Corridor Barrier for COVID-19
by Brad Keyes, CHSP, on Jan 21, 2021 1:00:00 AM
Q: We are a nursing home and our local health department is advising us to install plastic barriers with zippers in corridors to provide an area of isolation for COVID-19 residents. It appears the local AHJ's are accepting this practice. Are there any standards/codes that allow this under emergency declaration?
A: Keep in mind - you have many authorities that want to tell you how to run your nursing home. You have CMS, your accreditation organization, your state licensing department, your state health department, your state fire marshal, your local fire inspector, your local health department, and your liability insurance company. Each authority has jurisdiction over your facility to a certain degree, based on the standards (or code) that they provide. Often the codes and standards that these authorities enforce are common to each other (i.e., the Life Safety Code), but sometimes they use entirely different set of codes and standards. All of the authorities are equal in the sense that once they say you must do something, then you must comply if you want the license, certification, accreditation, etc. that they offer. Just because one authority says it is permissible to do something, does not mean that it is okay with all of the other authorities.
In your situation, it appears that you are considering installing a plastic barrier with a zippered opening across a corridor which is a means of egress, in order to control air movement for infection control purposes. You ask if this is permitted under emergency conditions. First let me say that installing the plastic barrier would be a violation of section 18.104.22.168 of the 2012 Life Safety Code, which says “Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.” Obviously, taking the time to un-zip the barrier while attempting to egress would definitely be an impediment. So, first impressions would say installing a plastic barrier across the means of egress is not permitted.
But there is a view by many authorities that during the course of an emergency, you do what you have to do to provide care for your patients and staff, even if it is a violation of a code or standard. This of course would require the activation of your Emergency Response Plan (Emergency Operations Plan) and your Incident Command Center. The logic of allowing this barrier during a time of emergency is it would control the immediate threat of air-movement that might contribute to the on-going pandemic. But in this situation, the barrier would presumably be in place indefinitely since the pandemic is now in its 12-month with no end in sight.
There is no written standard that I am aware of from any of the authorities that says you may violate the Life Safety Code during an emergency event. This is one of those issues that seems to be overlooked when the surveyors conduct a review of the events. However, CMS has stated there is a procedure to request an 1135 Waiver that would allow you to defer certain LSC requirements until the emergency condition has passed. They (CMS) have issued memos regarding this procedure on issues such as routine inspection and testing, but not on creating an impediment to a means of egress.
If you install the plastic zippered barrier across the means of egress as the local health department has requested, you run the risk of receiving citations from one or more of the many other authorities that inspect your facility. My suggestion would be to contact each of your authorities individually and ask them if they would permit the temporary plastic zippered barrier under the conditions of an emergency for COVID-19. If they all say yes, then you may do it without any concern for a citation. If one or more says no, then you may not do it. Another suggestion would be to install regular cross-corridor doors that are side-hinged and swinging, in lieu of the plastic zippered barrier. While that would cost more, it would comply with the codes and standards.