Insights Category: Technical Information

With Massachusetts’ recent adoption of NFPA 1 as part of the new State Fire Code, each construction project a specific NFPA 241 Construction Fire Safety Program. The owner, general contractor(s), and the subcontractors each play an integral role in demonstrating compliance; from proper documentation to collaborative implementation.

NFPA 241 Section 7.2 outlines the owner’s responsibility for fire protection in a building under construction; “The owner shall designate a person who shall be responsible for the fire prevention program and who shall ensure that it is carried out to completion…The fire prevention program manager shall have the authority to enforce the provisions of this and other applicable fire protection standards.” As such, building owners should minimally be responsible for the following:

  1. Assign Fire Protection Program Manager (FPPM) and Alternate
    This individual will be responsible for the enforcement and implementation of the building/campus NFPA 241 Plan and serve as the point of contact for any first responders.
  2. Develop, Manage, and Implement Master Building/Campus NFPA 241 Program
    Provides baseline approach to fire protection and life safety for building. This is used/referenced by current and future construction projects. Depending on complexity, assistance from a fire consultant may be necessary.
  3. Confirm General Contractors and their Subcontractors are developing/implementing their respective Project Level NFPA 241 Plans and Impairment Plans.
  4. Coordinate all impairments on site.
  5. Property Maintenance
  • Fire alarm / Fire Protection / Secondary Power
  • *Smoke Control (most commonly overlooked)
  • Semi-annual testing / Maintenance schedule available on site / Proof of performance and functional criteria are satisfied.
  • Fire Drills / Evacuation Plans

General Contractor’s Role

All GC’s working in the building will be required to issue an independent, Project-Level NFPA 241 Plan for each individual project. Said Plan should reference and incorporate the policies and procedures included in this Program, while speaking to specific fire protection, life safety, and safeguards that are appropriate for the scope of work at hand.

8th Edition 780 CMR

The current Massachusetts State Building Code (8th Edition; also known as 780 CMR) is an amended version of the 2009 International Building Code (IBC). The base 2009 IBC code introduced a new requirement for a fire service access elevator (FSAE) in buildings with an occupied floor more than 120 feet above the lowest level of fire department vehicle access (780 CMR 403.6.1). Massachusetts amended Section 403.6.1 to require a FSAE in buildings more than 70 feet in height above grade plane such that FSAE are required in all hi-rise buildings. In order to serve as the FSAE, an elevator must satisfy the following conditions (780 CMR 3007):

  • The FSAE must serve every floor of the building;
  • The FSAE must be open to a lobby that is:
    • 150 square foot& minimum with an 8-foot minimum dimension on every floor except the street floor.
    • Enclosed by 1-hour smoke barriers with 3/4 –hour doors.
    • Provided with direct access to an exit enclosure.
  • A Class I standpipe hose connection must be provided in the exit enclosure having direct access from the FSAE lobby;
  • FSAE must be continuously monitored at the fire command center; and
  • Normal and standby power must be provided in accordance with 780 CMR Chapters 27 & 30

9th Edition 780 CMR

The 9th Edition 780 CMR is an amended version of the 2015 IBC. For further information about the adoption date of the 9th Edition 780 CMR, applicable codes, and the code adoption process please see Code Red Consultants Blog Post titled Building Code by Chris Lizewski.

The 2015 IBC, and thus 9th Edition 780 CMR, significantly changes the requirements related to FSAEs. The 2015 IBC base code requires that in buildings with an occupied floor more than 120 feet above the lowest level of fire department vehicle access, no fewer than two fire service access elevators, or all elevators, whichever is less, be provided. Additionally, it is important to note the draft amendments for public review do not amend IBC Section 403.6.1 as was done for the 8th Edition 780 CMR. The impact of this code change is twofold in that buildings less than 120 feet in height above the lowest level of fire department vehicle access no longer require a FSAE; however, buildings exceeding this threshold now need two FSAE instead of one. It is important that this code change be considered early in design based on the considerable impact on building core configuration.

In addition to the above code change, the 2015 IBC also introduces the following notable changes:

  • Under the 8th Edition 780 CMR it was required that a Class I standpipe hose connection be provided in the exit enclosure having direct access from the FSAE lobby. This requirement has been updated such that the exit enclosure containing the standpipe must have access to the floor without passing through the fire service access elevator lobby. A change was made to this requirement in order to prevent the passage of smoke from the floor to the FSAE lobby and hoistway when firefighters run hoses from the standpipe to the floor (2015 IBC 3007.9.1).
  • Access to not less than one of the required exits from the floor must be provided without travel through enclosed elevator lobbies (2015 IBC 1016.2)
  • A pictorial symbol designating which elevators are fire service access elevators must be installed on both sides of the hoistway door (2015 IBC 3007.6.5).

Continue to monitor the Code Red Consultants Blog for updates relating to the proposed timeline of the 9th Edition 780 CMR code adoption and any proposed changes to the FSAE.

When is a Special Inspector required?

  • New smoke control systems designed to comply with IBC Section 909 are required to be tested by a Special Inspector (IBC Section 909.18.8.1).
  • Existing smoke control systems where the original design has been altered or where new smoke control equipment is installed may also require a smoke control Special Inspector as determined by the local AHJ.
  • Smoke control systems subject to the requirements of IBC Section 909 include any of the following active or passive systems:

•  Atrium smoke exhaust systems
•  Stairwell pressurization
•  Smokeproof enclosures (ventilated vestibules)
•  Elevator pressurization
•  Zone smoke control systems
•  Underground buildings
•  Use Group I-3 windowless buildings

Who can serve as a Special Inspector?

  • The Special Inspector is required to have expertise in fire protection engineering, mechanical engineering and certification as air balancers (IBC Section 909.18.8.2). It is not uncommon for the Special Inspector to consist of a team of individuals capable of satisfying the requirements for engineering expertise and air balancer certification.

When should the smoke control Special Inspector get involved?

  • It is recommended that the smoke control Special Inspector get involved during the design process. The Special Inspector can provide a review of the design with an eye towards properly integrating the many building components that make up a smoke control design.

When is special inspection testing required to be performed?

  • Duct leakage testing is required to be performed prior to the concealment of ductwork (IBC Section 909.18.1(1))
  • Prior to occupancy and after sufficient completion, testing of pressure differentials, flow measurements, and detection and control verification is required (IBC Section 909.18.8.1(2))

What documentation is required to be prepared by the Special Inspector?

  • The Special Inspector is required to prepare a complete testing report that is reviewed, signed and sealed by a registered design professional. A copy of the final report is required to be filed with the fire code official and a copy is required to be maintained in an approved location within the building (IBC Section 909.18.8.3.1).The report is required to include the following:

•  Identification of all devices by manufacturer
•  Nameplate data
•  Design Values
•  Measured Values

Given the adoption of the new MA State Comprehensive Fire Code earlier this year, ever increasing attention is being paid to construction fire safety in the context of NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations.

Code Red Consultants has been assisting construction and ownership teams in understanding and applying NFPA 241 by means of the development of NFPA 241 Construction Fire Safety Programs; with one such plan being developed for the marquee Millennium Tower Project.

Assisted by this plan, Suffolk Construction has been able to seamlessly transition their existing construction fire safety practices to address the requirements of NFPA 241, while keeping their project and site safe for abutters, constructors, and responding personnel.

While the terminology may be similar, the code does not actually link the occupancy classification of a building or space to the applicable occupant load factor for means of egress design requirements. This is a common misconception we see many designers make that can have a significant impact on the required number or size of exits in a building. When determining the occupant loads for your facility’s egress requirements, it is important to consider the difference between the occupancy classification of the building, and function of the space for the area you are evaluating.

  • Occupancy Classification – based on a building’s use and purpose as determined by Chapter 3 of the International Building Code (IBC). This classification (or several if the facility is a mixed occupancy) is applied throughout all areas of a building.
  • Occupant Load – based on the “function of space”, which is defined independently of the building’s occupancy classification.

While in most cases, the occupancy classification of a building or space aligns with its intended function, this is not always the case. For example, in a typical office building, the office space and any small conference/meeting rooms with less than 50 people will be classified as a Group B Business Occupancy (IBC 303.1, 304.1). However, the function of space for the small conference/meeting rooms align themselves most closely with “assembly without fixed seats, unconcentrated (tables and chairs)” in IBC Table 1004.1.1 and should be loaded with the corresponding occupant load factor accordingly. When calculating the occupant load factor for the conference/meeting rooms, 15 net square feet per occupant should be applied. Often times, we see designers loading these spaces at 100 gross square feet per occupant for “business areas” since they are defined as Group B Occupancies, however this is not technically correct and can have a significant impact on egress design. We often get asked if this same approach would apply to a “breakout” space that, while looking very similar to the conference room described above, differs in that its intended to only act as collaboration space for employees sitting in adjacent cubicles/offices. While the language in the IBC does not directly address this distinction, we often find in practice that the building official is accepting of utilizing an occupant load factor of 100 gross square feet for this type of breakout space if it can be illustrated that it is in-fact a non-simultaneous use with the surrounding offices. This is just one small facet of occupant loads. Stay tuned for Part II which will address the difference between net and gross calculations.

Joint Commission Releases 2014 Top Citations Update Every 6 months or so, the Joint Commission publishes lists of the top citations across the various types of health facilities it accredits. The top 10 citations for the first half of 2014 were recently released, and not surprisingly, fire protection/life safety deficiencies continued to dominate the list. The top 10 citations and some of our thoughts are provided below:

  1. 53% – EC.02.05.01: The hospital manages risks associated with its utility systems.
    This citation includes issues related to inadequate utility systems design or function and jumped from #10 in 2013 to #1 this year. With a strong focus on infectious disease prevention and control, it should come as no surprise that the surveyors are taking a close look to make sure facilities are properly inspecting, testing, and maintaining all of their utility systems, as well as checking for appropriate pressure relationships between sterile and dirty areas.
  2. 52% – LS.02.01.20: The hospital maintains the integrity of the means of egress.
    Maintaining the integrity of the means of egress always seems to fall at the top of the list as facility managers’ struggle with policing corridor clutter and keeping egress paths clear. A few useful thoughts to help manage corridor clutter:

    1. Egress corridors more than 8 feet in width can partitioned off to store computers and equipment within alcoves.
    2. Dead end corridors beyond an egress stairwell can be used to store equipment less than 50 feet in area.
    3. Suites, as identified on your life safety plans, are considered as groups of rooms and not corridors, and may be used to store equipment within hallways provided that at least 44 inches of clearance is maintained.
    4. Facilities may elect to use the waiver permitted under CMS S&C-12-21 to utilize the 2012 NFPA 101 provisions which allow projections into corridors for wheeled equipment and fixed furniture under certain circumstances. The waiver election must be documented, noted in the Additional Comments section of the BBI, and brought to the attention of surveyors upon arriving on-site.
  3. 51% – EC.02.06.01: The hospital establishes and maintains a safe, functional
    A common deficiency under EC.02.06.01 that has been popping up lately is that all safety showers, eye wash stations, and drench hoses are tested per ANSI, OSHA, Joint Commission, and other requirements as indicated in the hospital policy. What does this mean?

    1. Use a risk assessment to determine placement of showers and eye washes. 
    2. Providing a testing policy which specifies test intervals (weekly expected). 
    3. Document all test results. 
    4. Ensure the water is tepid between 60°F – 100°F.

    Other issues that commonly plague hospitals include unsecured oxygen cylinders (see our blog post here), and inadequate ventilation, temperature, and humidity levels within the facility.

  4. 50% – EC.02.03.05: The hospital maintains fire safety equipment and fire safety building features.
    Having organized, well-documented inspection and testing reports for your fire protection and life safety equipment and systems is critical. Challenges continue to revolve around facilities holding contractors accountable to provide timely documentation that indicates full compliance with the required standard. Providing follow up documentation that deficiencies from punch lists, work orders, or failed system testing are also commonly overlooked and must be documented to illustrate full compliance. Some best practices include adding applicable code editions and references on all sheets, and cross-referencing test report with corrective work orders.
  5. 50% – IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  6. 49% – LS.02.01.10: Building and fire protection features are designed and maintained to minimize the efforts of fire, smoke, and heat.
    In nearly half of all hospitals, the life safety surveyors continue to cite facilities for problems related to fire/smoke barrier management including penetrations, fire doors, and damper issues. Unsealed penetrations and fire doors with no labels and excessive undercut and gaps continue to be issues for facility managers to stay on top of. Be aware: combustible foam is not a UL-Listed firestop assembly and cannot be used to seal penetrations. While the product may state UL approved for “fireblocking” this is intended for residential use, and is not appropriate for firestopping.
  7. 49% – RC.01.01.01: The hospital maintains complete and accurate medical records for each individual patient
  8. 46% – LS.02.01.30: The hospital provides and maintains building features to protect individuals from the hazardous of fire and smoke.
    Another key issue is maintaining building features is providing accurate, up-to-date life safety plans. Minimally, the life safety plans should illustrate:

    1. Fire safety features
    2. Areas of the building that are sprinklered/unsprinklered
    3. Hazardous storage areas 
    4. Fire/smoke barriers 
    5. Suite boundaries, including sizes and types 
    6. Smoke compartments, including locations and sizes 
    7. Chutes and shaft enclosures 
    8. Any approved equivalencies or waivers
  9. 44% – LS.02.01.35: The hospital provides and maintains systems for extinguishing fires.
    One of the most common issues we see here is maintaining the 18” clearance beneath sprinklers within a storage area. Note that perimeter shelving above the 18” line is permitted unless located directly beneath a sprinkler.
  10. 36% – EC.02.02.01: The hospital manages risks related to hazardous materials and waste.

One of the most frequent topics we receive questions on is existing building code requirements. There is often a lot of confusion for commercial construction projects in existing buildings relative to what upgrades will be triggered by the planned scope of work, if any. In our opinion, answering that question requires experience and an in-depth understanding of the requirements and scoping language for existing buildings. Here are a few of the most common questions we receive:

What requirements govern commercial construction projects in existing buildings in Massachusetts?

The Massachusetts State Building Code 8th Edition (780 CMR) is an amended version of the 2009 International Building Code (IBC). Within the Massachusetts amendments to the 2009 IBC, Section 3401.1 deletes Chapter 34 Existing Structures in its entirety and replaces it with the International Existing Building Code (IEBC), 2009 Edition, with Massachusetts amendments. This amended version of the International Existing Building Code is referred to as the Existing Building Code of Massachusetts.

This code governs repairs, renovations, alterations, changes in use, and additions to existing buildings including those that are historic.

It is also helpful to know that there are additional existing building scoping requirements contained in Section 102.6 of 780 CMR. These requirements outline the general philosophy the code takes with existing buildings that were originally constructed under previous codes and have been legally occupied. These scoping requirements provide a clarity on fundamental understandings relative to previously approved existing conditions, safety features which may no longer be required in the new code, and minimum levels of safety for egress, lighting and ventilation.

Accessibility requirements to public areas in buildings are covered by 521 CMR, the Massachusetts Architectural Access Board requirements. All of the accessibility requirements within the Massachusetts Existing Building Code have been deleted and replaced with a reference to 521 CMR. It should be noted that 521 CMR has a different set of scoping requirements that are unique to that code.

Where can I find the Massachusetts amendments to the 2009 International Existing Building Code?

The Massachusetts Board of Building Regulations and Standards (BBRS) website contains electronic copies of the amendments. They can be found at the following link: Link to Massachusetts Amendments. The applicable version of the Massachusetts amendments is located in the amendment section of the web site and are dated 6-20-2014. Please note that electronic versions of the building code posted on this website are not official. Official copies must be purchased from the state bookstore. Additionally, there is a helpful official interpretation issued by the BBRS on certain applications of the Massachusetts Existing Building Code requirements that can be found at the following link: BBRS Official Interpretations.

How do I use the Massachusetts Amendments with the base 2009 IBC or 2009 IEBC?

The BBRS recommends the following process when evaluating code compliance in accordance with 780 CMR, the Massachusetts State Building Code:

  1. Find the topic in the base code (either the 2009 IBC or 2009 IEBC)
  2. Check the Massachusetts amendments to either document to see if the base language is changed in anyway under the “8th Edition Base Volume” link on the BBRS website.
  3. Check to see if any subsequent changes to the 8th Edition base volume has occurred by looking under the “Check Amendments since August 2010” portion of the BBRS web site.

A building official requested a Chapter 34 report or existing building code analysis. What do I need to include?

First, if your project is a simple repair, it may not even require a permit. Section 105.2 of 780 CMR outlines the types of repair work that are exempt from permit. These include cosmetic upgrades such as painting, carpeting, tiling, and similar finish work.

If your work does require a permit, Section 101.5.4.0 of the Massachusetts Existing Building Code states that the code official can request an investigation and evaluation of the existing building in accordance with the provisions of this code. There is no specific form that needs to be filled out to document this analysis. The level of analysis needed will vary depending on the scope of the project and the condition of the existing building. The investigation and evaluation is required to minimally document the effects of the proposed work on at least the structural, means of egress, fire protection, energy conservation, lighting, hazardous materials, and ventilation for the space under consideration and potentially the entire building if impacted by the proposed work. The results of this analysis are required to be submitted to the building official in written form.

The analysis should also indicate the compliance method that is used to perform the evaluation. The Massachusetts Existing Building Code contains three different compliance options:

  1. The Prescriptive Compliance Method contained in Chapter 3
  2. The Work Area Compliance Method contained in Chapter 4-12
  3. The Performance Compliance Method contained in Chapter 13

For each permit, only 1 compliance method is allowed to be used. If you select to use the Work Area methodology you are permitted to identify multiple scopes of work (i.e. Level 1 Alteration and Repair) on the same permit.

Who can prepare an existing building code analysis?

780 CMR and the Massachusetts Existing Building Code do not outline a set of minimum credentials to prepare this investigation and analysis. Most often it is a registered design professional, such as an architect, engineer, code consultant, or some combination thereof.

What compliance methodology should I use?

Answering this question really requires an understanding of the planned project and the condition of the existing building. We have tried to outline, in general, the conditions when we recommend use of each of the compliance methodologies:

  1. Prescriptive Compliance Method: This methodology is based on outlining scoping criteria for different types of work (i.e. addition, alteration, change in use, etc.). It follows the general philosophy that new work should meet new construction requirements and existing previously approved conditions can remain. There is not language that addresses specific applications, so it leaves the application of the scoping criteria up to interpretation. We find this methodology most useful on projects in relatively new buildings that are generally code compliant, small projects with very limited scope, or substantial renovation projects where the substantial replacement of the interior of the building is being replaced.
  2. Work Area Compliance Method: This methodology is based on first defining the classification of the work to be performed and the “work area”. The definition of “work area” should be reviewed, as it specific to reconfigured space. The aforementioned BBRS interpretations provide a useful example of how to determine the “Work Area”. Unlike the Prescriptive Compliance Method, this methodology has more specific language for certain applications, which can help limit room for differing interpretations on when retroactive upgrades are required. We find this methodology most useful where there is a significant renovation project to a portion of the building, with portions of the existing building remaining unaltered.
  3. Performance Compliance Method: This methodology is a scoring system. Positive points are given to safety features and negative points are given to deficient conditions. A passing score is needed for the approach to be acceptable. This methodology is most useful where there is a known deficient condition with one system that will remain that is offset by other safety features that may exceed the minimum code requirements. For instance, work occurring within an existing building which has various shafts which are not enclosed in fire rated construction, but the building does have a compliant sprinkler system and fire alarm/detection system. This method may be useful to use if it is impractical to upgrade the construction of the shafts within the building. We find this methodology to be used much less in practice when compared with the Prescriptive or Work Area methodologies, however is a valuable tool to have in your back pocket on existing buildings with unique or challenging circumstances.

As you can tell from the questions above, the Massachusetts Existing Building Code can be a puzzling and intimidating document to navigate. Knowing where to begin and the various options available is a critical first step in making sure your next existing building project gets off on the right foot.

On February 11th, the Board of Building Regulations & Standards (BBRS) released an official interpretation to clarify requirements for existing buildings. This latest interpretation is one of the most significant to date as it addresses 4 key points associated with 780 CMR 34 (2009 International Existing Building Code with MA Amendments). Here’s what you need to know:

  1. Compliance Alternatives – Compliance Alternatives, developed for existing buildings where the code for new construction cannot be met, are NOT required to be issued by a registered design professional. With that said, the services of a registered design professional may be warranted for complex issues that require a specific knowledge or area of expertise.
  2. Sprinkler Protection in Existing Buildings Undergoing a Change in Use – The extent of sprinkler protection required in existing buildings undergoing a change in use has been widely misunderstood. IEBC Section 912.1.1.2 specifies that the extent of sprinkler protection is limited to the area undergoing the change in use where separated by fire rated construction from the remainder of the building. However, this approach conflicts with the general notion in Massachusetts that multiple fire areas cannot be created to prevent sprinkler requirements as noted in 780 CMR 903.2. The interpretation clarifies that the extent of sprinkler protection required may be limited to only the areas undergoing the change in use in the existing building by using the building separation method as described in IEBC Section 912.1.1.2. Note that sprinkler protection may still be required throughout the entire building by MGL Chapter 148 Section 26G if the building totals more than 7,500 gross square feet and is undergoing a “major alteration”. Official guidance on MGL Ch.148 S.26G can be found here: http://www.mass.gov/eopss/docs/dfs/osfm/boards/asab-official-approved-26g-guidance.pdf
  3. Multiple Levels of Alteration – A project issued under a single permit may indicate several different levels of alterations. For example, a building being altered with a portion of the electrical system being replaced on the first floor and the construction of a new room on second floor would be classified as a Level 1 Alteration and a Level 2 Alteration. The work occurring on the first floor would be considered as a Level 1 Alteration due to the replacement of an existing system serving the same purpose, and the work on the second floor would be considered as a Level 2 Alteration due to the addition of new walls. Note that although a single permit can include multiple alteration levels, more than one compliance method (such as Work Area Compliance Method and Prescriptive Compliance Method) cannot be used on a single permit.
  4. Definition of Reconfigured Space – The determination of the level of alteration under the Work Area Compliance Method is contingent upon the defining what is considered as the work area. Per IEBC Section 202, the work area is defined as “…all reconfigured spaces as indicated on the construction documents.” Until now, the term “reconfigured space” was ambiguous and left to the building official to interpret. The BBRS has clarified that space is considered as reconfigured if it changes the manner in which occupants egress from the space in terms of travel or distance to exits. This is an important concept to recognize because the work area of a building does not necessarily include all of the areas where work is being done. In the past example in Item #3 above, the work area would consist of the reconfigured room on the second floor only since this is the only space where egress travel and distance has changed. Although work is occurring on the first floor due to replacing the electrical system, this does not include any reconfigured space and thus is not included in the determination of the work area.

Here’s a link to the official BBRS interpretation, which contains useful diagrams illustrating which constitutes reconfigured space: http://www.mass.gov/eopss/docs/dps/buildingcode/inf3/2014-01-official-interpretation-existing-buildings-approved-february-11-2014.pdf

At the end of January 2014, the Joint Commission released an article Found Here clarifying the storage requirements for freestanding nonflammable medical gas cylinders. The main update is that once a cylinder valve is opened, the cylinder is no longer permitted to be stored with the full, unopened containers even if gas remains in the cylinder. This clarification means that a cylinder, even if newly opened, should be segregated from full (unopened) cylinders. Facilities are required to segregate cylinders into three racks – full (unopened), partial, and empty. Each rack should have cylinders securely stored and clearly labeled so users can quickly identify the proper containers in the event of an emergency. Facilities should review their medical gas storage policies against this clarification as it will likely be a point of emphasis in future inspections.

While we’re on the topic, here are a few other important items to note relative to medical gas cylinder storage:

  • The 2005 Edition of NFPA 99 Section 9.4.3 limits the total volume of nonflammable gases that are not stored in enclosures to 300 cubic feet (12 cylinders) within a smoke compartment.
  • Oxygen cylinders that are mounted on gurneys, wheelchairs, and medical equipment, but are not actively being used by patients are considered to be in use and do not count towards this threshold. See CMS S&C-07-10 for CMS position on this issue which has been endorsed by the Joint Commission.

The holiday season is upon us again and that means one thing for hospitals: decorations. From artificial trees and wreaths to paper snowflakes and ornaments hanging from the ceiling, hospitals provide a variety of decorations throughout the holiday season. Despite the memos that are typically circulated throughout hospitals to remind staff of their facility’s policies that limit decorations to only those that are flame retardant, facility managers constantly struggle with staying on top of non-compliant decorations. Thanks to the new categorical waivers permitted by The Centers for Medicare and Medicaid (CMS) and The Joint Commission (TJC), there is more flexibility in restrictions on combustible decorations than have been allowed in the past.

The 2000 Edition of NFPA 101 Section 18/19.7.5.4 states that “combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.” There is an exception for combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. This provision appears to be cut and dry requiring all decorations to be flame-retardant, but leaves it up to the Authority-Having-Jurisdiction (AHJ) to determine if the decorations constitute a fire development hazard. Given the number of AHJs assigned to a hospital coupled with varying interpretations, the most conservative approach has been for facilities to require all decorations to be flame-retardant regardless of size.

On March 9, 2012, the CMS Survey & Certification Group issued memorandum S&C-12-21-LSC which provided instructions for waivers of specific requirements contained in the 2012 Edition of NFPA 101. Section 18/19.7.5 on Furnishings, Mattresses, and Decorations was one of four sections which CMS allowed a waiver to be elected. The provisions of this section were revised and expanded in the 2012 Edition of the Code to make health care occupancies more homelike. Section 18/19.7.5.6 contains the requirements for combustible decorations which was revised as follows:

“Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:

  1. They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
  2. The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
  3. The decoration exhibits a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.
  4. The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:
    • Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 19.7.5.6(B), (C), or (D) [Items 2, 3, 4 below].
    • Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
    • Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
    • Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons in a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
  5. They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

In order to utilize the waiver for the combustible decorations, a waiver request was initially required to be processed in the regular fashion with input from the State Survey Agency and final approval by the CMS Regional Office. However, CMS released memo S&C 13-58-LSC on August 30th, 2013 which allowed the waivers specified in S&C 12-21-LSC as well as 8 other provisions to be addressed as categorical waivers.

Facilities that want to take advantage of the combustible decoration waiver to utilize the 2012 NFPA 101 provisions must formally elect to use the waiver and document their election decision. As long as the requirements of the waiver are met, the election is not required to be submitted to CMS for approval nor do you need to wait until cited to utilize the waiver. It should be noted that the use of the waiver must be brought to the attention of the life safety surveyor at the entrance prior to the start of a survey. Additionally, TJC requires the election of the waiver to be identified in the additional notes section of the BBI on the electronic Statement of Conditions.

By electing to utilize the waiver for combustible decorations, hospitals are provided with more leniency regarding their allowance for combustible decorations on walls, ceilings, and non-fire-rated doors. Regardless of whether the waiver is utilized, facility managers and their staff should also keep an eye out for the following issues as they perform their daily rounds:

  1. Decorations should not obstruct or block fire extinguishing or fire alarm equipment such as fire extinguishers or manual pull stations.
  2. Decorations should not be hung from sprinklers, or located adjacent to a sprinkler such that it would obstruct the sprinkler discharge pattern.
  3. Decorations should not be placed on fire rated doors having a required rating or 45-minutes or greater, regardless of their size.
  4. Decorations should not obstruct the required clear width of corridors.