Expand each section below to find answers for many of the most frequently asked questions about this program.
If you can't find your question, please send an email to Facilities Compliance.
What is the Above Ceiling Work Certificate & Permit Program?
It is a compliance program administered by UK HealthCare Facilities Compliance that requires anyone accessing above-ceiling spaces in a UK HealthCare facility to be trained and certified. Work that impacts fire- or smoke-rated barriers additionally requires a project-specific permit approved before work begins.
Why was this program created?
Above-ceiling spaces in healthcare facilities contain life safety systems, fire and smoke barriers, sprinkler lines, fire dampers, and fire alarm devices that protect patients who cannot self-evacuate in an emergency. The program exists to ensure these systems are not damaged or compromised during routine maintenance, construction, or installations, and to maintain compliance with Joint Commission, CMS, and NFPA standards.
Who must participate?
Everyone, including UK HealthCare employees (Facilities Maintenance, IT, Biomedical, Clinical Engineering, etc.), contractors, subcontractors, and vendors who performs any work above the ceiling in a UK HealthCare building must participate. There are no exceptions based on trade, employer type, or scope of work.
What is the Above Ceiling Work Certificate?
It is a credential issued to individuals who have completed the required Above Ceiling Safety Training and passed the assessment. It verifies that the holder understands fire barrier identification, firestopping requirements, sprinkler protection rules, electrical safety, infection control, eFacTS usage, and the Soleran permit process. A physical identifier (badge sticker or ID card) is issued upon completion.
How do I get certified?
Do I need the certificate just to lift a ceiling tile and look?
Yes. The certificate is required before anyone removes a ceiling tile or accesses any above-ceiling space for any reason, including visual inspection only.
If I am part of a larger project, does everyone on the job need certification?
No. There must be at least on certified individual on the project site at all times though. Depending on the size of the project, contractors may want to require certifications for each subcontractor's responsible person If the work is minor, the primary contractor can be certified if he is at the project site and overseeing all aspects of the work every day.
How long is the certificate valid? One (1) year.
Renewal training must be completed before the certificate expires. Working with an expired certificate is a policy violation.
What happens if I work above the ceiling without a valid certificate?
It is a policy violation subject to immediate work stoppage, removal from the site, revocation of certification, and — for contractors — potential contract termination. UK employees may also face disciplinary action under UK Human Resources policies.
What is the difference between a Certificate and a Permit?
The certificate authorizes the individual — it proves you have been trained. The permit authorizes the specific project — it documents what work will be done, where, and when, and requires Facilities Compliance review and approval. You must have a certificate before you can apply for a permit.
When do I need an Above Ceiling Permit? A permit is required when work involves any of the following:
When in doubt, contact Facilities Compliance before starting work.
How do I apply for an Above Ceiling Permit?
The application must include: contact information, project location (campus, building, floor, room), work description, start and end dates, confirmation that eFacTS life safety drawings were reviewed, firestopping product specifications, and a description of items to be installed, modified, or removed.
When can I start work?
Only after the permit status shows "Approved" in Soleran. You will receive an email notification upon approval. Starting work before approval is a policy violation.
Do I need to keep a copy of the permit on site?
Yes. A printed copy of the approved permit must be available at the work site at all times during the project.
Who reviews and approves the permit?
UK HealthCare Facilities Compliance reviews all permit applications. Incomplete applications will be returned for correction. Facilities Compliance may conduct a pre-work site survey before approving.
What do I do when the project is finished?
Log into Soleran, navigate to your approved permit, scroll to the "Permit Completion" section, check the "Request Closeout of Permit" box, and submit. Facilities Compliance will be automatically notified and will schedule a post-work inspection.
What happens after I request a closeout?
Facilities Compliance conducts a post-work inspection verifying that: all barrier penetrations are properly firestopped with UL-listed systems, all ceiling tiles are properly seated with no gaps, nothing is touching or supported by sprinkler piping, all junction boxes are covered, all open knockouts are sealed, and the space is free of debris and abandoned materials. If deficiencies are found, you must correct them at your own expense before the permit will be closed.
Who is responsible for ensuring permits are obtained?
Any person responsible for the work or project. UK Project Manager, FMHC Manager, Supervisor, IT Project Manager, Contractors, responsible parties for vendors, etc.
Does a permit cover the entire building or just one location?
Permits are valid only for the specific location, time period, and scope of work described in the application. A new permit is required for new tasks, locations, dates, or any material change in scope.
What are the rules for working around sprinkler systems?
Nothing may touch, rest on, be supported by, or be attached to fire sprinkler piping or sprinkler system supports — including data cables, ductwork, pipe insulation, conduit, or any other material. This is one of the most frequently cited Joint Commission deficiencies.
What are the cable management requirements?
All cabling must be installed in conduit or properly supported using cable trays or J-hooks. Refer to IT and FMHC standards for more information. Cables cannot be draped over ductwork, piping, hangers, or laid directly on ceiling tiles or the grid. All cabling in plenum spaces must be plenum-rated.
What are the electrical requirements?
All junction boxes must have covers properly installed. All open knockouts must be sealed. All electrical work must comply with NFPA 70 (National Electrical Code) requirements.
What must I do with the ceiling tiles when I'm done?
All ceiling tiles must be replaced and seated flush with the grid — no gaps. Damaged tiles must be replaced, not just repositioned.
What do I do with leftover materials and debris?
All abandoned materials, wire, conduit, and construction debris must be removed from above the ceiling upon project completion.
What if I find a pre-existing problem above the ceiling — something I didn't cause?
You must report it to Facilities Compliance. Do not leave deficiencies unreported, even if they were there before you arrived.
What is a rated barrier?
A rated barrier is a fire or smoke barrier — a wall, floor, or ceiling assembly — engineered to prevent the spread of fire and smoke through a building. In a healthcare facility, rated barriers are critical because many patients cannot self-evacuate. Types include fire barriers, smoke barriers, and smoke partitions, each with specific rating requirements.
How do I know if I'm working near a fire or smoke barrier?
Check by:
You must consult eFacTS Life Safety Drawings before penetrating any wall, floor, or ceiling assembly.
What if there is no hard ceiling barrier above me?
You still need an Above Ceiling Work Certificate and/or permit for any work above 9 feet in areas without a hard ceiling. Contact Facilities Compliance to confirm permit requirements for your specific scope.
What firestopping products are approved?
Only UL-listed firestopping materials and systems are approved, installed per manufacturer's instructions. All firestopping installations must be approved. You must provide documentation of the products used. Non-compliant installations must be corrected at the permit holder's expense. Reference the UL Product iQ database at https://iq.ulprospector.com for UL system lookups.
When must barrier penetrations be sealed?
Any penetration of a fire-rated or smoke-rated barrier must be sealed with approved firestopping before the end of the workday, unless Facilities Compliance has granted a written exception to the timeline.
What are the most common violations this program is designed to prevent?
What happens if I am found to be in violation of the policy?
Violations may result in any combination of:
Can my project be shut down?
Yes. Any project found to be impacting a rated barrier without an approved permit will be immediately halted. Work cannot resume until a permit is obtained and approved.
Does Facilities Compliance conduct inspections even when I haven't requested one?
Yes. Facilities Compliance conducts unannounced random audits of active above-ceiling work and periodic inspections of above-ceiling spaces throughout facilities, independent of the permit process. Workers must have their certification identification available and be able to present it upon request.