Smoke Compartment Barrier Door Gaps

Smoke compartment barrier doorsI want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor doors that are not fire-rated or used in a smoke compartment barrier are permitted to have gap clearances up to ½-inch in smoke compartments that are protected with sprinklers. In this memo they have conflicting points; the subject line of the memo stated: “Permitted Gaps in Corridor Doors and Doors in Smoke Barriers”, but in the content of the memo they say “This information does not apply to doors in smoke barriers, which have other requirements.”

Click on this link to access this CMS memo:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/CMS1198675.html?DLPage=1&DLFilter=07-18&DLSort=3&DLSortDir=ascending

To be clear, the maximum gap for the proper clearance of smoke compartment barrier doors is 1/8 inch; not ½ inch, and it is not dependent on whether or not the smoke compartment is sprinklered. Sections 18/19.3.7.6 of the 2000 LSC references section 8.3.4 of the same code and the Annex section of 8.2.4.1 says the maximum gap for smoke compartment barrier door clearances is 1/8 inch.

The CMS memo addressed corridor doors that are not fire-rated or located in a smoke compartment barrier. Corridor doors are those doors which separate a room or an area from the corridor. Can a corridor door also be a fire-rated door or a door in a smoke compartment barrier? Yes, certainly; and in those situations the more restrictive requirements must apply.

The bottom line: Doors in smoke compartment barriers must not have gap clearances that exceed 1/8 inch per the 2000 LSC. The CMS S&C memo 07-18 only applies to non-fire-rated corridor doors that are not located in a smoke compartment barrier.

Privacy Curtains or Screens?

Q: The health care facility where I work needs additional privacy on the nursing floor from the rest of the building.  I would like to know if we could mount a ceiling track across the beginning of the nursing hallway, with a lightweight privacy curtain that can be drawn open or closed as needed; or place two decorative lightweight free-standing folding screens placed at the entrance to the nursing hallway.?

A: Assuming the nursing hallway that you refer to is an exit access corridor; then no, neither option that you suggest would comply with the LSC. Section 19.2.3.3 of the 2000 LSC edition requires the corridor to be arranged to avoid any obstructions for the convenient removal of non-ambulatory patients. That means nothing may be placed in the corridor that could obstruct access, such as the screen. A curtain hanging down from the ceiling would not be permitted according to section 7.5.2.2, which could conceal the path to the exit. However, permanently installed side-hinged swinging privacy doors would be permitted and are often used in situations like the one that you described. The new barrier for the doors would not have to extend to the deck above and would be permitted to terminate at the ceiling. The doors and frame would not be required to be fire rated, and would not have to have positive latching hardware. Any changes to the facility should be reviewed by your state and local authorities.

Alcoves and Areas Open to the Corridor

Alcove Web 2When does a wide spot in the corridor have to meet the requirements for areas open to the corridor? This question was raised to me in regards to a clean linen cart parked in an alcove of the corridor. Does it have to comply with the section on corridor width or the section on areas open to the corridor? This is just one more example of an issue that is not clearly defined in the Life Safety Code and as best as I can tell, the answer lies with the authority making the interpretation of the code.

First we need to understand the two issues. According to section 18.2.3.3 of the 2000 edition of the LSC, corridors in areas that are intended for the housing, treatment or use of inpatients in new construction healthcare occupancies are required to be no less than 8 feet wide in clear and unobstructed width. In areas where inpatients are not expected to use the corridors, the clear and unobstructed width is required to be 44 inches. Corridors wider than the required width are permitted to have alcoves that contain non-combustibles as long as the alcove area does not exceed 50 square feet, and does not encroach on the required width of the corridor. If it exceeds more than 50 square feet, then the area could be classified as a hazardous area if it contained combustibles, and clean linen would most certainly be classified as combustible. So, the alcoves need to be no more than 50 square feet, if they are going to contain clean linen carts.

According to section 18.3.6.1, areas open to the corridor must comply with a variety of requirements, which includes smoke detectors. But if the alcove is considered a wide spot in the corridor, then it would not have to comply with section 18.3.6.1 and have smoke detectors. So, the question remains: When is an alcove just a wide spot in the corridor and when does it have to meet the requirements for 18.3.6.1 and have smoke detectors?  And if we are asking the same question for existing conditions, it gets a bit more complicated as sprinklers may or may not be required.

Anyway… When the Life Safety Code is not clear, then the answer is up to the authority having jurisdiction to make an interpretation and rule on the issue. The LSC actually says that (in so many words) in section 4.6.1.1. So, if I were the AHJ, I would say an alcove is just a wide spot in the corridor and does not have to meet the requirements for areas open to the corridor in sections 18/19.3.6.1. But, I’m not the AHJ, and they never ask me what I think anyway.

 

New Construction Corridor Doors

door_thickness[1]I was recently asked what the Life Safety Code required for the thickness and composition of a corridor door in new healthcare occupancy construction. The individual asking me the question was thinking of installing 3/4 inch thick doors on nurse server cabinets which open onto the corridor. I recited from memory: 1.75 inch thick, solid-bonded, wood core doors that limit the passage of smoke and have positive latching hardware. There are some basics in life that cause one to memorize such things and corridor doors is just one of those items in the Life Safety Code for me.

The person asking the question asked me to provide the code reference where it says that. So, I looked it up in Chapter 18 (the chapter for new construction in healthcare occupancies) and …. it’s not there. The code is void of that description for corridor doors in the new construction chapter. Section 18.3.6.3.1 (of the 2000 edition) of the Life Safety Code essentially says corridors doors have to limit the passage of smoke, and they do not have to comply with NFPA 80 , and the distance between the bottom of the door and the floor cannot exceed 1 inch. Also, section 18.3.6.3.2 says corridor doors are required to positively latch, and roller latches are not permitted. Nowhere in Chapter 18 can I find that the corridor door had to be constructed to be 1.75 inch thick, solid-bonded and wood core. I even pulled out the handbook for the LSC and it was silent on the subject for new construction. I looked up the same section in the 2012 edition of the LSC to see what it says and it too was very silent as well.

So why was I so quick in quoting corridors doors need to be 1.75 inch thick, solid-bonded wood core? Because that is the requirement for corridor doors in existing construction. Oh… Now it makes sense. One needs to remember that section 4.6.7 says in part, that alterations and new equipment needs to comply with new occupancy chapters, and at the very least must meet the requirements for existing conditions. So, I said they cannot install a new corridor door that does not meet the requirements for an existing corridor door, which is 1.75 inch thick, solid-bonded, wood core.

I was asked where in the code it says that and I referred him to section 19.3.6.3.1. I then read the Exception #2 to 19.3.6.3.1 which says corridor doors in smoke compartment fully protected with automatic sprinklers are exempt from this requirement, although they are required to be constructed to resist the passage of smoke…. Oops!…. There’s the hidden truth. Corridor doors in existing occupancies located in smoke compartments that are fully protected with sprinklers are not required to be 1.75 inch thick, yada yada yada.

Corridor doors in new construction are located in smoke compartments that are fully protected with sprinklers, so by the definition of section 4.6.7, a 3/4 inch thick door on a nurse server cabinet that opens onto the corridor would be permitted in new construction, as long as it resists the transfer of smoke and positively latches.

Wow… I learned something new that day. It never ceases to amaze me to learn of the little nuances and intricacies involved in understanding the Life Safety Code. That was a good day for me. I really appreciated that question as it made me learn the truth.

Nurse Server Cabinet Doors

Q:  We have wall mounted recessed cabinets in our corridors next to the patient room doors that have access doors on both the corridor side and the patient room side allowing staff to pass through supplies without having to open the patient room door. These cabinet doors have roller latches. Do they have to comply with the standard that prohibits roller latches on corridor doors?

A: Yes they do. The wall mounted cabinet that you described are often referred to as Nurse Server cabinets. They allow staff to stock the cabinets with supplies from the corridor side, without entering the patient room. A door is a door whether it serves a patient room, closet, mechanical shaft or a cabinet. If the door is mounted in the corridor wall, then it has to meet the requirements of section 19.3.6.3.2 of the 2000 edition of the Life Safety Code (LSC), which prohibits roller latches in non-fully sprinklered buildings. The Joint Commission, HFAP and CMS together banned roller latches on corridor doors in 2005, so they are not allowed in corridor doors under any condition. While 19.3.6.3.2 does allow an existing door to have a device to keep it closed when a force of 5 lbf is applied at the latch edge of the door, this is not allowed in new construction conditions. The Joint Commission has set a date of March 1, 2003 to determine what qualifies as existing construction and new construction, but this is not universally accepted by all authorities having jurisdiction (AHJ). CMS and HFAP set a similar date of March 11, 2003 for that distinction, but many other AHJs do not recognize a specific date to set a threshold of what has to qualify as new or existing construction. Many AHJs would require the existing nurse server door to meet new construction requirements at the time it was installed, and those conditions must be maintained for the life of the cabinet. Therefore, when the nurse server cabinet was installed, corridor doors would most likely require positive latching hardware (if installed since 1970) and the door must be maintained to that requirement. Another issue to look at is whether or not the nurse server door resists the passage of smoke, as required in 19.3.6.3.1. A cabinet style of door may not meet this requirement, while a millwork style of door and frame would. As always, check with your state and local authorities to see if they have more restrictive requirements.

Means of Egress Widths in Suites

Q: During a recent survey, we were cited for not maintaining at least 36 inches of clear width in our suites for exiting purposes. I thought one of the advantages of suites is corridor widths are not required to be maintained, according to section 19.2.3.3 (exception #2) in the 2000 edition of the Life Safety Code (LSC). Why would we have to maintain 36 inches clearance?

A: You are correct when you say corridor widths are not required to be maintained in a suite-of-rooms, however, the surveyor was basically correct in that aisle widths must be maintained in all areas of the means of egress. Let’s review the basic concept of a suite: A suite is just a large room with a lot of smaller rooms inside it. There are constraints on the size of the suite and limitations on the travel distances from inside the suite to the corridor door. One of the advantages of a suite is what looks like a corridor inside the suite is actually just a common space, and the width does not have to be maintained to 8 feet clearance, as you pointed out. However, the means of egress must meet minimum clearances according to section 7.3.4.1 which is at least 36 inches clearance for new conditions and 28 inches for existing. The means of egress is defined in section 3.3.121 as “A continuous…way of travel from any point in the building…to a public way…” The means of egress applies to all rooms including suites even if there are no corridors in that area, so you would have to comply with section 7.3.4.1 and allow a minimum aisle width of 36 inches for new construction, or 28 inches for existing conditions.

Waiting Areas

Q: Our Risk Management Department has conducted an assessment of our waiting areas in our hospital.  They are stating that staff should be able to see all patrons who are waiting in lobbies and corridors.  If they cannot, then mirrors or cameras should be installed allowing staff to monitor their behavior.  I’m guessing their concern is for an individual passing out in the waiting area. Is there a code requirement for staff observation or cameras?

A: It depends on the circumstances. Waiting areas that are open to the exit access corridor are required to meet criteria found under section 19.3.6.1 in the 2000 edition of the Life Safety Code (LSC). This criteria includes, among other things, either direct supervision by a staff member or smoke detection in the open areas. Depending on the Accreditation Organization (AO) that you have, and your local and state authorities, direct supervision may be interpreted to mean staff in attendance to observe the waiting area, or a closed circuit television system which is monitored by another individual. The code at this point does not say ‘constant supervision’ which implies the supervision by the staff must remain constant. Direct supervision implies observation of the open areas is not constant. As far as meeting the code requirements, it seems to me that the addition of smoke detectors would far outweigh the cost of having staff observing the open areas. As always, please check with your local or state authorities to see if they have other requirements.

Corridor Alcoves

In regards to corridor clutter, one of the most frequent comments safety professionals hear from nurses and other point-of-care workers, is “I have no place to put the ____” and you can fill in the blank with just about anything. The sad thing is, this is true more often than not. Nurses like to have ‘things’ close by and near their patients, for quick access, and it’s not their fault there simply isn’t suitable space to store them.

Now, I can imagine some of you may be saying, “But Brad, those nurses keep leaving things in the corridor even after I’ve told them that they can’t do that”, which may very well be true. But you have to ask yourself, ‘Why are they doing that?’ Why do nurses want ‘stuff’ in the corridor even when they’ve been told not to? Before I can even get that last sentence out, I know some will say it’s because the nurses are lazy and they don’t want to walk the extra 30 – 50 feet to the storage room. Well, that may be true, but you may be surprised how often that is not the case.

Nurses are some of the best trained people in the hospital. If it weren’t for nurses, none of us would have a job in healthcare. The hospital exists to provide care for the patients and the nurses are the ones who do that the best. Nurses have the patient’s best interests at heart, and everything they do is geared towards providing excellent care for their patient. Many nurses believe by having certain medical equipment, such as blood pressure cuff machines, EKG machines, IV pumps, and the like, accessible and close by the patient’s room, they are providing the best care possible for the patient. In their minds, keeping those items in the storage room 30 – 50 feet down the corridor would only delay the ability to provide excellent care, so they need that stuff in the corridor, just outside the patient room.

Once the facility managers accept this concept, now they can begin thinking like the nurses, and try and find ways to help them have these items nearby. One solution is the creation of alcoves in the corridor, just like the one in the picture. Here’s how one hospital accomplished this…

First, they found a former patient room on the nursing unit that was being used to store items, including large items such as beds, patient lifts and extra mattresses. Inside this former patient room was a bathroom which was not used and only taking up valuable space. So, the facility manager decided to tear out the bathroom and pushed back the corridor wall that contained the entrance door to the room, about 5 feet. He rebuilt the wall separating the corridor from the storage room, which left him with a very nice alcove for the items that nurses used most often. By tearing out the bathroom, the hospital had to re-route plumbing and electric lines, and fix the floor, but the end result was very beneficial for the nurses. And this actually created more storage space since the unused bathroom was eliminated. Now the nurses can store equipment in the alcove, without having to open the door and place it in the storage room. This is a big advantage for those items that nurses want quick access to.

This ‘after-the-fact’ process of creating alcoves in the corridor is not cheap. The one in the picture cost around $15,000 or so, but if your administration is serious about solving corridor clutter in your organization, they should be able to provide the funds. I suggest you seriously consider this approach… It is a great satisfier for the nurses and you’ll make friends for the rest of your career.

Locked Doors to Utility Rooms?

Utility rooms, whether they are clean utility rooms, or soiled utility rooms, are not required to be locked according to any NFPA standard, Joint Commission standard or CMS Condition or standard. However, if there is a perceived risk to safety because a utility room door is left unlocked and the hospital has failed to assess that risk, then the surveyor or inspector has every right to cite the organization for ‘interior spaces which are unsafe to occupants of the building’. This would be scored under EC.02.06.01, EP 1 for Joint Commission, or under §482.41 for CMS. The big problem with §482.41 for CMS is this is a ‘Condition’ rather than a standard that would be considered out of compliance and that alone would trigger a full-fledged CMS validation survey, which is very undesirable.  So this is something you definitely do not want to happen at a hospital.

So, the way a risk assessment is conducted to determine if a perceived risk is OK as is, or if something further needs to be done to compensate for that risk, is very simple. Take a sheet of paper, draw a vertical line down the middle, and list all the ‘Pros’ of the risk on the left side and all the ‘Cons’ of the risk on the right side. Whichever side has the most items or the most severe items listed, wins. If the ‘Pro’ side wins, then you don’t have to lock the door, but if the ‘Con’ side wins, then the doors should be locked.

Here’s an easy example: For a pediatric unit, where it is not uncommon to see children patients walking up and down the corridor (even though they are supervised) a clean or soiled utility room door which is not locked poses a HUGE risk to safety for the children, and the utility room doors should be locked. However, utility room doors on a geriatric unit does not pose the same risk as there are far fewer children roaming the hallways, so the doors could remain unlocked.

The risk assessment has to be documented, and I always advise my clients to have many stakeholders involved in the risk assessment process, including:

  • Safety officer
  • Security manager
  • Facility manager
  • Infection Control manager
  • Nurse manager
  • Chief Nurse Executive
  • Risk manager
  • Etc.

Then, once the risk assessment is complete, I advise them to have it reviewed and approved by the Safety Committee, and get it in the minutes. Then, if ever challenged by a surveyor or inspector who thinks the doors should be locked, you can tell them:

  • There is no code or standard that requires the doors to be locked
  • An assessment to determine the level of risk to the patients was conducted by an interdisciplinary team of professionals who decided that the doors are not required to be locked (or are required to be locked, depending on the outcome of the risk assessment)
  • This risk assessment decision was affirmed by the organization’s Safety Committee and here are the minutes to indicate that

The risk assessment process is a great tool to use when decisive action is not clear, or when the codes and standards do not seem to address an issue very well. You can never go wrong with a risk assessment especially if many different professionals (who have the best interests for the safety of the patient at heart) agree on the conclusion.

One last thing… Risk assessments are not ‘forever’. They should be renewed once a year to see if any of the conditions have changed.

New Corridor Width Requirements

Here is a change in the Life Safety Code that I believe will do more harm than good: Changing what can be left unattended in hospital corridors. Currently, the 2000 edition of the LSC only permits attended items in the corridor, such as housekeeping carts, linen carts, foodservice carts, provided they are being attended by an individual. The exceptions to this rule have allowed crash carts and patient isolation supply carts (provided the cart is serving a patient on contact precaution isolation) to be left unattended.

The constant struggle that facility managers had with nurses and technicians was staff leaving items in the corridor, as the picture to the left indicates. The items left in the corridor were done so for various reasons: 1). Staff felt certain medical equipment such as blood pressure cuff machines and IV pumps were necessary to be placed in the corridor for quick and effective patient care; 2). Staff believed there simply was no other place to store the equipment; 3). Some room items such as chairs, tables and even beds were ‘temporarily’ stored in the corridor that ended up being hours and days, and 4). It simply was not convenient for staff to return equipment to their designated storage room. Whatever the reason, leaving unattended equipment in the corridor was not permitted by the 2000 edition of the LSC, and hospitals would be cited by surveyors if they discovered it.

Well, some of that could be changing when the new 2012 edition of the LSC is finally adopted. If CMS adopts the 2012 edition in its entirety, meaning they will not exclude any sections, then I believe facility managers will have new problems concerning items stored in corridors. Here is the reason why I believe that: Section 19.2.3.4 of the 2012 edition will now permit certain wheeled equipment to project into the required width of the corridor, provided the clear width of the corridor is not reduced to less than 5 feet, and there is a written fire safety plan and training program that addresses the relocation of the wheeled equipment during a fire. The permissible wheeled equipment is limited to 1). Equipment and carts in use; 2). Medical equipment not in use; and 3). Patient lift and transport equipment.

Number 1 above is the same as what the 2000 edition currently allows. But number 2 (Medical equipment not in use) sounds to me to be medical equipment that is in storage. The Annex section makes note that equipment ‘not in use’ is not the same as equipment ‘in storage’, but does not offer an explanation on how to tell the difference. And number 3… Patient lift and transport equipment can now be stored in corridors? How can that be safe for the swift and immediate evacuation of patients during a fire emergency?

Here are the potential problems as I see it:

  1. Give the staff an inch and they will take a mile. If you educate and train the staff that they can now store some equipment in the corridor as long as you have 5 feet clear width, they will certainly take more than that. They don’t carry tape measures with them and the possibility of something projecting into the 5 foot clear width requirement is likely.
  2. Where is staff going to relocate the wheeled equipment to, during a fire alarm? If the equipment does not have a designated storage room, then it will have to be stuffed into any empty room that staff can find. What happens when there are no empty rooms available?
  3. The new 2012 edition requires only wheeled equipment to be left in the corridor. Staff will soon either forget this stipulation or try to sneak in chairs, tables, and other non-medical equipment that does not qualify.
  4. How are you going to differentiate between medical equipment not in use, and medical equipment in storage? Unless there is a layer of dust on the stored equipment, it will all look the same. A surveyor may not believe the equipment is not stored.
  5. The ever-present Computers on Wheels (COWs) were not addressed in this new section. Are they considered medical equipment? That is yet to be decided.
  6. The new section says ‘transport’ equipment is allowed to be left unattended in corridors. That means you can expect a bunch of wheelchairs and gurneys lined up in the corridor. But not beds, or at least that seems to be what the code implies. You can guess that once staff sees gurneys and wheelchairs allowed to be stored in the corridor, they will try to add beds as well.
  7. During a fire emergency where patients are being evacuated from their rooms, most of them will be evacuated in their beds. Those beds never roll in a straight line, but take up more corridor room than the width of the bed. And there usually is a monitor, IV pump, or other medical equipment that trails along. All told, evacuating a patient in their bed requires at least 5 feet of corridor to do so quickly and safely. If medical equipment is still in the corridor, how do other staff individuals and fire-fighters get access into the unit when patients are being evacuated out of the unit?

At the minimum, this will require education, training, and then frequent surveillance to make sure this new section is followed correctly. More visits on the floors to make sure everything is within code. And then there is the section that allows fixed furniture that is screwed to the floor or wall, to project into an 8 foot wide corridor as long as the clear width remains 6 feet. There are other restrictions on the fixed furniture issue, but I don’t see fixed furniture in hospitals very often, if ever. I have been told that this section was created with nursing homes in mind, where patients are a bit more mobile and the fixed furniture allows for rest stations in strategic areas in the corridors.

That’s what I think about this new requirement. I would appreciate hearing from you what you think…