Ambulatory Surgical Center Waiting Rooms

Q: Can an Ambulatory Surgical Center (ASC) have a waiting room that is shared with another physician’s practice that is not associated with the ASC, but is located in the same building?

A: No, it cannot. Section 20/21.3.7.1 of the 2000 Life Safety Code states the ambulatory health care occupancy must be separated from other tenants and occupancies with 1-hour fire-rated barriers. The ASC is located in an ambulatory health care occupancy and the physician’s practice is another tenant and is presumably located in a business occupancy. This separation between tenants and occupancies includes waiting rooms and areas.

In addition, the Centers for Medicare & Medicaid Services (CMS) S&C memo 10-20-ASC dated May 21, 2010, specifically states ASC must have waiting areas that are separate from other tenants and occupancies by 1-hour fire-rated barriers. The logic expressed in the CMS memo is patients occupying an ASC waiting area for the purpose of receiving treatment may not be capable of evacuating without assistance; therefore the ASC waiting area needs to comply with all of the fire safety requirements afforded to ambulatory health care occupancies. The CMS memo does say existing ASC that are cited to be non-compliant in regards to the waiting area requirements may submit waiver requests, but waivers will not be allowed for ASC classified as new construction facilities (designed or constructed prior to March 11, 2003). Please be advised that the CMS categorical waivers do not apply to this situation.

Ambulatory Surgical Center Mixed Occupancies

Q: We have an Ambulatory Surgical Center (ASC) located in a one story nonsprinklered building, and is separated from a physician’s office. The exit access from the ASC leads into a corridor which is within the physician’s practice. Since this corridor is not technically part of the ASC, is the ASC responsible for having the corridor wall opposite from the occupancy separation to be 1-hour fire rated?

A: You raise an excellent point: Once you leave the ambulatory health care occupancy and enter a different occupancy type, does the means of egress have to comply with ambulatory health care requirements? According to sections 20/21.1.2.2 of the 2000 edition of the Life Safety Code (LSC), the answer is yes. This section says all means of egress from ambulatory health care occupancies that traverse non-ambulatory health care spaces must conform to requirements of the LSC for ambulatory health care occupancies. The exception to this requirement would be if the barrier between the ambulatory health care occupancy and the contiguous occupancy qualifies as a horizontal exit, then the means of egress in the contiguous occupancy does not have to meet the more rigorous requirements for ambulatory health care occupancy, provided the means of egress is not through a high-hazard area. Horizontal exits are required to be 2-hour fire rated. So, how does this apply to you? If your ASC qualifies as new construction (built after March 11, 2003), then the means of egress in the physician area (outside of the ASC) must have 1-hour fire rated walls that extend from the floor to the deck above (unless they terminate at a ceiling that is also 1-hour fire rated); or if the building is protected with automatic sprinklers throughout; or the barrier between the ASC and the physician’s offices is a 2-hour fire rated horizontal exit. If the ASC qualifies as existing construction (built on or before March 11, 2003) then there are no requirements for the corridors, and what you currently have would be acceptable.

O2 Cylinders in Ambulatory Surgical Centers

Q: Since the Life Safety Code addresses ambulatory surgery centers in chapters 20-21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage of compressed gas cylinders?

 A: According to the CMS S&C-07-10 memo dated January 12, 2007, Ambulatory Surgical Centers (ASC) are included in the scope of that interpretation memo and ASC are required to abide by the 2005 edition of NFPA 99, section 9.4.3. This allows them the same advantage as hospitals with no storage requirements for 300 cubic feet and less of non-flammable compressed gas per smoke compartment. For storage of non-flammable compressed gas over 300 cubic feet and less than 3,000 cubic feet per smoke compartment, the ASC needs to comply with Chapter 13 of NFPA 99, section 13-3.8 which refers back chapter 8. Section 8-3.1.11.2 provides the requirements for storage of non-flammable compressed gas in quantities less than 3,000 cubic feet, which do not include 1-hour fire rated barriers. However, since the CMS S&C memo grants a special dispensation for ASC to follow the 2005 edition of NFPA 99, for 300 cubic feet and less of compressed gas, then they are the same as hospitals in regards to storage of compressed gas. According to the CMS S&C memo, cylinders in use are not to be counted as cylinders in storage. Therefore, they are not included in the calculation of cubic feet of compressed gas when considering storage requirements.  NFPA 99 requires full compressed gas cylinders to be segregated when stored with empty compressed gas cylinders.

Fire Damper Testing Frequencies

Q: Our facility is a freestanding ambulatory surgical center and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story building with multiple tenants. We had a state inspection recently and they asked us for documentation that we tested our fire and smoke dampers every 4 years. What are they looking for? We’ve been in the building for 13 years and no one has ever asked us about fire and smoke damper testing before.

A: Since it appears that the inspector is holding you accountable for compliance with the 2000 Life Safety Code, I will assume you need to comply with chapter 21, for existing ambulatory health care occupancies. Section 21.5.2.1 requires compliance with section 9.2 which in turns requires compliance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition. Section 3-4.7 of NFPA 90A requires the fire and smoke dampers to be tested once every 4 years. For clarification, CMS did issue an S&C memo on October 30, 2009 which permitted hospitals to change the frequency of fire and smoke damper testing to once every six (6) years, but this memo only applies to hospitals, and not to ambulatory health care occupancies. It is not unusual for authorities who inspect your building to fail to ask for certain documentation (such as test results of the fire/smoke dampers), and then at a later date, another authority will request that information. Just because the previous surveyors/inspectors did not ask to see this information, does not mean it was not required.  This inspector is now holding your organization accountable to what has always been a Life Safety Code requirement.

Smoke Compartments in ASC

Q: We are a freestanding ambulatory surgical center (ASC) and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story building with multiple tenants. During a recent state inspection, I was asked where our smoke compartments are located. I know that we have a 2-hour fire barrier between us and the other suites on our level, but I am not aware that we have any designated smoke compartments. Do we need smoke compartments?

A: You did not mention how many patients are incapable of self-preservation at any one time, so I will assume it is at least 4 or more patients, since that is the threshold to decide if the ASC is required to comply with ambulatory health care occupancy requirements, or business occupancy requirements. Ambulatory health care occupancy smoke compartment requirements are found in section 21.3.7.2, which requires your ASC to be sub-divided into not less than two smoke compartments. However, there are some exceptions to this requirement:

  1. ASC facilities that are less than 5,000 square feet and are protected by an approved smoke detection system do not need to be sub-divided.
  2. ASC facilities that are less than 10,000 square feet and are protected throughout by an approved automatic sprinkler system do not need to be sub-divided.
  3. An area in an adjoining occupancy may be permitted to serve as a smoke compartment for the ASC facility, provided all of the following criteria is met:
  • The separating barrier must be at least 1-hour fire rated, and have doors that are self-closing.
  • The ASC facility is less than 22,500 square feet.
  • Access from the ASC facility to the other occupancy is unrestricted.

So, to answer your question, based on the size of your ASC and whether it has smoke detection or sprinkler protection, it may not require a smoke compartment barrier. If a smoke compartment barrier is required, you might be able to utilize the 2-hour fire rated barrier between you and your neighbors, if you are less than 22,500 square feet and if there is unrestrictive access to the other occupancy.

Delayed Egress on Doors in Ambulatory Health Care Occupancies

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A friend of mine was working on a project involving ambulatory health care occupancy, and they wanted to use a delayed egress lock on an interior door.  The 2000 Life Safety Code (LSC) limits special locking arrangements to exterior doors in ambulatory health care occupancy, but the 2012 LSC does not include that limitation.  They wanted to know what I would recommend.

Well, they are correct: The 2012 edition of the LSC did away with the limitations of the special locking arrangements found in section 7.2.1.6 of the LSC. Section 20/21.2.2.2 of the 2012 edition of the LSC now permits delayed egress locks on any door in the path of egress, where the 2000 edition of the LSC limited them to the exterior door.

I assumed that the individual who asked me the question was bound by the 2000 edition of the LSC, such as a Joint Commission accredited organization, or perhaps a CMS provider for Medicare. My initial thought is the organization would have to comply with the conditions of the 2000 edition of the LSC, and cannot take advantage of the more lenient 2012 edition until such time that edition is adopted by CMS and/or Joint Commission.

However, CMS did issue a categorical waiver to healthcare organizations to allow them to use many of the provisions of the 2012 edition of the LSC now, before the 2012 edition is actually adopted (which may be at least another 12 months away). I reviewed the CMS S&C memo 13-58 once again, and while CMS did state in one of their opening paragraphs that they have the authority to grant waivers for ambulatory surgical centers, they failed to do so in the body of their memo. They have a categorical waiver on doors to allow healthcare occupancies to use the more liberal 2012 LSC position on delayed egress locks, but that categorical waiver only applies to healthcare occupancies, and not ambulatory surgical centers, assuming the ambulatory health care occupancy my friend was referring to was an ambulatory surgical center.

Therefore, I concluded that the organization should (or must) comply with the 2000 edition of the LSC and only install special locking arrangements on exterior doors. Once the 2012 edition of the LSC is adopted, they can then install delayed egress locks on interior doors.

I also mentioned that if the facility in question is only accredited by The Joint Commission, and does not receive any funds from CMS as a Medicare or Medicaid provider, then they could contact the Standards Interpretation Group (SIG) at Joint Commission and ask them if they would accept a Traditional Equivalency to allow them to use special locking arrangements on interior doors of their ambulatory care occupancy. (The telephone number for SIG is:  630-792-5900, select option 6.) My guess is they will, provided the organization meets all the requirements for a traditional equivalency.

If the facility in question actually is part of a larger organization that does have a CMS control number (CCN), then I advised my friend that they have no choice by to comply with the conditions of the 2000 edition of the LSC.

My friend replied asking if they could request a standard CMS waiver to allow the organization to install the delayed egress lock on an interior door now, before the 2012 edition of the LSC is adopted.

My reply was yes, there is always the possibility for a waiver, but CMS will not accept a waiver request unless it is in response to a survey deficiency. In other words, the waiver process is not valid until someone representing CMS cites a deficiency.

As a safety professional, I would never recommend or advise a client to knowingly violate the current edition of the LSC, even though we know that issue will be viewed differently in a more recent edition. There is always the chance that CMS may not adopt the 2012 LSC, although I would be very surprised if they did not.

However, any organization may do what they want, and often times they disregard the advice of a safety professional, and violate the LSC, taking the risk that they will not get caught. In this case, it is understandable as the presumption is the 2012 edition will be effective within the next 12 months or so, and they may feel they will not have any surveys or inspections before then.

So… in summary: The waiver process is not available to them since they have not been cited for non-compliance with the LSC. And, as a safety professional I cannot advise them to violate the LSC. What they do after that is their own business, and risk.

I have some clients who ignore my advice, preferring to ask other safety experts until they find someone who agrees with the answer they want. Hey… it’s their hospital, not mine. I always advise clients to follow the current rules, regulations, codes and standards, but if they decide otherwise, then that’s on them.

Separation of Occupancies

Q: Do different occupancies have to be separated by fire-rated barriers both horizontally as well as vertically? We are considering installing a dialysis unit on the second floor of a medical office building and the CMS interpretive guidelines say it must be separated from other tenants on the same floor by a one-hour fire wall. Shouldn’t a horizontal barrier be required as well?

A: Yes, I would agree. The 1-hour fire rated separation that the Life Safety Code (2000 edition), section 20.1.2.1 requires does include horizontal separations as well as vertical. I agree with you that the interpretive guidelines do not clearly state horizontal separations, but the LSC does make the generic statement that the ambulatory care occupancy must be separated from other occupancies with 1-hour fire rated construction, and does not limit the separation to just vertical barriers.

Ambulatory Care Occupancy Sprinklers

Q: We are in the process of renovating an existing two story office building where a dialysis unit will be located on the lower level. According to our state requirements, we have to designate the dialysis area to meet ambulatory care occupancy. We plan on installing automatic sprinklers in the renovated dialysis area, but do we have to install sprinklers in the rest of the building?

A: It depends on the construction type of the building. According to section 20.1.6.3 of the 2000 edition of the Life Safety Code, new construction standards for ambulatory care occupancies will require the installation of an automatic sprinkler system throughout the entire building (even though only part of it is ambulatory care) if the construction type is unprotected (000). Also, if the lower level that the dialysis unit is located on is below the level of exit discharge, then the floor must be at least 1-hour fire rated, unless the entire facility is under your organization’s control and all hazardous rooms are properly protected in accordance with section 8.4.

Conversion from Business Occupancy to Ambulatory Care Occupancy

Q:  We discovered our offsite free standing Dialysis center is in a building that is classified as Business Occupancy, but we were recently told by a consultant that the building has to be classified as Ambulatory Care Occupancy. Is this true? If so, what differences between the two occupancies should we be aware of?

A: It really depends if you are under the authority of CMS or not. If the dialysis center receives Medicare & Medicaid reimbursements, then you must follow CMS’s requirements. In a memo to their state survey agencies (S&C Letter 09-24) dated February 11, 2009, the dialysis unit must be classified as either existing ambulatory care occupancy, or new ambulatory care occupancy. In this memo CMS defines a new occupancy as a dialysis facility that receives their approval for construction on or after February 9, 2009, and they define an existing occupancy which receives approval for construction or renovation prior to February 9, 2009. However, if you are not under the authority of CMS, then the occupancy type is determined by the number of patients in the unit that are incapable of self-preservation. If there are 4 or more patients incapable of self-preservation at any given time, then the unit would have to be considered ambulatory care occupancy. But many authorities having jurisdiction (AHJ) have made the interpretation that all patients on dialysis is incapable of self-preservation, therefore, if you have 4 or more patients in the Dialysis center, then ambulatory care occupancy requirements apply. To be sure, you need to determine how your AHJ interprets the capability of the average dialysis patient to be able to disconnect themself from the machine, arise, and walk out of the unit under their own power, without assistance from anyone. There are differences between ambulatory care and business occupancies. Here is a short-list of ambulatory care occupancy requirements that differ from business occupancy:

  • Construction type: sprinklers required if Type II (000) Type III (000) and Type V (000)
  • Corridor width (44 inches)
  • Two approved exits from the unit
  • Travel distance to the exit cannot exceed 150 feet (200 feet if sprinklered)
  • Minimum door opening is 32 inches
  • A manual fire alarm system
  • Smoke compartment barriers unless the unit is less than 5,000 square feet and protected with smoke detectors, or unless the unit is less than 10,000 square feet and the area is protected with automatic sprinklers
  • A 2-hour fire rated barrier separating the dialysis unit from a healthcare occupancy, or a 1-hour fire rated barrier separating it from any other occupancy

Ambulatory Care Soiled Utility Room

Q: We have an ambulatory healthcare occupancy which has clean supply and soiled linen rooms.  Since these rooms are considered storage with combustibles, the Life Safety Code (LSC) views them as hazardous areas.  These rooms are sprinklered which does not require the room to have 1-hour rated barriers. Do these rooms require doors that need to latch?  It does not appear so, as I read the LSC.

A: You’re right. A soiled utility room in an ambulatory care occupancy that is protected with automatic sprinklers does not require fire rated walls and no doors are required. Sounds strange but this is why: Section 21.3.2 of the 2000 edition of the Life Safety Code refers to section 39.3.2 for protection from hazards, which identifies storage rooms as hazardous rooms that need to comply with section 8.4. This section allows on option to sprinkler the room or to provide 1-hour fire rated walls. If you chose the 1-hour fire rated walls, then you would have to provide a ¾ hour fire rated door and frame, that self-closes and positive latches. But in your scenario, your clean supply and soiled linen rooms were sprinklered, and 8.4 does not require self-closing and latching doors. Also, section 21.3.6 says there are no requirements for corridors, so that means there are no requirements for corridor doors. This is quite different than healthcare occupancy which would require self-closing and latching doors even if the rooms were sprinklered.