Author(s): Angelo Verzoni. Published on May 1, 2020.

Compliance on Hold

As health care facilities scrambled to expand patient capacity amid the coronavirus pandemic, fire and life safety code compliance took a back seat. Should that worry us?  

Related Content

Listen to an NFPA Journal Podcast on how health care facilities in the US prepared for the COVID-19 patient surge
Read the April 2020 NFPA fact sheet, “Maintaining Safe Health Care Facilities in Extraordinary Times”

Read the April 2020 NFPA white paper, “Temporary Compliance Options for Code Modifications, Alternate Care Sites, and Facilities Related to Health Care”

On March 22, Texas Governor Greg Abbott issued an executive order that temporarily suspended a number of state building code provisions, mostly related to maximum hospital room occupant load. The order was part of an effort to give jurisdictions throughout the state the opportunity to more easily expand their patient capacity as Texas—and the United States as a whole—braced for a surge in patients sickened by COVID-19, a novel coronavirus that became a global pandemic earlier that month.

Throughout March and April, similar decisions were being made across the US as communities pursued modifying existing health care facilities, or rapidly building temporary ones, to meet patient demand. As of April 10, the US Army Corps of Engineers had received over 1,000 requests from cities seeking guidance on establishing temporary hospitals, according to a recent NPR report. And in a March survey of more than 1,000 US code officials, conducted by the International Code Council, more than a quarter of respondents reported receiving building permit requests for temporary structures, many to serve as health care facilities.

On the federal level, the Centers for Medicare & Medicaid Services (CMS) announced a pause in survey inspections for violations outside of infection control and patient abuse measures. That announcement came on March 13, the same day the World Health Organization declared COVID-19 a global pandemic. “They’re worried, obviously, about infection control right now, but there’s some relaxation going on around regular inspections for things like fire and life safety,” Jon Hart, an engineering technical services lead at NFPA, said of the CMS announcement on an NFPA Journal Podcast that aired March 21.

While the need to expand patient capacity to meet the surge caused by coronavirus was clear, the need to roll back regulations to achieve it generated some concern among building fire and life safety professionals. But it was, for the most part, a risk they were willing to take—an unprecedented action taken in an unprecedented time. And in interviews with NFPA Journal, they stressed that under such extraordinary circumstances, facility managers, designers, and authorities having jurisdiction (AHJs) can still take steps to achieve an adequate level of safety in existing and newly created health care facilities without adhering strictly to codes and standards like NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code.

“Everybody’s concerned, but we have to play with the hand that’s been dealt,” Robert Solomon, director of the Building and Life Safety Division at NFPA, said in late March. “You can still make these facilities safe, to a degree, without adhering to every bell and whistle in the codes and standards—at least on a temporary basis.”


By April 3, the number of confirmed COVID-19 cases in New York City had topped 50,000. More than 1,500 people had died from the virus. The city’s hospital system was overwhelmed, with officials rushing to convert nearly every square foot of patient care areas to intensive care units (ICUs), and to establish temporary hospitals in convention centers, parking lots, and hotels.

Less than 200 miles away, in Rhode Island, Keith Burlingame hoped his state wouldn’t become the next New York, but he and other state code officials were preparing for the worst. That preparation included relaxing certain state building code regulations to allow not only for increased patient capacity, but also for housing the state’s homeless population and a number of prisoners who were set to be released during the coronavirus pandemic, said Burlingame, executive director of the Rhode Island Fire Safety Code Board of Appeal and Review. But while the state had agreed to relax—or as Burlingame referred to it, “grant relief from”—passive code provisions related to things like occupant loads and hallway widths, it didn’t do the same for active provisions related to systems like fire alarms.

“If we had, for example, an old hospital building from the 1950s that had been converted into a business and we wanted to repurpose it back to a hospital, it might not meet the requirements for a new hospital in Chapter 18 of NFPA 101, but it could very likely meet the requirements for an existing hospital in Chapter 19,” Burlingame said. “The corridor width might not be compliant now, but we think that would be a reasonable relief provided it has a fire alarm and sprinkler system.”

Sprinklers, Burlingame conceded, weren’t going to be a feasible protection measure in every new health care occupancy the state might have to create to address the pandemic, such as field hospitals. In those cases, however, other fire safety measures were being explored. “Maybe in the most severe situations we will have staff doing fire watches or even have a firefighter detail issued,” he said.

WORLDWIDE PHENOMENON  In Sao Paulo, Brazil, a temporary hospital for coronavirus patients was erected inside a stadium. (Getty Images)

As regulatory exceptions like this were being implemented across the US, NFPA released a white paper and a fact sheet in early April to help facility managers, designers, and AHJs navigate the situation. Both documents indicate, for instance, that portions of NFPA codes and standards can still be used to enhance safety at health care facilities without those facilities meeting the codes in their entirety.

“With the peak of [COVID-19] cases expected within weeks in some locations, it will be impossible to modify or construct spaces in strict compliance with fire and life safety codes,” the fact sheet reads. “In these extraordinary times, however, we can still look to the intent of these documents and use portions, such as the equivalency clauses, goals, and objectives of NFPA 101 or the risk-based approach of NFPA 99, in order to guide these difficult decisions.”

Guidance came from state and federal levels as well. On April 5, for example, the Massachusetts Office of the State Fire Marshal and Division of Professional Licensure issued a joint memorandum outlining considerations for achieving safety in repurposed and temporary structures during the coronavirus pandemic. Temporary hospitals were already being built in the state’s largest cities, Boston and Worcester, as the number of coronavirus cases in Massachusetts approached 20,000, the fifth highest in the country.

“Building inspectors must work closely with local and state building and fire officials to expedite proposal reviews, permitting, and safe occupancy of these tent structures and temporary uses of existing buildings,” the memorandum said. It provided a number of measures these officials could take to reach an adequate level of safety in these structures without necessarily being in compliance with local codes for that occupancy type, such as keeping tents at least 20 feet apart from one another, ensuring emergency vehicle accessibility, and including fire alarm and carbon monoxide detection systems—even if it’s simply the use of battery-operated smoke alarms.

In New York City, the US Army Corps of Engineers, working on behalf of the Federal Emergency Management Agency, was brought in to assist with much of the city’s temporary hospital planning and design. As in Rhode Island, the use of existing buildings that already met some level of codes became key to their efforts.

“When we were first asked to come in three and a half weeks ago … they wanted us to build a hotel,” Lt. General Todd Semonite, chief of engineers and commanding general of the Corps, told NPR. “You can’t build a hotel in three weeks. So what we said was let’s go into an existing facility—a large field house, a convention center, a hotel—that already has code [compliance for fire and electrical safety] … and then build an ICU-like capability inside.” The Corps took similar approaches to establishing temporary health care facilities in other large cities like Detroit, Chicago, and Miami, Semonite said.

Oxygen control valves at a temporary COVID-19 hospital under construction at the national tennis center, located in the Borough of Queens in New York City. (Getty Images)

Not everyone has been eager to jump on board with relaxing regulations or pausing the inspection, testing, and maintenance (ITM) of fire and life safety systems in health care facilities in the face of the pandemic. In Little Rock, Arkansas, fire protection engineer and hospital facility manager Joshua Brackett had only put one thing on hold as of April 10—any ITM that required shutting down air-handling units in his facilities, part of Baptist Health, Arkansas’s largest health care system.

“You have to be careful,” Bracket said. “You can’t think just because CMS has suspended survey inspections that you can relax your own ITM procedures and that it’s right. You still need to do, at a minimum, the risk assessments associated with whatever actions you’re contemplating. We have codes in place for a reason.”

ANGELO VERZONI is staff writer for NFPA Journal. Top photograph: Getty Images