Jun 15 2017

Locked Mechanical Room

Category: Door Locks,Mechanical Rooms,Questions and AnswersBKeyes @ 12:00 am
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Q: The computer server is located in the mechanical room. IT wants the room locked for HIPAA compliance. Is it permissible to lock a mechanical room? Doesn’t locking compromise access to electrical panels, fire panel, water shutoff, etc. in an emergency?

A: Yes… you can lock a door into a mechanical room, as far as NFPA is concerned; you just can’t lock the door in the path of egress. Does a locked door to a mechanical room restrict access to electrical distribution panels? Yes it does, but that is a good thing. According to NFPA 99-2012, section 6.3.2.2.1.3 access to overcurrent protective devices (i.e. circuit breakers) serving Category 1 or Category 2 rooms must be secured to allow access for authorized individuals only. So, having these distribution panels inside a locked mechanical room meets the requirement of NFPA 99.

It is expected that authorized individuals will have a key or device to access this room in the event of an emergency. Make sure any locks that are installed on the door does not lock the door for those individuals exiting the mechanical room. It is not uncommon for Information Technology to place intermediate distribution frames containing servers in various locations around the facility. The challenge is to meet all of the requirements for limiting access for HIPAA compliance and still allow regular access for other items in the room.


May 12 2017

Dead Bolt Locks on Office Doors

Category: Door Locks,Questions and AnswersBKeyes @ 12:00 am
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Q: Does section 7.2.1.5.10.2 of the 2012 edition of the LSC, which prohibits more than one releasing actions to operate the door apply to office doors within a healthcare occupancy? For example, the nurse manager’s office opens to the corridor, and she wants to place a deadbolt lock on the door. Does the addition of a deadbolt lock create a violation? Does egress from a single office require the same “single motion” requirement as the remainder of the path of egress?

A: Yes, it does. As long as the door (no matter where the door is located) is in the path of egress, then it must comply with 7.2.1.5.10.2 and be operable with only one releasing motion. A door to an office qualifies as a door in the path of egress, because if you’re inside that office, the door in in your path to the way to get outdoors. Now, it is possible that if there were two entrances (doors) to the same office, you could designate one of the doors as being in the path of egress, and the other door as not being in the path of egress. This way, the door that is not in the path of egress could have a dead-bolt lock that requires more than one releasing motion, but that may not help you with this situation.

Please understand that since this requirement to have no more than one releasing operation to operate the door is found in chapter 7 of the 2012 LSC, it applies to all occupancies, with the exception of residential occupancies as the standard states. This means it applies to your medical office buildings, administrative buildings, clinics, and as well as your hospital. Deadbolt locks that operate separately from the door latch set just are not permitted.

The 2012 LSC section 7.2.1.5.10.6 does allow existing conditions where two releasing operations on a door serving an area having an occupant load not exceeding three persons to remain. But that does not allow you to install locks on that door… it is only available for existing conditions.

Rest assured, there are multiple types of locks that are available for doors that can be operated with only one releasing motion. The most common includes a deadbolt that retracts when the door handle is operated, and those are commonly found in hotels. There are other types of locks that are incorporated into the door handle and will unlock the door when the door handle is turned.


Apr 03 2017

Patient Sleeping Room Locks

Category: Door Locks,Patient Rooms,Questions and AnswersBKeyes @ 12:00 am
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Q: Are locks permitted on patient room doors? Where can I locate the NFPA requirements for adding new hardware to patient room doors?

A: Section 19.2.2.2.2 of the 2012 Life Safety Code says locks are not permitted on patient sleeping room doors. Then, an exception to this standard says key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room. What this means is you can lock the door to a patient sleeping room as long as the person on the inside of the room can open the door and get out.

However, before you think about adding deadbolt locks to existing doors, section 7.2.1.5.10.2 of the same code says you cannot have more than one lock or latch to operate the door. This means a deadbolt lock that is separate from the door latch set is not permitted because it takes two actions to operate the door: 1) Unlock the lock, and; 2) Turn the latch set handle. What you can have is a lock that automatically unlocks the door when the latch set handle is turned. These are also called hotel suite locks, because they are common in hotels. There is a deadbolt that is integrated with the latch set, and a person may unlock the door by simply grasping the latch set handle and turning.

If by chance the door in question is a fire-rated door, according to NFPA 80 you are permitted to make minor changes to the door in order to install new hardware, provided the hardware is listed for use on a fire rated door assembly.


May 16 2016

Dead-bolt Locks on Bathroom Doors

Category: Door Locks,Questions and AnswersBKeyes @ 12:00 am
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Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors. Is this permitted?

A: Actually, dead-bolt locks with a thumb-turn on the inside would be permitted on restroom doors, provided the doors to the restrooms are not positive latching. Restroom doors are not required to latch, therefore the larger restrooms rarely have positive latching hardware. Section 7.2.1.5.4 of the 2000 Life Safety Code© says doors in the means of egress are not permitted to have more than one action to operate the door. If the door had a latch-set and a dead-bolt lock then that would not be permitted since it takes two actions to operate the door (unlock the dead-bolt and turn the latch-set). But since the bathroom door does not require a latch-set, then a dead-bolt lock that can be unlocked from the egress side would be permitted.


Oct 12 2015

Controlled Access Locks

Category: Door Locks,Questions and AnswersBKeyes @ 12:00 am
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Q: While conducting fire drills in the hospital, one of the questions on our drill evaluation sheet is, “Did the security doors in the fire zone release properly?” We have controlled areas where the doors are locked to control access into the unit. To exit the unit only requires the push of a button and the doors release. So are we in compliant with this controlled access not releasing during the fire alarm activation since the exit is not controlled? Or should the doors release to allow free entry and exits?

A: Doors in the path of egress in a healthcare occupancy are not permitted to be locked. However, there are three (3) exceptions to this requirement:

  • Delayed egress locks complying with section 7.2.1.6.1, 2000 LSC
  • Access-control locks complying with section 7.2.1.6.2
  • Clinical needs locks complying with section 19.2.2.2.4

By the sound of your situation, it appears to me that you do not have delayed egress locks and you do not have clinical needs locks, which leaves access-control locks. However, it also appears that your description of the security door locks may not be in compliance with section 7.2.1.6.2. Here is a summary of the requirements for access-control locks:

  1. A motion sensor must be mounted on the egress side to detect occupants approaching the door, and automatically unlock the door in the direction of egress
  2. A loss of power to the control system automatically unlocks the door in the direction of egress
  3. A manual release button must be mounted 40 to 48 inches above the floor, and within 5 feet of the door, that when operated will directly interrupt the power to the lock, independent of the control system, for a minimum of 30 seconds. The button must be labeled with the words “PUSH TO EXIT”.
  4. The door must unlock in the direction of egress upon activation of the building fire alarm system or the building sprinkler system.

So, it appears to me that you are missing the motion sensor on the egress side of the door that would automatically unlock the door when someone approaches. Also, it sounds like your locks are not interconnected to the building fire alarm system to automatically unlock on an alarm. According to section 7.2.1.6.2, these are required. Also, check the ‘PUSH TO EXIT” button to make sure it interrupts power to the locks for a minimum of 30 seconds, when depressed.


Jan 05 2015

Main Lobby Locked Doors

Category: Door Locks,Questions and AnswersBKeyes @ 6:00 am
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Q: We have a separate building on our campus that includes our behavioral health unit, along with related offices and meeting rooms for the support staff. The behavioral health unit is segregated from the offices and meeting rooms and patients would never be in these offices or meeting rooms. There are secured doors preventing the patients from entering the main lobby area. The path of egress for the offices and meeting rooms is through the main lobby. This is a secured facility, so much so that the egress doors from the main lobby of the facility are locked with the use of electronic mag-locks. The only way the doors will release is through one of the three methods: Swipe an employee badge to release the mag-locks; a person in the cubicle to push a button to release the mag-locks; or when the fire alarm system is activated. Are we in compliance with the Life Safety Code with our mag-lock doors for egress concerns in our lobby?

A: It does not appear that you are. As you state, the behavioral health unit is segregated from the rest of the facility by secured doors and the path of egress for the offices and meeting rooms is through the main lobby, so locking those egress doors would not be permitted. Section 19.2.2.2.4 of the 2000 Life Safety Code does not allow doors in the path of egress to be locked. The exceptions to 19.2.2.2.4 allow delayed egress locks and access-control locks, but in this case, it does not appear that you could use clinical needs locks on doors in the path of egress that are shared by the offices and meeting rooms.

Typically, authorities having jurisdiction do not allow clinical needs locks on more than one set of doors in the path of egress for behavioral health units. You could install delayed egress locks on the main lobby egress doors as long as the entire facility is either sprinklered or protected with detectors. A card-swipe reader could be installed to deactivate the delayed egress function so people could exit without activating the delayed egress alarm. Or, you could install access-control locks on the doors, although they really are not locks for people egressing. Follow the requirements for delayed egress and access-control locks found in sections 7.2.1.6.1 and 7.2.1.6.2 of the 2000 Life Safety Code.


Sep 08 2014

Door Locks

Category: Door Locks,Questions and AnswersBKeyes @ 6:00 am
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Q: We have been asked to install a lock on a door in the path of egress through an office. For security reasons they would like to lock the doors to and from this area. We are thinking of using an electric strike fail safe connected to fire alarm on both doors. This is not in a patient care area, and the doors would only be used by staff.

A: In a hospital, there are only three permissible methods to lock a door in the path of egress: 1) Delayed egress; 2) Access-control; and 3) Clinical needs. Let’s eliminate clinical needs right off the bat, as that refers to a behavioral health unit or an Alzheimer’s unit. Delayed egress may be a possibility, but the hospital needs to be fully sprinklered or fully smoke detected, and you cannot have more than one delayed egress lock in the path of egress to the public way. Delayed egress does not provide true security for the doors, just a 15 second delay which if activated can be very annoying to the staff. I don’t see this as a suitable arrangement.  The more logical approach is the access-control locks, which allows you to provide security to prevent unauthorized individuals from entering the space, but it does not prevent anyone from exiting the space. Section 7.2.1.6.2 of the 2000 edition of the Life Safety Code describes the requirements for access-controlled egress:

  • A sensor must be installed on the egress side of the door to detect an occupant approaching the door and automatically unlock the door. This sensor must also be wired where a loss of power to the sensor unlocks the door.
  • A loss of power to the access-control system must unlock the door.
  • A manual release ‘Push to Exit’ button must be installed on the egress side of the door, 40 – 48 inches above the floor, and within 5 feet of the door. The manual release button must be labeled with a sign that reads ‘Push to Exit’. When operated, the manual release button must directly interrupt power to the lock independent of the access-control system, and the door must remain unlocked for a minimum of 30 seconds.
  • Activation of the building’s fire alarm system and/or sprinkler system must unlock the door, and remain unlocked until the fire alarm system has been manually reset.

Access-control locks do not provide any security in the path of egress. In your question, you stated that the door in question is in the path of egress. If that is truly the case, then there is no way you can legally lock this door. I would advise the hospital to re-configure their walls and path of egress to allow the office space they desire without locking a door in the path of egress. Another issue to consider: Is the door in question required to latch? If so, then access-control locks cannot be used in lieu of latching. Even though the door may be locked by a mag-lock, it still needs to latch (if required). The phrase “fail safe” means different things to different people. Typically, for locksmiths ‘fail safe’ means when power is removed, the locks remain locked, but for fire safety people the phrase ‘fail safe’ means the lock remains unlocked.


Apr 14 2014

Card Readers on Door Locks

Category: Door Locks,Questions and Answers,StairwellsBKeyes @ 5:00 am
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Q: During a recent survey, the surveyor said a card reader on the stairwell door cannot be located on an adjacent wall or door frame, but it must be an integral part of the lockset itself. Is this true? They were talking about card readers on the stairwell side for re-entry to a floor.

A: Did the surveyor cite you for non-compliance? If not, surveyors sometimes say things that are misunderstood, especially if there is no citation. Doors not in the path of egress are permitted to be locked, and a re-entry door from a stairwell usually is not in the path of egress. As long as the re-entry door in the stairwell is not in the path of egress then I do not see any reason that what you describe would be a problem. The Life Safety Code would allow for a card reader device to unlock a stairwell re-entry door as long as the door is not in the path of egress.  If the card reader is mounted in the stairwell on the door leading to a floor of the building (not a discharge door), then the card reader is not on the egress side of the door. There is nothing in the Life Safety Code, or in NFPA 80 Standard for Fire Doors and Fire Windows, (1999 edition) that would require the card reader to be mounted on the door leaf, rather than the on the wall near the door. Therefore, it is clear that the LSC permits card-access readers to be mounted on the wall near the door, since it is not a device or motion to operate the door. I cannot think of any situation that would require the card-access reader to be mounted on the door leaf, itself.


Mar 31 2014

Locked Doors for Utility Rooms?

Category: Door Locks,Questions and Answers,Soiled Utility RoomsBKeyes @ 6:00 am
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Q: Where is the reference in the Life Safety Code that requires the doors to housekeeping or soiled utility rooms to be locked? I have a Risk Management director that tells me the code requires these doors to be locked.

A: There is no Life Safety Code requirement to lock housekeeping or soiled utility room doors. There is no Joint Commission, CMS or any other national authority that requires housekeeping or soiled utility room doors to be locked. Where hospitals get into trouble with CMS and the accreditation organizations on this issue is the failure to assess the risk to safety for patients and staff, when these doors are left unlocked. Each of the national authorities has a standard that requires hospitals to either identify safety and security risks in the environment, or their standard requires the hospital to maintain a safe environment for their patients.  An unlocked utility room that contains a risk to the patients would certainly be suspicious to a surveyor that the environment may not be safe for the patients. A housekeeping room may contain cleaning supplies that could be considered dangerous to unauthorized individuals (such as children). If the door to the housekeeping room was left unlocked, then people could gain access to the hazardous items and hurt themselves or others. Likewise for soiled utility rooms, which by definition would have soiled linens which may be bio-hazardous. This does not mean all soiled utility rooms or housekeeping rooms need to be locked. They just have to be assessed for the safety or security risks associated with the contents of the rooms. In my encounters, most of the soiled utility rooms that I see in hospitals are unlocked. Only soiled utility rooms where children are prevalent are the ones that are typically locked. Now, on the other hand, most (if not all) housekeeping janitor’s closets that I see are locked, partly due to the hazardous cleaning chemicals stored in them, but also because Housekeeping doesn’t want their other supplies stolen. But, to be sure, there is no direct requirement in the LSC or in the accreditation organization standards to keep these doors locked.


Jul 01 2013

Locks vs Latches

Category: Door Locks,Doors,Questions and AnswersBKeyes @ 6:00 am
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Q: A surveyor cited us for not having positive latching doors to our entrance of the ICU suite. We have magnetic-locks on those doors and pointed out that they serve as positive latching. He refused our position and cited us anyway. Don’t magnetic locks qualify as positive latching hardware on doors?

A: No, they do not. Locks are not the same as positive latches. The magnetic locks that you mentioned are most likely access-control locks as described in section 7.2.1.6.2 of the 2000 edition of the Life Safety Code. Those electronic magnetic locks are required to unlock upon activation of the fire alarm system. That’s when you need the corridor door to positively latch the most: during a fire. Also, make sure there is a motion sensor mounted on the egress side of the doors served by the magnetic locks, along with a button mounted on the wall within 5 feet of the doors, when activated will unlock the magnetic-locks for a minimum of 30 seconds. The button must be labeled “Push to Exit”.


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