Occupancy Separation

Q: I am a consultant hired by a health system to review a potential building they want to purchase. The architect on this project tells me that the building is NFPA 220 construction type II (111) which is basically a 1-hour rated assembly. The building is a fully sprinklered three story building, and has a mixed use including business and ambulatory healthcare occupancies. The health system is planning on buying the building and is looking to put a free-standing emergency clinic on the first floor which you’ve said needs to be healthcare occupancy. The second floor is a business occupancy. Here’s where it gets strange and I want to make sure I’m not crazy. The floor separation between the first and second floors in this case (business and healthcare) would need to be two-hour fire rated. But Type II (111) buildings have one-hour fire rated floors. I’ve received a drawing from the architect that states the construction type as II (111), but it shows the floors being upgraded to two-hour fire rated construction. The question is, can we have a two-hour floor supported by a one hour steel frame?

A: From my point of view, if they can document that the floor is 2-hour fire rated, then that should be enough for an AHJ to approve the separation between healthcare and business occupancies. I would view it as this: The floor is 2-hour fire rated, and it meets the requirements for a separation between healthcare and business occupancies, and it meets the requirements for Type II (111) construction type. Now, my opinion does not count, so I suggest they get an interpretation from their AHJs, including their accreditation organization.

By the way… CMS was the one who said in late 2016 that Emergency Departments need to be healthcare occupancies. Since then, they have modified their position a bit. Now they are saying an ED must be healthcare occupancy if they provide patient observation rooms. CMS’ rationale is if the patient is sleeping in an observation bed, then that should qualify it as healthcare occupancy. (I don’t agree, but my opinion does not count.) CMS does concede that an ED may be classified as ambulatory healthcare occupancy provide there are no observation beds.

Inpatients in Outpatient Locations

Q: Back in June of 2017, you posted an article about “Inpatients in Outpatient Locations”, but I am unable to access that posting. Can you re-post that article as I am interested in what you have to say about inpatients being treated in outpatient areas.

A: Yeah… I pulled that posting from my website because it had inaccurate information in it. That was an “Oops” on my part. I believe in my original posting (which is now gone) I said it was not permitted to take inpatients out of a healthcare occupancy, into an adjoining ambulatory healthcare occupancy or an adjoining business occupancy for treatment or exam. I based this thought on CMS’ position that one or more outpatients in an ASC requires the ASC to be classified as an ambulatory healthcare occupancy, instead of the four-or-more that NFPA says. For some reason, I thought this carried over to non-ASC ambulatory healthcare occupancies, which I found out it does not.

So, to be sure, section 19.1.3.4.2 of the 2012 LSC does say ambulatory care facilities, medical clinics, and similar facilities that are contiguous to healthcare occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. But the key point here, is the inpatients must be capable of self-preservation. This means they are capable of getting up out of the wheelchair or off of the gurney under their own power and exit the building without assistance from others. Most inpatients in a healthcare occupancy (at least the traditional hospital and nursing home healthcare occupancy) are not capable of self-preservation. So be extra careful by ensuring staff only take those inpatients that are capable of self-preservation into adjoining non-healthcare occupancies for treatment or exam.

I apologize for the confusion and misinformation.

Separation of Different Occupancies

Q: There is an existing clinic which is classified as business occupancy that leases space within a rehabilitation and nursing center. Does this need to be separated by a 2 hour rated partition? Does the egress corridor from the clinic to the exterior need to be rated?

A: Uhm… my answer is … it depends. You state the clinic is a business occupancy, but you did not state what occupancy the rehabilitation and nursing center is. I’m not sure what you mean by a ‘nursing center’… is that a hospital, a nursing home, or is it something else? Is the rehabilitation center classified as a hospital or a nursing home? Or is it outpatient only? Are there any patients in the rehabilitation center that are incapable of self-preservation? If so; how many?

If the rehabilitation center and the nursing center is a different occupancy than the clinic (which you say is a business occupancy), then yes, the different occupancies must be separated by fire rated barriers. The fire rating of these barriers depends on whether or not the occupancy (other than the business occupancy) is healthcare occupancy. Where healthcare occupancy is separated from any other occupancies, the fire rating on the barrier must be 2-hours. However, if the occupancy of the rehabilitation and nursing center is not healthcare occupancy, then the fire rating on the barrier separating the occupancies is only required to be 1-hour rated.

Corridors in new construction business occupancies must be constructed with 1-hour fire rated walls, according to section 38.3.6.1 of the 2012 LSC. But the exceptions to 38.3.6.1 say the requirement for 1-hour fire rated walls does not apply:

  • Where exits are available from an open space;
  • Within a space occupied by a single tenant;
  • Within buildings protected throughout by an approved sprinkler system.

If the business occupancy is considered existing construction, then there are no requirements for the corridor walls. If the rehabilitation and nursing center exits into and through the business occupancy, then the corridor in the business occupancy must meet the requirements for corridors in the occupancy where the rehabilitation and nursing center is located.

Medical Office Building Occupancy Classification

Q: A Hospital System that I do work for is in the process of constructing a Medical Office Building off-campus (over 250 yards from the Hospital). The building will house exam rooms, treatment rooms, and procedure rooms for a Provider Based Physician. In the past, we would consider this a Business Occupancy. We have heard that for an off-campus Provider Based Physician we will need to use a more restrictive code. Is this true, and if so, do we use the Healthcare Occupancy or the Ambulatory Healthcare Occupancy for this building type?

A: On June 30, 2016, CMS issued a correction to their Final Rule to adopt the 2012 Life Safety Code. This correction specifies that all ‘hospital outpatient surgical departments’ have to meet Ambulatory Health Care Occupancy (AHCO) requirements regardless how many outpatients are incapable of taking action for self-preservation.

One of the confusing issues in this CMS communication is the phrase ‘hospital outpatient surgical departments’. Initially, most people would think that phrase describes Ambulatory Surgical Centers (ASC) because the word ‘surgical’ is used. But in follow-up communications with CMS, they described this phrase ‘hospital outpatient surgical departments’ to mean any service that qualifies under the definition of AHCO.

Section 3.3.188.1 of the 2012 LSC describes AHCO as:

  • Outpatient treatment for patients that renders the patient incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Emergency or urgent care for patients who, due to the nature of the injury or illness are incapable of taking action for self-preservation under emergency conditions without the assistance of others.

This description is beyond just ASC; it includes all sorts of procedures, such as:

  • Endoscopy
  • Bronchoscopy
  • Colonoscopy
  • MRI / CT Scan
  • Cath Labs
  • Some therapy units, such as Aqua-Therapy
  • Etc.

Since the 2012 LSC says four or more outpatients in order to qualify for AHCO, CMS felt the need to issue a correction to their Final Rule to say now it is 1 or more outpatients to qualify as an AHCO.

What this means, if the physician’s office was doing a minor procedure and it only involves one outpatient at a time, and that minor procedure qualifies under 3.3.188.1 as being an AHCO, then the building (or story) must meet AHCO occupancy requirements even if there is only one outpatient involved in the entire facility. Under the 2012 LSC definition, that physician office would qualify as being a Business Occupancy, but with the new CMS correction to the Final Rule, it now must be AHCO.

And this is retroactive to existing conditions.

Creating Separated Occupancies

Q: I have a 3 story hospital and I would like to have a mixed occupancy classifications for different floors. The basement floor is for support – no patients are ever on this floor for any reason. The top floor is administration. Patients are occasionally on this floor if they are being transported to the adjacent hospital – always in the company of nursing staff and only for 1-2 minutes at a time during transport. No treatments and no overnight stays on this floor. Can I declare the main floor to be healthcare occupancy and the other two floors to be business occupancy? If so, what are the proper steps to make this happen; do I need to involve an architect, do the life safety plans need to be retitled, can I make this decision myself or do I need approval of some sort?

A: You should not make this decision by yourself. You need to employ an architect who has healthcare experience and a good working knowledge of the Life Safety Code.

You did not mention what your facility construction type is (according to NFAP 220). Take a look at 19.1.6.1 of the 2012 LSC… there is a Table that lists all of the approved constructions types for existing hospitals. It is important to know because you will need a 2-hour fire rated barrier between the floors where you want separated occupancies in your facility.

It appears you should not have any issues in making the lower level a business occupancy, and there may be some possibility for the upper level as well. But the experienced architect needs to conduct a field review to ensure exiting, construction type and other factors are correct to allow separated occupancies in your facility.

Once the review has determined you can make these changes, then your Life Safety drawings need to be updated and perhaps your state or local AHJ may want to review this change as well.

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.

Emergency Departments: Healthcare Occupancy Only

In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments are now required to be classified as healthcare occupancies only. For most of the hospitals this will not be a problem, but for those hospitals that have already classified their ERs as ambulatory healthcare occupancy, they will have to make a change back to healthcare occupancy. This also affects those free-standing Emergency Departments that were designed and approved as ambulatory healthcare occupancies; they also must meet the requirements for a healthcare occupancy.

This all came-about when the accreditation organizations (AO) submitted their revised and updated standards for the change to the new 2012 Life Safety Code. One particular AO created an introduction to their Life Safety chapter and explained the differences in occupancies and gave an ER as an example of an ambulatory healthcare occupancy. CMS wrote back and said no, ERs cannot be ambulatory healthcare occupancies because they provide sleeping accommodations for patients who are on 24-hour observation.

Many of the AOs objected to this change and pointed out that the ER does not provide sleeping accommodations and besides there are situations where there are less than 4 patients under 24-hour observation. CMS would not budge on this issue, and it is their (CMS’) position that the ER does provide sleeping accommodations for 4 or more patients and therefore they must be classified as healthcare occupancies.

This rather severe interpretation by CMS was communicated with the AOs, however it has yet to be released by CMS to the general public. Be aware: It appears that the AOs are prepared to enforce this decision by CMS, because if they do not, and CMS conducts a validation survey after the AO survey, then the AO can be held accountable for not citing the issue.

It is important to understand that there were advantages for a healthcare organization to claim their ER is an ambulatory healthcare occupancy. If the ER was too large to qualify as a suite under the healthcare occupancy requirements, then it may qualify as a suite under the ambulatory healthcare occupancy requirements because under the ambulatory healthcare chapters, suites are unlimited in size. Also, if the ER cannot qualify as a suite, there are no requirements for corridor doors to the exam rooms in an ambulatory healthcare occupancy.

So, for some healthcare organizations, re-classifying their ERs back to be a healthcare occupancy may be a serious challenge.

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.

Critical Access Hospitals vs. Acute Care Hospitals

research[1]I’m no expert on the differences between a Critical Access Hospital (CAH) and an Acute Care Hospital (hospital), but I’m learning. Having been an advisor to American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP) for nearly 3-years now has provided me with an enlightenment that I never expected.

First of all, I learned that CAHs are not hospitals. Well, technically they are not according to CMS, who determines whether a healthcare facility is a CAH or a hospital. If you are ill and need help that a hospital can offer, a CAH healthcare facility will take good care of you and you would not necessarily know the difference. From all appearances, a CAH looks like a hospital, only smaller. Did you know that in 2013, there were 1,332 certified Critical Access Hospitals in the United States, according to reports from CMS? That over 25% of all the acute care hospitals registered in the country.

A new CAH cannot start out by being a CAH. It first must be accredited as a hospital; then it must apply to CMS to become a CAH. There are many qualifying factors that contribute to becoming a CAH, of which this is what I know:

  • CAHs can only have 25 inpatient beds
  • CAH locations have to be more than a 35 mile drive from any other hospital or CAH
  • CAH locations have to be more than a 15 mile drive from any other hospital or CAH in area with mountainous terrain or secondary roads
  • Be located in a rural area
  • Furnish 24-hour emergency care services, 7 days a week
  • Have an average length of stay of 96 hours or less

Why do hospitals want to become a CAH? Mainly for the reimbursement rate that CMS offers to CAHs. Critical Access Hospitals are certified to receive cost-based reimbursement from Medicare. This  reimbursement is intended to improve their financial performance and reduce hospital closures. Each hospital  is responsible for reviewing its own situation to  determine if CAH status would be advantageous. Critical  Access Hospitals are certified under a different set of  Medicare Conditions of Participation that are more  flexible than the acute care hospital conditions of  participation. Since most hospitals (and CAHs) earn the majority of their income from Medicare reimbursements, having the advantage of being a CAH is definitely a benefit. As of January 1, 2004,  CAHs are eligible for cost plus 1% reimbursement, and capital improvement costs are included in allowable costs  for determining Medicare reimbursement. Without the financial advantage of being designated as a CAH, many rural areas in the country would not have healthcare available to them.

There is a story of hospital attempting to become a CAH but they didn’t meet the driving distance from a specialty hospital that did not serve the general public. It took them nearly five years to convince CMS that they qualified as a CAH because the other hospital within their 35 mile radius did not serve the people from that area. Fortunately, CMS finally agreed.

So, you’re wondering why am I telling you all this? Well, Joint Commission recently published the top five findings by surveyors in 2013 for all of the disciplines, CAHs and hospitals alike. Now, from what I understand the same LS surveyors who survey hospitals also survey CAHs. If that is true, then there is one significant difference in the results of those surveys in 2013. Take a look at this:

 Critical Access Hospital

% of Surveys

Standard

Subject

60%

EC.02.03.05

The critical access hospital maintains fire safety equipment and fire   safety building features.

54%

EC.02.05.01

The critical access hospital manages risks associated with its   utility systems.

49%

LS.02.01.20

The critical access hospital maintains the integrity of the means of   egress.

47%

IC.02.02.01

The critical access hospital reduces the risk of infections   associated with medical equipment, devices, and supplies.

44%

LS.02.01.30

The critical access hospital provides and maintains building features   to protect individuals from the hazards of fire and smoke.

Hospitals

% of Surveys

Standard

Subject

52%

LS.02.01.20

The hospital maintains the integrity of the means of egress.

52%

RC.01.01.01

The hospital maintains complete and accurate medical records for each   individual patient.

48%

LS.02.01.10

Building and fire protection features are designed and maintained to   minimize the effects of fire, smoke, and heat.

47%

EC.02.05.01

The hospital manages risks associated with its utility systems.

46%

IC.02.02.01

The hospital reduces the risk of infections

The difference that is notable is EC.02.03.05, which is the standard for testing and inspection of fire safety features. For CAHs it is number 1 on the list, cited on 60% of all the surveys. For hospitals it is number 6 on the list and cited on 44% of the surveys. Not sure why there is such a difference, but perhaps it is because CAHs have less resources available to the facility manager to ensure all of the work is actually accomplished.

The rest of the standards are pretty close to being even:

  • EC.02.05.01              54% for CAHs;           47% for hospitals
  • LS.02.01.20              49% for CAHs;           52% for hospitals
  • LS.02.01.30              44% for CAHs;           43% for hospitals

 I think Critical Access Hospitals are neat… especially when you need one out in the rural areas.

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.