Nov 08 2017

Hazardous Cart in Corridor

Category: Hazardous Areas,Questions and AnswersBKeyes @ 12:00 am

Q: I recently heard that a hospital was cited for leaving a construction cart unattended in the hall and the surveyor inventoried the entire cart and cited the hospital for each hazardous item present. Can they do this and is there a life safety code addressing this issue?

A: Yes they can do this, as they are an authority having jurisdiction. They get to interpret the Life Safety Code as they see fit. While this finding may seem to be “ticky-tacky” to you, the bottom line is the surveyor has the right to ensure your facility is safe for patients, staff and visitors. If there is an unattended cart containing sharp objects, toxic chemicals, flammable gases, etc., in the corridor where it is available to unauthorized individuals, then that really is a legitimate safety issue. You ask if this is a Life Safety Code violation, and I would say it can be considered a LSC violation, based on section of the 2012 edition. Also, section 19.3.2 discusses hazardous areas, and technically speaking, an unattended cart containing these “hazardous items” is considered in storage, and therefore would have to meet the requirements of 19.3.2. All-in-all, it really is a legitimate finding, and the hospital needs to take action to prevent it from happening again in the future.

Oct 30 2017

Paint Storage

Category: Hazardous Areas,Questions and AnswersBKeyes @ 12:00 am

Q: Is it okay to store latex paint in a mechanical/air handler room? The mechanical room is located in the hospital and is in a 2 hour fire rated wall enclosure.

A: This is an issue that is addressed by the Life Safety Code, but is not always enforced the same way by authorities.

Section of the 2012 Life Safety Code specifically states “Paint shops” are hazardous areas. The interpretation by the AHJ would likely be that all paint needs to be stored in a hazardous room that meets the requirements of So, from that perspective, the cans of latex paint would have to be stored in a hazardous room.

Now, can your AHU mechanical room qualify as a hazardous room? I believe it can, provided there is no fuel-fired equipment in the room, and it meets the requirements for hazardous room found in section But not all AHJs actually interpret this section of the LSC in the same way. Some state and local AHJs do not like to see any storage in mechanical rooms, since the main purpose of the mechanical room is to house the air handling units. But since storage is at such a premium for hospitals, why not double up and allow storage in mechanical rooms provided it meets all of the code requirements?

As you may see, not all AHJs think this way, and you may encounter some resistance to this way of thinking.

Sep 27 2017

Hazardous Areas

Category: Hazardous Areas,Questions and AnswersBKeyes @ 12:00 am

Q: Does section of the 2012 Life Safety Code allow hazardous rooms to not be constructed with one-hour fire rated barriers if it is fully fire sprinklered? If healthcare oocupancies were considered new occupancies prior to the adoption of the 2012 Life Safety Code, are they now considered existing?

A: Section of the 2012 LSC for existing healthcare occupancies says hazardous areas must be safeguarded by a fire barrier having a 1-hour fire rating, or it must be provided with an automatic sprinkler system. This is an ‘either/or’ issue. The hazardous room is either protected with 1-hour barriers, or it is protected with sprinklers. Section says if the sprinkler option is used, then the hazardous area must be separated by smoke partitions. It is important to point out that this is for existing healthcare occupancies, and not for new healthcare occupancies.

Yes… If your facility was classified as a new healthcare occupancy last year under the 2000 LSC (i.e. prior to CMS adopting the new 2012 LSC on July 5, 2016), then it is classified as existing healthcare occupancy today under the 2012 LSC. However, this does not mean you can down-grade any feature of fire protection that was required under new occupancy requirements that is not required under existing occupancy requirements. Section 4.5.8 of the 2012 LSC says whenever any device, equipment, system, condition, arrangement, level of protection, is required for compliance with the LSC, such device, equipment, system, condition, arrangement, level of protection shall thereafter be maintained, unless the LSC exempts such maintenance. In other words: Once you are required to build something, you must maintain that for the life of the building, unless the new occupancy chapter no longer requires it.

So… If you built a new hazardous area last year and you constructed it to have 1-hour fire rated barriers, and it was protected with sprinklers because it was constructed under the new occupancy chapter requirements, you cannot down-grade the hazardous area to no longer have 1-hour fire rated barriers just because it is now classified as existing conditions. You must maintain that hazardous area under the new occupancy chapter requirements for the life of the building, or until the LSC no longer requires it for new conditions.

May 09 2016

Hazardous Rooms of Different Options

Category: Hazardous Areas,Questions and AnswersBKeyes @ 12:00 am

Q: There appears to be many different ways a hazardous room is maintained: If it is sprinklered, does it have to be 1-hour rated? If it is existing construction, does it have to be sprinklered? What rules apply if there is a lay-in ceiling? What are the basic requirements for a hazardous room?

A: A hazardous room in a hospital includes a room larger than 50 square feet used for the storage of combustible supplies. How many combustible supplies are needed to make it a hazardous room? Not much, but it is a judgment call by the surveyor. If the room is designated ‘existing conditions’ (created prior to March 11, 2003) then there are two options on how it has to be maintained:

  • If there are no sprinklers in the room, then the walls need to be one-hour fire rated and extend from the floor to the deck above, and the door to the room needs to be ¾-hour fire rated, self-closing and positive latching.
  • If there are sprinklers in the room, then the walls only have to be smoke resistant, and extend from the floor to the ceiling, as long as the ceiling also resists the passage of smoke. The door to the room may be non-rated, but must be self-closing and positive latching.

If the room is designated ‘new conditions’ (created on or after March 11, 2003) then there is only one option for the room: The room must be sprinklered, and the walls must be one-hour fire rated and extend from the floor to the deck above, and the door must be ¾-hour fire rated, self-closing and positive latching. Also, if the supply room was originally constructed to ‘new conditions’, but before March 11, 2003, it cannot be down-graded to ‘existing conditions’, but must be maintained as ‘new conditions’. Any ceiling that has sprinklers or smoke detectors must be maintained to resist the passage of smoke. This is because smoke and heat will migrate above the ceiling if there are cracks, voids or missing tiles, and the detectors and sprinklers may not activate properly.

Jun 16 2014

Hazardous Areas

Category: Hazardous Areas,Questions and AnswersBKeyes @ 5:00 am

Q: If hazardous areas like a carpentry shop and a paint shop are combined in a separate building distant from hospital building, what can be an appropriate reference to determine the required fire and life safety measures? If this building is a single story and has HVAC ductwork, is it required to provide smoke compartmentation and fire dampers also?

A: It is apparent that the building you described does not house patients, so it could be considered business occupancy or industrial occupancy. It really depends on what else is in the building besides the carpentry shop and paint shop. For example, if this separated building also houses offices or general storage, then I could see it having to comply with business occupancy requirements. In business occupancies, hazardous areas which have a degree of hazard greater than that normal to the general occupancy of the building must be enclosed with 1-hour fire rated barriers, or protected with an automatic sprinkler system. These code references are found in the 2000 edition of the Life Safety Code, sections, and 8.4. However, if the separated building is not mixed with offices or general storage, and is only a carpentry shop and a paint shop, then you could classify it as an industrial occupancy. Section 40.3.2 does not require added protection of hazards in industrial occupancies as long as the hazards are not considered ‘high hazards’. A high hazard (another name for this is a ‘severe hazard’) is one in which quantities of flammable, combustible, or hazardous materials are present that are capable of sustaining a fire of sufficient magnitude to breach a 1-hour fire separation. According to NFPA 90A, 1999 edition, fire dampers are only required in fire barriers of 2-hour rating or greater, with the exception of a 1-hour fire rated vertical shaft, or if the HVAC duct is open ended (a return air plenum ceiling) on one side of a 1-hour fire rated barrier. Your question indicated the building is single story so it appears that a vertical shaft is not present. If the option of a 1-hour fire rated barrier is selected for the protection around the carpentry shop and paint shop in a business occupancy, and the HVAC duct is open at the fire barrier, then a fire damper would be required. Please check with your local and state authorities to determine if they have other requirements which may apply.

Nov 04 2013

Multiple Trash Containers

Q: We just completed a renovation of our cafeteria dining area and as part of the project an 8 container trash cabinet was built and installed in a separated area off of the dining floor. It is sprinklered and the containers are all 32 gallons. The cafeteria area is a separate smoke compartment. Is this allowed?”

A: Well, this is an interesting question. The answer is… it depends on the square footage of the trash cabinet and how it is constructed. I would say each individual 32 gallon trash container would have to be physically separated from all the others by a cabinet wall, which would create a small, individual room or area for the container. The reason for this is section of the 2000 edition of the LSC, which only allows up to 32 gallons of trash collection capacity in a given 64 square foot area. This means, if there are no physical separations between trash containers then I could see a surveyor or inspector citing you for having more than 32 gallons capacity in a given 64 square foot area. Since each individual compartment for the trash containers would presumably be less than 50 square feet in size, then you would not have any problems meeting the requirements of for hazardous areas. It is interesting to note that the exception to does allow more than 32 gallons capacity in a 64 square foot area provided the area qualifies as a hazardous area, but it is unlikely that an 8 container trash cabinet could do so. The key element in your question is the comment that the individual trash containers do not exceed 32 gallons each.

Oct 14 2013

Oxygen Cylinders and Clean Linen Carts

Q: Are oxygen cylinder tanks (in holders) allowed to be stored in alcoves in corridors? Also, what about clean linen carts? I am told that our accreditation organization allows this, but I don’t know if CMS does.

A: Oxygen cylinders are permitted to be stored outside of a designated room, provided they are properly secured; they do not infringe upon the required corridor width; and the aggregate total of cubic feet of medical gas in cylinders (all gas, not just oxidizing gas) does not exceed 300 cubic feet per smoke compartment. So, a couple E size cylinders in holders, stored in an alcove sounds acceptable to me.

Under normal conditions, the presence of combustibles, such as paper, cardboard, plastics, and clean linen are not considered to be hazardous until the area in which they are contained exceeds 50 square feet. A clean linen cart in an alcove that does not exceed 50 square feet appears to not meet the requirements of a hazardous area (see, and therefore does not have to be contained in a room designated as a hazardous room. However, some accreditation organizations may take a different look at this, and consider the volume of a 6 foot tall, by 4 foot wide, by 2½ foot deep clean linen cart to be sufficient capacity of combustibles to be a significant threat, even though it does not meet the LSC definition of a hazardous area. I know that at least one accreditation organization requires the corridor and alcove to be sprinklered in order to store a clean linen cart there.

Mar 04 2013

Temporary Storage in Patient Rooms

Q: We have a short-term project where we need to find some space to store equipment until they are installed. The equipment is electronic and needs to remain in their cardboard boxes until it is installed. We think we need to store these items for 6 – 8 weeks. Can we use patient rooms that are not in service as temporary storage areas?

A: Your question is more like “Can we violate the Life Safety Code (LSC) for a short period of time?” In some situations you are permitted to violate the LSC. Section of the 2000 edition of the LSC says you are permitted to occupy the building during construction, repair, alterations, or additions where alternative life safety measures (aka Interim Life Safety Measures), which are acceptable to the authority having jurisdiction, are in place. If the equipment that you wish to store in the out-of-service patient rooms qualifies as construction, repair, alterations or additions, then I would say you have a legitimate position, as long as you implement alternative life safety measures. The measures that you implement should be in accordance with your policies.  However, out-of-service patient rooms cannot be used for storage of combustibles (in this situation, the cardboard boxes would be considered combustible) that is not associated with construction, repair, alteration or additions. The reason is most patient rooms are not constructed to meet the requirements for hazardous storage rooms. Make sure you perform the alternative measures and document each inspection.

Feb 04 2013

Closures on Inactive Door Leafs?

Category: Doors,Hazardous Areas,Questions and AnswersBKeyes @ 5:00 am

Q: A consultant has mentioned that several of our doors to hazardous areas are non-compliant.  The door configuration is such that there is a normal 3’x7’ door paired with a small, inactive leaf about 1’x7’.  The inactive leaf has an automatic flush bolt but is not provided with a self-closer. I realize that hazardous rooms need self-closing positively latching doors under the new construction healthcare occupancy requirements, but I cannot find any discussions on inactive leaves.  My question to you is do you know of any requirements where the configuration I described would be allowed?

A: Section of the 2000 edition of the Life Safety Code requires fire doors to be in compliance NFPA 80 Standard for Fire Doors and Fire Windows, 1999 edition. Section 2-4.4.5 of NFPA 80 discusses the requirements for an inactive leaf in a room which is not occupied by people. The exception to this section of the code specifically states that self-closing devices on the inactive leaf are not required. The caveat in this exception is the phrase “where acceptable to the authority having jurisdiction” and the interpretation is subject to their whim. So, if you ever get an AHJ that does not permit it, then you’re out of luck. But you could proceed with the conditions of the exception until such time an AHJ says you can’t. As far as I know, Joint Commission and CMS are in agreement with this exception.

Nov 12 2012

Document Shredding Containers

Q: During a recent survey, the surveyor noted that we had two 64 gallon capacity containers which we use for document shredding, sitting side-by-side in the laboratory work room. He stated we couldn’t have them in the room because they exceeded 32 gallons capacity. I was under the impression that if it was in a secured area and in a room with positive latching and sprinkled it was OK. How far off am I? What about other areas, such as medical records?

A: Section of the 2000 edition of the LSC says trash containers greater than 32 gallons must be stored in a hazardous room. Most authorities will consider document shredding containers to be equal to trash containers. Also, section says all laboratories that employ flammable liquids in quantities less than what would be considered severe are considered hazardous areas. So, your laboratory is already considered to be a hazardous area, and should be protected accordingly. If it is new construction (plans for construction approved by local authorities on or after March 11, 2003) it would be required to be fully protected with automatic sprinklers and be protected with 1-hour fire rated barriers. If it is existing conditions (plans for construction approved by local authorities before March 11, 2003) then it needs to be protected with automatic sprinklers or with 1-hour fire rated barriers. You are allowed to have as many 64-gallon document shredding containers in the laboratory as you would like, since the laboratory is already classified as a hazardous area. Unless there are other contributing factors, it appears to me that the surveyor is incorrect in this finding. The medical records area would have to qualify as a hazardous room in order to allow the 64 gallon containers in there. [Editor’s note: The 2012 edition of the LSC will exempt approved document shredding containers up to 96 gallons capacity from having to be stored in a hazardous room.]

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