Attachment H VA-Joint Commission LSC Clarifications Document.pdf

Clarifications for Community Living Center (CLC) Life Safety Surveys: (Rev: 6‐09‐23)

Date: June 9, 2023

From: Office of Occupational Safety and Health (HEFP/19HEFB)

Subject: Clarifications for Community Living Center (CLC) Life Safety Surveys

1. Fire Drills at unexpected times. (KTag‐712)

Fire drills in VHA facilities are not required to be conducted “at unexpected times” as identified in K712.

Issue 23 (copied below) in the VHA‐Joint Commission Clarification Document with an effective date of September 4, 2017, documents that VHA does not follow the “at unexpected times” requirement that CMS enforces. Community Living Center surveyors are to follow the guidelines in the VHA‐Joint Commission Clarification Document.

2. Fire Drills that are within a building where the CLC is located. (KTag‐712)

NFPA 101, 19.7.1.6 requires one drill per shift per quarter in healthcare occupancies. If the facility performs a fire drill in a building that includes a CLC, that fire drill would count as a fire drill for the CLC provided that CLC staff responded in accordance with the facility fire response plan as required by NFPA 101, 19.7.1.2. In the case where a fire drill assumes the fire origin to be in a location outside of the CLC portion of the building, the response plan might only require the staff in the CLC to listen to the alarm message/signal to determine the location of the fire origin, but take no further action. In this case, the CLC staff would still be counted as participating in the fire drill. NFPA 101 does not mandate that the fire origin for a fire drill occur in the CLC portion of a building for the drill to count for the CLC.

3. Fire Drills – Transmission of Fire Alarm Signal. (KTag‐712)

The term “transmission of a fire alarm signal” as mentioned in NFPA 101, 19.7.1.4 could be interpreted to mean (1) the electronic transmission of an alarm signal to a remote station or fire department, or (2) activation of the notification appliances to notify occupants in the facility. A fire alarm signal is NOT required to be transmitted to a remote station or fire department when conducting a fire drill. In addition, between 9 p.m.

and 6 a.m., a coded announcement may be used in lieu of activating notification appliances for fire drills. In a healthcare occupancy, when fire drills are conducted, the fire alarm system notification appliances are to be used to provide notification except during the hours between 9:00 p.m. and 6:00 a.m., during which time an alternative announcement may be used in lieu of the notification appliances in accordance with NFPA 101 (See background material below). The HITF Interpretation of June 2014 (See Attachment B) addresses alarm signals during fire drills and a fire alarm signal is NOT required to be transmitted to a remote station or fire department when conducting a fire drill.

====================== ===== Background Material ===== ======================

NFPA 101(2018), 19.7.1.4 states the following:

19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

However, NFPA 101, 19.7.1.7 provides an exception to 19.7.1.4 as follows:

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

4. Sprinklers in closets and casework (wardrobes/lockers). (KTag‐351)

While sprinklers are required in closets within nursing homes, most VHA CLCs are equipped with casework (wardrobes/lockers) for the storage of patient’s personal belongings. Casework is different than closets.

Sprinklers are not required in casework (wardrobes/lockers). See Attachment A for details.

5. Exit discharge characteristics. (KTag‐271)

In accordance with NFPA 101, 7.1.6.1.2, VHA permits existing exit discharges that are nonpaved surfaces that are nominally level in accordance with NFPA 101, 7.1.6.3 and that are maintained in accordance with NFPA 101, 7.1.10; and VHA does not require the existing nonpaved surfaces to meet the requirements of NFPA 101, 7.1.6.2. VHA does not follow the CMS requirements that go above the requirements in NFPA 101.

The HITF Interpretation of June 2009 (See Attachment C) addresses “Exit Discharge” and does not mandate a hard packed all weather travel surface from the exit discharge to a public way. Grass, dirt, or gravel may be acceptable in some situations. For example, a grassy surface that leads away from the building in a climate that gets little or no snow would be acceptable in accordance with the HITF interpretation. Remember, as a general rule, exit discharges are not designed for nursing home patients, but for the general public.

In addition, NFPA 7.1.6.1 allows approved existing walking surfaces to be permitted to be continued in use as follows:

7.1.6.1.2 Approved existing walking surfaces shall be permitted.

6. Cooking Facilities. (KTag‐324)

This is to clarify that therapy cooking facilities are not required to be protected. There are basically four options in NFPA 101 for providing protection for cooking facilities in healthcare occupancies.

1. No protection. No protection is required for limited cooking or food warming and this includes therapy cooking facilities in health care occupancies. (See NFPA 96, A.1.1.4) Therapy cooking facilities are not required to be protected in accordance with NFPA 96 nor are they required to be protected in accordance with NFPA 101, 18/19.3.2.5.3 or 18/19.3.2.5.4.

2. Full protection in accordance with NFPA 96. This is required for commercial cooking and has no limit on the amount of cooking done or on the number of people served.

3. Protection in accordance with the provisions of NFPA 101, 18/19.3.2.5.3. This applies to residential or commercial cooking facilities that are open to the corridor and used on a routine basis to cook for no more than 30 persons within a smoke compartment. This requires numerous protection provisions as well as smoke detection in accordance with NFPA 101.

4. Protection in accordance with the provisions of NFPA 101, 18/19.3.2.5.4. This is the same as in number 3 above except that the cooking facilities are not open to the corridor and no smoke detection is required for the cooking facilities.

Attachment A Clarifications for Community Living Center (CLC) Life Safety Surveys: (Rev: 6‐9‐23)

Clarification on Sprinklers in Clothes Closets, Wardrobes, Lockers, and Casework in VA CLCs Attachment A: Page 1 of 6

Clarification on Sprinklers in Clothes Closets, Wardrobes, Lockers, and Casework in VA Community Living Centers (Nursing Homes)

March 29, 2018

The question has come up as to whether sprinklers are required within clothes closets in VA Community Living Centers1 (CLCs). A discussion of closets should also include wardrobes and lockers since they serve a similar purpose, and in terms of fire protection there is effectively no difference between a closet, a wardrobe, or a locker of the same size and construction.

In the VHA‐Joint Commission Clarification Document dated September 4, 2017, Issue 15 (see Item A in the Appendix) addresses sprinklers in small closets other than clothes closets and wardrobes. For the small closets addressed in Item 15 (such as hose cabinets, hose closets, and electrical closets that are shallow in depth), 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. With respect to wardrobe units, Issue 15 refers to NFPA 13 (2016 edition), section 8.1.1(7), and the Healthcare Interpretations Task Force (HITF) Interpretation No. 2 of December 2008. With respect to clothes closets, Issue 15 refers to NFPA 101, 18/19.3.5.10.

NFPA 13 (2016 edition), section 8.1.1(7) permits sprinklers to be omitted from “furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy” (see Item B in the Appendix).

HITF Interpretation No. 2 of December 2008 states that sprinklers are not required to be installed within wardrobes that are attached or freestanding within a fully sheathed alcove, provided that the sprinkler protection of the room includes the floor space of the alcove (see Item C in the Appendix).

VA considers wardrobes to fall under the category of casework. The VA definition of casework is:

“cabinetry and other built‐in equipment that is not intended to be portable or moveable. This also includes patient wardrobes which are designed with plumbing and or electrical fixtures built into them.” (Reference: IL 10A4‐84‐8, February 29, 1984. This document is available for review on the CEOSH web site).

Beginning in 1993, VA eliminated all fire protection requirements for new installations of casework in any sprinkler‐protected space. Further guidance on the definition of casework was also provided:

“casework is the built‐in cabinetry, built‐in wardrobe lockers and other equipment that is not intended to be moveable, but is not furniture.” (Reference: Engineering Management Service National Conference Call Minutes, December 8, 1993, page 1. This document is available for review on the CEOSH web site).

NFPA 101 (2018 edition), sections 18/19.3.5.10 permit sprinklers to be omitted in clothes closets of patient sleeping rooms in hospitals under certain conditions, but this permission is limited to hospitals and does not apply to nursing homes (see Item B in the Appendix).

In order to apply the above requirements, a distinction must be made between casework (such as a wardrobe or locker) and a closet. In the context of NFPA 13 and NFPA 101, a closet will generally have the same floor level and ceiling height as the room or space into which the closet opens. All of the

1 VA Community Living Centers were previously known as VA Nursing Home Care Units.

Attachment A: Page 2 of 6 photos below show casework in accordance with the VA definition. Casework does not require sprinkler protection, as discussed above.

Examples of casework (wardrobes/lockers) for which sprinklers are not required

Attachment A: Page 3 of 6

Attachment A: Page 4 of 6

Attachment A: Page 5 of 6

Appendix: Supporting Information

Item A. Issue 15 of the VHA‐Joint Commission Clarification Document, effective date September 4, 2017

Item B. Applicable Code References

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.

A.8.15.8.2 Portable wardrobe units, such as those typically used in nursing homes and mounted to the wall, do not require sprinklers to be installed in them. Although the units are attached to the finished structure, this standard views those units as pieces of furniture rather than as a part of the structure; thus, sprinklers are not required.

8.15.9* Hospital Clothes Closets. Sprinklers shall not be required in clothes closets of patient sleeping rooms in hospitals where the area of the closet does not exceed 6 ft2 (0.55 m2), provided the distance from the sprinkler in the patient sleeping room to the back wall of the closet does not exceed the maximum distance permitted by 8.5.3.2.

A.8.15.9 This exception is limited to hospitals as nursing homes, and many limited-care facilities can have more combustibles within the closets. The limited amount of clothing found in the small clothes closets in hospital patient rooms is typically far less than the amount of combustibles in casework cabinets that do not require sprinkler protection, such as nurse servers. In many hospitals, especially new hospitals, it is difficult to make a distinction between clothes closets and cabinet work. The exception is far more restrictive than similar exceptions for hotels and apartment buildings. NFPA 13 already permits the omission of sprinklers in wardrobes [see 8.1.1(7)]. It is not the intent of this paragraph to affect the wardrobe provisions of NFPA 13. It is the intent that the sprinkler protection in the room covers the closet as if there was no door on the closet (see 8.5.3.2).

NFPA 101, 2018 edition:

18/19.3.5.10* Sprinklers shall not be required in clothes closets of patient sleeping rooms in hospitals where the area of the closet does not exceed 6 ft2 (0.55 m2), provided that the distance from the sprinkler

Attachment A: Page 6 of 6 in the patient sleeping room to the back wall of the closet does not exceed the maximum distance permitted by NFPA 13.

A.18/19.3.5.10 This exception is limited to hospitals, as nursing homes and many limited care facilities might have more combustibles within the closets. The limited amount of clothing found in the small clothes closets in hospital patient rooms is typically far less than the amount of combustibles in casework cabinets that do not require sprinkler protection, such as nurse servers. In many hospitals, especially new hospitals, it is difficult to make a distinction between clothes closets and cabinet work. The exception is far more restrictive than similar exceptions for hotels and apartment buildings. NFPA 13 already permits the omission of sprinklers in wardrobes [see 8.1.1(7) of NFPA 13]. It is not the intent of 19.3.5.10 to affect the wardrobe provisions of NFPA13. It is the intent that the sprinkler protection in the room covers the closet as if there were no door on the closet. (See 8.5.3.2.3 of NFPA 13.)

Item C. Healthcare Interpretations Task Force Interpretation No. 2, December 2008

Attachment B

Clarification on Transmission of Fire Alarm Signals During Fire Drills Attachment B: Page 1 of 1

HITF Interpretation of June 2014

Attachment C

Clarification on Exit Discharge Requirements Attachment C: Page 1 of 3

HITF Interpretation of June 2009

Attachment C: Page 2 of 3

Attachment C: Page 3 of 3