Jun 19 2017

Healthcare vs. Ambulatory Healthcare Occupancy

Q: A surgery suite (5 ORs), PACU (8 bays), and ASU (17 rooms), newly built on the 3rd floor of a business occupancy building. A 2 hour box was constructed all the way around the floor (above, below, adjacent) and it was designed to meet healthcare occupancy. These are the operating rooms not only for ambulatory surgery (same day) patients but for the hospital’s in-patients as well. How should this area be classified in regards to occupancy designation? Does the potential for a large number of in-patients in the units mean it gets classified as healthcare even if there is no overnight sleeping?

A: One may agree with your logic that as long as there are not any overnight sleeping rooms provided within the unit, it could be classified as an ambulatory healthcare occupancy. But, to take an inpatient out of the healthcare occupancy and perform surgery on them in the ambulatory healthcare occupancy seems to be contrary to the intent of having different occupancies. Is the patient an inpatient or an outpatient? If inpatient, they have surgery in healthcare occupancies. If an outpatient, they have surgery in an ambulatory healthcare occupancy.

The bottom line… You are bringing inpatients from the hospital into the surgery area, therefore the surgery area must be healthcare occupancy. From my perspective, healthcare organizations should not be taking inpatients out of healthcare occupancies to ambulatory healthcare occupancies to perform surgery on them.

Jun 06 2016

Fire Barriers in Ambulatory Healthcare Occupancies -Part 2

 Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to install a fire barrier after the unit is constructed and if there are any other options. Your comments would be appreciated.

A: Well…. From a code standpoint, you may be obligated to have two different barriers:

  1. A 1-hour fire rated barrier to separate the ambulatory healthcare occupancy from other units that are not ambulatory healthcare occupancies (i.e. physician’s offices that would be classified as business occupancies). See sections and of the 2000 Life Safety Code.
  2. A 1-hour rated smoke compartment barrier to subdivide your ambulatory healthcare occupancy into two compartments. Exceptions to this requirement apply if your unit is less than 5,000 square feet and the unit is fully protected with smoke detectors, or if the unit is less than 10,000 square feet if the unit is fully protected with automatic sprinklers. See section of the 2000 Life Safety code.

If you receive Medicare & Medicaid reimbursement funds then you are obligated to comply with these codes. However, CMS does allow you to apply for a waiver if compliance with the Life Safety Code is a hardship for the organization. You cannot apply for a waiver until you are first cited for a Life Safety Code deficiency by an accreditation organization or a state agency surveying on behalf of CMS. But there are no guarantees that CMS would grant approval of a waiver request for this deficiency. Even if they did, the waiver is only valid for 3 years then you have to be cited again and then you have to submit a waiver request again. At best, it is a temporary process… not a permanent solution. My suggestion is to make plans to resolve the deficiency as soon as possible and if you get cited in the meantime, you can always submit a waiver request as part of your Plan of Correction.

May 30 2016

Fire Barriers in Ambulatory Healthcare Occupancies – Part 1

Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?

A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.

May 23 2016

ASC Fire Alarm Testing

Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.

A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section of the 2000 edition of the LSC requires compliance with section 9.6. Section requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.

Jul 27 2015

Ambulatory Healthcare Occupancies

Category: Ambulatory Care Occupancy,Questions and AnswersBKeyes @ 12:00 am

Q: How do I determine if our outpatient facility is an ambulatory healthcare occupancy?

A: Based on what the 2000 Life Safety Code says, an ambulatory healthcare occupancy is a building or portion thereof used to provide services or treatment simultaneously to four or more patients that: 1) Provides on an outpatient basis, treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others; or 2) provides on an outpatient basis, anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others. Ambulatory healthcare facilities shall be separated from other tenants and occupancies by walls and barriers not less than 1-hour fire resistance rating. The ambulatory healthcare facility shall be divided into not less than two smoke compartments. Facilities of less than 5,000 square feet and protected with approved automatic smoke detection system do not have to be subdivided, and facilities of less than 10,000 square feet and protected throughout by an approved, supervised automatic sprinkler system do not have to be subdivided into two smoke compartments. Not less than 15 net square feet per ambulatory healthcare facility occupant shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounges and other low hazard areas on each side of the smoke compartment for the total number of occupants in adjoining compartments. I also bring to your attention that in their proposed rule to adopt the 2012 Life Safety Code (issued in April, 2014) CMS stated they will seek to change the rules that govern ambulatory healthcare occupancies. Currently it requires four or more persons incapable of self-preservation to be classified as an ambulatory healthcare occupancy. If CMS gets their way that will be reduced to 1 or more persons incapable of self-preservation will require an ambulatory healthcare occupancy, and all of the above LSC references would apply. The big thing here is the 1-hour fire rated separation barriers and the ambulatory healthcare area divided into at least two smoke compartments. That would be a substantial cost to retroactively install those barriers after the area is occupied.

Jan 12 2015

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.


Dec 08 2014

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/ 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.

Oct 13 2014

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/ 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.

Aug 25 2014

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- 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.

Apr 21 2014

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 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.

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