Equivalencies for Exit Enclosures

Q: We have a hospital with a number of exit enclosures. These passageways have a large number of unrelated utilities running above the ceiling. Modification will not only be very expensive, but very difficult. Can we use NFPA 101A FSES equivalencies for alternate compliance?

A: Section 7.1.3.2.1 (10)(h) of the 2012 LSC does say “Existing penetrations protected in accordance with 8.3.5” as an exception regarding utility penetrations into an exit enclosure, so the undesirable utility penetrations in the exit enclosures may be acceptable if you can prove they are ‘existing’ conditions. According to CMS, anything designed or constructed prior to July 5, 2016 is considered existing conditions as far as the 2012 Life Safety Code goes, but not all other authorities agree with this concept entirely. Ever since the 1988 edition and all of the subsequent editions of the LSC, it has said that penetrations of ductwork, conduit, pipes, etc., that do not serve the exit enclosure are prohibited.

Many authorities having jurisdiction enforce this to present day…. Meaning if the utility was installed in 1992 in the exit enclosure but does not serve the exit enclosure, then it still can be cited today because it was not installed correctly ‘back then’. But the 1985 edition does not say that. So, any utility installed in an exit enclosure that does not serve the exit enclosure before the 1988 edition was adopted would be considered ‘existing’ and since it wasn’t prohibited when it was installed, it would be permitted to remain, provided it met the requirements of 8.3.5. For CMS, they were on the 1985 edition until March 11, 2003.

But Joint Commission had been adopting the new editions of the LSC shortly after they were published. So, they were on the 1991 edition back in 1992, which is as far as my memory goes. It’s all a crap-shoot…. Some surveyors will recognize the July 5, 2016 date as the only threshold between new and existing and will allow the existing utilities in the exit enclosure, and then some surveyors will be more scrutinizing and try to determine when the utilities were installed. But to answer your question, if you get cited, you could always go for an equivalency (NFPA 101A FSES) as part of your Plan of Correction, but you would have to prove a significant hardship in complying with the LSC.

One can assume it will be costly to install a 2-hour fire-rated ceiling in the exit enclosure to cover-up the utilities, but the CMS Regional Office is the entity to make the decision to approve the FSES equivalency or not, and you need to convince them whether or not it is a significant hardship. CMS does not accept equivalencies unless the deficiency is first cited, so you will have to wait to get cited by your accreditor or state agency surveying on behalf of CMS. And don’t forget to conduct an assessment for ILSMs now of the deficiency… most authorities will expect you to do so. But equivalencies are only valid until the next triennial survey, so it would be best to make long-range plans to resolve the issue, rather than continuously presenting equivalency requests.

Exiting from Hospital into Medical Building

Q: A main circulation corridor in a Hospital (Institutional Use I-2, 8′ wide) passes thru the 2-Hr Use Group separation of adjacent medical offices (Business Use B) and re-enters the Institutional zone (2-Hr wall) for egress to a fire egress stair. Building has automatic sprinkler system. Are egress corridor movements between Institutional and Business Use permitted? Must all sections of that corridor sequence maintain a consistent width of 8′ clear?

A: [Boy… I wish you architects would use NFPA nomenclature instead of IBC…]. If I understand your question correctly, my reply would be yes… you can exit from the hospital into a business occupancy, but there are extenuating circumstances. Section 6.1.14.1.2 of the 2012 LSC says when an exit access (i.e. corridor) from an occupancy traverses another occupancy, the multiple occupancy must be treated as a mixed occupancy. For you, that means the most restrictive occupancy requirements apply, which in your case would be healthcare occupancy.

So, this means everything required for healthcare occupancy must be met in the business occupancy building, such as:

  • Construction type
  • Fire alarm system
  • Sprinklers
  • Fire-dampers/smoke dampers
  • Corridor width
  • Corridor doors
  • Fire safety plans
  • Door latching and locking requirements
  • Etc.

However, if you can call the 2-hour fire barrier separating the healthcare occupancy from the business occupancy, a horizontal exit, then you would not have to meet the requirements of healthcare occupancy, in the business occupancy building.

Exit Doors From OR

Q: Are operating rooms required to have two (2) exit doors? I have not seen this room but am under the assumption it is between 400 and 500 square feet.

A: According to section 18.2.5.5.2 of the 2012 Life Safety Code, non-sleeping rooms of more than 2500 square feet must have not less than two exit access doors remotely located from each other. Since the operating room you described is 400 to 500 square feet, I would say you are under the threshold for having to meet the requirement to have two doors to the corridor.

Now, if the Surgery area is a suite, there would not be a requirement for two exit access doors until you reached 2500 square feet total for the entire suite, which would include the operating room.

Exit Doors

Q: We have converted our old hospital building into a combination of outpatient facilities and office (business) uses. There are three exits that have no fire listings on the door or frame. All three have panic hardware, but not fire-rated hardware on them. It has been the common practice to dog these doors during the day so anyone ingressing does not have to push the release to enter, just pull the door open. These are all marked exits. Do these non-rated doors still have to positively latch to prevent drafts should there be a fire? Everything I find mentions fire rated doors, but does not mention non-rated doors.

A: The answer to your question is… it depends. You do not clarify if the three exits that you mention are upper floor doors to exit stairwells, or lower level doors to exit discharges. Since you didn’t specify, I will presume the ‘exit doors’ that you mention are doors on the level of exit discharge directly to the outdoors. (If they were doors to exit stairwells or exit passageways, then they must be fire rated and must be equipped with fire-rated hardware that cannot be ‘dogged-down’ to disable the latching mechanism.) So… presuming the doors in question open directly to the outdoors, it depends if they are required to be fire-rated. If the building is Type I or Type II construction, then the exterior exit doors are not required to be fire-rated if the exterior walls are non-load-bearing (typically, Type I and Type II construction has exterior walls that are non-load-bearing). However, if the exterior walls are load bearing, then the doors must be fire-rated and must positively latch. If the building is Type III construction, then by design, the exterior walls are load-bearing and the exit doors would then be required to be fire-rated. So… presuming the doors in question are not required to be fire-rated, then there is no Life Safety Code requirement for the doors to positively latch and to have fire-rated hardware. That means horizontal crash bars on the door leaf that are capable of being dogged-down (rendered incapable of latching) would be permitted. As discussed, it all depends on whether or not the wall that the doors are located in, is a fire-rated barrier.

Strange Observations – Part 14

Continuing in a series of strange things that I have seen when consulting at hospitals…

Isn’t this a winner…? I should submit this picture to Lori Greene so she can share it on her website “I Dig Hardware”.

I remember asking the staff who accompanied me during the survey why they locked this Exit door, and they said they didn’t want people going through there.

This is why we have inspections in our hospitals….

Exiting Through an Enclosed Courtyard

Q: I have an existing 3 story building in an urban environment with an exterior stair which discharges into an enclosed rear yard. The access to a public way is through an exit access passageway through the basement and up an enclosed stair to the street in front. This is very common in the city. The building is used as an ambulatory clinic (business occupancy) and the AHJ is not allowing the exterior stair to be considered an exit because of the necessity to pass back through the building. I cannot find this prohibition in the LSC but maybe there is some history on this?

A: Did you ask the inspector for a code reference? Usually, they are pretty good about sharing that information. But section 7.7.1 of the 2012 LSC would agree with the inspector and not allow the arrangement you describe. The exit discharge may discharge to an open court provided the open court provides occupants a safe access to the public way without re-entering the building. The NFPA LSC handbook on 7.7.1 discusses this in greater detail. I would say the inspector got it correct.

Exiting Through Other Occupancies

Q: If I want to classify my building as a healthcare occupancy, even though I have a business or ambulatory healthcare occupancy in it, I know I need to meet the most restrictive occupancy, which would be healthcare. I know that I need to meet construction type, fire protection, and allowable floors for the healthcare occupancy, but what about exiting requirements?

A: Where inpatients are expected to exit through any other occupancy, you need to maintain the exiting requirements for healthcare occupancy even if the occupancy is something else. As an example, if an Emergency Department is classified as an ambulatory healthcare occupancy, the required width of corridors for exiting is 44 inches. However, if inpatients are expected to use the path of egress from the healthcare occupancy into and through the ambulatory healthcare occupancy, then the required width must be maintained for healthcare occupancy (which is 8 feet) even in the ambulatory healthcare occupancy.

Strange Observations – Part 6

Door with Conflicting SIgnage Web 2Continuing in a series of strange things that I have seen while consulting at hospitals….

This series of pictures is just plain sad… and wrong. The top picture shows a door in the path of egress with an ‘Exit’ sign over it. If you look closely, there is a magnetic lock on this door and there is a sign posted on the door as well. This door is in an exit access corridor and lead from one physician’s office area to another physician’s office area and for some reason was equipped with a magnetic lock. But the magnetic lock did not qualify for the exceptions to 19.2.2.2.4 of the 2000 LSC for delayed egress locks or access-control locks.

Take a look at the bottom picture… The picture is a close-up of the sign on the door. The sign says “This is not an exit…” but the ‘Exit’ sign over the door says “This is an exit”. That’s a conflict. To be sure, the door is an exit as this door was located in an exit access corridor and without the designated exit it would have been over a 100 foot dead-end corridor (which is not permitted). So, the exit is necessary.

But the conflicting signage is just wrong. Just because one physician’s office did not want people exiting into his area, you cannot lock the door and say the door is not an exit.

Close up of Door With Conflicting Signage Web 2I remember we tried to find out what actually releases the magnetic lock and the staff that I was with could not say. They said they were not sure if it released on a fire alarm and they checked with security and it did not release on any signal that security could transmit.

This is the type of deficiency that will lead to an Immediate Jeopardy decision and cause all sorts of headaches for a hospital.

Strange Observations – Part 5

Blocked Exit Door Web 2Continuing in a series of strange things that I have seen while consulting at hospitals….

I don’t remember where in the hospital I took this picture but it is apparent that it is in a seldom used area. Someone felt it was okay to store tables and chairs in this area, and didn’t realize it was creating an obstruction to the exit doors. Or, even worse, they may have realized it and not cared that they are blocking access to the exit doors.

Whenever a surveyor finds access to an exit is obstructed, it can (and often does) lead to an adverse decision. Some accreditation organizations can consider this a condition level finding, which means the survey team returns within 45 days for a follow-up survey, and they notify CMS. And other accreditation organizations may even consider this an Immediate Jeopardy (IJ) issue that will get you another focus resurvey within 22 days and most likely a visit from CMS.

Don’t put yourself in a position whereby you are standing in the CEO’s office explaining why your lack of action lead to an adverse decision. Be pro-active and do frequent rounding looking for obvious problems.

 

Exit Discharge Illumination

images3LU8KUQ0I was talking to a hospital facility manager recently and he was miffed that a surveyor cited him for not having emergency power lighting on the exit discharge outside the hospital. He has been at this hospital for nearly 30 years and takes any deficiency as a personal affront to his abilities as a facility manager. Besides, he told me, this has never been a problem before so why is it a problem now? (I hear that a lot!)

Section 7.8.1 of the 2000 Life Safety Code requires the exit discharge to be illuminated all the way to the public way. Sections 18/19.2.9.1 requires emergency lighting in accordance with section 7.9, which requires emergency power for illumination of the exit discharge to the public way. The definition of public way is:

“A street, alley, or other similar parcel of land essentially open to the outside air deeded, dedicated, or otherwise permanently appropriated to the public for public use and having a clear width and height of not less than 10 feet.”

Under most interpretations from the accreditation organizations, the parking lot of a hospital can be considered to meet the requirements of a public way, even though it may not be “deeded to the public”. So, the path of the exit discharge to the parking lot would need to have illumination that is fed from normal power and emergency power. But the illumination for the parking lot would not have to be emergency power illumination, since the requirement is to have emergency power illumination only to the public way, not at the public way. This is a generalized interpretation, and it may or may not apply to all situations. You need to determine before your next survey if your exit discharge lighting meets this requirement.

Also, the illumination source needs to be arranged so the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candles. This means you need two-bulb fixtures, or multiple single-bulb fixtures. The issue of LED fixtures is an interesting one. Technically, a LED fixture is comprised of many LED lamps, so I could see a single LED fixture as qualifying as a multiple lamp fixture. I haven’t heard of any authority say anything to the contrary, at least.