The Joint Commission reports fewer major fire safety violations in recent years, but smaller breaches of smoke and fire barriers are on the rise. According to a Joint Commission publication, surveyors found unsealed penetrations in fire barriers in at least half of the facilities visited. Those breaches would allow smoke and combustion products to invade the adjacent compartment, diminishing patient safety.
Activity above the lay-in ceiling often involves contractors running cable who breach a barrier to create holes to accommodate cables. The Joint Commission recommends limiting personnel who have enough access to create those barriers. Those workers should be trained on the barrier repair process, known as fire-stop or smoke-stop repairs.
A barrier access program might include the following actions:
• Reconciling life safety drawings with actual barriers.
• Requiring a label or stamp that identifies the type of barrier to be placed at access points.
• When repairs are made, requiring digital pictures of the correctly repaired opening.
• Conducting random barrier inspections to ensure they are being maintained.
• Requiring that a percentage of repairs be field tested to ensure they meet the design standards for the repair of an opening.
• Creating charts that identify proper fire- or smoke-stop techniques associated with the openings.
• Using one manufacturer of fire-stop products (to ensure consistent application.
• Evaluating annually if spaces around pipes, conduit, cables and wires are protected with an approved fire-rated material.
Fire Protection Updates Effective in 2012