May 04 2015

Staff On-Call Sleeping Rooms

Category: On-Call Sleeping Rooms,Questions and AnswersBKeyes @ 1:00 am
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Q: Does the Life Safety Code require hospital staff sleeping rooms have smoke detection inside the room and door closers installed? We have an on-call sleeping room for physicians in our Labor & Delivery unit and a consultant said we need smoke detectors and a closer on the door.

A: The answer is yes, the Life Safety Code (2000 edition), does require it. Section 6.1.14.2 says where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards must comply with the most restrictive life safety requirements of the occupancies involved. This means where there is a dominate occupancy (such as healthcare occupancy in the Labor & Delivery unit) that also has a small portion of a different occupancy (such as the staff on-call sleeping room which is actually hotels and dormitories occupancy) and these two occupancies are not separated by a 2-hour fire rated barrier, then this means the two occupancies are mixed, and the most restrictive requirements of both occupancies apply. As you indicated, hotel and dormitory occupancy does require single station smoke alarm and a closure on corridor doors to sleeping room (see sections 29.3.4.5 and 29.3.6.3). However, there is an exception to section 6.1.14.2 which says where incidental to another occupancy, buildings used as follows shall be permitted to be considered part of the predominant occupancy and subject to the provisions of the Code that apply to the predominant occupancy:

  1. a) Mercantile, business, industrial, or storage use;
  2. b) Nonresidential use with an occupant load fewer than that established by Section 6.1 for the occupancy threshold.

This exception is allowing small incidental use of one occupancy to not have to comply with the requirements of that particular occupancy, and instead may comply with the requirements of the predominant occupancy, which in your case would be healthcare occupancy. There is only one catch, though. The phrase ‘incidental’ is ambiguous and is not defined. Therefore, the authority having jurisdiction (AHJ) gets to answer the question: What does incidental mean? I do not know what state and city you are located in, so I do not know who your AHJs are, but it’s a sure bet you have 5 or 6 AHJs who enforce the Life Safety Code, and it is likely that not all of them would make this interpretation the same way:

  • Joint Commission (or one of the other accreditation organizations)
  • CMS
  • State fire marshal
  • State public health
  • Local fire inspector
  • Insurance company

Since you have so many AHJs who have the right to interpret the phrase ‘incidental’, my advice is to take a very conservative approach and do not consider the exception, and go with installing a single station smoke alarm and a closure on the door to the corridor for the sleep room. By the way, most of the AHJs accept the fact that a smoke detector connected to the building fire alarm system in a hospital is equivalent to a single station smoke alarm, so you may be okay by just installing a smoke detector, rather than a single station smoke alarm. That’s your call.


Oct 07 2013

On-Call Sleeping Rooms

Q: We have a physician on-call sleeping room inside our labor and delivery unit. A surveyor told us that we need audible smoke alarms in each on-call sleeping room. We have smoke detectors, but rely on staff waking up any sleeping physicians in the event of a fire alarm. Isn’t that good enough?

A: Well, the surveyor is correct, although most AHJs usually allow smoke detectors connected to the building fire alarm system as being sufficient. Non-patient sleeping rooms in the healthcare occupancy do require single-station smoke alarms, such as the battery powered type found in residential homes. They are not required to be inter-connected with other smoke alarms or the building fire alarm system. Your hospital has multiple occupancies inside the facility, such as Healthcare, Ambulatory Care, Business, Mercantile, and Hotels & Dormitory Occupancies. If you have chosen to have mixed occupancies rather than separated occupancies (at least in the case of the on-call sleeping rooms) then you have to comply with the most restrictive requirement of the multiple occupancies. In the case of the on-call sleeping rooms, section 26.3.3.5 of the 2000 LSC does require single-station smoke alarms. I would not install your building fire alarm occupant notification device (horn/strobe unit) as they are not required and are too costly. Just buy simple 9 volt residential style smoke alarms and install them no more than 12 inches below the ceiling. Put these devices on your PM schedule to have the batteries replaced once per year.