo Detector

PFI Plan for Improvement

PIO Public Information Officer

PL Public Law

PPE Personal Protective Equipment xviii

PSI Pounds per Square Inch

RCA Root Cause Analysis

REX Request to Exit

RF Radio Frequency

RIT Rapid Intervention Team

RTI Response Time Index

SAFE Safety Automated Facility Evaluation

SCBA Self-Contained Breathing Apparatus

SCI-HC Spinal Cord Injury - Home Care

SEPSS Stored Emergency Power Supply System

SOC Statement of Condition

SOP Standard Operating Procedure

SRF Surveyor Report Form

SS Supervisory Switch

STP Standard Temperature and Pressure

SVH State Veterans Home

TB Technical Bulletin

TIL Technical Information Library

UL Underwriters Laboratory

USFA United States Fire Administration

VA Department of Veterans Affairs

VACO Veterans Affairs Central Office

VARO Veterans Affairs Regional Office

VCT Vinyl Composition Tile

VDC Volts Direct Current

VHA Veterans Health Administration

VISN Veterans Integrated Service Network xix

WMD Weapons of Mass Destruction

WS Waterflow Switch

Chapter 1 Public Law

C h a p te r

P u b lic L a w

1. Public Law

1.1. Federal Fire Safety Act of 1992

1.1.1. Evaluation Summary

Effective October 26, 1994, in newly constructed or leased federal office space housing 25 or more employees:

a. High rise office space shall be sprinkler-protected. For leased facilities, the requirement for sprinkler protection applies only if the space is greater than

35,000 square feet and some portion of the space is located on or above the sixth floor.

b. Other newly-constructed or leased office space housing 25 or more employees has hazardous areas protected with sprinklers or equivalent protection.

c. The above requirements are met when major renovations of office space occur.

d. Hard-wired smoke detectors are provided for all quarters as new occupants move in or by October 26, 1995.

e. Sprinkler protection and smoke detectors are provided for newly constructed, newly purchased, or renovated multi-family quarters after October 26, 1992.

1.1.2. Discussion

The Federal Fire Safety Act of 1992, part of Public Law 102-522, affects all federal government agencies involved with facilities and housing for federal employees. The intent of the law is to improve the level of fire protection in federal government buildings and housing. All of the requirements of the law were effective as of October 26, 1992, except for the requirements for leased space.

The effective date for federally-leased office space was October 26, 1994. The following key provisions of the law will affect the Department of Veterans Affairs

(VA):

a. Sprinkler protection or an equivalent level of safety is to be provided when constructing, purchasing, leasing, or renovating federal employee office buildings in accordance with the requirements of the law. Sprinkler protection is only required as noted above. By definition, a federal office building is an office building, either owned or leased by the federal government, that is regularly occupied by more than 25 full-time federal employees in the course of their employment.

b. Smoke detectors and/or fire sprinkler protection are to be provided in housing for federal employees in accordance with the requirements of the law.

c. Local fire departments are to be invited to prepare pre-fire plans for any building or housing unit the federal government owns, leases, or operates.

See Section III, VA Fire Departments, for further information.

1.1.3. Reference

a. Public Law 102-522, Federal Fire Safety Act of 1992.

1.1.4. Enclosures

Enclosure 1-1 Highlights of the Federal Fire Safety Act of 1992

Enclosure 1-2 Questions and Answers About the Federal Fire Safety Act of http://vaww.hefp.va.gov/resources/1-1-highlights-federal-fire-safety-act-1992 http://vaww.hefp.va.gov/resources/1-2-questions-and-answers-about-federal-fire-safety-act-1992 http://vaww.hefp.va.gov/resources/1-2-questions-and-answers-about-federal-fire-safety-act-1992

Chapter 2 VA Policy a p te r

V A

P o lic y

2. VA Policy

2.1. Construction Process

2.1.1. Evaluation Summary

Building construction is in compliance with or is equivalent to the most current edition of National Fire Protection Association® (NFPA®) 101, Life Safety Code®

(LSC).

2.1.2. Discussion

The Department of Veterans Affairs (VA) Fire Protection Design Manual provides guidance on fire protection design for construction in the VA. In order to meet the requirements of The Joint Commission, VA buildings must comply with or be equivalent to the requirements of NFPA 101 and the documents referenced therein. For design features not addressed by NFPA 101 or the documents referenced by NFPA 101, VA buildings will comply with the requirements of the

International Building Code (IBC) as identified in Program Guide (PG)-18-3 Topic

1 [available online on the Office of Construction & Facilities Management (CFM)

Technical Information Library (TIL). For design features that are addressed by both the IBC and NFPA 101 or a document referenced by NFPA 101, the requirements of NFPA 101 or the document referenced by NFPA 101 shall be used exclusively (this applies even if the IBC requirements are different).

In the 2012 Edition of NFPA 101, the core section for minimum construction requirements is Section 8.2, Construction and Compartmentation. This section will lead a reader to Section 1.6, Minimum Construction Requirements, of the appropriate occupancy chapter. For example, in Chapter 18, New Health Care

Occupancies, for the code reference 18.1.6; 18 is the chapter, and 1.6 is the section for minimum construction requirements for that chapter.

Some occupancies, such as business (NFPA 101, Chapters 38 and 39) and industrial (NFPA 101, Chapter 40), have no minimum construction requirements.

Minimum construction requirements for health care occupancies can be found in

Chapter 18, New Health Care Occupancies, and Chapter 19, Existing Health Care

Occupancies, of NFPA 101. The requirements for the various construction types

[e.g., Type II (222)] are located in NFPA 220, Standards on Types of Building

Construction. NFPA 220, Chapter 4, explains the different types of construction.

The Fire Protection Handbook (18th Edition, Section 7/Chapter 2, Building

Construction) explains in detail and provides illustrations of the different types of construction members.

The basic requirement for most health care buildings four stories and higher is that all load-bearing members and floors must be rated at least 2-hour fire-resistive.

https://vaww.hefp.va.gov/resources/va-fire-protection-design-manual-9th-edition http://www.cfm.va.gov/TIL/cPro.asp

Several resources are available that provide examples of fire-resistive construction and fire-rated assemblies. The Underwriters Laboratory (UL), Inc., Fire Resistance Directory, is one that is often referenced. A copy can be obtained by calling the main office in Northbrook, IL, at (847) 272-8800, fax:

(847) 272-8129, or email to northbrook@us.ul.com. UL also has a website at http://www.ul.com.

Another reference that gives simple, easy to follow descriptions of fire-resistive assemblies constructed of gypsum materials is the Fire Resistive Design Manual available from:

Gypsum® Association

6525 Belcrest Road, Suite 480

Hyattsville, MD 20782

Phone (301) 277-8686

Email: http://www.gypsum.org

The VA currently has an equivalency for floor slabs in some medical centers.

Refer to Chapter 3, VA Guidance, for more information on this equivalency and the procedures to obtain equivalencies.

2.1.3. References

All specific paragraph references in the discussion above are from the code edition cited below. Users should consult the current edition.

a. Fire Resistance Design Manual, Gypsum Association.

b. Fire Resistance Directory, Underwriters Laboratories.

c. International Building Code.

d. NFPA 101, Life Safety Code (2012 Edition).

e. NFPA 220, Standard on Types of Building Construction (2012 Edition).

f. NFPA Fire Protection Handbook (18th Edition).

g. PG 18-3, Topic 1, Codes, Standards, and Executive Orders. Available online on the CFM TIL.

h. VA Fire Protection Design Manual.

2.2. Project Review for Fire Code Compliance

2.2.1. Evaluation Summary

Construction and renovation projects are reviewed for compliance with applicable fire codes, in accordance with Veterans Health Administration (VHA) Directive

7712, Fire Code Reviews of Delegated Construction Projects.

mailto:northbrook@us.ul.com http://www.ul.com/ http://www.gypsum.org/ http://www.cfm.va.gov/TIL/cPro.asp https://vaww.hefp.va.gov/resources/va-fire-protection-design-manual-9th-edition https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797 h a p te r

V A

P o lic y

2.2.2. Discussion

VHA) Directive 7712 requires that all delegated construction projects must be provided a fire protection review by qualified individuals to ensure compliance with

VA referenced fire codes and standards and that fire protection engineering firms or expertise be part of the design and construction of selected projects as part of the Architect/Engineer (A/E) team. The specific requirements in the directive include the following:

a. A special fire protection and LSC review is conducted on all delegated major and minor projects and any non-recurring maintenance (NRM) project where the scope of work:

• Is primarily fire protection (greater than 50 percent of the total project cost is for fire protection such as fire alarm or sprinkler systems, etc.); or,

• Includes significant renovation or construction where specific fire code requirements would be applicable.

b. For these special fire protection and life safety reviews, a qualified individual conducts the review. A Veterans Integrated Service Network (VISN) Safety and Fire Protection Engineer would be a qualified individual. Other qualified individuals would be an external third-party Fire Protection Engineer knowledgeable of the NFPA National Fire Codes and knowledgeable of exit calculations, sprinkler system and fire alarm system requirements, LSC requirements, etc.

c. For delegated projects other than as described, fire code reviews are conducted at the facility by the facility Safety Officer and others, as needed.

d. Sufficient reviews are conducted as needed at various stages of design and construction to ensure fire code compliance, but a minimum of one review is required prior to construction contract award.

e. A fire protection engineering firm or expertise is part of the design and construction of selected projects as part of the A/E team. All delegated major and minor projects, unless exempted by the VISN Director, and any NRM projects where the scope of work is primarily fire protection (greater than 50 percent of the total project cost is for fire protection such as fire alarm or sprinkler systems, etc.), must use a Fire Protection Engineer (see subparagraph 5e of VHA Directive 7712, for specific qualifications).

f. It should be noted that a fire code review of the design is required, even if a fire protection engineering firm or fire protection engineering expertise is part of the design team.

2.2.3. References

a. VHA Directive 7712, Fire Code Reviews of Delegated Construction Projects.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797

b. VA Fire Protection Design Manual.

2.3. Construction/Renovation Activities

2.3.1. Evaluation Summary

Construction and renovation activities are in compliance with NFPA 101 and

NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition

Operations.

2.3.2. Discussion

Construction, repair and improvement operations must comply with NFPA 101

(Chapter 43, Building Rehabilitation) and NFPA 241 when referenced in the occupancy chapter, as well as applicable Joint Commission Environment of Care

(EC) requirements. The key fire safety issues that affect construction activities include the following:

a. Interim Life Safety Measures (ILSM). Where construction activities are ongoing, the building may continue to be occupied as long as the means of egress and other required fire protection features are in place, or applicable

ILSM are implemented to compensate for fire protection features temporarily impacted by the construction activity. More information on ILSM can be found in the VHA Comprehensive Environment of Care Guidebook.

b. Hot Work (Welding and Cutting). Where welding and/or cutting operations take place during construction, a Hot Work Program will need to be implemented as described in further detail in Section 2.9 of this chapter.

Additional safety information on welding and cutting operations can be found in Chapter 18 of the Construction Safety Guidebook.

c. Sprinkler and Fire Alarm Impairments. Impairments of the existing fire alarm and sprinkler systems must be kept to a minimum where possible. When these systems are taken out of service, interim measures as described in

NFPA 101: 9.6.1.6 and 9.7.6 will be required.

d. Smoking Policy. Interior construction areas are designated as no smoking areas.

e. Fire Extinguishers. In general, fire extinguishers must be provided and conspicuously located in the construction areas. They must also be maintained in accordance with NFPA 10, Standard for Portable Fire

Extinguishers.

f. Flammable and Combustible Liquids. These should be stored outside of interior construction zones, if possible. Where these items are located within a building, they must comply with NFPA 30, Flammable and Combustible

Liquids Code.

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g. Proper Storage and Disposal of Combustible Supplies. Combustible supplies should be stored by the contractor away from the interior building construction zones, if possible. Where combustible storage is inside, particular attention should be made to ensure that the storage area does not impact a means of egress and is contained in a room protected as a hazardous area. During construction, accumulation of empty combustible boxes and debris should be removed and disposed of as soon as possible to minimize the fire load inside the building.

VA Master Construction Specifications require that appropriate measures be taken when demolition or construction activities are taking place. The General

Requirements of the VA Master Construction Specification Section 01 00 00, Paragraph 1.5 (available online on the CFM TIL), provides additional key fire safety items by which contractors must abide during VA construction contracts.

2.3.3. Frequently Cited Annual Workplace Evaluation (AWE) Findings

The following fire safety deficiencies are among those frequently cited as findings during AWE surveys. See Enclosure 2-1, Frequently Cited Fire Safety AWE

Findings, for a list of frequently-cited fire safety findings, specific code references and recommended corrective actions.

Related Findings:

a. In an area not protected by an operational sprinkler system, a temporary construction partition does not have at least a 1-hour fire-resistance rating with opening protectives having at least a 45-minute fire protection rating.

b. A temporary construction partition is not constructed of non-combustible or limited-combustible materials.

c. A temporary construction partition is not smoke-tight.

d. A temporary construction partition extends only to the suspended ceiling and not to the slab above or is not complete above the suspended ceiling.

Therefore, the temporary construction partition does not protect the space over the adjacent area from exposure to the construction area.

2.3.4. References

All specific paragraph references in the discussion above are from the code edition cited below. Users should consult the current edition.

a. NFPA 101, Life Safety Code (2012 Edition).

b. NFPA 241, Standard for Safeguarding Construction, Alteration, and

Demolition Operations.

c. VA Master Specification Section 01 00 00 - General Requirements. Available online on the CFM TIL.

http://www.cfm.va.gov/TIL/cPro.asp http://vaww.hefp.va.gov/resources/2-1-frequently-cited-fire-safety-awe-findings http://vaww.hefp.va.gov/resources/2-1-frequently-cited-fire-safety-awe-findings http://www.cfm.va.gov/TIL/cPro.asp

2.3.5. Enclosure

Enclosure 2-1 Frequently Cited Fire Safety AWE Findings

2.4. Fire Plans

2.4.1. Evaluation Summary

The facility has a plan for the protection of all persons in the event of fire, their evacuation to areas of refuge and out of the building if needed and the protection of the physical plant from damage due to smoke (products of combustion) and fire suppression water.

a. Employees are trained in the response to fire alarms.

b. Written copies of the plan are available to all personnel.

c. Fire hazards specific to operating rooms are addressed.

d. Employees are trained on patient evacuation procedures.

e. The fire plan is implemented according to The Joint Commission, Commission on Accreditation of Rehabilitation Facilities (CARF), College of American

Pathologists (CAP) and NFPA criteria.

2.4.2. Discussion

A detailed, routinely-exercised fire plan is critical to protecting patients, visitors, and staff from injury due to fire and products of combustion resulting from the fire.

Fire plans are also needed to stipulate who will respond to close control valves for water and oxygen; open windows; turn-off electrical power; turn heating, ventilation and air conditioning (HVAC) systems on or off; and minimize water damage.

The Operating Room (OR) presents very unique fire safety issues as flammable

(e.g., skin preparations) and combustible materials (e.g., towels, sheets, sponges, tubing, body gases, and hair), enriched oxygen atmospheres (e.g., oxygen and nitrous oxide) and ignition sources (e.g., lasers, electrosurgical units, lights, defibrillators) are routinely used, completing the fire triangle. It is very important that OR staff participate in fire drills in order to practice what they would do in the event of a fire in the OR.

2.4.3. Frequently Cited AWE Finding

The following fire safety deficiencies are among those frequently cited as findings during AWE surveys. See Enclosure 2-1, Frequently Cited Fire Safety AWE

Findings, for a list of frequently-cited fire safety findings, specific code references, and recommended corrective actions.

Related Finding:

Some kitchen staff members were not sure how to activate the chemical fire suppression system.

http://vaww.hefp.va.gov/resources/2-1-frequently-cited-fire-safety-awe-findings file://///vhaceomul6/Guidebook/Guidebooks/Fire%20Safety/Enclosures/Encl%202-1%20FrqntlyCitedFSAWEFindings.docx http://vaww.hefp.va.gov/resources/2-1-frequently-cited-fire-safety-awe-findings h a p te r

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2.4.4. Reference

a. VHA Directive 7712, Fire Protection Code Reviews of Delegated Construction

Projects.

2.4.5. Enclosure

Enclosure 2-1 Frequently Cited Fire Safety AWE Findings

2.5. Fire Drills

2.5.1. Evaluation Summary

Fire drills are conducted in accordance with NFPA 101, The Joint Commission, CARF and CAP requirements.

2.5.2. Discussion

Fire drills in health care and ambulatory health care occupancies are held quarterly on each shift, and each drill will include the transmission of a fire alarm signal to the fire department and a simulation of emergency fire conditions.

According to NFPA 101, business occupancies [this includes most of the community-based outpatient clinics (CBOCs)] must only hold fire drills periodically where practicable when occupied by more than 500 persons or with more than

100 persons above or below the street level. However, The Joint Commission requires an annual fire exit drill for business occupancies.

When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of the audible alarms. For drills, ambulatory patients should be moved to safe areas when possible, but non-ambulatory patients need not be moved.

When an employee discovers a fire in an occupied space, rescue of the occupants must be performed first. The discoverer of the fire must notify other staff members in the area by using a code phrase to activate the fire alarm system. All employees must respond to the fire alarm in some fashion as determined by their supervisors and outlined in the facility fire plan.

A matrix has been developed to provide guidance on the frequency of fire drills in each type of occupancy. The most stringent requirement must be followed. The

Fire Drill Requirement Matrix and VA Form 10-0056b, Fire Drill Record and

Critique Report, are available online on the HEFP website.

2.5.3. References

a. CARF Behavioral Health Standards Manual.

b. CARF Employment and Community Services Standards Manual.

c. CARF Medical Rehabilitation Standards Manual.

d. Commission on Laboratory Accreditation Program.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797 http://vaww.hefp.va.gov/resources/2-1-frequently-cited-fire-safety-awe-findings https://vaww.hefp.va.gov/resources/fire-drill-requirement-matrix-0 https://vaww.hefp.va.gov/resources/va-form-10-0056b-fire-drill-record-and-critique-report https://vaww.hefp.va.gov/resources/va-form-10-0056b-fire-drill-record-and-critique-report

e. Fire Drill Requirement Matrix. Available online on the HEFP website.

f. NFPA 101, Life Safety Code.

g. The Joint Commission Comprehensive Accreditation Manual for Ambulatory

Care.

h. The Joint Commission Comprehensive Accreditation Manual for Behavioral

Health Care.

i. The Joint Commission Comprehensive Accreditation Manual for Home Care.

j. The Joint Commission Comprehensive Accreditation Manual for Hospitals.

k. The Joint Commission Comprehensive Accreditation Manual for Long Term

Care.

2.6. Fire Investigation Program

2.6.1. Evaluation Summary

a. All fires resulting in serious injury, death, or exceeding $10,000 in damages are investigated in accordance with VHA Handbook 7701.1, Occupational

Safety and Health (OSH) Program Procedures. The local Fire Marshall, qualified station staff, or other individuals can assist as appropriate.

b. The facility has standard operating procedures (SOPs) that address how the fire scene is to be secured after the fire and before clean-up to permit an investigation in accordance with VHA Directive 7712, Fire Protection Code

Reviews of Delegated Construction Projects.

c. All fire incidents are reported in accordance with VHA Directive 7711, Fire

Incident Reporting.

2.6.2. Discussion

1. The investigation, reporting and trending analysis of fire incidents are important parts of a Facility Safety Program and are beneficial to the VA as a whole. On the facility level, analysis of fire incident information can assist staff in the identification and correction of unsafe conditions, hazardous activities and improperly operating fire alarms and other equipment. On the national level, analysis of fire incident information can assist VA in developing more effective policies and evaluating the performance of different types of fire alarms and fire suppression systems and can provide valuable information for the evaluation of National Fire Protection Standards.

2. A Board of Inquiry is required for fires resulting in serious injury, death, or exceeding $10,000 in damages.

a. VHA Handbook 7701.1. Per paragraph 12(a)(6), the VISN Director is responsible for appointing a chairperson to oversee a Board of Inquiry.

https://vaww.hefp.va.gov/resources/fire-drill-requirement-matrix-0 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwjCoons4MzmAhXxlOAKHeqaCwcQFjABegQIBBAC&url=https%3A%2F%2Fwww.vendorportal.ecms.va.gov%2FFBODocumentServer%2FDocumentServer.aspx%3FDocumentId%3D598346%26FileName%3DVA259-13-R-0264-015.pdf&usg=AOvVaw0NPxjTNDfp89XzNDW_byLk https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwjCoons4MzmAhXxlOAKHeqaCwcQFjABegQIBBAC&url=https%3A%2F%2Fwww.vendorportal.ecms.va.gov%2FFBODocumentServer%2FDocumentServer.aspx%3FDocumentId%3D598346%26FileName%3DVA259-13-R-0264-015.pdf&usg=AOvVaw0NPxjTNDfp89XzNDW_byLk https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10208 h a p te r

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This board investigates work-related fatalities; in-patient hospitalizations of three or more employees; overexposure of facility personnel to radiation;

and fires resulting in serious injury, death, or exceeding $10,000 in damages, in accordance with 29 Code of Federal Regulations (CFR)

1960.29(d), Labor. It is recommended that:

• Fire incidents/investigation be chaired by the Occupational Safety and Health (OSH) safety professional on the Board of Inquiry.

• Local-level Root Cause Analyses (RCAs) involving fire incidents/investigation be chaired by an OSH professional.

b. VHA Handbook 7701.1. Per paragraph 12 (a)(6)(f), VHA facility officials must verify and notify the VISN Director, Union representative and appropriate regulatory agency of any event that may warrant a VISN

Board of Inquiry within 8 hours of discovery (as soon as possible is best).

Events that must be reported to the VISN include:

• Work-related fatalities.

• Incidents resulting in the in-patient hospitalization of three or more persons.

• Fires resulting in serious injury, death, or exceeding $10,000 in damages.

• An overexposure to radiation event.

3. A fire investigation should include review of circumstances beyond fire cause, especially if a substantial incident has occurred. The information contained in the Fire Investigation/Reconstruction Guide (Enclosure 2-2) would be helpful for fire investigation/reconstruction of a significant event. Enclosure 2-2 provides a guide for the investigation, as well as a recommended format for the written report. Enclosure 2-3 is a form for collecting the more technical information needed by computerized fire model programs that are sometimes used for fire investigation purposes. If litigation is pending, this form could also be useful.

4. For a discussion of fire incident reporting, see Section 2.7, Fire Incident

Reporting.

2.6.3. References

a. VHA Directive 7712, Fire Protection Code Reviews of Delegated Construction

Projects.

b. VHA Directive 7711, Fire Incident Reporting.

c. VHA Handbook 7701.01, Occupational Safety and Health (OSH) Program

Procedures.

https://vaww.hefp.va.gov/resources/2-2-fire-investigationreconstruction-guide https://vaww.hefp.va.gov/resources/2-2-fire-investigationreconstruction-guide https://vaww.hefp.va.gov/resources/2-3-fire-investigationreconstruction-information-fire-model-fire-protection-engineering https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9797 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10208 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5397 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5397

2.6.4. Enclosures

Enclosure 2-2 Fire Investigation/Reconstruction Guide

Enclosure 2-3 Fire Investigation/Reconstruction - Information for Fire Model

[Fire Protection Engineering Tool (FPETOOL)]

2.7. Fire Incident Reporting

2.7.1. Evaluation Summary

The facility has a formal process for reporting fire incidents in accordance with

VHA Directive 7711, including:

a. The respective VISN office is notified via email within 24 hours of the incident if property damage is expected to exceed $10,000 in value; the incident results in any casualties to patients, employees, or other individuals; or if it generates significant media coverage.

b. The online fire incident reporting system is used to report incidents within 30 days.

c. Employee casualties are reported in accordance with federal and VA OSH requirements. A Board of Inquiry is conducted when there is a fatality.

d. Fire incidents involving patients or employees are handled in accordance with

VA patient safety and Occupational Safety and Health Administration (OSHA) requirements.

e. Local fire authorities are requested to report facility fire incidents in accordance with local protocol.

2.7.2. Discussion

VHA Directive 7711 requires facilities to report fire incidents via the online web-based system. In addition, all significant fire incidents must be reported via the normal chain of command.

The directive requires reporting of all reportable fire incidents at VHA-owned and

VHA-leased facilities. It is also the responsibility of VHA staff to report incidents in non-VA facilities for which the staff become aware. If VHA staff learns of a fire at a non-VA facility, to the extent feasible, the incident is to be reported in the same manner as a fire at a VHA-owned or VHA-leased facility. These other facilities include community-based, non-VA facilities that provide overnight sleeping accommodations for Veterans through a VHA program, including but not limited to, facilities falling under the Community Nursing Home Program, Community

Residential Care Program (including medical foster homes), Domiciliaries

(DOMs), Homeless (Grant) and Per Diem Facilities, Outpatient Clinics, one- and two-family dwellings where home health care is provided to Veterans, and Non-

VA clinics and physician offices that are contracted by VHA to provide treatment for Veterans.

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A reportable fire incident is defined by VHA Directive 7711 as an ignition resulting in an uncontrolled flame of any size, or an explosion, in which the flame or explosion results in:

• Any casualty, whether an injury or fatality, to any patient, employee, visitor, or contactor; or

• Any damage to real or personal property (for example, a small trash can fire or an ignition of patient bed linen or clothing).

Fire Incident Reports and Structure Fire Incident Reports are to be entered online for any reportable fire incident and must be completed within 30 days of the incident. The reports are available on the Healthcare Environment and Facilities

Programs (HEFP) Fire Incident Reporting website.

However, other related incidents, such as false alarms or discharge of a fire extinguishing system or device for a non-fire, are not to be reported as a fire incident. The system can be used to track these types of incidents if the facility chooses to do so. All property damage needs to be reported to obtain an accurate assessment of total damages for all of VHA. Data can be retrieved from the HEFP

Fire Incident Reporting website pivot table.

2.7.3. Reference

a. VHA Directive 7711, Fire Incident Reporting.

2.8. Smoking and Supplemental Oxygen Use

2.8.1. Evaluation Summary

The facility has developed and implemented policies and procedures regarding smoking and the use of supplemental oxygen, including:

a. Smoking is only permitted in designated areas.

Reference VHA Directive 1085, Smoke Free Policy for VA Health Care

Facilities.

b. Fire-resistant smoking aprons or other non-combustible attire (e.g., Nomex), if available, are provided for patients who may be susceptible to dropping their smoking material due to mental or physical limitations.

Patients are instructed not to use supplemental oxygen immediately prior to igniting, and while smoking a cigarette, pipe, or other smoking material.

c. Oxygen cylinders, oxygen concentrators, and associated oxygen equipment are not permitted to be taken into designated smoking areas.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10208 http://vaww.hefp.va.gov/occupational-safety-health-gems/fire-incident-reporting http://vaww.hefp.va.gov/occupational-safety-health-gems/fire-incident-reporting http://vaww.hefp.va.gov/occupational-safety-health-gems/fire-incident-reporting http://vaww.hefp.va.gov/occupational-safety-health-gems/fire-incident-reporting https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=10208 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8424 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8424

2.8.2. Discussion

Three primary methods for providing oxygen therapy are compressed gas, oxygen concentrators and liquid oxygen. A detailed discussion on oxygen therapy can be found in VHA Directive 1173.13, Home Oxygen Program.

A detailed discussion of smoking regulations can be found in the VHA

Comprehensive Environment of Care Guidebook, Chapter 5, Implement, Section

5.1.3.c, EC 02.01.03. NFPA 101: 19.7.4, permits smoking in health care occupancies; however, The Joint Commission does not permit smoking…