Attachment L_SVH NH_Life Safety Checklist.pdf

VHA State Veterans Home Per Diem Program

Physical Environment Inspection Report

Checklist for Sprinkler-Protected State Veterans Nursing Home Care Facilities

All Code References are from NFPA 101-2012 according to 38 CFR Part 51.200.

This checklist (current as of 1-10-2021) is a summation of the requirements found in Chapter 19, Existing Healthcare

Occupancies of the Life Safety Code. This checklist is not intended to be comprehensive. The user is cautioned to consult the code prior to answering the following questions.

Facility Name: ________________________________________________________________________

Facility Address: ______________________________________________________________________

Inspected By: ________________________________________________________________________

Date Inspected: _______________________________________________________________________

See Below **

Item Standard Reference Yes No NA

Building Construction

1-1

Is the building containing the nursing home protected throughout by a fire sprinkler system?

Note: Nursing Homes under the State Home Per Diem Program are required to be sprinklered throughout, as of August 13, 2013. This inspection report is intended for existing nursing homes that are sprinklered throughout in accordance with 19.3.5.1. For nursing homes that are not sprinklered throughout, this checklist does not fully address requirements for features such as, but not limited to, corridors, hazardous areas, and smoke barriers. Refer to Chapter 19 of NFPA 101.

19.3.5.1

1-2a

Is emergency power available to operate illumination of all exit signs and lighting for the means of egress, fire alarm and medical gas alarms, emergency communication systems, and generator task illumination?

19.5.1.2

1-2b

Does the emergency power system meet the requirements of NFPA

101, Life Safety Code?

Note: NFPA 101 States: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life. NFPA 99 is not retroactive to existing systems and equipment.

1-2c

Is emergency power provided for electrical life support devices IF the facility provides life support services?

1-2d

Is the emergency power source an on-site emergency standby generator of sufficient size to serve the connected load or another approved source?

Note: NFPA 101 States: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life. NFPA 99 is not retroactive to existing systems and equipment.

1-3

Is emergency lighting provided for the means of egress? 19.2.9

7.9.1.1

Item Standard Reference Yes No NA

1-4

Does the building construction meet the basic requirements of NFPA

101, paragraph 19.1.6.1?

19.1.6

1-5

Are all hazardous areas (including boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 ft2, paint shops, repair shops, rooms with soiled linen in volume >64 gal, rooms with collected trash in volume exceeding 64 gal, rooms or spaces larger than 50 ft2, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction, and laboratories) enclosed by smoke resisting partitions and self- or automatic-closing doors?

19.3.2.1

19.3.2.1.5

1-6

Where fireplaces are provided in smoke compartments containing patient sleeping areas, do they comply with all of the following?

1. They are direct-vent gas fireplaces, as defined in NFPA 54, and all of the following criteria are met:

a. They are installed, maintained, and used in accordance with NFPA 101, 9.2.2.

b. They are not located inside of a patient sleeping room.

c. The smoke compartment in which the direct-vent gas fireplace is located is protected throughout with quick response or residential sprinklers.

2. The direct-vent fireplace includes a sealed glass front with a wire mesh panel or screen.

3. The controls for the direct-vent gas fireplace are locked or located in a restricted location.

4. Electrically supervised carbon monoxide detection (connected to the fire alarm control panel) is provided in the room where the fireplace is located.

19.5.2.3 (2)

1-7

Where solid fuel-burning fireplaces are provided, do they comply with all of the following?

1. They are used only in areas other than patient sleeping areas.

2. Such areas are separated from patient sleeping spaces by construction having not less than a 1-hour fire resistance rating.

3. The fireplace complies with the provisions of NFPA 101, 9.2.2.

4. The fireplace is equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650°F and constructed of heat-tempered glass or other approved material.

5. Electrically supervised carbon monoxide detection (connected to the fire alarm control panel) is provided in the room where the fireplace is located.

19.5.2.3 (3)

1-8

Do all wall and ceiling finishes have a Class A, Class B, or Class C flame spread rating?

19.3.3.2

1-9

Is automatic elevator recall (Phase I and II Fire Fighters Emergency

Operations) provided for all elevators that have a travel distance of 25 feet or more, above or below the level that best serves emergency or firefighting or rescue personnel?

19.5.3

9.4.3.2

ASME A17.3

1-10

Are laundry chute openings onto the corridors protected by 1-hour fire rated, self-closing doors with approved and listed frames (or sealed by fire-resistive construction)?

19.5.4.1

1-11

Are all exit stairs enclosed by 1-hour or greater rated construction? 7.1.3.2.1 (1)

7.1.3.2.1 (2)

1-12

Are all other vertical openings (shafts, chutes, elevator hoistways, etc.)

enclosed by 1-hour or greater rated construction?

19.3.1.1

Means of Egress - Arrangement

2-1

Are exit stairs, which continue more than one-half story beyond the level of exit discharge, interrupted at the level of exit discharge by partitions, doors, gates, or other effective means?

7.7.3.4

2-2

Are all corridors serving patient sleeping rooms a minimum of 48 inches in clear width? (See also 6-2)

19.2.3.4

2-3

Are projections into the corridor in compliance with the referenced section?

Note: Projections into the required width are permitted for wheeled equipment, provided that all of the following conditions are met:

1. The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 inches.

2. The fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.

3. The wheeled equipment is limited to the following:

a. Equipment in use and carts in use

b. Medical emergency equipment not in use

c. Patient lift and transport equipment

19.2.3.4

7.3.2

2-4

When furniture is located in a corridor, are all the following criteria met?

1. The corridor width is at least 8 ft. wide,

2. The fixed furniture is securely attached to the floor or to the wall.

3. The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft. Note: The 6-inch projections allowed by the code do not reduce the clear width.

4. The fixed furniture is located only on one side of the corridor.

5. The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2.

6. The fixed furniture groupings are separated from each other by a distance of at least 10 ft.

7. The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.

8. Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses’ station or similar space.

9. If the smoke compartment contains patient sleeping rooms, the smoke compartment is protected throughout by quick response or residential sprinklers.

19.2.3.4 (5)

2-5

Are there two remote exits provided on every story, accessible from every part of every story, and accessible from each smoke compartment? (Egress is permitted through an adjacent smoke compartment provided that the two required egress paths are arranged so that both do not pass through the same adjacent smoke compartment.)

19.2.4

2-6

Is corridor access compliant with the referenced section? 19.2.5.6

2-7

Are suites in compliance with the referenced section? 19.2.5.7

2-8

Does every corridor provide access to at least two approved exits without passing through any intervening rooms or spaces other than corridors or lobbies?

19.2.5.4

2-9

Are the means of egress properly marked with exit signage? 19.2.10

2-10

Do all patient rooms have an outside window? 38 CFR 51.200 line #150

Means of Egress - Doors

3-1

Are doors to hazardous areas equipped with self-closing or automatic-closing devices?

19.3.2.1.3

3-2

Are exit stair enclosure doors and horizontal exit doors (if provided) positive latching and self-closing (or automatic-closing per 19.3.1.8)?

19.3.1.7

3-3

Do exit access doors swing in the direction of exit travel when serving an occupant load of 50 or more?

7.2.1.4.2

3-4

Are corridor doors equipped with a suitable means to keep the door closed when a force of 5 pounds is applied at the latch edge of the door? (Not required for rooms such as bathrooms that have no combustibles stored in them.)

19.3.6.3.5

19.3.6.3.6

3-5

Area all doors in a means of egress at least 32 inches wide? 19.2.3.6

3-6

Are doors within a means of egress equipped with hardware that will open without the use of a tool or key from the egress side, except as permitted by (A) and (B) below?

(A) Where the clinical needs of patient require specialized security measures or where patients pose a security threat, and provided staff can readily unlock the doors at all times; or,

(B) Where patient special needs require specialized protective measures for their safety, and provided that all of the following are met:

1. Staff can readily unlock doors at all times.

2. A total (complete) smoke detection system is provided throughout the locked space, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.

3. The building is protected throughout by an automatic sprinkler system.

4. The locks are electrical locks that fail safely so as to release upon loss of power to the device.

5. The locks release by independent activation of each of the following:

a. Activation of the smoke detection system required by (2) above, and

b. Waterflow in the automatic sprinkler system required by (3) above.

19.2.2.2.4

19.2.2.2.5.1

19.2.2.2.5.2

19.2.2.2.6.

3-7

Where doors are locked against egress for other than as permitted in 3-

6 above, do the locks meet the locking arrangements required for:

1. delayed-egress or

2. access controlled locks or

3. elevator lobby exit access door locking?

19.2.2.2.4

7.2.1.6.1

7.2.1.6.2

7.2.1.6.3

Smoke Barriers

4-1

Is each story that contains more than 30 patient sleeping beds divided into at least two smoke compartments?

19.3.7.1

4-2

Is the smoke compartment area 22,500 sq. ft. or less, and the travel distance to reach a smoke barrier door 200 ft. or less?

19.3.7.1 (1)

4-3

Are all doors in smoke barriers self- or automatic-closing? 19.3.7.8

4-4

Are smoke barrier doors substantial, such as 1-3/4 inch solid bonded wood core doors or equivalent, and if a door contains a vision panel, is it wired glass in a steel frame or fire rated glazing?

19.3.7.6

4-5

Do doors in smoke barriers close the door opening leaving only the minimum clearance necessary for proper operation, and are they without louvers or grilles?

19.3.7.8

8.5.4.1

4-6

Are penetrations in smoke barrier walls properly sealed to resist the passage of smoke?

19.3.7.3

8.5.1

Protection - Sprinkler - Fire Alarm - Kitchen

5-0 Where cooking facilities are provided, are they protected in accordance with 5-1 or 5-2 or 5-3?

Note: Where residential cooking equipment is used for food warming or limited cooking, the equipment is not required to be protected in accordance with 9.2.3, and the presence of the equipment does not make the area to be classified as a hazardous area.

19.3.2.5

19.3.2.5.2

9.2.3

5-1

Where commercial cooking is provided to cook for an unlimited number of persons, are all of the following met?

• It is protected in accordance with NFPA 101, 9.2.3.

Note: This would require grease producing appliances in the kitchen to be protected by an UL 300 fire extinguishing system in accordance with NFPA 96.

• It has a readily accessible means available to manually activate the fire extinguishing system.

• The automatic fire extinguishing system protecting cooking equipment is inspected, tested, and maintained by a properly trained and qualified person on at least a semi-annual basis and the testing confirms that:

o The operation of the kitchen fire extinguishing system automatically shuts off all sources of fuel and heat to the equipment protected by the system, and o The shutdown devices are of the type that requires manual resetting prior to fuel or power restoration.

• Are hoods, grease removal devices, fans and ducts inspected semi-annually and cleaned as needed?

Note: A minimum semi-annual inspection frequency was determined based on Table 11.4. However, the table can be used to adjust the minimum inspection frequency based on actual use. Cleaning is required if warranted by the inspection.

19.3.2.5.1

9.2.3

NFPA 96-2011

10.4.1.

10.4.4.

11.2.1

5-2 Cooking Equipment Open to the Corridor for ≤ 30 persons.

Where residential or commercial cooking equipment used to prepare meals and it is open to the corridor, are all of the following met?

• It is used to prepare meals for not more than 30 persons.

• There is only one cooking facility in the smoke compartment.

• The portion of the health care facility served by the cooking facility is limited to 30 beds and separated from other portions of the health care facility by smoke barriers.

Cooking Equipment-Hood-Fire Suppression

• The cooktop or range is equipped with a range hood of a width at least equal to the width of the cooking surface, with grease baffles or other grease-collecting and cleanout capability.

• The hood system has a minimum airflow of 500 cfm.

• If the hood system is not ducted to the exterior, it has a charcoal filter to remove smoke and odor.

• The cooktop or range complies with all of the following:

a. It is protected with a fire suppression system.

b. There is a manual release of the extinguishing system provided that is accessible to staff.

c. There is an interlock provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated.

• A switch is provided within the cooking facility meeting all of the following:

a. It deactivates the cooktop or range.

b. It is a locked switch, or the switch is located in a restricted location.

c. It is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.

d. It is on a timer, not exceeding a 120-minute capacity that automatically deactivates the cooktop or range, independent of staff action.

Detection and Alarm for Cooking

• Are not less than two AC-powered photoelectric smoke alarms, interconnected in accordance with NFPA 101, 9.6.2.10.3, equipped with a silence feature located not closer than 20 ft. from the cooktop or range? Note: The smoke alarms are permitted to be located outside the kitchen area where such placement is necessary for compliance with the 20 ft. minimum distance criterion.

Operational Requirements

• The use of solid fuel for cooking is prohibited.

• Deep fat frying is prohibited.

• Portable fire extinguishers are provided.

19.3.2.5.3

5-3 Cooking Equipment Separated from the Corridor for ≤ 30 persons.

Where residential or commercial cooking equipment used to prepare meals and it is separated from the corridor by walls that resist the passage of smoke, are all of the following met?

• It is used to prepare meals for not more than 30 persons.

• There is only one cooking facility in the smoke compartment.

• The portion of the health care facility served by the cooking facility is limited to 30 beds and separated from other portions of the health care facility by smoke barriers.

Cooking Equipment-Hood-Fire Suppression

• The cooktop or range is equipped with a range hood of a width at least equal to the width of the cooking surface, with grease baffles or other grease-collecting and cleanout capability.

• The hood system has a minimum airflow of 500 cfm.

• If the hood system is not ducted to the exterior, it has a charcoal filter to remove smoke and odor.

• The cooktop or range complies with all of the following:

a. It is protected with a fire suppression system.

b. There is a manual release of the extinguishing system provided that is accessible to staff.

c. There is an interlock provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated.

• A switch is provided within the cooking facility meeting all of the following:

a. It deactivates the cooktop or range.

b. It is a locked switch, or the switch is located in a restricted location.

c. It is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.

d. It is on a timer, not exceeding a 120-minute capacity that automatically deactivates the cooktop or range, independent of staff action.

Operational Requirements

• The use of solid fuel for cooking is prohibited.

• Deep fat frying is prohibited.

• Portable fire extinguishers are provided.

19.3.2.5.4

Sprinkler System

5-4

Are sprinkler systems electrically supervised by the fire alarm system? 19.3.5.1

5-5

If provided, are laundry chutes provided with sprinkler protection at the top, bottom, and every other floor between?

19.5.4.3

9.5 & 9.7

5-6

If existing privacy curtains are used, (1) are the privacy curtains provided with mesh that has openings in the mesh equal to 70 percent or greater (usually at least ½ inch measured on the diagonal) and does the mesh extend a minimum of 18 in. from the sprinkler deflector, or

(2) are sprinklers and curtains located such that the curtains do not obstruct sprinkler discharge?

19.3.5.11

A.19.3.5.11

NFPA 25-2011

5.2.1.2

A.5.2.1.2

5-7

Is a minimum of 18 inches vertical clearance maintained between the top of all storage and ceiling sprinkler deflectors?

NFPA 25-2011

5.2.1.2

A.5.2.1.2

Fire Alarm System

5-8

Are areas open to the corridor provided with direct staff supervision or provided with smoke detection connected to the fire alarm system?

19.3.6.1

5-9

Are manual fire alarm pull boxes provided? 19.3.4.1

5-10

Is occupant notification provided? 19.3.4.3.1

9.6.3.

General Maintenance

6-1

Are doors and associated hardware in good repair? 4.6.12.1.

6-2

Is the means of egress (exit access, exits, and exit discharge) free of any obstructions or impediments to full and instant use? This includes the accumulation of snow and ice.

7.1.10.

6-3

Are stairwells kept free of obstructions and storage? 7.1.3.2.3

7.2.2.5.3

Inspection and Testing Requirements

7-1

If battery powered emergency lights are used, are they tested monthly for thirty (30) seconds and are they functionally tested annually for not less than 1½ hours?

7.9.3

7-2

Are sprinkler system main drain tests performed annually and are records maintained?

NFPA 25-2011

13.2.5

7-3

Are sprinkler water flow alarms and valve supervisory tamper switches tested semi-annually?

NFPA 72-

2010, Table

14.4.5 (15)

7-4

Are electric fire pump churn tested monthly and diesel fire pumps churn tested weekly; and are all fire pumps flow tested annually?

NFPA 25-

2011, 8.3.

7-5

If a generator set is utilized for emergency power, is it inspected weekly and tested under load for at least 30 minutes on a monthly basis? Permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

19.5.1.1, 9.1.3

NFPA 110

8.4.1

7-6

Does the fire alarm system automatically transmit an alarm to the municipal fire department?

19.3.4.3.2

7-7

Does documentation exist to show that the fire alarm system is tested in accordance with NFPA 72-2010?

19.3.4.1

9.6.1.3

7-8

Does documentation exist showing that quarterly fire drills are conducted on all shifts and under varied conditions?

19.7.1.6

7-9

Are fire extinguishers inspected approximately every thirty (30) days and serviced annually?

NFPA 10-2010

7.2.1. & 7.3.1

Operational Features

8-1

Where the fire alarm system is out of service (for more than 4 hours in a 24 hour period) or where the sprinkler system is out of service (for more than 10 hours in a 24 hour period) has the facility notified the fire department and established a fire watch or evacuated the building?

9.6.1.6

9.7.6.

NFPA 25-

2011, 15.5

8-2

Does the facility have a written fire safety plan to include the following:

(1) Use of alarms

(2) Transmission of alarms to fire department

(3) Emergency phone call to fire department

(4) Response to alarms

(5) Isolation of fire

(6) Evacuation of immediate area

(7) Evacuation of smoke compartment

(8) Preparation of floors and building for evacuation

(9) Extinguishment of fire

Are the employees trained in the use of the plan?

Note: Review the facility policy/plan and records of training to staffs.

Interview staff and listen on how they address a fire.

19.7.2.2

19.7.2.3

8-3

Does the facility have a smoking policy that addresses all items in the referenced section?

19.7.4

8-4

Are portable space heating devices prohibited in healthcare occupancies in the facility unless they meet both of the following?

1. They are used only in non-sleeping staff and employee areas, and

2. The heating elements do not exceed 212°F.

19.7.8

8-5

Do Alcohol-Based Hand Rub dispensers comply with the requirements of the referenced section?

19.3.2.6

8-6 Are existing electrical installations safe such that they do not present a serious hazard to life? NOTE: Existing installations shall be permitted to be continued in service provided they do not present a serious hazard to life.

19.5.1.1 9.1.2

8-7 Is the storage and use of cylinders and containers for nonflammable gas in accordance with NFPA 99?

Reference grid – provided by

VA page 12.

8-8

Are combustible decorations prohibited unless they meet at least one of the five provisions below?

1. They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.

2. The decorations meet the requirements of NFPA 701.

3. The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, using the 20 kW ignition source.

4. The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with (a), and (b) or (c) below:

a. Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door, and

b. Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment except as provided in (c) below, or

c. Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons.

5. They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.

19.7.5.6

**All answers are based upon visual inspection or information provided by the facility personnel to the reviewer.

VA OXYGEN GUIDE

Indoor Oxygen Storage and Liquid Oxygen Storage and Transfilling Requirements by Peter Larrimer PE (Based on 2012 Edition of NFPA 99)

Typical Oxygen

Container Sizes

The number of containers identified provides a quantity of gas that is:

(all nonflammable gases must be included in total volume)

Liquid Oxygen Transfilling

Rooms - Additional

Requirements

Less than 300 ft3

300 ft3 to 3000 ft3 Greater than 3000 ft3

The requirements in this column for liquid transfilling rooms are in addition to the storage requirements that are identified in the columns to the left for the respective amount in the dewars.

E cylinders (~25 ft3 per cylinder)

12 or less 13-120 121 or more

H cylinders (~250 ft3 per cylinder)

1 12 13 or more

Liquid Dewars (@41 liters) 41 liters of liquid O2 ≈1235 ft3 gas

0 2 (based on a 41-liter dewar)

3 (based on a 41-liter dewar)

Reqmts per storage amount:

Less than 300 ft3

300 ft3 to 3000 ft3 Greater than 3000 ft3

Construction No

Requirements

Noncombustible enclosure that is lockable.1

One hour rated enclosure with 45 minute self closing door (with lock).2

Room separated from any portion of a facility where patients are housed, examined, or treated by a one hour fire-rated enclosure with 45-minute self-closing door and sprinklers, and ceramic or concrete flooring.3

Ventilation None4 Natural with two openings or mechanical ventilation.5

Natural with two openings or mechanical ventilation.6

Required to comply with

NFPA 55. NFPA 55 is not prescriptive.7 Recommend using criteria for >3000 ft3.

Temperature No

Requirements

Shall not exceed 125 °F8 Shall not exceed 125 °F9 Same

Electrical No

Requirements

No Requirements Mechanical ventilation (if provided) and lighting are required to be on essential electrical system.10

Same

Operational No

Requirements

Not permitted to be stored with flammable gases, liquids, or vapor.11

Five (5) foot separation from combustibles in a sprinklered space, twenty

(20) foot separation from combustibles in nonsprinklered space, or stored in a cabinet that has a minimum ½ hour fire rating .12

Not permitted to be stored with flammable gases, liquids, or vapor.13

Personnel transfilling are required to have training on the risks associated with handling and use of liquid oxygen and the dewars.14

Signage No

Requirements

Caution Sign required on the door; “Caution

Oxidizing Gases Stored

Within – No Smoking”15

Caution Sign required on the door; “Caution

Oxidizing Gases Stored

Within – No Smoking”16

Same except that a sign is also required to indicate that “transferring is occurring”. 17

DATE: 5/1/2019

Attachment E_SVH NH_Life Safety Checklist Final_1_10_2021

REFERENCES

1 NFPA 99 (12), 11.3.2.1

2 NFPA 99 (12); 11.3.1; 5.1.3.3.2 (4)

3 NFPA 99 (12); 11.5.2.3

4 NFPA 99 (12); 9.3.7.3.

5 NFPA 99 (12); 9.3.7.5 Not a retroactive requirement.

6 NFPA 99 (12); 9.3.7.5 Not a retroactive requirement.

7 NFPA 99 (12); 9.3.7.4 Not a retroactive requirement.

8 NFPA 99 (12); 9.3.7.7, 11.3.2.5; 5.1.3.3.1.7 Note the conflict between 9.3.7.7 and 11.3.2.5.

9 NFPA 99 (12); 9.3.7.7, 11.3.2.5; 5.1.3.3.1.7 Note the conflict between 9.3.7.7 and 11.3.2.5.

10 NFPA 99 (12); 11.3.1; 5.1.3.3.2(8); 9.3.7.5.3.4 Not a retroactive requirement.

11 NFPA 99 (12); 11.3.2.2

12 NFPA 99 (12); 11.3.2.3

13 NFPA 99 (12); 11.3.2.2

14 NFPA 99 (12); 11.5.2.3.1

15 NFPA 99 (12); 11.3.4

16 NFPA 99 (12); 11.3.4

17 NFPA 99 (12); 11.5.2.3.1 (3)