Jun 26 2017

Carpet on Corridor Walls

Category: Carpet,Corridors,Questions and Answers,WallsBKeyes @ 12:00 am

Q: I have a nursing home that is over 20 years old that has carpet on the corridor walls below the handrails. I am been told that this carpet must be removed. I am not able to find any information on the 20-year old carpet that gives the flame spread rating. What are my options other than removing it?

A: It depends on who is telling you to remove the carpet and why. If you were cited by a state surveyor or an accreditation organization, ask them to please identify the standard and reason for the citation. They should be able to identify the precise standard, code, or regulation why the carpet needs to be removed.

I suspect the violation comes from of the 2012 Life Safety code where existing interior finish materials have to be Class A or Class B on corridor walls, which would require a flame spread rating between 0 – 75, and a smoke development rating of 0 – 450.

If you cannot prove that the flame spread rating and smoke development rating of the carpet falls within these parameters, then you have no choice but to remove the carpet from the walls. After 20 years… it’s time for an upgrade.

Jun 23 2017

Required Width of New Corridor

Category: Corridors,Questions and AnswersBKeyes @ 12:00 am

Q: We have a corridor that connects an existing elevator lobby on the 2nd floor of a three story hospital to a new addition. The corridor is used for the transfer of personnel and patients from one building to another. It is not an exit corridor; there are exits on each end of the connector. As designed the corridor is 7′-7″ clear. Is this width permitted, or do we need to re-design to get the 8′ clear width?

A: All corridors are exit access corridors and are part of the path of egress. They just aren’t all required to be 8 feet wide. Where there are no inpatients, the corridor can be 44 inches wide. In your situation, the corridor between the elevator lobby and the new addition would be considered an exit access corridor because inpatients are wheeled in this corridor. One may believe that this corridor would have to be 8 feet wide since inpatients use this corridor, but it is an existing condition that is connected to a new addition, which requires you to comply with Chapter 43 on rehabilitation, according to section of the 2012 LSC.

Now, section does define a modification as the reconfiguration of any space; the addition, relocation, or elimination of any door or window, the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment. Section requires all modifications to comply with the requirements for new construction.

The question is, does the existing corridor have to comply with and be modified to meet new construction requirements? I don’t believe it does, but that is a question for the authorities over design and construction of the healthcare facility.

My advice is as follows:

  1. Obtain a written interpretation from your state or local authority over design and construction.
  2. If it is possible and practical to do so, then widen the corridor to at least 8 feet;
  3. If it is ‘impractical’ to widen the corridor, then assess it for ILSM, and implement compensation activities as your policy dictates. You can then wait to see if the AHJ (i.e. a surveyor from your accreditation organization) considers it a deficiency, and submit your reasoning that it is impractical to resolve and see if they agree. If they do not, then you can submit a waiver request after the survey.

May 31 2017

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 of the 2012 LSC. It says hazardous areas shall be protected in accordance with section 8.7. Section 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” Section 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 does not apply to healthcare occupancies because section actually permits ABHR dispensers in egress corridors. Similarly, section 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

Mar 27 2017

Connecting Bridge

Q: We have a connecting bridge between two of our buildings. On one side of the bridge is healthcare occupancy and on the other side is business occupancy. There is a 2-hour fire rated barrier between the bridge and the healthcare occupancy building. We have offices on the bridge, which are protected with sprinklers. What would the requirements be for these offices since they open into the egress corridor?

A: Since you have a 2-hour occupancy separation between the healthcare occupancy and the business occupancy, then you treat the bridge as if it is a corridor in a business occupancy. Each corridor has to have two exits, which in your case, one exit would be into the business occupancy building, and the other exit would be into the healthcare occupancy building. The offices on the bridge would have to meet the requirements for separation found in the business occupancy chapters. For new construction business occupancies, section of the 2012 LSC requires the corridor walls to be 1-hour fire rated, unless one of the following is met:

  • Exits are available from an open floor area;
  • The space is occupied by a single tenant;
  • The building is protected throughout by an automatic sprinkler system.

For existing construction business occupancies (construction design approved prior to July 5, 2016) there are no requirements. However, if constructed between March 11, 2003 (the date the 2000 LSC was adopted) and July 5, 2016, a surveyor could expect that you be compliant with new construction requirements.

Feb 08 2017

Corridor Door Louver

Category: Corridors,Doors,Questions and AnswersBKeyes @ 12:00 am

Q: Is there a code that says anything about adding a vent through a door that is in the corridor of our hospital?

A: Well… you might be able to do that legally on a very few specific corridor doors (i.e. bathroom doors, toilet rooms doors, shower room doors), but no, you cannot install a louver in a typical corridor door in a hospital because section of the 2012 LSC says corridor doors have to resist the passage of smoke. Therefore, a louver in a door would not resist the passage of smoke.

Now, a very few specific corridor doors do not have to resist the passage of smoke as described in section (1), and you would be permitted to install a louver in those doors.

Aug 10 2015

Corridor Width

Category: Corridors,Questions and AnswersBKeyes @ 12:00 am

Q: Can you give me the NFPA Life Safety Code (2000 edition) reference showing 8 foot required width in egress corridors in an existing healthcare occupancy?

A: There is no direct LSC reference that requires 8 feet wide corridors in existing hospitals. But; it’s an interpretation. Section of the 2000 Life Safety Code says corridors have to be at least 4 feet wide in existing healthcare occupancies. Section 4.6.7 says when you make alterations, you must meet new construction requirements. Section requires 8 feet wide corridors in new construction healthcare occupancies. So, let’s say you have 7 foot wide corridors in an existing hospital. That’s legal. But the minute you make an alteration (including storing something non-combustible in the corridor) now it must meet the requirements for new construction, which is 8 feet. So, the correct way of stating corridor width in existing healthcare occupancies is the corridor must be free and clear up to 8 feet wide. If the corridor is 7 feet wide: That’s okay as long as the width is free and clear.

Apr 13 2015

Handrails in Corridors

Category: Corridors,Handrails,Questions and AnswersBKeyes @ 6:00 am

Q: I am working on an aesthetic corridor remodel for a hospital. Can you please tell me if there are specific requirements as to handrail locations (i.e- one side of the wall vs. both sides, at what locations, for what amount of distance, etc.)?

A: In regards to healthcare occupancies, and specifically hospitals, there is no Life Safety Code requirement for handrails in an exit access corridor. There are requirements for stairs, exit enclosures, ramps and exit passageways to have handrails, but the LSC does not have any requirements for corridors. However, there are other codes and standards to consider. The Facility Guidelines Institute requires hospitals to comply with ADA requirements in regards to handrails in corridor, unless the functional program narrative specifically decides against them. What this means, if the hospital has a written program that describes the use and activities that the corridor serves is not consistent with handrails, then it is permissible not to install them. An example of this may be a Psychiatric unit where a handrail could possibly be removed and used as a weapon. In essence, the hospital gets to decide if there will be handrails, but the reason needs to be plausible and written down in a program narrative. Also, compliance with ADA requirements is required whenever new construction or renovation of an existing area is conducted. I do not believe just installing new wallpaper qualifies as renovation, so compliance with ADA would not be required. I strongly recommend that you contact the local and state authorities to determine if they have regulations that would require handrails.

Feb 24 2014

Privacy Curtains or Screens?

Category: Corridors,Curtains,Questions and AnswersBKeyes @ 6:00 am

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 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, 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.

May 06 2013

Nurse Server Cabinet Doors

Category: Corridors,Doors,Questions and AnswersBKeyes @ 6:00 am

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 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 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 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.

Nov 19 2012

Means of Egress Widths in Suites

Category: Corridors,Questions and Answers,SuitesBKeyes @ 5:00 am

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 (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 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 and allow a minimum aisle width of 36 inches for new construction, or 28 inches for existing conditions.

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