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Construction Site During a Survey

by Brad Keyes, CHSP, on Jul 10, 2020 1:00:29 AM

Q: What would a surveyor would be looking for if they were to show up at our hospital and find that there is construction going on? What steps would the surveyor take, and would they walk only the outside of the construction site or would they go into the construction site?

A: I can only answer that based on my experience as a surveyor. I would definitely go into the construction site (if it was not restricted), and here are some things I would be looking for:

1.  Are the sprinkler heads impaired? Often times the hospital construction staff does not fully understand what constitutes an impaired sprinkler. They often mistakenly think as long as water pressure is still applied to the sprinkler heads (meaning nobody closed the control valve), then the sprinkler heads are not impaired. The error in this belief is, once the ceiling tiles are removed from the suspended grid system, that impairs the sprinkler heads in that area. Sprinklers are supposed to be mounted no more than 12-inches below the ceiling, which they are when there is a suspended acoustical tile and grid ceiling. But remove even one (or more) ceiling tiles from the grid, now the sprinkler heads are 4 – 5 feet below the ceiling, which is now the deck above.

2.  Same question for required smoke or heat detectors, as above. Are they impaired because the ceiling tiles were removed? Similarly to sprinkler heads, required smoke and heat detectors must be mounted to within 12-inches of the ceiling. If the ceiling tiles are removed, then the ceiling now becomes the deck above, which is more than 12 inches from the required smoke or heat detectors. And… heat detectors are not an acceptable substitute to avoid having to implement ILSM measures, for a required smoke detector that has been removed. You can place heat detectors where required smoke detectors were once located for construction, but that does not absolve the hospital from implementing ILSM measures for an impaired required smoke detector. Not all smoke detectors located in a hospital are ‘required’ by NFPA codes and standards. Many smoke detectors are installed at the whim of a designer. If the smoke detector is NOT a required smoke detector, then it can be removed for construction without any ILSM assessment or implementing measures necessary.

3.  If the sprinklers or required smoke detectors are impaired, then has the organization conducted an Interim Life Safety Assessment (ILSM) assessment? The ILSM assessment is required by section 4.6.10.1 of the 2012 Life Safety Code (LSC), and by standards found within the accreditation manual. The ILSM assessment must evaluate that the sprinklers or smoke detectors are impaired and implement alternate measures to compensate for the impairment. According to section 9.6.1.6 of the 2012 LSC (and also by accreditation standards), a Fire Watch must be implemented whenever the fire alarm system is impaired for 4 or more hours in a 24-hour period. Similarly, section 15.5.2(4)(b) of NFPA 25-2011 requires a Fire Watch whenever the sprinkler system is impaired for 10 or more hours in a 24-hour period (See item #4 below for more requirements on a Fire Watch). Often times the hospital staff does not fully understand the required smoke detectors or sprinkler heads are impaired, so they either do not conduct an ILSM assessment, or if they do, the assessment does not require the implementation of a Fire Watch.

4.  If a Fire Watch is implemented, is it a continuous Fire Watch? Section A.15.5.2(4)(b) of NFPA 25-2011 (and enforced by CMS), all Fire Watches must be continuous by trained, dedicated individuals who patrol the impaired area continuously, without breaks or lunch periods, until the Fire Watch is completed, or they are relieved by another trained, dedicated individual. This means the Fire Watch cannot be conducted by someone who has other responsibilities while conducting the Fire Watch. The surveyor would want to see what the training program is that the hospital has for the person doing the Fire Watch. This means the training has to be documented, and there should be a policy explaining the process for training. It is highly recommended that the hospital does the Fire Watch themselves, and not to rely on a contractor to perform this duty, mainly because the contractor will not do an adequate performance.

5.  Is there a marked means of egress inside the construction area for the construction workers? This would require an illuminated ‘EXIT’ sign over the door to the exit from that area, that would most likely mean an internally illuminated ‘EXIT’ sign, sourced by EM power. Technically, an externally illuminated ‘EXIT’ sign would be acceptable, but the external illumination source would have to be continuous and tied into the Emergency Power system (Life Safety branch). A minimum of 5-foot-candles of illumination is required on the ‘EXIT’ sign. I find many construction managers want to use cardboard ‘EXIT’ signs, and they could if they bothered to have the correct external illumination source. Photoluminescent ‘EXIT’ signs are permitted, but they have to have a continuous source of illumination (does not have to be EM source) as long as the building is occupied (i.e. 24-hours per day), which is difficult to do.

6.  Is there a fire alarm pull station located within 5-feet of the exit inside the construction area? Are there fire alarm occupant notification devices, such as chimes, horns or strobes inside the construction area to alert the construction workers of a fire emergency? Just because it is a construction site does not mean the hospital can ignore these basic requirements for activating the fire alarm system, and being alerted by the fire alarm system.

7. Is the entrance to the construction site (from the occupied area) closed off, and restricted? Sometimes, construction staff will try to keep the means of egress open and accessible to clinical staff with an ‘EXIT’ sign over the door to the construction area, because they mistakenly believe there must be at least 2 means of egress from the occupied area at all times. No… this is not true when construction activity closes down one of the required means of egress. That is what ILSM assessment are for. When a means of egress is impaired (or closed) for any reason, the ILSM assessment should require an additional Fire Drill in the impaired area. This is typically an accreditation standard requirement.

8.  Have the construction workers received basic training on the hospital’s fire response plan? This would entail the acronym RACE, which would require anyone observing a fire to:

  • Rescue whoever is in danger of the fire
  • Activate the alarm by pulling the manual station, and by calling the emergency number
  • Confine the fire by closing doors
  • Evacuate, or extinguish the fire using portable fire extinguishers.

This is a very easy thing for surveyors to evaluate, simply by asking the construction workers if the hospital provided basic fire-response training, and see if they can explain what RACE means.

9.  Are portable fire extinguishers properly placed inside the construction area? NFPA 10 requires fire extinguishers to be located inside an area of higher hazard, which a construction site would qualify as. Fire extinguishers must be mounted at least 4-inches above the floor, and no more than 60-inches above the floor. This means fire extinguishers cannot be sitting on the floor inside construction areas.

10.  Is there an appropriate barrier between the construction site and the occupied area? New codes and standards now require the barrier to be 1-hour fire-rated and extend from the floor to the deck above IF the construction area is not protected with sprinklers. To be properly protected with sprinklers, the sprinkler heads would have to be turned upwards to within 12 inches of the deck. If the construction site IS protected properly with sprinklers, then the barrier may be non-rated, but it cannot be plastic or tarp barriers, even fire-retardant plastic is not permitted as the barrier. So, the barrier would still have to be steel studs and drywall, that extends from the floor to the underside of the ceiling, as long as the ceiling is not plastic or tarp construction.

11.  Does the construction area have a negative air in respect to occupied areas? Make sure they don’t turn-off the negative air machines at the end of the day.

Topics:Construction BarrierExit SignsSurvey FindingsFire WatchConstructionSmoke DetectorsILSMSprinklersEgress

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