Code Compliance

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					Codes & Compliance
 What does the sinking of the

have to do with Building Codes?
                Codes and TITANIC

• Water-tight            • Smoke & fire
  Compartments             compartments
   – Bulwarks               – 2 hr. walls
   – thresholds/ doors      – fire doors
• # Life boats           • # Exits
• Steel strength         • Materials fire ratings
• Crew training          • Staff training
        Why the TITANIC was a disaster

• Pressure from White Star line
• Poor judgement on Captain’s part
• Hole exceeded compartments
• Inadequate # of lifeboats
• Steel was brittle (sulfur content too high: in
  cold water lost strength)
• Crew not trained to deal with situation
Code Compliance

            Code Compliance

Organizations have a moral and legal obligation to
provide a safe environment for building

Building codes and government regulations
mandate the minimum requirements and standard
for public health and safety.
           Code Compliance

OSHA and building code enforcement agencies
hold owners and operators accountable for the safe
and sanitary maintenance of their facility.

The Authority Having Jurisdiction may very from
facility to facility. The AHJ for Life Safety is
appointed by the Governing Board.
     Document & Demonstrate Compliance With:

     • AIA                    • JCAHO
    • ANSI                     • NFPA
• Building Codes                • CDC
    • ADA                    • ASHRAE
     • EPA                      • FDA
                       Required Permits

• Emission
   – Boilers
   – Incinerators
   – ETO Usage
• Burn Permits
• Confined Space
• Elevators
• Heliports
NOTE: Many are unique to local, state, & city codes.
     Code Compliance

The word “Shall” indicates
  mandatory requirement.
 "Always do right- this will
gratify some and astonish the

      - Mark Twain (1835-1910)
                 Life Safety

• Design, construction, and compartmentation
• Provision for Detection, alarm, and
• Fire prevention and the planning, training,
  and drilling programs for the isolation of
  fire, transfer of occupants to areas of refuge,
  or evacuation of the building.
                      Life Safety

• The National Fire Protection
  Association Manual
  (NFPA) 101, 2000 Edition
• Joint Commission
  Accreditation of Healthcare
  Accreditation Manual for
                    Life Safety

• NFPA 72, National Fire
  Alarm Code, 1999 Edition

• NFPA 110 Standard for
  Emergency and Standby
  Power Systems, 2002
         Life Safety Assessment

• Statement of Conditions (SOC)
  – A current organization-wide SOC must be
    completed for all buildings housing and treating
    an organization’s patients, regardless of
         Life Safety Assessment

• Statement of Conditions
  – The exception is Business Occupancy that are
    (1) freestanding or (2) connected to a health
    care occupancy but separated by a two-hour fire
    barrier and do not serve as a required means of
    egress from the health care occupancy.
                Life Safety

• Fire Drills – Hospitals require one per
  shift per quarter

• Interim Life Safety Plan—Hospitals
  require a minimum of two per shift per
               Life Safety

• At least 50% of required drills are
• External illuminated exit sign require 6
  inch letters. Internal illuminated exit
  signs require 4‖ Letters
              Response Training
    Fire response training evaluated at least
• When & how to sound alarms
• When and how to transmit for offsite fire
• Containment of smoke and fire
• Transfer of patients to areas of refuge
• Fire extinguishment
• Specific fire response duties
• Preparation for building evacuation.
                 Life Safety

• NFPA 101 requires doors to readily open from the
  egress side. Be aware!

• Exception 1, allows for the door to be locked in
  the interest of the patient —subject to the
  approval from the Authority Having Jurisdiction.
                   Life Safety

• Egress Capacity is the ability of an egress
  component or system of components to meet the
  demand of occupants traversing the means of
• The Public Way is defined as a street, alley or
  other similar parcel of land open to the outside air,
  dedicated to public use, with a clear width and
  height of at least 10 feet.
                 Life Safety

• Dead-end corridors occur where an occupant
  may enter a corridor thinking there is an exit
  and must retrace the path traveled to find an
  exit. In the 2000 Edition of NFPA 101, 30
  feet corridors are allowed for new
              Life Safety

• Equivalencies—are alternative approaches
  to life safety and require a Fire Safety
  Evaluation System (FSES). FSES are the
  responsibility of the Authority having
              Life Safety

• Class A fire extinguishers are used for
  ordinary combustibles such as wood,
  paper, cloth, household rubbish, rubber
  and many plastics.
• Class C fire extinguishers are used for
  Energized Electrical Equipment
             Life Safety

• Portable Fire Extinguishers should be
  inspected every 30 days
• Travel distance to any fire extinguisher
  should not be more than 75 feet from any
          Life Safety

• Health Care Occupancy
• Business Occupancy
• Ambulatory Health Care Center
               Life Safety

• Fire Alarm systems involve three
   – Initiation
   – Notification
   – Control
• In general, the order of precedence for
  fire alarm signals is alarm, supervisory,
  and trouble signals.
               Life Safety

• Pull Stations should be unobstructed,
  accessible, and within the natural path of
• There should be at least one pull station at
  each required exit
• Additional ones located so that the total
  travel distance to a pull station does not
  exceed 200 feet.
               Life Safety

Patient care areas are categorized into three
– General Care Areas
– Critical Care Areas
– Wet Locations

NFPA 70, Article 517-18, 517-19 and 517-20
                  Life Safety

NFPA groups essential electrical systems in to
 three major categories.
  – Type 1
  – Type 2
  – Type 3

  NFPA 99 2002 edition 4.4
                    Life Safety
• Hospitals require Type 1 Essential Electrical
  System (EES).
• It should include
   –    exit route illumination,
   –   emergency communication,
   –   illumination to exit signs,
   –   critical equipment/systems
   –    and critical service areas.
• The EES shall be installed IAW applicable
  standard (NFPA 70 Article 517-30)
                  Life Safety

• The EES, Type 1 system is subdivided into
  two branches
  – Critical branch
  – Life Safety branch
• Any device connected to the life safety
  branch must be restored to operation within
  10 seconds (NFPA 99 (d))
                        ESSENTIAL ELECTRICAL SYSTEM (EES)
                           FOR HEALTHCARE FACILITIES

             TYPE 1                           TYPE 2    TYPE 3
        • Hospitals
       • Ambulatory Care
          with Critical Care

    Emergency              Equipment System

Life Safety     Critical
  Branch        Branch
                Life Safety Branch

          Devices allowed on Life Safety Branch
•   Illumination for means of egress
•   Exit Signs
•   Alarm and alerting devices
•   Fire ALARMS
•   Alarms for systems specified for vacuum systems
•   Hospital communications
•   Generator Set Task Illumination
•   Elevator cab lighting, control, communication
•   Automatic Doors
•   Auxiliary functions of the Fire Alarm (NFPA 72)

•     An equivalency is method of protection
    that provides equal to or greater level of
    protection dictated by code.

• It ―IS NOT‖ a waiver or deletion of the
  code requirement. (NFPA 101 1.5.1, 2000
            Life Safety

The Life Safety Code is administered
and enforced by the authority having
   jurisdiction designated by the
 governing authority. (NFPA 101,
            JCAHO Standards

• The JCAHO Environment of Care standards
  state that all health care facilities will
  prohibit patients, visitors, and staff from
  smoking inside of any buildings in which
  healthcare services are rendered.
"The significant problems we face
  cannot be solved at the same level
  of thinking we were at when we
  created them."

  – - Albert Einstein (1879-1955)
          Where to Find the Answers

• NFPA 101 – Life Safety   • JCAHO is not a code
• NFPA 99- Standard for
  Health Care Facilities
• NFPA 110 - Generators
• NFPA 72 – Fire Alarms
• NFPA 45– Labs Using
• NFPA 80 – Fire Doors
• NFPA 13 – Sprinklers
• NFPA 70 - NEC
Back up slides
            Inspecting, Testing, and Maintaining

                   Fire Protection
                  Medical Gas Testing

Utility                                   PM
Management                                Schedules

                                          Life Cycle
Inventory             Generator Testing
        Inspecting, Testing, and Maintaining

• All Supervisory Signal Devices – Quarterly
• Valve tamper switches and water flow devices –
• Smoke Detectors – Annually
• Electro-mechanic releasing devices – Annually
• Heat Detectors – Annually
• Manual Fire Alarm Boxes – Annually
• Occupant Alarm Notification Devices - Annually
         Inspecting, Testing, and Maintaining

• Fire Pumps – churn (no flow) – Weekly
• Fire pumps – full flow – Annually
• Water tank high and low level alarms –
• Water Tank low-temperatue alarms (cold weather
  – Monthly
• Main drains (at all system risers) – Annually
• Connections – Fire Department (Inspect) --
         Inspecting, Testing, and Maintaining

• Package suppression systems over cooking
  equipment – Semiannually
• CO2 and other gas package suppression systems –
• Standpipe systems – Every Five Years
• Required Fire Dampers – Test & Maintain --Every
  Four Years
• Required Smoke Dampers – Every Four Years
        Inspecting, Testing, and Maintaining

•HVAC Shutdown Devices – Annually

•Sliding and Rolling Fire Doors/Windows –

•Battery-powered lights required for egress includes
a functional test at 30-day intervals for a minimum
of 30 seconds; and annual test for a duration of 1 ½
        Inspecting, Testing, and Maintaining

• Maintenance & Testing of Healthcare Emergency
  Power Supply System
  – NFPA 110 states that the manufacturer is the final word
    on generator maintenance
  – NFPA 110 requires one set of EPSS manuals be kept on
         Inspecting, Testing, and Maintaining

• Generators need only to be inspected on a weekly
  basis (not exercised)
   – NFPA 99 states ―Generator sets shall be tested twelve
     (12) times a year with testing intervals between no less
     than 20 days or exceeding 40 days‖ IAW NFPA 110.
     The tests shall be conducted for at least 30 continuous
     minutes under a dynamic load that is at least 30 percent
     of the nameplate rating of the generator.
          Inspecting, Testing, and Maintaining

• JCAHO states that all equipment in the utility
  management plan must be tested at least annually.
• A routine maintenance and operational testing
  program shall be initiated immediately after the
  EPSS has passed acceptance tests.
• The maximum time period of 10 seconds before
  the EPSS kicks in applies no matter what the
  circumstance and without exception.
          Safety & Resource Protection

• Safety and Resource Protection
  –   Provide a level of safety and security
      • Patients, visitors, and staff
      • Facilities and property
      • Personal property