Continuing in a series of strange things that I have seen while consulting at hospitals…
I apologize for the photo being out of focus. I only had my new smart phone for a few days when I took this and I was having difficulty adjusting to the technology (okay… so I’m an old guy… deal with it).
The yellow sign is flexible, and is mounted on a magnet. Yet it projects more than 4 inches into the corridor.
Should I write it up …?
Q: I have a CEO that wants furnishings (seating) in the corridor. I informed her that would be acceptable if we maintained five feet and the furnishings are bolted to floor and follow the 2012 Life Safety Code. Well, this action would not make the furnishings aesthetically appealing, according to her. So, if the required width of the corridor is maintained and the furnishings are kept to one side of corridor and are not fixed to the wall or floor, will that meet the requirements of the Life Safety Code?
A: Assuming the seating arrangement is located in an area where inpatients would egress, and if the seating arrangement is in a wide spot in the corridor that does not obstruct the required 8-foot width of the corridor, then you do not have to meet the more restrictive requirements of 18.104.22.168 (5) of the 2012 LSC, that does require the seating to be secured to the wall or floor. However, you do have to meet one of the nine (9) subsections of 22.214.171.124 for corridor separation, most likely subsection eight (8) that requires:
- Each area does not exceed 600 square feet
- The area is equipped with smoke detectors
- The area does not obstruct access to required exits.
But the problem with seating that is not secured to the floor or wall, is the chairs get moved around by un-informed individuals (i.e. visitors), and eventually they obstruct the required width of the corridor, or they obstruct access to required exits (such as an egress from a mechanical room). If you choose to go the route of 126.96.36.199, make sure you perform frequent walk-throughs of the area to ensure nobody is rearranging the furniture.
Q: I enjoyed your recent post regarding Christmas decorations. However, can you please simplify for me the rules on Christmas decorations in hospitals? The percentages are a little confusing, I think. Thank you very much.
A: Not to be a smarty-pants, but here is a simple interpretation:
DON’T ALLOW ANY DECORATIONS!
I know that would not be very popular, but that would be the safest and easiest. But here is another way of looking at decorations:
- If your building is fully sprinklered, the LSC permits up to 30% of the walls and ceilings to be covered with combustible decorations.
- Combustible decorations that are not mounted to the walls or ceilings are not permitted (i.e. Christmas trees)
- Decorations that are not attached to the walls or ceilings must be flame retardant
- You cannot use an extension cord (or a power strip) to power electrical decorations
- All electrical decorations must be UL listed
Q: Within our X-ray department we have a room (7 1/2 ft. by10 ft.) that was our dark room for film reading years ago. We would like to make this a sleep room for staff that get called in. It has a sprinkler head; if we install a sounder base detector can we make this a sleep room and be compliant?
A: Sleeping with the old X-ray developing chemicals….? What a lovely thought.
Yes, I think you can convert this room to a staff sleep room. Your thought of putting in a smoke detector with an occupant notification device is good, but let’s look at the other items that may be needed.
First you need to confirm which occupancy chapter you need to comply with. Staff sleeping rooms is not covered under the Healthcare occupancy chapters, so you would consider “Lodging or Rooming Houses” occupancy or “Hotels or Dormitories” occupancy chapter. Reviewing the definitions of each, “Hotels or Dormitories” occupancy chapter is for 16 or more people, and “Lodging or Rooming Houses” occupancy chapter is for no more than 16 people. So, I would say that you need to follow “Lodging or Rooming Houses” occupancy chapter, and specifically, chapter 26 for new construction.
Section 188.8.131.52.1 of the 2012 Life Safety Code requires single-station smoke alarms must be installed in every sleeping room. So, according to this requirement, you would need to install a single-station smoke alarm, that has an annunciating device as you suggested. Some AHJs allow hospitals to install a building smoke detector in lieu of a single-station smoke alarm, but be aware not all AHJs see it that way.
Section 184.108.40.206 requires the sleeping room to be separated from the corridor by smoke partitions. So that means there cannot be any louvers in the door or walls.
Section 220.127.116.11 requires the door to the sleeping room to be self-closing (i.e. door closer) if the building is not fully protected with automatic sprinklers.
Section 18.104.22.168 requires the sleeping room to be protected with sprinklers, as you mentioned.
According to section 22.214.171.124.1, the door to the sleeping room cannot be locked against the means of egress. But section 126.96.36.199.4 covers that in depth and only allows certain exceptions to door locks. Keep in mind that section 188.8.131.52.10.2 does not allow the installation of deadbolt locks that are separate from the latch-set hardware.
As always, have this plan reviewed and approved by an architect and then obtain necessary approvals from your state and local authorities.
That should do it….
Q: What are your thoughts on using CO2 extinguishers in an HVAC mechanical room, instead of an ABC type?
A: It likely would be a situation where you would be non-compliant with NFPA 10-2010, and therefore you would not be compliant with the 2012 LSC. A CO2 extinguisher carries a BC rating, meaning it is classified for use on flammable liquid fires and electrical fires. But what about fires in your mechanical room that are caused by normal combustibles (paper, cardboard, plastic, linen, etc.)? I’ve yet to see a mechanical room that did not have some level of combustibles stored in the room (filters, boxes of spare parts, trash bags, etc.).
I would recommend ABC fire extinguishers for all mechanical rooms, and the dry powder type is the most common and affordable to use. However, if the mechanical room has sensitive electronic equipment, then perhaps a Clean Agent ABC type extinguisher would be more appropriate.
CO2 extinguishers have a limited value, and should only be used in areas where you have flammable liquids in use and storage, such as laboratories, pharmacies, and perhaps a grounds garage.
Continuing in a series of strange things that I have seen while consulting at hospitals…
Clearance to all electrical equipment (i.e. panels and disconnect switches) must be maintained for 36 inches in front of the panels from the floor to a point 6-feet 6-inches above the panels, or to the top of the panels whichever is higher.
That means the table and shelving unit need to be removed.
Q: During our inspection our surveyor was looking for 3/8″ holes, 3 feet upstream, before the smoke detectors in the ductwork. He requested testing procedures for the duct detectors from the tester who stated the test was performed by putting smoke onto the duct detector, which shut down the air-handler unit. The surveyor says the smoke must be inserted 3 feet prior to duct detector to test the actual tube for blockages. Can you tell me the actual regulation that states this requirement?
A: According to NFPA 72-2010, section 184.108.40.206, the method to conduct testing of fire alarm systems must comply with Table 220.127.116.11:
14(g) Smoke detectors
1) Smoke detectors/smoke alarms shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol, acceptable to the manufacturer of the aerosol or the manufacturer of the smoke detector/smoke alarm and identified in their published instructions, shall be permitted as acceptable test methods. Other methods listed in the manufacturer’s published instructions that ensure smoke entry from the protected area, through the vents, into the sensing chamber shall be permitted.
6) Duct detectors
In addition to the testing required in Table 14(g)(1), duct smoke detectors utilizing sampling tubes shall be tested by verifying the correct pressure differential (within the manufacturer’s published ranges) between the inlet and exhaust tubes using a method acceptable to the manufacturer to ensure that the device will properly sample the airstream. These tests shall be made in accordance with the manufacturer’s published instructions for the device installed.
Here is a summary on how to test duct detectors:
- The test must ensure smoke/aerosol enters the sensing chamber and an alarm responds.
- You must verify the correct air pressure differential between the inlet and exhaust tubes, in accordance with the manufacturer’s instructions.
So, while the vendor appears to be testing the detector, it does not appear he is testing the air pressure differential of the inlet and outlet tubes. I don’t see anything in NFPA 72-2010 that requires putting smoke/aerosol in the actual air tube for duct detectors. I do see where that is required for air sampling smoke detectors, but duct detectors are not the same as air sampling smoke detectors.
Q: I notified our administration that Christmas decorations are basically forbidden in a healthcare occupancy. We do have a few floors that are business occupancy and they were wondering what the restrictions of decorating are within a business occupancy (we are fully sprinkled). I do not see anything about this in the Life Safety Code pertaining to business or mixed occupancy. Do you mind sharing any advice?
A: Well…. Actually, the Life Safety Code does address this issue and there is a difference between occupancies. Section 18.104.22.168 of the 2012 LSC prohibits combustible decorations in a Healthcare Occupancy (i.e. hospital), with the exception (and this is a rather generous exception) of wall and/or ceiling mounted combustible decorations that cover 20% of the wall and ceiling surface in non-sprinklered smoke compartments, 30% of the wall and ceiling surface in a sprinklered smoke compartment, and 50% of the wall and ceiling surface in patient sleeping rooms that have a capacity of no more than 4 persons in smoke compartments that are full protected with sprinklers.
In chapter 39 for Business Occupancies, there are no restrictions, so decorations are not restricted. However, you cannot have non-UL listed electrical decorations, and the National Electrical Code prevents you from using extension cords to power electrical decorations.
Q: I have a healthcare occupancy under existing construction. The building was built back in the 50’s and 60’s, with a major renovation in 1992. The available plans have indicated the fire-rated walls and doors, but there are other doors not specifically designated as smoke doors or fire-rated doors. My question is, what doors would fall under the description of corridor doors? Would it be all doors that exit directly into the egress corridor? Some of these doors are to normally occupied offices, some are to patient rooms, and some are to conference rooms that are only occupied during meetings.
A: Corridor doors are those that separate the corridor from a room, suite, or area. They are not cross-corridor doors that separate a corridor from another corridor. Do not be fooled by a double set of doors, as they can be either corridor doors (an entrance to a room, or suite), or cross-corridor doors (smoke barrier doors, or privacy doors in a corridor).
Here is a summary of the Life Safety Code requirements for corridor doors:
- Corridor doors must comply with section 22.214.171.124 of the 2012 LSC, and have certain requirements that they must meet, such as:
- They must resist the passage of smoke (no holes in them)
- They must be 1¾-inch thick, solid-bonded wood core
- Constructed with materials that resist fire for a minimum of 20 minutes (NOTE: This does not mean the corridor doors must be 20-minute fire rated).
- Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets and similar auxiliary spaces that do not contain flammable or combustible materials are not required to comply with the above requirements.
- In smoke compartments protected throughout by automatic sprinklers the corridor door construction requirements listed above are not mandatory, but the corridor doors must resist the passage of smoke (no holes).
- Corridor doors are not required to meet the NFPA 80 standards for fire-rated door assemblies, unless the door also serves a fire-rated barrier.
- The clearance between the bottom of the corridor door and the floor (i.e. undercuts) must not exceed 1 inch.
- The corridor doors must have positive latching hardware.
- Corridor doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials are not required to have positive latching hardware.
You will notice section 126.96.36.199 does not say anything about self-closing devices for corridor doors, because they are not required on corridor doors, unless the corridor serves another purpose, such as a smoke barrier, horizontal exit, or hazardous area.
Check with your state and local authorities before you make any modifications, to determine if they have other regulations or requirements regarding corridor doors.
Q: NFPA 101-2012, section 7.9.3 requires 1½-hour testing of battery powered emergency lights annually. The Joint Commissions wording of EC.02.05.07 EP-2 states to do that OR the hospital replaces all batteries every 12 months and performs a random test of 10% of all batteries for 1½-hours. Because NFPA 101 does not give that second option, can we really do that (the second option) and be compliant? We’ve felt it’s easier to replace the batteries annually and test a random 10% during that time period than to test all of the over 100 battery powered emergency lights we have. Secondly, NFPA 101-2012, section 7.9.3 does not mention egress vs. task battery powered emergency lighting. Seeing it is located in chapter 7 ‘Means of Egress’, is it implied it only means battery powered emergency lights used for egress? Joint Commission specifically says egress lighting. Several of our battery powered emergency lights are task lights and this would allow us to cut down on monthly and annual testing. Do we need to be as stringent on task lighting as we are on egress lighting to remain compliant?
A: First of all, Joint Commission dropped the option of replacing the batteries and testing 10% of the battery powered emergency lights, in the 2018 CAMH manual, standard EC.02.05.07, EP 2. Starting January 1, 2018, you need to conduct monthly tests and annual tests of all battery powered emergency lights.
I am aware that Joint Commission tries to give the hospitals a break by saying only the battery powered emergency lights used for egress and Exit signs need to be tested. And in their 2018 manual, standard EC.02.05.07, EP 2 they inserted a new section that says battery powered emergency lights in new construction/renovated sedation and anesthetizing areas are tested for 30 minutes annually. But please understand that Joint Commission’s standards are not compliant with the 2012 Life Safety Code, section 188.8.131.52 (3) which requires 90-minute annual test. If you follow Joint Commission’s standards on this issue, you may be cited by a state surveyor for not complying with the annual testing requirements of section 184.108.40.206.1 (3).
Section 220.127.116.11 of the 2012 LSC says if you have an existing feature of life safety that is not required by the LSC but is obvious to the public then you must maintain it or remove it. I think we’d all agree that battery powered emergency lights would be obvious to the public whether they are used to supplement the EM powered egress lighting or if they are used for task lighting in certain areas. According to the 2012 LSC, section 7.9.3, maintaining it includes the monthly 30-second test and the annual 90-minute test.
To be compliant with the 2012 LSC, you need to test the battery powered emergency lights monthly and annually. I suggest you re-evaluate the need for all of the battery powered emergency lights that you have, and invest into self-diagnostic units to eliminate the monthly test requirements.
Q: If I replace a smoke barrier door with a fire door, does the wall now have to be brought up to fire-rated wall code or will it still be considered the same smoke barrier code? We were told by an inspector that now the wall would have to be a fire-rated wall even though it’s not needed to be.
A: This issue is becoming a sticky wicket. I’ve had this question raised numerous times recently. I kind-of see where the surveyor is coming from: If the fire-rated door assembly is obvious to the public as a fire door, then the public could conclude that the barrier is also a fire-rated barrier. Kind-of makes sense. But that’s not what the Life Safety Code says. It is clear to me that the LSC does require all fire-rated doors to be tested regardless if they are located in a fire-rated barrier or not.
Section 18.104.22.168 says existing features of life safety obvious to the public, if not required by the LSC must be maintained or removed. Most AHJs will say a fire-rated label on the door is obvious to the public, although an unofficial NFPA interpretation is saying a fire rated label is not obvious to the public. In this situation, we have to go by what the AHJ says. Section 22.214.171.124 says fire-rated doors must comply with NFPA 80-2010, so all fire rated doors must be tested and inspected regardless if they are located in a fire-rated barrier.
But there is nothing in this section of the LSC or any other section that clearly says a fire-rated door assembly located in a barrier requires the barrier to be a fire-rated barrier. The AHJ has the right to interpret the Life Safety Code, but in my opinion this interpretation is way over the top. But, if you do get cited for this, it really is an easy solution: Just pop the fire-rated labels off the door.
Q: I’m getting conflicting answers as to when generator batteries need to be replaced. Some say in a hospital they need to be replaced every 5 years unless the hospital is a trauma center then it is every 3 years. I have also been told that it doesn’t matter if it is a trauma center; hospital or nursing home; the batteries need to be replaced every 3 years. Can you please tell me what is correct?
A: The correct answer as to how often generator starting batteries need to be replaced in hospitals depends on which authority having jurisdiction you’re talking to. That may be why you are receiving conflicting answers. The typical hospital has 5 or 6 different authorities having jurisdiction (AHJ) that enforce the Life Safety Code:
- CMS (Medicare/Medicaid)
- Accreditation Organization (i.e. Joint Commission)
- State health department
- State fire marshal
- Local fire inspector
- Insurance company
Any one of these AHJs may have a requirement for testing/inspection/replacement of generator starting batteries that the other AHJs may not have. The hospital would have to comply with the most restrictive.
First… I cannot find any specific requirements in the NFPA codes and standards for generator starting batteries to be replaced at a different frequency if the generator serves a trauma center or not. But the hospital’s state or local AHJ may have a specific requirement that addresses trauma centers that I am not aware of.
Second… According to NFPA 110-2010, the hospital is required to replace lead-acid batteries used for generator starting every 24 – 30 months. This would be enforced by the CMS standards and the accreditation organization (AO) standards. This is found in the Annex section A.126.96.36.199.1 of NFPA 110-2010, and CMS and the AOs usually (not always) enforces the Annex section requirements of the NFPA standards.
I checked the 1999 edition of NFPA 110 and the Annex section in that edition recommended replacing the batteries every 24 – 30 months, so I don’t see anything in current or past NFPA standards that would support your 5-year frequency to replace generator starting batteries.
NFPA 101-2012 Life Safety Code requires all healthcare occupancies and ambulatory healthcare occupancies to comply with NFPA 110-2010, so this means all hospitals, nursing homes, and trauma centers, would have to have their generator starting lead-acid batteries replaced every 24 – 30 months, according to CMS and AO standards.
I suggest you contact the hospital’s state and local authorities to determine if they have more restrictive requirements.
Continuing in a series of strange things that I have seen while consulting at hospitals…
In a Type I or Type II construction type structure (which most hospitals are) you are not allowed to have any combustible structural supports, including wood coverings over floors.
Overhead lift equipment raises elevator equipment to this platform, which serves as an extended floor. Then they roll the equipment to the elevator machines. Wood platforms are not permitted.
Remember what I said… Equipment rooms are a huge source of non-compliance on safety issues. They are out-of-sight/out-of-mind and nobody is assigned to maintain them.
Q: In the 2012 edition of the Life Safety Code, section 188.8.131.52 (9) states dispensers of alcohol based hand rub (ABHR) solution are permitted to be installed directly over carpeted floors in fully sprinkled smoke compartments. My question is: Does this go with business occupancies as well?
A: I would say surveyors would likely ‘borrow’ from chapter 19 and apply certain requirements regarding ABHR dispensers in business occupancies. But there is a huge difference between healthcare occupancies and business occupancies for ABHR dispensers. Section 184.108.40.206 is a healthcare occupancy chapter, and anything written in chapter 19 applies to just existing healthcare occupancies. The Life Safety Code requirements for a business occupancy are found in chapter 38 for new construction business occupancies and chapter 39 for existing business occupancies.
It is interesting to note that chapters 38 & 39 do not have the similar language found in chapters 18 & 19 for healthcare occupancies that permit ABHR dispensers in corridors (i.e. 18/220.127.116.11). Therefore, section 38/18.104.22.168 is the applicable standard and must be followed, which says hazardous areas must comply with section 8.7. Section 22.214.171.124 says no storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure. Where chapters 18 & 19 for healthcare occupancies have exceptions that actually permit ABHR dispensers in corridors, chapters 38 & 39 do not for business occupancies. In fact, chapters 38 & 39 actually requires compliance with section 126.96.36.199 which prohibits the handling of flammable liquids (and ABHR solution is considered a flammable liquid) in an egress.
That is why ABHR dispensers are not permitted in business occupancy corridors. Since the business occupancy chapters do not address ABHR dispensers, other than saying flammable liquids cannot be stored or handled in the egress, surveyors would likely follow the chapter 19 requirements on ABHR dispensers for other regulatory requirements in business occupancies. They could easily enforce the width separation and the requirement to keep the dispenser away from ignition sources and other requirements. Since chapters 38 & 39 are silent on the issue of ABHR dispensers, the surveyors could ‘borrow’ from chapter 19 and enforce that, as long as it does not conflict with section 188.8.131.52.
Q: We are a hospital and if there was a fire, say at the northeast part of the building does everyone throughout the whole building have to evacuate the building or only the ones on that side of the building? Same thing with fire drills; does everyone have to evacuate?
A: No… Everyone does not have to evacuate. You never want to evacuate the building unless it is absolutely necessary. Evacuation should always be horizontal and local. This means if 4 west has a fire, then the occupants on 4 west evacuate to 4 east, (or 4 north, or 4 south). You do not take patients down the stairs unless it is absolutely necessary. If you do have to evacuate vertically, you use an elevator that is not actively involved with the fire to evacuate the patients. Forget all those signs that say “In Case of Fire – Use Stairs”. That does not apply to evacuating patients. The Life Safety Code actually says it is permissible and recommended that you use elevators in the evacuation of patients, as long as the elevator is not actively involved in the fire.
For fire drills, you use simulated patients (put a staff member in a wheelchair and observe the other staff members push the wheelchair to an adjoining smoke compartment). You must observe that they did evacuate a simulated patient to the adjoining (horizontal) smoke compartment. That is why it is important to identify which set of cross-corridor doors are smoke barriers.