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CFR(s): NFPA 101

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1 1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)

This STANDARD is not met as evidenced by:
Based upon observation, a review of records and staff interview, the facility fails to assure that a building undergoing, repair, renovation, modification, or reconstructions complies with the requirements of Chapter 18 and 19. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting all patients, visitors and staff. The facility has a census of 720 at the time of the inspection.

During the 50% inspection on 5/14/19 it is observed:

1. At 10:26 AM in the PET control room the ceiling is observed removed from the room. There is an interstitial space lid located in most of this room. However, the space between the existing pendant sprinkler heads and this lid exceeds the maximum allowed distance between the deflector and the ceiling. At 10:27 AM the construction separation between the renovation area and the existing hospital for the operating room project does not meet a 1-hour fire rating. Exposed studs are seen, and plastic sheeting is used to separate large areas near the ceiling.

2. At 10:30 AM, in the operating room control desk project the sprinkler system has been removed under the interstitial space lid. There is no sprinkler protection observed in an approximate 20' X 20' area of this room. At 10:31 AM the construction separation between the renovation area and the existing hospital for the operating room project does not meet a 1-hour fire rating. Exposed studs are seen, and plastic sheeting is used to separate large areas near the ceiling.


Construction personnel and hospital EHS staff were present and acknowledged the findings.

NFPA Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1-hour fire resistance rating and openings shall have at least a 45-minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2

CFR(s): NFPA 101

Sprinkler System Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

This STANDARD is not met as evidenced by:
Based on observation, record review and interview the facility does not assure the fire watch procedure and policy is followed as required for implementation when the fire sprinkler system is out of service or impaired for more than 10 hours in a 24-hour period. This deficient practice would prevent proper notification of insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction as required, affecting all visitors, patients, and staff. The facility has a census of 720 at the time of the inspection.

Findings include:

During interview and policy review on 5/14/19 at 12:00 PM, and 3:00 PM, it is revealed that the facility's written policy for implementing a fire watch for sprinkler system impairment is to have taken affect anytime the sprinkler system is out of service for more than 4 hours. The policy states under the policy heading, "The fire suppression and fire alarm signaling systems shall be operational throughout the facility. Anytime either of these systems becomes impaired due to an unplanned circumstance, the facility must immediately start an informal Fire Watch (per Kansas State Fire Marshal Fire Fact 085). If the conditions remain after a four (4) hour Informal Fire Watch within a twenty-four (24) hour period for the impairment of the system(s), then a Formal Fire Watch must be immediately implemented. It should be noted that the requirements apply to the interstitial spaces above the area where the fire alarm or sprinkler system is out of service. All areas are to be checked at least hourly. More frequent checks may be mandated by the Environmental Health and Safety Department, Hospital Construction, Hospital Maintenance, or Property Manager, or designee if conditions exist which could cause a fire." Under the informal fire watch heading it states, "If the conditions above are expected to exist for over four (4) hours within a twenty-four (24) hour period, a Formal Fire Watch shall be initiated." Under the definitions heading the policy states, "Formal Fire Watch - A planned outage of the building's fire alarm system or sprinkler system that exceeds four (4) hours in a twenty-four (24) hour period." However, at the time of the 50% inspection, a portion of the sprinkler system had been out of service for approximately 45 days, and a portion of the sprinkler system had been removed for approximately 14 days and a fire watch was not being performed.

Construction personnel and hospital EHS staff were present and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7