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Working in facilities management, it is easy to get caught up in the day-to-day details of keeping up with inspections and building maintenance. However, every once in a while we hear about something happen that serves as a reminder of the real reason life safety codes are put into place.
As you have probably heard already, a fire broke out in a hospital in Eastern India last week and took the lives of over 90 patients. Through investigations, authorities discovered that the required life safety systems were not installed or put into place when the building was constructed. Fire and smoke spread from the basement of the hospital through air ducts and into patient rooms leaving little time for anyone inside to escape.
As you know, maintaining your life safety systems isn’t important just to pass your inspection, but also is a matter of life and death for the occupants of your facility in a fire. Making sure that your fire dampers are functioning, your fire doors automatically close and latch, your fire walls are probably firestopped, and checking all of these systems on a regular basis will not only help you pass your inspections, but will also save lives.
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Fire walls and fire doors are one of the most important components of a passive fire protection system and are required to be maintained regularly by IBC and NFPA 101. But when it comes to firestopping, industry experience counts.
Recently, an independent third party surveyor recently determined that when trades or in-house staff installs firestop systems, it is done correctly only 32% of the time. However, when a specialty contractor installs firestop systems using the proper UL systems, it is done correctly over 86% of the time. Using a specialty firestop contractor for your firestopping projects increases your chances of passing inspection by 54%.
When choosing a contractor, there are several things you should look for:
- Ensure they are licensed to do work in California in the trade they are proposing work.
- Check their experience in your facility type (ex. Healthcare, Commercial, etc.)
- Ask if they perform the work themselves and make sure they do not subcontract the work out.
- Make sure they have liability insurance to cover the work they are doing.
- Ensure their staff consists of a trained and professional workforce.
Establishing a Firestop Maintenance Program with a specialty contractor is a great way to stay on top of the penetrations in your firewalls and help you maintain your compliance with life safety codes. In this type of program, the contractor comes out regularly to install firestop, sealing any penetrations in your fire walls. This ensures that your fire walls maintain compliance at all times, so you won’t have to worry about firestopping when it comes time for your inspections.
Click here to learn more about PREVENT’s Firestop Maintenance Program.
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The National Fire Protection Association (NFPA) and Door Hardware Institute (DHI) recently teamed up to host a webinar regarding fire door inspections and maintenance. The association had come to the conclusion that many fire door inspectors were not properly inspecting fire rated doors due to limited knowledge and experience. This, combined with a lack of available training for inspectors, has led to an overall increase in the amount of failing fire doors during building fires.
According to NFPA 80, fire doors are one of the most important components of passive fire protection in a building. However, in order to properly hold back and compartmentalize fire, fire doors must be kept in appropriate working condition at all times. Many individuals assume that because the door closes completely and latches, or because there is a label on the door assembly, that the door is in working condition. However, this is not the case. These fire doors can deteriorate from use and every fire door needs a tune-up occasionally. Door clearances, hardware, glaze, and modifications, are all things that need to be properly inspected and maintained on a regular basis.
Fire door inspections are required by NFPA 80 to be performed no less than annually on all fire doors and DHI recommends these inspections be performed by trained and experienced individuals. Don’t leave your door inspections to chance. PREVENT has trained fire door inspectors on staff and has performed thousands of fire door inspections across the west coast. We can also make the appropriate repairs and help you to get certified, so you won’t need to call multiple contractors. We make it easy. Call us today and we’ll help you make sure that your fire doors are up to code. Click here for more information.
PREVENT recently attended a mid-year CSHE meeting in Southern California in which George Mills, of The Joint Commission (TJC), spoke and reviewed the Top 6 Most Cited Standards by TJC in the first half of 2011. The results were surprising and we felt that it was important to pass this information along so that our customers and friends are able to maintain their facility’s compliance with life safety code.
The chart below highlights some of the basic standards mentioned that are falling below acceptable levels. 
Mills reported that over 46% of facilities inspected were cited for penetrations in fire walls and fire rated doors, which translates into a lack of firestopping installed in required areas and basic fire door maintenance. Fire doors and fire walls are required to be maintained in accordance with IBC, NFPA 80, NFPA 5000, and NFPA 101. Mills stressed that managing barriers and maintaining fire wall integrity is the most important activity for hospital facilities managers to address and also recommended fire door inspections every 6 months, if not more for higher traffic doors, as “basic door maintenance is falling below critical levels.”
He also mentioned the importance of life safety documentation and its on-hand availability; no documentation, means the work has not been done. Make sure to keep your life safety documentation in a safe and accessible location, so that it’s available when it’s time for inspection. Mills also stressed the importance of deficiency resolution regarding life safety citations and issues. Facilities managers have 45 days to take corrective action.
Don’t forget that PREVENT can help you address your life safety issues quickly and efficiently. We can perform most life safety services, including firestop maintenance programs, basic firestopping service, fire and smoke damper testing, repair, and inspection, fire door inspections and repairs, commercial air duct cleaning, and install photoluminescent exit systems and signs. Call us at anytime to discuss your needs. PREVENT is on your side and can provide a quick turnaround if you anticipate an inspection.
Take the “Firedrill” out of Staying in Compliance – Avoid the “one-side of the wall” firestop mistakes
In conversations with our Field Sales Reps the subject of tight hospital budgets keeps comes up often and is of major concern to many of you. Dealing with budget constraints makes staying in compliance with the firestop safety codes much more difficult.
Delaying or otherwise not doing the necessary upgrades and maintenance of firestop systems may create the sudden need for major project work to be done immediately prior to a scheduled Joint Commission inspection. This can create some significant expense outlays, and be made even worse by overtime and other expenses associate with that type of last minute exercise. In addition, we know upper management doesn’t like this either – not to mention having to beat the inspection clock also adding to your daily headaches.
We’ve got some ideas that we have gleaned from talking with many of you at tradeshows and local ASHE meetings as well as day-to-day in your facilities. Here what others are doing and recommend you don’t do.
Implementing a Regular Maintenance Program
We have heard many stories of frenzied “all in one shot” “let’s get it all in compliance today” rushed projects before the inspectors show up “events.” Not only is this stressful, it is unnecessary. Many facilities are implementing a regular Firestopping Maintenance Program, either monthly, bi-monthly or quarterly — depending upon your budget and needs. Performing regular preventative maintenance and upgrading your current firestopping systems provides for more assured compliance and more importantly a safer facility. In addition, your Finance Department and upper management will be much happier if the bills are spread out – making it much easier to budget and fund.
Don’t Try and Save with Poor Quality
Many a facility manager have told us they wish they’d brought us in sooner. So they say, resist the temptation to bring it in house or employ contractors of questionable credentials in order to possibly save a few dollars. This can come back to bite you in the form of failed inspections and lack of facilities compliance with firestopping codes. Recently, we were at a facility that paid a local contractor to do their firestopping. As the Joint Commission was walking down the hallway, checking all the firestop work everything was looking good until he walked into a patient room. You guessed it, no firestopping at all on the other side of the wall…this was true throughout the facility. Ouch.
Make sure your Firestopping Contractor is licensed in your state and a member of FCIA (Firestop Contractors International Assoc) – FCIA contractors keep abreast of all the latest firestopping construction techniques, materials and thinking. Also, question how much you are saving and measure the quality of your results from an in-house DIY approach.
In our efforts to work with clients on keeping their facilities in compliance on an ongoing basis, PREVENT Life Safety Services has a quarterly or monthly firestopping program that you can sign up for. This enables you to spread the cost of these necessary safety upgrades over a longer period of time while maintaining the safety of your facility. Paying a premium for a “Rush- Job” can become a thing of the past.
Give us a call to discuss your budget and the timing of a regular firestopping maintenance program.
Do You Know Where Your MDRO’s Are?
In addition to considerations for dealing with with Multi-Drug Resistant Organisms (MDROs), one of the top concerns expressed by medical professionals managing infection prevention and control at medical facilities is the spread of Aspergillus contamination among critically ill patients. Aspergillus can be found in HVAC systems and contaminated dust that is disturbed during the maintenance or construction process. Aspergillus has also been found in unfiltered air, carpeting, food and ornamental plants in hospital settings.
These spore reservoirs have been specifically linked to under-maintained HVAC systems, which makes it critically important to establish a regular schedule of air duct cleaning. The HVAC system cleaning needs to be conducted by a highly trained professional expert in medical facility ventilation systems to prevent the spread of these dangerous spores. This is a first line of defense in the on-going war against hospital caused infections. Experienced operators of HVAC cleaning services will be able to manage air duct cleaning activities in the medical facility with the least amount of disruption to patients and staff.
Our company has developed a unique approach to ceiling accessed cleaning that creates a sealed airspace. By using our patented Solution Containment Unit, we are able isolate and filter the contaminated air through HEPA filters before it is released back into the hospital environment. The Solution Containment Unit also allows for minimal impact to facility operations around the workspace, allowing typical activities to resume as normal during the cleaning process.
Proper Air Duct Cleaning PREVENTs Mass HAI’s
Studies have shown that microbial infected particles can remain in an unfiltered airspace for a considerable amount of time after the initial air suspension. HAI’s are defined by the CDC as infections “for which there is no evidence that the infection was present or incubating at the time of hospital admission.” HAIs are typically acquired 3 different ways:
- Direct Contact between patient and medical staff or visitors.
- Droplet infection through coughing, sneezing, or sharing food.
- Airborne Transmission of microbial infected aerosol particles.
One of the easiest and surest ways to minimize the possibility of HAIs caused by stagnant air flow is to increase the capacity of your HVAC system to filter and move more air throughout your facility. In addition to proper filtration of air, it is also important to have your HVAC system set up to allow for the flow of air from clean to less clean areas of your facility. If your facility is somewhat vintage, the importance of regular and professional cleaning of your HVAC system becomes much more critical in ensuring the health of patients and hospital staff. A regular schedule of vent and air duct cleaning is key to the proper functioning of all ventilation systems whether in the OR, Patient Rooms, or Waiting Areas.
Mission Critical – Why firestopping
Firestopping is a crucial part of any life safety system. The main purpose of firestopping is to fill annulus or gaps between penetrating conduit and a fire barrier. By using the firestop to cover the voids, it prevents poisonous smoke and gas from penetrating from one room to the next, thus isolating the fire and smoke to a confined area. By isolating the fire and smoke, not only will you most importantly save lives, but you will also prevent the spread of smoke. By isolating the fire and smoke through firestopping, you will not only prevent wide spread damage often caused by smoke, but you will add time to the evacuation procedure, which saves lives!
5 Common Firestopping Mistakes
Avoid these common mistakes when applying firestop materials to ensure your facility’s safe operation.
- Mixing Materials and Systems. Firestopping has many techniques that must be followed, as well as regulations required for installation. A flaw that commonly seems to appear with unprofessional installers is that they tend to mix firestopping material using different brand of firestopping. This is a major “No-No” and will void the fire rating of the material.
- Inadequate labeling of firestop work. Another common mistake by inexperienced installers is that they don’t label the firestop to indicate system and materials. By labeling the firestop, it provides a future technician the necessary information should the firestop process need to be reapplied or expanded.
- Misuse of New technologies or systems. Often new products are not installed correctly by untrained personnel. For example often cable protection systems (i.e. EZ Paths.) are overfilled beyond the recommended 2/3rds capacity. Another example is using firestop muffins that are designed to protrude from a hole. Instead they are tucked-in with space surrounding the muffins, rendering them ineffective for trapping smoke and fire.
- . Often instead of using approved firestop material, unprofessional technicians use everything from core cutouts,
 mortar and concrete, expandable  combustible foam and a variety of other unrated materials. None of these materials will meet the fire rating standards and expose the hospital or facility to significant damage.
- Incorrect Bonding. Another common mistake is to bond firestop to combustible material, such as plastic bushing as opposed to bonding to a fire wall or fire barrier.
These are just a few of the many common mistakes made by inexperienced and unprofessional installers of firestop. This is why it is so crucial that the installer be thorough, regularly-trained and experienced. When it comes to Life/Fire Safety Services there is no margin for error!
Fire dampers are a life safety issue. They keep smoke and flames from spreading throughout a building, saving lives and preventing unnecessary injury, in case of a fire.
Codes and Regulations
The Joint Commission, the regulatory agency that accredits hospitals, requires that in-patient hospitals inspect their dampers every six (6) years. For non-inpatient care buildings, such as medical office buildings and out-patient surgery centers, the requirement is every four (4) years. Anything newly installed such as a new wing or a renovation must be inspected within 12 months.
Most facility staffs are busy enough, keeping their fire dampers inspected and up to code often falls on the back burner. That’s where an outside services group can be helpful and save labor and repetitive work. We can help you make sure your dampers are up to code and working correctly.
Inspection Process
The first step is to physically inspect your dampers. The most conscientious contractors use specialized portable infection control units. At Prevent our containment unit called The Solution gives us ceiling access and ensures that dirt and debris stay contained within the unit — and all outer air flow is filtered, through the built-in HEPA unit. (See more on “The Solution”)
After the Inspection – Addressing Repairs
We recommend, and the Joint Commission requires that any deficiencies found in the fire dampers inspection process require immediate repairs. If we find a deficiency or something not working correctly, we’ll address it immediately. Our team can mobilize in less than 24 hours, meeting your needs whether it’s at night or on the weekend.
Prevent is one of the few inspection companies licensed to do fire damper repairs. We can typically do any type of repair, from routine fixes such as replacing actuators, cutting access to more complex corrections.
Compliance Reporting
To keep you in compliance with key regulatory agencies such as The Joint Commission or CMS, detailed reporting should be provided. Prevent provides detailed daily logs of all inspections indicating any problem areas or repair needs. In addition, we provide an annotated copy of your floor plans indicating damper locations inspected. Both are helpful documents to support your Joint Commission review process.
Take Action
Call us to discuss and help you address your fire and smoke damper issues.
Most of us can recall the photographs of people streaming out of the World Trade Center after the planes hit in 2001. What most people don’t know, however, is that what helped many people survive was photoluminescent egress systems (PLES). This glow-in-the-dark technology marks the exits of buildings with the goal of guiding people out safely in case of an emergency.
Photoluminescent exit systems work. When interviewed, 9/11 survivors listed PLES markings among the Top 3 things that helped them get out of the building and live to talk about it.
When the power gets knocked out and no emergency generator is available, photoluminescence is invaluable. Now, it’s a requirement for all buildings as part of the 2009 International Building Code (IBC) for all buildings taller than 75 feet.
Besides the obvious safety benefit, photoluminescence is a great “green” product because it doesn’t require any power source and uses natural sunlight to charge. It can be used at any location, requires no wires or electricity and brings a cost savings because you don’t have to supply power during the year. Just as an example, if your facility uses 500 exit signs, you can save $3000 a year by using photoluminescent exit signs instead of LED signs, not to mention, no bulb changing or periodic testing.
Whether you are undertaking new construction, doing a retrofit or building an addition, we can help you determine your needs for this energy-efficient product that is crucial for safety.
We’ll come look at your facility, discuss requirements about what does and doesn’t need to be marked and give you an estimate to ensure that a building’s occupants have all possible advantages for exiting a building safely and quickly in case of a life-threatening emergency.
photo luminescent egress systems (PLES). This glow-in-the-dark technology marks the exits of buildings with the goal of guiding people out safely in case of an emergency.
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