Review Process for Health Care Facilities
When performing work that is considered construction, remodeling, or an addition to a State-regulated health care facility, plans and specifications must be submitted to the State of Michigan Bureau of Fire Services (MBFS) in accordance with this guideline.
The guideline is intended to outline basic requirements and to show how the plan review and inspection process is handled at the University, including interaction between the University and MBFS. The guideline is NOT intended to provide specific requirements for construction of buildings or installation of required life safety systems or equipment. All work must be performed in accordance with the MBFS Administrative Rules for Health Care Facilities Fire Safety, the Codes and Standards that are referenced by the Administrative Rules, and any other applicable law, rule, code, or standard.
Plan review submittals to MBFS must be coordinated through the UMHS FP&D. Copies of all plans and specifications that are sent to MBFS must also be sent to OSEH Fire Safety Services for review.
- Determine Applicability
- Plan Submittal
FP&D maintains a list of buildings which contain health care occupancies. The list can be found at the end of the "Supplemental Codes and Regulatory Agencies for UMHHC Facilities" document published on the FP&D website. However, please bear in mind that the list of health care facilities contained in the Supplemental Design Guideline may not be complete, and that the actual use of the building or space must govern the plan review submittal process. Designers should consult the list as standard practice but must validate the data before proceeding with the project. If any discrepancies are discovered, they should be brought to the attention of Heather Lewis, the Manager of Architectural Services at FP&D.
If it is determined that a building or space contains an MBFS-regulated health care occupancy, it must then be determined if the scope of work will require a plan review submittal. MBFS requires that plans and specifications be submitted for any project involving construction, remodeling, or an addition to the building. Submittals are NOT required for work that is limited to routine maintenance functions or cosmetic remodeling.
"Remodeling" is defined as an alteration or change of a fire-rated assembly, or the installation of new equipment required by the MBFS Administrate Rules.
"Cosmetic Remodeling" is defined as surface changes solely to the wall, floor, and ceiling that do not decrease the fire rating of the wall, floor, or ceiling, including the replacement of windows and doors.
"Maintenance" is defined as repair required to keep a building and its component parts in an operative condition at all times, including the replacement of its component parts when, for any reason, the component parts are no longer dependable. "Maintenance" does not include remodeling.
Note: If you have determined that the scope of work for your project involves ONLY "cosmetic remodeling" or "maintenance," a submittal to MBFS is not required. However, a submittal to OSEH Fire Safety Services may still be required, in accordance with the Fire Safety Review Process for Non-Regulated Facilities and Projects Outside the Scope of MBFS Review.
If you have determined that the scope of work for your project involves construction, remodeling, or an addition, plans and specifications must be submitted to MBFS. Plan review submittals must contain ALL of the following, if they are applicable to the scope of work being performed:
- A complete floor plan and layout of the building drawn accurately to scale.
- The use of each room.
- The dimensions of each room.
- The size, location, direction of swing, and fire rating of each door and frame assembly.
- The size and location of windows.
- The wall construction, including the fire-resistance rating.
- The type of construction as identified in national fire protection association pamphlet no. 220, 1995 edition, entitled "Standard on Types of Building Construction."
- The number of stories, including basement and attic areas.
- The interior finish classification.
- The location of fuel-fired equipment.
- The type of furnace and water heater.
- Air-handling system specifications.
- Fire detection and alarm system plans and specifications that are in compliance with the provisions of the State of Michigan Fire Prevention Code.
- Sprinkler or other suppression system plans and specifications that are in compliance with the provisions of the State of Michigan Fire Prevention Code.
- The type, size, and location of fire extinguishers.
- Other pertinent information that is required to determine compliance with the MBFS Administrative Rules.
ONLY the information that is applicable to your project is required. For example, if the project does not involve altering or replacing a furnace or air handling equipment during the renovation of an office suite in an existing building, it IS NOT necessary to submit information regarding the furnace or air handling equipment, even though these items are listed above.
Note: Plans for work involving the practice of architecture or engineering must be sealed by a registered architect or engineer.
Special rules apply to construction, renovation, and additions that affect fire alarm systems, fire suppression systems, the outside configuration of the building, and installation or modification of electrical equipment or wiring. More information regarding these rules, and required submittals, are below.
- Construction barriers and means of egress during construction:
The MBFS Administrative Rules for Health Care Facilities Fire Safety provide for the following:
1-3.11.1. A person may occupy a building or portion of a building during construction, repair, alterations, or additions only if all means of egress and all fire protection features in the building and on-site are in place and continuously maintained for the part occupied and if the occupied portion is separated from the part under construction by a wall that has a 1-hour-fire-resistance rating. The temporary 1-hour-rated wall that is used for separation may be constructed of combustible material. Instead of having all means of egress and fire protection features in place, the health care facility may take other measures that would provide equivalent safety if approved by the office of fire safety. A health care facility or part of a health care facility shall not be occupied, in whole or in part, without approval from the office of fire safety and the department of consumer and industry services, bureau of health systems.
All construction barrier requirements for each project should be reviewed with the University of Michigan Health System Safety Management Services Department (SMS). Les Weick is the Construction Safety Specialist with SMS. Mr. Weick will coordinate any required review of construction barriers and/or means of egress with MBFS and the Bureau of Health Systems. OSEH Fire Safety Services is also available to assist with these evaluations if requested.
- Change of occupancy:
This guideline is intended to be used in renovation projects taking place in buildings with existing health care occupancies. If your renovation project involves creating health care space in a building that does not contain this occupancy already, or involves converting the building or space from one type of health care occupancy to another, the MBFS will review the ENTIRE building as if it were new construction. Their review WILL NOT be limited to the renovated area, and a complete set of plans for the building will have to be submitted, demonstrating that the entire facility is in compliance with the applicable codes and standards. Prior to beginning a project that will involve converting an existing, non-heath care building to health care use, UMHS FP&D, as well as OSEH Fire Safety Services, must be consulted.
- Separation of occupancies:
The MBFS Administrative Rules for Health Care Facilities Fire Safety incorporate the 1997 edition of the NFPA 101 Life Safety Code by reference. The Life Safety Code requires that "when two or more classes of occupancy occur in the same building or structure and are intermingles so that separate safeguards are impracticable, means of egress facilities, construction, protection, and other safeguards shall comply with the most restrictive life safety requirements of the occupancies involved."
The Life Safety Code also contains specific provisions regarding required separations between Health Care occupancies and other occupancies (See sections 12-1.2 and 13-1.2 of the Life Safety Code). In general, if a building contains a Health Care occupancy, the entire building will be subject to the MBFS plan review and inspection process for construction, remodeling, and additions. This includes space within the building that is not used for health care purposes. However, MBFS may waive the required architectural plan review and inspection under some circumstances, as outlined below.
In some cases, a construction or remodeling project will affect only a portion of a building that is separated from the health care occupancy. If it has been confirmed that the construction area is not going to be used for health care purposes, and is completely separated from the health care area of the building by at least 2-hour fire-resistance-rated construction, and the project will not affect egress from the Health Care occupancy, submission of architectural plans and specifications to MBFS will generally not be required. The existence of the 2-hour separation will have to be confirmed by the design professional responsible for the project. After the existence of the 2-hour separation is confirmed, a review should be conducted with OSEH Fire Safety Services and a representative from FP&D, at which time a plan will be developed for proceeding with discussions with MBFS. The final determination regarding any required plan review submittal will come from MBFS.
If a project involves any modification to the building’s fire alarm or fire suppression system, and the fire alarm or suppression system serves both the health care and non-health care compartments of the building, MBFS review will be required for these systems. MBFS will generally NOT review the submittal for compliance with code in the non-health care compartment, but WILL require that the certified firm responsible for the fire alarm or suppression system installation complete an FS-12A form, documenting that the installation in the non-health care areas will not adversely affect the normal required operation of the system serving the heath care areas.
If a project involves a building containing two different MBFS regulated occupancies, such as Heath Care and Dormitory or Health Care and Classroom space regulated by the Administrative Rules for New and Existing School, College and University Fire Safety, MBFS will review the project in accordance with the most restrictive requirements of the appropriate Administrative Rule and the Life Safety Code. However, if the occupancies are separated with 2-hour or greater fire-resistance-rated construction, MBFS may choose to apply the Administrative Rules separately in each compartment. Projects involving these types of occupancies are obviously complex, and should always involve discussions with FP&D, OSEH Fire Safety Services, and MBFS as early in the design process as possible.
When a project involves renovations to a non-health care, separated compartment of a health care building, and MBFS has agreed that they will not conduct an architectural plan review, the plans and specifications must be submitted to OSEH Fire Safety Services in accordance with the Fire Safety Review Process for Non-Regulated Facilities and Projects Outside the Scope of MBFS Review.
- Projects that affect the outside configuration of the building:
When a project will affect the outside configuration of an MBFS-regulated instructional building, a site plan and specifications that detail all of the following information, as applicable, must be submitted to MBFS and to the local fire department:
- The available water supply.
- Hydrant locations.
- Vehicle access routes.
- Fire lanes.
The site plan and specifications should be submitted to MBFS along with the other required plans and specifications for the project. The submittal to the local fire department should be made to OSEH Fire Safety Services. FSS will coordinate any necessary review with the Ann Arbor Fire Department, or other local fire department for projects outside the City of Ann Arbor.
Projects involving fire alarm systems and/or fire suppression systems:
When a project involves installation of new fire alarm devices, installation of new fire suppression system(s), or modifications to existing fire alarm or suppression systems, complete shop drawings for the affected system(s) must be submitted to MBFS. MBFS requires that these drawings be prepared by a certified firm, in accordance with the requirements of the State of Michigan Fire Prevention Code. The University of Michigan Plant Department Fire Protection Shop is a State-certified firm, and can prepare the necessary drawings. If outside contractors are used for this work, they must be certified, and they are responsible for submitting shop drawings to MBFS. In either case, copies of the shop drawings must also be submitted to OSEH Fire Safety Services and Factory Mutual.
Projects involving electrical work:
MBFS requires that any electrical wiring and equipment installed in heath care buildings be in compliance with the Michigan Electrical Code. This includes the Code’s requirements for electrical inspections and issuance of an electrical inspection certificate. The electrical inspection certificate must be issued by an inspection authority that has been found to be acceptable by MBFS. In the case of the University, the Code Inspection Group in AEC is considered to be an acceptable inspection authority. All electrical work requiring an electrical code inspection must be inspected by an AEC Electrical Inspector, and a copy of their Final Electrical Inspection Certificate must be given to the MBFS Fire Marshal Inspector at the time of the final MBFS inspection.
If a project is limited ONLY to electrical work, it must be submitted to MBFS if the scope of work involves altering a fire rated assembly, or involves a required life safety system. If the project involves only minor work (such as relocating an electrical outlet or installing additional outlets in an existing room), without altering a fire rated assembly, the project DOES NOT need to be submitted to MBFS for review. However, the project must still be inspected in accordance with established University procedures.
It should also be noted that the Michigan Electrical Code does NOT require electrical construction permits or electrical inspections for certain types of electrical work. If your project consists ONLY of this type of work, it is not necessary to submit plans to MBFS for approval, unless the work will involve altering a fire rated assembly (such as a rated wall, ceiling, or floor). The following types of electrical work DO NOT require permits in accordance with the Michigan Electrical Code:
- Minor repair work, which is defined as "electrical wiring not in excess of a valuation of $100.00."
- The installation, alteration, repairing, rebuilding, or remodeling of elevators, dumbwaiters, escalators, or man lifts performed under a permit issued by an elevator inspection agency of the state of Michigan or political subdivision of the state of Michigan.
- The installation, alteration, or repair of electrical equipment and its associated wiring installed on the premises of consumers or subscribers by or for electrical energy supply or communication agencies for use by such agencies in the generation, transmission, distribution, or metering of electrical energy or for the operation of signals or transmission of intelligence.
- The installation, alteration, or repair of electric wiring for the generation and primary distribution of electric current, or the secondary distribution system up to and including the meters, where such work is an integral part of the system owned and operated by an electric light and power utility in rendering its duly authorized service.
- Any work involved in the manufacture of electric equipment, including the testing and repairing of such manufactured equipment.
- The installation, alteration, or repair of equipment and its associated wiring for the generation or distribution of electric energy for the operation of signals or transmission of intelligence where such work is in connection with a communication system owned or operated by a telephone or telegraph company in rendering its authorized service as a telephone or telegraph company.
- Any work involved in the use, maintenance, operation, dismantling, or reassembling of motion picture and theatrical equipment used in any building with approved facilities for entertainment or educational use and which has the necessary permanent wiring and floor and wall receptacle outlets designed for the proper and safe use of such theatrical equipment, but not including any permanent wiring.
- The installation, maintenance, or servicing of burglar alarm systems within a building or structure.
- The installation, maintenance, or servicing of listed residential and commercial lawn irrigation equipment, except any permanent wired connections exceeding 30 volts.
- The construction, installation, maintenance, repair, and renovation of telecommunications equipment and related systems by a person, firm, or corporation primarily engaged in the telecommunications and related information systems industry. This exemption does not include the construction, installation, maintenance, repair, and renovation of a fire alarm system.
If you are unsure whether your scope of work involves one of the above items, an AEC Electrical Inspector should be consulted.
Other equipment and systems:
The MBFS administrative rules call for certain work (see list below) to be performed in conformance with specified regulatory requirements. You should be prepared to demonstrate that these requirements have been met, if such documentation is requested by MBFS.
- Equipment which utilizes natural gas and related natural gas piping must be installed in compliance with the provisions of NFPA 54, the National Fuel Gas Code. Natural gas piping and equipment should be inspected by an AEC Mechanical Inspector.
- Elevators, escalators, dumbwaiters, and moving walks must be installed and maintained in accordance with the State of Michigan Elevator Code. Any work related to this equipment should be coordinated with the University of Michigan Plant Department Elevator Shop.