Comments on Revisions to Life Safety (EC5)
Note: ASHE comments are highlighted in yellow.
Note: Current EC 5.20, Compliance with the Life Safety Code, will be replaced with a new Life Safety (LS) Standard. The LS Standard is not available for review at this time.
General Comment
The chapter numbering should stay the same as it is now to provide continuity with existing plans. Leave Life Safety as EC 5
Current Standard: EC.5.10 Current EP: 5
The organization reviews proposed acquisitions of bedding, window draperies, and other curtains, furnishings, decorations, and other equipment for fire safety.
Revised Standard: EC.4.01.0 Revised EP: 2
The [organization] uses fire-safe bedding, window treatments, privacy curtains, furnishings, and decorations. (see also NFPA 701)
This is creation of a new code. The EP as stated is not in agreement with NFPA 101, Chapter 18 and 19. As per the 2000 Edition of NFPA 101, upholstered furniture and mattresses in spaces that are sprinkled do not need to meet the requirements of Chapter 10 for flame resistance, cigarette ignition and char length.
Use direct NFPA 101 code language or make a direct reference to the code, not just "see also...". This EP needs to be consistent with the code.
Following are the applicable NFPA references:
19.7.5.2 Newly introduced upholstered furniture within health care occupancies shall meet the criteria specified when tested in accordance with the methods cited in 10.3.2(2) and 10.3.3.
19.7.5.3 Newly introduced mattresses within health care occupancies shall meet the criteria specified when tested in accordance with the methods cited in 10.3.2(3) and 10.3.4.
10.3.2* “Where required by the applicable provisions of this Code, upholstered furniture and mattresses shall be resistant to a cigarette ignition (that is, smoldering) in accordance with the following:
(2) Where required by the applicable provisions of this Code, mocked-up composites of the upholstered furniture, unless located in rooms or spaces protected by an approved automatic sprinkler system, shall have a char length not exceeding 1.5 in. (3.8 cm) when tested in accordance with NFPA 61, Standard Method of Test for Determining Resistance of Mock-Up Upholstered Furniture Material Assemblies to Ignition by Smoldering Cigarettes.
(3) *Where required by the applicable provisions of this Code, mattresses, unless located in rooms or spaces protected by an approved automatic sprinkler system, shall have a char length not exceeding 2 in. (5.1 cm) when tested in accordance with Part 1632 of the Code of Federal Regulations 16.
10.3.3* Where required by the applicable provisions of this Code, upholstered furniture, unless the furniture is located in a room or space protected by an approved automatic sprinkler system, shall have limited rates of heat release when tested in accordance with NFPA 266, Standard Method of Test for Fire Characteristics of Upholstered Furniture Exposed to Flaming Ignition Source, or with ASTM E 1537, Standard Method for Fire Testing of Real Scale Upholstered Furniture Items, as follows:
(2) The total energy released by the single upholstered furniture item during the first 5 minutes of the test shall not exceed 40 MJ.
10.3.4* Where required by the applicable provisions of this Code, mattresses, unless the mattress is located in a room or space protected by an approved automatic sprinkler system, shall have limited rates of heat release when tested in accordance with NFPA 267, Standard Method of Test for Fire Characteristics of Mattresses and Bedding Assemblies Exposed to Flaming Ignition Source, or ASTM E 1590, Standard Method for Fire Testing of Real Scale Mattresses, as follows:…”
Current Standard: EC.5.30 Current EP: 5
Staff in all areas of every building where patients are housed or treated participates in drills to the extent called for in the facility’s fire plan (see EC.5.10 for required content of fire response plan).
Revised Standard: EC.4.02.0 Revised EP: 4
Staff in all areas of every building where [patients] are housed or treated participate in drills according to the [organization]’s fire response plan. Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., a
visual notification is permitted instead of audible alarms.
This may be interpreted as implying that the visual notification appliances of the fire alarm system need to be activated. Many fire alarm systems do not have the ability to activate only the visual devices. The visual devices can be as disruptive as the audible devices. If the intent is to use a device portable visual device such as a hand held strobe or sign to initiate the drill with staff, it should be stated as such.
Current Standard: EC.5.40 Current EP: 16
All horizontal and vertical sliding and rolling fire doors are tested for proper operation and full closure at least annually.
* *For additional guidance, see NFPA 80-1999 edition (section 15-2.4).
Revised Standard: EC.4.03.0 Revised EP: 20
The [organization] documents the testing every 12 months, plus or minus 30 days, of all sliding and rolling fire doors for proper operation and full closure.
Why has the phrase, "plus or minus 30 days" been placed in this EP? This should be removed to remain consistent with other EPs.
Current Standard Text: EC.5.50
The organization develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code®.
Revised Standard: EC.4.04.0
The [organization] protects occupants during periods when the Life Safety Code© (LSC) is not met or during periods of construction.
Leave the standard as originally stated or modify as follows. ". The [organization] protects occupants during periods when a building does not meet the applicable provisions of the Life Safety Code®.
Revised Standard: EC.4.04.0 Revised EP: 1
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: inspecting exits in affected areas on a daily basis.
Revised Standard: EC.4.04.0 Revised EP: 2
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: notifying the fire department (or other emergency response group) and initiating a fire watch when a fire alarm or sprinkler system is out of service more than 4
hours in a 24 hour period in an occupied building.
Footnote: For further guidance, see Life Safety Code,NFPA 101, 2000 edition.
Revised Standard: EC.4.04.0 Revised EP: 3
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: providing temporary but equivalent systems when any fire system is impaired.
Revised Standard: EC.4.04.0 Revised EP: 4
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: inspecting and testing temporary systems monthly.
Revised Standard: EC.4.04.0 Revised EP: 5
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: providing additional fire-fighting equipment.
Revised Standard: EC.4.04.0 Revised EP: 6
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: using temporary construction partitions that are smoke-tight, or made of noncombustible material, or made of limited combustible material that will not
contribute to the development or spread of fire.
Revised Standard: EC.4.04.0 Revised EP: 7
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: increasing surveillance of buildings, grounds, and equipment, with special attention to construction areas and storage, excavation, and field offices.
Revised Standard: EC.4.04.0 Revised EP: 8
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: enforcing storage, housekeeping, and debris removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.
Revised Standard: EC.4.04.0 Revised EP: 9
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: providing additional training to those who work in the [organization] on the use of fire-fighting equipment.
Revised Standard: EC.4.04.0 Revised EP: 10
The [organization] has a written Interim Life Safety Measure (ILSM) policy that includes criteria for evaluating when and to what extent the following apply: conducting additional fire drills, at a minimum of two drills per quarter.
Revised Standard: EC.4.04.0 Revised EP: 12
The [organization] communicates the location of alternate exits to everyone in the building.
Revised Standard: EC.4.04.0 Revised EP: 13
The [organization] conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.
Revised Standard: EC.4.04.0 Revised EP: 14
The [organization] trains those who work in the [organization] to compensate for impaired structural or compartmental fire safety features.
Note: compartmentalization is the concept of using various building
components (fire walls and doors, smoke barriers, fire rated floor slabs, and so forth) to prevent the spread of fire and the production’s combustion, and to provide a safe means of egress to an approved exit. The presence
of these features varies depending upon the building occupancy classification.
EP 1 through 10 should be one EP. If a facility does not have a written ILSM policy, are all 10 EP's scored.? The original EP could be simplified, but still keep all of the required elements for a written policy in one EP.