ABHR Dispensers in Business Occupancy Corridors?

Q: Can you give me some direction in the Life Safety Code on where alcohol-based hand rub (ABHR) dispensers are not allowed in business occupancy corridors?

A: Take a look at section 39.3.2.1 of the 2012 LSC. It says hazardous areas shall be protected in accordance with section 8.7. Section 8.7.3.2 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 unless otherwise permitted by 8.7.3.1.” Section 8.7.3.1 discusses the various methods to store flammable liquids. ABHR product is mostly alcohol which is a flammable liquid; therefore, it is not permitted in any location that would jeopardize egress (i.e. corridors).

Section 8.7.3.2 does not apply to healthcare occupancies because section 19.3.2.6 actually permits ABHR dispensers in egress corridors. Similarly, section 21.3.2.6 does as well for ambulatory health care occupancies. But, chapters 38 and 39 do not have any such language… therefore, ABHR dispensers are not permitted in egress corridors of business occupancies.

If you’re wondering, when the requirements in the core chapters (chapter 1 – 10) differ with the requirements of the occupancy chapters, the occupancy chapters govern (see section 4.4.2.3).

Converting the Lower Level to Business Occupancy

Q: Our life safety drawings list the basement level at the Hospital as healthcare. There are no patient services in the basement and only support services. I would like to change this to business, but my question is what do I gain as far as items such as hallway clutter, corridor clearance etc. I know the accreditation organization will want to inspect the support services that are located in the basement. My biggest problem is the basement hallways are consistently used as staging areas as new equipment is delivered to the hospital. Equipment can be in the hallways for weeks before it is installed or delivered to the end user.

A: That would be a great idea to designate the lower level as business occupancy… but make sure the facility qualifies for it. For starters, what is the Construction Type? You need to be at a minimum, Type II (222) construction type. You need a solid 2-hour fire rated horizontal barrier between the business occupancy and the healthcare occupancy. Is the lower level used as an exit level discharge? Does any of the upper healthcare occupancy floors egress through the lower level to get to the outside? If so, then the path of egress through the business occupancy that is used for the upper healthcare occupancy must meet all of the requirements for healthcare occupancy. Is there any service, care, or treatment activity for inpatients on the lower level? If so, at any given time how many inpatients would be on the lower level? This may be a sticky wicket as some AHJs do not allow even one inpatient in a business occupancy. Is the hospital’s cafeteria on the lower level? Again, if this is true, then you may often find inpatients in the cafeteria eating with their families. Not a good issue to have in a business occupancy.

Based on the Life Safety Code, advantages of designating the lower level a business occupancy are many… There are no corridor requirements in a space occupied by a single tenant so that means there are no requirement to separate rooms (other than hazardous rooms) from the corridors with doors; and if you have doors they don’t have to latch. You still have to maintain fire rated doors to exit enclosures. Required corridor width would be 44 inches if you have corridors so you are permitted to store non-combustible items in the corridors provided you have at least 44 inches width left over. You still have to maintain your smoke compartments and smoke barriers though, since you are one floor below a healthcare occupancy.

Fire Alarm Systems in Business Occupancies

Q: We are converting a facility that was used as a physician’s office into our women’s clinic and OB/GYN facility. There were previously 4 exam rooms and we are making it into 6 exam rooms. This unit has no fire alarm, no sprinklers, not even a stand-alone smoke detector. This doesn’t seem right in today’s environment.

A: It appears what you are describing is a business occupancy. Section 38.3.4.1 of the 2012 LSC says this about fire alarm systems in business occupancies: “A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:

  1. The building is two or more stories in height above the level of exit discharge;
  2. The occupancy is subject to 50 or more occupants above or below the level of exit discharge;
  3. The occupancy is subject to 300 or more total occupants.”

If your facility does not meet any of the above requirements, then you would not be required to have a fire alarm system. Also, section 38.3.5 does not require business occupancies to have sprinklers. But please check with your state and local authorities to see if they have other requirements.

Fire Alarm System in a Business Occupancy?

Q: We have a physician practice that currently has fire extinguishers and a “panic button” that contacts 911. We do not have fire alarms, smoke detectors or a sprinkler system. Are we required to have any of those in the practice?

A: The answer is… maybe yes and maybe no. Sorry; that’s not much of an answer, but not all offsite small business occupancies actually require a fire alarm system.

If the physician practice is truly a business occupancy, meaning there is no procedures being conducted where patients are rendered incapable of self-preservation, then section 39.3.4.1 of the 2000 Life Safety Code says this for existing conditions:

A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:

  • The building is two or more stories in height above the level of exit discharge
  • The occupancy is subject to 100 or more occupants above or below the level of exit discharge
  • The occupancy is subject to 1,000 or more total occupants.

For new construction in business occupancies (meaning new construction or renovation documents approved by local authorities after March 11, 2003), section 38.3.4.1 of the 2000 Life Safety Code says this:

A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following conditions exists: 

  • The building is two or more stories in height above the level of exit discharge
  • The occupancy is subject to 50 or more occupants above or below the level of exit discharge
  • The occupancy is subject to 300 or more total occupants.

 

The occupant capacity is calculated by taking the total gross area of the floor (or building) in square feet, and dividing it by 100 square feet per person. So, a 5,000 square foot story would have an occupant load of 50 persons.

So, as you can see, if the physician practice is a business occupancy and meets the requirements for a new or existing occupancy, then a fire alarm system is not required, according to the Life Safety Code.

Sprinkler systems are not required in business occupancies, whether they are new construction or existing construction.

Now, there may be other codes or standards that you need to comply with, so please check with your local and state authorities to determine what their requirements are.

Required Width of an Excess Access Corridor

Q: What is the required width for an exit access corridor in an office building?

A: That depends on the occupancy classification of the building. If the building is classified as business occupancy, then sections 38/39.2.3.2 of the 2000 Life Safety Code (LSC) would apply. The clear width of an exit access corridor in a business occupancy (office building) serving an occupant load of 50 or more, is 44 inches. But for occupant loads less than 50 persons, section 7.3.4.1 of the LSC would apply and the clear width is lowered to 36 inches.

When the Life Safety Code talks about the occupant load of a room or area, it is always calculated per section 7.3. Table 7.3.1.2 has occupant load factors that are used along with the gross area to determine the number of persons allowed. For a building classified as business occupancy the occupant load factor is 100 square feet per person. This means in order to have an occupant load of 50 persons you need 5,000 square feet of area.

If the office building is classified as an ambulatory health care occupancy, then according to section 20/21.2.3.2, the required width of the corridor is limited to just 44 inches. There are no deviations for less than 50 occupants.

Business Occupancy Testing

Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual fire drill but what about the testing of fire alarm system and sprinkler system?

A: Assuming the two-story office building that you refer to is classified as a business occupancy, the requirements for testing, inspection and maintenance are found in section 39.3.4.1 of the 2000 Life Safety Code, which refers to section 9.6. Section 9.6.1.4 requires the fire alarm system to be tested, inspected and maintained in accordance with NFPA 72 (1999 edition). Likewise, section 9.7.5 requires required sprinkler systems to be maintained in accordance with NFPA 25 (1998 edition). If your sprinkler system is not a ‘required system’, you still need to maintain it, according to 4.6.12.2. The testing, inspection and maintenance requirements found in NFPA 72 and NFPA 25 are the very same requirements that healthcare occupancies need to comply with. The bottom line is: You need to test, inspect and maintain the fire alarm system and the sprinkler system in a business occupancy at the very same frequency and level as you would in a hospital.

Fire Drills at Offsite Blood Draw Locations

Q: We were recently cited by a surveyor for not conducting annual fire drills at our offsite blood draw locations. I have reviewed the Life Safety Code for business occupancies and we have only 4 employees at these offsite locations, which is less than the 100-person threshold required by the LSC to conduct drills. These locations are rented inside commercial buildings. Do you think we have to conduct fire drills at these locations?

A: Yes I do, because your accreditation organization says you have to. I think the accreditation organization standard is very clear: “The hospital must conducts fire drills annually from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.”  The building you described sounds like a business occupancy, and the act of drawing blood from a patient is certainly ‘treatment’. So, they got you from two different angles. I would agree with the surveyor that a fire drill should have been conducted annually at the draw stations, regardless of their size or number of employees. This is an example where the accreditor’s standards over-ride the requirements of the Life Safety Code. It’s one disadvantage for the hospital having their own staff and quick draw station, rather than sub-contracting it out. The cost to manage the Environment of Care at these offsite locations is extensive, and probably wasn’t considered when the hospital opened them up. A fire drill is not an easy proposition at these types of small locations, situated within another building. The Life Safety Code requires the activation of the building’s fire alarm system whenever a fire drill is conducted. This would have to be coordinated with the building owner.

Offsite Clinic Fire Alarm System

Q: We have an offsite physician’s clinic with a fire alarm system that is tied into our main hospital campus control center and is monitored 24/7. Are we required to do quarterly off-premises monitoring transmission equipment testing at both facilities or just at our main campus?

A: Since this is a business occupancy there is no requirement to monitor the fire alarm, and have off-premises monitoring transmission equipment. However, if you do have the off-premises monitoring transmission equipment, then you must maintain and test it accordingly. The requirement to perform quarterly testing of the off-premises transmission equipment is found in NFPA 72 (1999 edition, for those organizations that need to comply with the 2000 edition of the Life Safety Code),  and the testing requirement is found in Table 7-3.2. If the offsite clinic is accredited by one of the accreditation organizations, or certified by CMS, then the requirements of NFPA 72 apply, and you would have to perform the quarterly testing as long as you have the equipment. However, if the offsite facility is not accredited or certified, then you would have to look at any local or state requirements to see what they expect for testing and inspections.

Outpatient Centers and Clinics

Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business?

A: The Life Safety Code defines different occupancies by the level of care and/or activities that take place in them. A hospital may have many different occupancy classifications, or it may have only one… it’s the organization’s decision. Here is a run-down on the most common occupancy classifications found in healthcare today, and their requirements:

Healthcare Occupancy

An occupancy used for purposes of medical care or other treatment where four or more persons are incapable of self-preservation; and provides sleeping accommodations for those patients.

Ambulatory Care Occupancy

An occupancy used for purposes of medical care or other treatment on an outpatient basis, where four or more persons are incapable of self-preservation, and does not provide sleeping accommodations.

Business Occupancy

An occupancy used for the transaction of business other than mercantile.

So, to answer your question, an outpatient center and clinic could very well be ambulatory care occupancy or it may be business occupancy; it all depends on what level of care and treatment is provided. It is permissible to have more than one occupancy in the same building, provide appropriate fire rated barriers separates the occupancies. A 2-hour fire rated barrier is required to separate a healthcare occupancy from any other occupancy, and a 1-hour fire rated barrier is required to separate different occupancies that are not healthcare.

There are distinct requirements for each occupancy, but the requirements are less for ambulatory care compared to healthcare, and they are even less for business as compared to ambulatory care. So there is an advantage to the organization if the clinic was classified entirely as business occupancy. However, you may not have 4 or more persons incapable of self-preservation in a business occupancy, so make sure you are in synch with that.

Also, CMS considers all ambulatory surgical centers (ASC) to be ambulatory care occupancies regardless of the number of patients incapable of self-preservation, and they also consider end stage renal disease (ESRD) dialysis centers to be ambulatory care occupancies if they are located on a floor other than the level of exit discharge, or if they are contiguous to a high-hazard occupancy. Be aware that in their proposed rule to adopt the 2012 Life Safety Code, CMS has indicated that they intend to classify facilities that have 1 or more patients incapable of self-preservation as an ambulatory care occupancy. Whether they will adopt that as a final rule is unclear, but you should be aware of the possibility.

 

Portable Fire Extinguishers

Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital?

A: The monthly inspection and annual maintenance requirements for the portable fire extinguisher is the same for all occupancies, and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:

  • Make sure extinguisher is in its designated place
  • Make sure the access to the extinguisher is not obstructed
  • Make sure the operating instructions on the nameplate is legible and facing outward
  • Make sure the safety seals and tamper indicators are not broken or missing
  • ‘Heft’ the extinguisher to determine fullness (pick it up and hold it)
  • Examine the extinguisher for obvious damage, corrosion, leakage or clogged nozzle
  • Make sure the pressure gauge (if so equipped) is in the normal operating range
  • For wheeled units, check the condition of the tires, wheels, carriage, hose, and nozzle
  • Make sure the HMIS label is in place

This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable) and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. An annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection is required. A 12 year hydro-test of the extinguisher is also required.