J-1502000-24DHA INTERIM LIFE SAFETY MEASURE POLICY.pdf

DEPARTMENT OF THE NAVY

NAVAL HOSPITAL PENSACOLA

6000 WEST HIGHWAY 98

PENSACOLA FL 32512-0003

NA VHOSPPNCLA INSTRUCTION 5100. 7C

From: Commanding Officer, Naval Hospital Pensacola

Subj: INTERIM LIFE SAFETY MEASURES

POLICY Ref: (a) NFPA 101: Life Safety Code®

NA VHOSPPNCLAINST 5100.

7C Code00 OH

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(b) The Joint Commission Hospital Accreditation Standard LS.01.02.01

1. Purpose. To provide for a series of administrative actions that temporarily compensate for the hazards imposed by existing Life Safety Code (LSC) deficiencies, hazards associated with construction, renovation, extensive maintenance or impairment of fire protection systems. The actions are intended to provide a level of life safety comparable to that required by the LSC under normal operating conditions. This is a complete revision and should be reviewed in its entirety.

2. Cancellation. NAVHOSPPNCLAINST 5100.7B.

3. Background. As per reference (a), chapter 4, no existing building will be occupied in whole or in part in violation of the provisions of the LSC, unless the following conditions exist:

a. A plan for correction has been approved;

b. The occupancy classification remains the same; and

c. No serious life safety hazards exist as judged by the Authority Having Jurisdiction (AHJ).

Buildings or portions of buildings will be permitted to be occupied during construction, repair, alterations and or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place.

4. Discussion. Hospitals and other healthcare occupancies typically provide sleeping accommodations and are occupied by persons who are incapable of self-preservation because of age, physical or mental disability, anesthesia and other forms of temporarily disabling medical treatment or because of security measures not under the occupant's control. Because the safety of healthcare occupants cannot be ensured adequately by dependence on evacuation of the building, the LSC states that healthcare facilities will be designed, constructed, maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants (reference (a), chapter 19).

5. General

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a. It is the policy of Naval Hospital Pensacola (NHP) to protect occupants during periods when the LSC is not met or during periods of construction, renovation or extensive maintenance that adversely affects the life safety status of the hospital. Appropriate Interim Life Safety Measures (ILSM) will be implemented in or adjacent to areas of the hospital, where such conditions exist, as deemed appropriate by the AHJ and the NHP Fire Safety Program Manager (FSPM). All personnel, including contract construction workers, will comply with the ILSM program.

Note: In accordance with reference (b ), this policy is primarily applicable to the hospital occupancy. Nevertheless, it is the intent ofNHP to maintain and operate all of its facilities in compliance with the LSC. Therefore, appropriate ILSM plans will be implemented for other patient care facilities, including the outpatient clinic and Naval Branch Health Clinics, in accordance with this policy.

b. Typically, LSC deficiencies are identified during safety surveys(an ILSM assessment will be completed when Requirements for Improvement's are identified during survey and cannot be immediately corrected), fire drills, fire safety inspections, construction projects and other environmental rounds. When the provisions of the LSC cannot be met in the hospital the deficiency is either corrected immediately (preferred) or managed using a corrective work order system (with tracking capabilities). When LSC deficiencies cannot be corrected immediately, the FSPM will be notified by Facility Management Department (FMD). The FSPM will conduct a risk assessment and when appropriate , an ILSM will be implemented in the affected area (s). FMD or the safety office will track resolution of each LSC deficiency.

c. To evaluate the need for an ILSM, FMD will provide a pre-construction risk assessment to the FSPM prior to all hospital projects involving construction, renovation, extensive maintenance or modification of existing life safety features. The FSPM will review the pre-construction risk assessment and perform a life safety risk assessment (LSRA) to determine if an ILSM needs to be implemented for the construction project. The written risk assessment and or ILSM will be reviewed by the facilities manager (or designee). The fire inspector and AHJ will be notified if an ILSM is required.

d. When life safety is compromised, one or more of the following measures will be implemented for the duration of the causal activity, as determined by LSRA.

(1) When the fire alarm system is out of service more than 4 hours in a 24-hour period, the hospital will notify the fire department and initiate a fire watch in the affected area(s) for the duration of the time period that the system is out of service or the area( s) will be evacuated.

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(2) When the sprinkler system is out of service more than 10 hours in a 24-hour period, the hospital will notify the fire department and initiate a fire watch in the affected area(s) for the duration of the time period that the system is out of service or the area( s) will be evacuated. Note:

The LSC defines "fire watch" as the assignment of a person or persons to an area for the express purpose of notifying the fire department, the building occupants or both of an emergency;

preventing a fire from occurring; extinguishing small fires; or protecting the public from fire or life safety dangers. The watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected as per reference (b ).

a. FMD will notify the FSPM in advance of the system outage and the FSPM will notify the fire inspector.

b. The fire watch will be staffed by the security department or the contractor.

c. The watch will require hourly roving patrols of the affected area(s) to include main corridors, high hazard areas and all unoccupied spaces. Note: Occupied spaces may be monitored by hospital staff working in the area. Notification and fire watch times will be documented. Security will use the Electronic Desk Journal to log fire watch rounds. Contractors may use paper or electronic logs and will provide a copy to FMD when the watch is finished.

d. When a fire protection system is impaired, it may be necessary to provide a temporary but equivalent fire alarm and detection system. The need for equivalent systems is based on the LSRA and will be decided by the AHJ. Temporary systems will be inspected and tested no less than monthly. FMD is responsible for this ILSM.

e. When means of egress are blocked or obstructed, the hospital will post signage identifying the location of alternative exits to everyone affected. If necessary, exit signage will be modified so as not to mislead building occupants. The FSPM is responsible for this ILSM.

f. Exits will be inspected on a daily basis. The need for these inspections is based on the LSRA. Inspections will be conducted by contractors, department safety representatives, clinic fire wardens, FMD or Safety.

g. Additional fire-fighting equipment will be provided as necessary. The need for this equipment will be based on the LSRA and decided by the AHJ. Contractors will provide portable fire extinguishers for all "hot" work areas. FMD is responsible for this ILSM. FMD must ensure that contractor brings a working, inspected, up-to-date 10-lb multi-purpose (ABC) dry chemical fire extinguisher to affected area(s).

h. Temporary construction partitions will be smoke-tight and made of noncombustible or limited combustible material (sheet rock, gypsum board, etc.) that will not contribute to the

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development or spread of fire. The Joint Commission's position is that plastic sheet barriers of a limited combustible type (rated material) are "tolerated" for short-term use. If the project includes any high-risk construction activities (torch cutting, welding, open flame, etc.) noncombustible barriers will be used. Contractors will provide documentation to verify material rating. FMD is responsible for this ILSM.

i. Increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. The need for increased surveillance is based on the LSRA and co-managed by FMD and Safety.

j. Enforce storage, housekeeping, and debris-removal practices that reduce the building's flammable and combustible fire load to the lowest feasible level. The need for these practices is based on the LSRA and co-managed by FMD and Safety. FMD is responsible for contractor enforcement and Safety is responsible for staff enforcement.

k. Enforce the "tobacco free" policy to prevent smoking-related fire hazards. FMD is responsible for facility-related contractor enforcement, Materials Management Department is responsible for other contractor enforcement and Security is responsible for staff enforcement.

l. Conduct one additional fire drill per quarter. The need for additional drills is based on the LSRA and decided by the AHJ. The FSPM is responsible for this ILSM.

m. Provide education to promote awareness of building deficiencies, construction hazards and temporary measures implemented to maintain fire safety. The need for education is based on the LSRA and may include the entire hospital or affected areas only. The FSPM is responsible for this

ILSM.

n. Train hospital staff to compensate for impaired structural or compartmental fire safety features, including additional training on the use of fire-fighting equipment, as necessary. The need for training is based on the LSRA and may include the entire hospital or affected areas only, as well as designated emergency response personnel. The FSPM is responsible for this ILSM.

Note: Compartmentalization is the concept of using various building components (e.g., fire and smoke-rated doors, walls and floors) to prevent the spread of fire and the products of combustion, so as to provide a safe means of egress to an approved exit. The presence of these features varies depending on the building occupancy classification.

6. Action. Staff knowledge and compliance are critical to the success of this policy. Department heads and supervisors are responsible for implementing appropriate measures and facilitating staff training in their respective areas, as defined by ILSM plans in effect. Questions or concerns should be referred to the FSPM or the Environment of Care Quality Management Board.

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7. Records Management. Records created as a result of this instruction, regardless of media and format, must be managed per Secretary of the Navy (SECNAV) M-5210.1 of January 2012 and NAVHOSPPNCLAINST 5210.lC.

8. Review and Effective Date. The Safety Officer will review this instruction annually on the anniversary of the effective date to ensure applicability, currency, and consistency with Federal, Department of Defense, SECNAV, and Navy policy and statutory authority using Operational Navy (OPNAV) 5215/40 Review of lnstruction. This instruction will automatically expire five years after effective date unless reissued or otherwise canceled prior to the five year anniversary date, or an extension has been granted.

9. Forms. OPNAV 5215/40 (May 2016), Review of lnstruction is available electronically on Naval Forms Online at: https://navalforms.docurnentservices.dla.mil/web/public/home .

A. H. BRANSTETTER

Releasability and distribution:

This instruction is cleared for public release and is available electronically only via NHP Intranet, Central Files at https://pcola-ap-shpntl/pages/default.aspx