compliance with other equivalent alternative life safety solutions.
a) Assessment Process. The process of determining compliance with NFPA
101 (reference 13a) may be facilitated by the use of JCAHO s (reference 13c)
"Statement of Conditions" document. Part 3 of the document is the "Life
Safety Assessment (LSA)" section, which consists of a check list form designed
to assess compliance with the Life Safety Code. The document provides a
systematic method of evaluating compliance, and each check list line item
addresses a particular fire/life safety feature and includes the applicable
reference paragraph or section of NFPA 101 (reference 13a).
b) Compliance Equivalency. Facilities determined not to comply with
NFPA 101 (reference 13a) for existing occupancies may be reevaluated utilizing
NFPA 101A (reference 13d). The Fire Safety Evaluation System (FSES)
methodology may be used to determine if existing conditions and systems are
equivalent to the Life Safety Code requirements.
c) Compliance. Facilities and/or facility feature(s) determined not to
comply with NFPA 101 ((reference 13a), and determined not to be equivalent to
NFPA 101 (reference 13a) by means of NFPA 101A (reference 13d), shall be
corrected. Corrections may be facilitated by the use of the JCAHO's Statement
of Conditions, Part 4, "Plan for Improvement (PFI)" The PFI should be
maintained and updated on a regular basis or as recommended by the JCAHO.
Construction Operations. Fire protection and life safety
provisions shall be provided during construction as specified by MIL- HDBK-
1008, the National Fire Protection Association Codes and Standards, and the
Interim Life Safety Measures (ILSM) of the JCAHO Manual (reference 13c). When
a facility is to be occupied during a renovation, alteration or upgrade,
consideration shall be given to the potential impact on life safety in
occupied areas. Construction and demolition phasing shall be planned so that
the integrity of fire and smoke partitions, exits, stairways, and vertical
shafts, which are contiguous with inpatient areas, are maintained to the
highest level possible. Appropriate safety measures in accordance with NFPA
101 (reference 13a) and NFPA 241 (reference 13q) will be incorporated into
Occupancy Classification. Occupancy classification of medical
facilities shall be defined by NFPA 101 (reference 13a). Facilities or
portions of facilities, which are not required to be health care occupancy,
may be classified as other occupancies provided that the requirements of NFPA
101 are satisfied.
Means of Egress. Facilities shall meet the requirements of the
Life Safety Code, NFPA 101 (reference 13a).
Horizontal Exits. Floors with inpatient sleeping rooms shall
utilize horizontal exits to the fullest extent possible to maximize "defend-
Areas of Refuge. Total evacuation of the occupants to the outside
of the building is often impractical for inpatients located on upper floors.
Therefore, areas of refuge shall be implemented through the use of smoke
Interior Finishes. Interior wall, ceiling and floor finishes, and
movable partitions shall conform to MIL-HDBK-1008 (reference 13b).
Carpeting. Carpeting and other textile wall coverings shall not
be utilized on walls in smoke compartments with sleeping areas and shall not
be utilized in other areas except as allowed by MIL-HDBK-1008 (reference 13b).