Strange Observations – Part 44

Continuing in a series of strange things that I have seen while consulting at hospitals…

I believe those electrical panels installed in this stairwell were for new access-control lock badge readers on a series of doors on the unit served by this stairwell.

Can’t do it… You cannot make new penetrations into a stairwell for anything that does not serve the function of the stairwell (with some exceptions, but this did not meet those exceptions).

As they should have done in the first place, they needed to relocate these panels to an equipment room on the unit.

Stairwell Exit Locked Door

Q: Can a stairwell door that leads to the outside of a hospital be locked with a lock that requires a code to unlock it? I seem to recall that the doors could be on magnets that release upon activation of the fire alarm and that have a touch pad that releases the doors within 15 seconds.

A: No… it can’t. According to of the 2012 LSC, doors in the means of egress must not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted as follows:

  • Delayed egress locks (
  • Access-control locks (
  • Elevator lobby locks (
  • Clinical needs locks (
  • Specialized protective measure locks (

I don’t know where in the hospital this stairwell exit door is located, but let’s assume it does not qualify for clinical needs locks (psychiatric care patients), specialized protected measure locks (OB, Peds, Nursery, ICU, ER), and elevator lobby locks. That leaves delayed egress locks, which requires the entire building to be sprinklered, and access-control locks which do not lock the door in the path of egress, just in the path of ingress, neither of which allows the use of key-pads to unlock the door in the path of egress.

If you decide to use one of the approved exceptions for door locking, please make sure you read the appropriate section of the Life Safety Code and comply with everything it requires. Most surveyors are pretty well informed on the LSC requirements for door locks and they will hold you accountable.

Strange Observations – Part 15

Continuing in a series of strange things that I have seen when consulting at hospitals…

This is an evacuation chair or sled that is hanging from a sprinkler drain pipe…

Two deficiencies with this one picture: 1) You cannot support anything off of sprinkler pipe; 2) You cannot store anything in the exit enclosure that can impede egress.

The reason why storing an evacuation chair in a stairwell landing impedes egress, is when someone goes to get the chair that person impedes egress for others using the stair.

Carpeting in Stairwells

Q: I have several hospitals that have been cited by surveyors for having carpet in the stairwells. Can you tell me if there is any code requirement that states that carpet is not allowed in the fire exit stairwell?

A: Excellent question. No… as far as I know, there is no direct standard that prohibits carpeting in exit enclosure stairwells. However, there are a few sections of the LSC that could shed light on this issue.

Section of the 2012 LSC says walking surfaces must be slip resistant. If a surveyor believes the carpet can be slippery, then that would be a problem. Section of the 2012 LSC says stair treads and landings must be free of projections that could trip stair users. This may be a bit of a stretch, but if the surveyor believes a carpet could become loose, it may trip the people using the stairs.

Annex section A. of the 2012 LSC says carpeting over the nose of a stair can create an unstable surface. “Any horizontal projections of resilient covering materials beyond the tread nosing and riser, such as carpet and underlayment, can interfere with user’s feet and thereby reduce usable tread depth.”

I think it is safe to say that carpeting is not prohibited, but in the opinion of the NFPA 101 technical committee, carpeting can interfere with the user of the stairs. If the technical committee fully believed carpeting on stairs was a serious impediment to exiting, they definitely would have banned it. It is important to understand that the Annex section is not part of the enforceable code, but rather is explanatory information provided by the technical committee for users of the Life Safety Code to understand what the technical committee was thinking when they wrote the standards.

Therefore, it is perfectly acceptable for an authority having jurisdiction (AHJ) to follow the recommendations provided in the Annex section… or not. It is just advisory information to help the AHJ interpret the LSC. The AHJ can use the information in the Annex section… or they can choose to ignore the information. I can’t say that I disagree with the surveyor… although I can’t remember the last time I saw carpeting in exit access stairwells.


Security Cameras in Stairwells

Q: Can I install security cameras in stairwells

A: You can…. But be prepared to remove them. Many Accreditation Organizations (AOs) and most states who survey on behalf of CMS do not allow cameras in stairwells. The reason for this is two-fold: 1) Section of the 2012 Life Safety Code does not permit new penetrations into the exit enclosure that does not serve the exit enclosure (with some exceptions). Many AHJs believe security cameras serve the facility and not just the exit enclosure; and 2) The concept of exit enclosures is to provide a clean environment that is free of any device that does not serve the purpose of the stairwell. The purpose of the stairwell is to evacuate people from the building in the event of an emergency. The security camera does not serve that purpose… a security camera monitors the activity of the people.

Anyway… I’m in favor of security cameras in stairwells, but my opinion does not matter, and many AHJs do not permit them. So, perhaps it would be best to not install them.

Elopement Risk

Q: We have a potential elopement risk at the nursing home where I work. A patient gets into the stairwell and down to the first floor and exits the building. We have an alarm system that alerts us when any door is activated. My question is: Can we install interrupter gates on the second floor leading down to the first to deter elopement risk?

A: I’m not sure what you believe to be an interrupter gate … but they won’t do you any good in restricting egress. By definition, an interrupter gate cannot restrict egress. If you are fully sprinklered, you can install delayed egress locks that will slow down egress for 15 seconds, allowing staff to respond to the local alarm and prevent someone from leaving. For normal egress you can provide authorized people ID badges that can be swiped or read on a card reader bypassing the delayed egress locks. You may even consider specialized protective measure locks as described in section of the 2012 LSC. They may cost you more, but they are effective for your concern.

Stairwell Fire Rating

Q:  We are being told by our local AHJ that a stairwell in a 2 story building has to be 2-hour fire resistance rated so that it meets the requirements of occupancy separation since one floor is healthcare and one floor is business. Do you agree?
A: Well…. That is a matter of interpretation, and I can understand the logic with the requirement to be 2-hour fire rated. Another way of looking at it is if a stairwell was only one hour fire rated, it would take a fire starting on the 1st floor (business occupancy) one hour to penetrate the stairwell barrier, and then it would take one more hour to penetrate the 2nd floor (healthcare occupancy) which is a total of 2 hours. Personally, I would not buy into that line of thought, and if I were an AHJ, I would not allow a 1-hour fire rated stairwell to separate a business occupancy from a healthcare occupancy. I would require it to be 2-hour rated. But, that’s me. Remember… Every AHJ has the right to interpret the Life Safety Code as they see fit.

Existing Mechanical Equipment Spaces Opening onto Exit Enclosures

Q: With the elimination of the CMS Waivers, I was trying to clarify what now applies for mechanical room combustibles storage (i.e. mechanical areas with only stairway and elevator access vs. hallway access and stairway access, or just hallway access). Does it mean no combustible storage without a “buffer room” to a stairway still applies as described in the old waiver? I was confused with NFPA 101-2012, Separation of Occupancies in Healthcare (Table which appears to show 2-hour separation for all Storage, normal to hazardous. Confused with their footnote: ‡The 1-hour reduction due to the presence of sprinklers in accordance with the single-dagger footnote is not permitted.

A: Let me clear up some of the issues that may be confusing you. First of all, CMS did not eliminate any waivers. Healthcare organizations may still submit waiver requests provided the non-compliance that is being requested to be waived has been cited first during an accreditation survey or state survey on behalf of CMS. Since CMS adopted the 2012 Life Safety Code all of the Categorical Waivers that they issued over the past few years have not been eliminated, but rather they have been completed. The Categorical Waivers (for the most part) allowed healthcare facilities to use certain sections of the 2012 LSC early, before CMS formally adopted the 2012 Life Safety Code. Since CMS did adopt the 2012 LSC on May 4, 2016, with an effective date of July 5, 2016, there is no need for the Categorical Waivers. They were not eliminated or deleted; they just were completed.

Under the 2000 Life Safety Code, openings in exit enclosures (i.e. stairwells) were limited from normally occupied spaces and corridors. This means unoccupied mechanical rooms that had their only access through a stairwell were non-compliant with the 2000 Life Safety Code. The Life Safety Code Technical Committee recognized that was a problem in many hospitals, so they changed the code in the 2012 edition, to allow existing openings into exit enclosures from mechanical equipment spaces to remain, provided the following conditions occur [see section]:

  • The door assemblies between the exit enclosure and the mechanical space are properly rated
  • The space is used for non-fuel-fired equipment
  • The space contains no storage of combustible materials
  • The building is fully protected by automatic sprinklers

So… if you are attempting to use the above section for mechanical rooms that open onto a stairwell, then you are not permitted to have any combustibles stored in the mechanical space. This means no boxes of filters; no cardboard boxes containing repair parts; no storage of anything that could burn. And the entire building has to be protected with sprinklers. However, if you do have a vestibule separating the mechanical space from the stairwell, then you do not have to comply with the above requirements since you are compliant with section

Table that you referenced is a table to identify the separation between differing occupancies… not a separation involving storage rooms within the same occupancy. There are many different occupancies that a healthcare facility may have: Healthcare occupancy, business occupancy, and even a storage occupancy are just a few. Anytime there are different occupancies that are contiguous and one of the occupancies is a healthcare occupancy, then the barrier separating the two occupancies must be 2-hour fire rated. This table has nothing to do with the separation required around a storage room inside a healthcare occupancy.

Security Cameras in Stairwells

Q: What is the Life Safety Code ruling on cameras and speakers in stairwells? Joint Commission was in and cited us on having cameras in the stairwells. We were told by the surveyor that they don’t pertain to the stairwells.

A: The Life Safety Code does not specifically address cameras in the stairwells, but section of the 2012 LSC does limit what penetrations are permitted into an exit enclosure. Conduit is permitted as long as the conduit serves the stairway. This seems to be an interpretation issue, and apparently, the surveyor decided the use of cameras does not fit the description in To me, a camera focused on people using the stairway seems to fit the description of “serving the stairway”, but it really doesn’t matter what I think.

If you can prove the camera installation qualifies as ‘existing’ conditions, then it should be accepted by the accreditor. The definition of ‘exiting’ conditions is any design, construction, or governmental approval that was in existence prior to July 5, 2016 (the date the 2012 LSC was adopted). However, since the 2000 LSC also prohibited new penetrations in stairwells for cameras, it is likely that a surveyor will hold you accountable to what the 2000 LSC required when you were supposed to comply with that edition, and that edition was adopted March 11, 2003. So, if the camera was installed in the stairwell since March 11, 2003, I can see that the surveyor would have a legitimate finding.

Evacuation Chairs in Stairwells

Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but the surveyor did not care that state fire marshal gave his blessing 8 years ago to have chairs at tops of stairwell and during the previous two Joint Commission surveys the chairs were not an issue. Your thoughts on this would be greatly appreciated.

A: First of all, it doesn’t matter what a state or local inspector or fire marshal says. Joint Commission and/or CMS does not have to comply with what a state or local authority says on an issue, and often does not care. All authorities having jurisdiction (AHJ) are equal, but separate. To have the permission or interpretation of one authority does not provide you with any leverage or influence with any other authority. Often times the authorities simply do not care what the other authorities say.

The Life Safety Code is not entirely clear on the subject of evacuation chairs mounted in stairwells. At one point (section of the 2012 Life Safety Code) the code says no space in the exit enclosure may be used for any purpose that has the potential to interfere with egress. One may conclude that if the evacuation chairs are mounted off to the side of the top landing where there is no possibility of egress interference, then you can mount an evacuation chair there. But the code does not specifically say that and it would have to be an interpretation by the authority to allow it.

But section also says an exit enclosure cannot be used for any purpose that has the potential to interfere with its use as an exit. According to the Annex section, the intent of this standard is the exit enclosure should be sterile with respect for fire safety hazards. The authorities can interpret this any way they want since the code is not clear.

Apparently, the Joint Commission (through the surveyor) is saying they will not allow it, and it is well within their right to say so. I have been in conferences where representatives from the Joint Commission engineering department say they do not allow stairwell evacuation chairs to be stored inside the stairwell.