No Longer Needed Surge Space
by Brad Keyes, CHSP, on Mar 4, 2021 12:00:00 AM
Q: We had built a temporary surge space due to the COVID pandemic. This surge space was attached to the hospital to provide flow for our ED patients. We had walled in a covered patio with non-fire rated material, sealed the floor, added a dry sprinkler line, and installed battery powered smoke heads with audible and visual alarms. This system was not tied into our fire alarm system. We used this space while under our EM plan. We have come out of EM plan. There is debate whether we can leave the space up and block it off until the public health crisis is over or if we need to immediately take the space down because we will no longer be using the 1135 waiver and we are out of EM plan. We know some tents are allowed to be left up, but this space is attached to the building. The heating sources for this space are outside units directly feeding the space. We have determined that this space cannot be used without the 1135 waiver and the waiver cannot be used outside of our EM plan. Thoughts on this?
A: Without knowing exactly what you have, it appears to me that your ‘surge space’ would be non-compliant with the Life Safety Code for construction type. You are correct saying that this space would be permitted under the 1135 general waiver that CMS allows for such surge spaces, but now that your EM plan is deactivated technically it is a violation even if it is not used since the construction type (and possibly other issues) are not properly separated from the main facility.
It seems to me to be a legitimate concern to want to leave the surge space set up in case it is needed since the pandemic is not over, even though you have deactivated your EM plan. But, as mentioned, it does not appear to comply with the Life Safety Code. I suggest you contact your key authorities and ask them if it is permissible to leave the area set up in anticipation of need for the COVID crisis. At a minimum, you would need to contact:
- Your state agency on licensure for the hospital
- Your state agency on design and construction of hospitals
- Your state fire marshal
- The CMS regional office for your area
- Your local building authorities
- Your local fire inspector
- Your accreditation organization
- Your liability insurance agency
You will need all of the above authorities to approve the decision to leave the area set up. If just one says no, then you need to either activate your EM plan or tear the surge space down.