Jul 31 2017

Clean Supply Room Storage

Category: Clean Supply Room,Questions and Answers,StorageBKeyes @ 12:00 am

Q: In an OB (obstetrics) supply room, can beverages such as apple juice, water or an ice machine be stored in the room with central supply items?

A: The Life Safety Code does not address this issue, and neither does any other NFPA standard that is referenced by the Life Safety Code, as far as I can tell. Since the Life Safety Code does not address this type of arrangement, then the Life Safety Code does not prevent this arrangement.

However, I believe it is an Infection Control issue. Supply rooms are considered clean rooms and must have a positive air pressure relationship with their surrounding areas, according to the FGI guidelines. Section 2.1-2.6.8 of the 2010 FGI guidelines specifically allows ice making equipment to be located in a clean supply room. Beverages in boxes, cans or bottles would be permitted to be stored in a clean supply room, provided they have not been opened (i.e. partially opened containers).

But the FGI guidelines are guidelines and not regulations or standards. I suggest you check with your infection control practitioner and discuss the issue with him/her. In my way of thinking, they would have final say on the issue since the Life Safety Code does not address the issue.

Jul 10 2017

Storage of ABHR Solution

Q: I am looking for clarification on the storage of alcohol based hand rub (ABHR) solution. I know the standard indicates that no more than 10 gallons of ABHR can be stored in a single smoke compartment. However, my question is how much can be stored in a room designated as a hazardous area? We were recently cited for having 11 gallons (total) of ABHR stored in an area that we have identified as a hazardous area. It is sprinkled; has a 2-hour rated door, and this storage area is within our purchasing area which is also behind a 2-hour rated smoke compartment door. Any clarification you could provide would be helpful. Is there something additional we need to have in place to store this Class 1B flammable liquid in the hazardous area?

A: Actually… you have that backwards. Not more than 5 gallons of ABHR solution is permitted to be stored in a single smoke compartment without meeting the requirements of NFPA 30 Flammable and Combustible Liquids Code; not 10 gallons. So, if you were cited for having 11 gallons of ABHR solution stored outside of NFPA 30 requirements, then you were 6 gallons (or 120%) over the limit which is a significant amount. The 10 gallon limit is the amount of ABHR solution in dispensers (not storage) per smoke compartment.

So… what does NFPA 30 require for storage of class IB flammable liquids?

  • Section 4.2.3 says the maximum size metal or plastic container for class IB liquids is 5 gallons (this is where the maximum 5 gallons of ABHR in storage comes from);
  • Section 4-3.1 says not more than 60 gallons of class I or class II flammable liquids may be stored in a single storage cabinet;
  • Section 4-3.2 says not more than three storage cabinets are permitted in one fire area (i.e. smoke compartment);
  • Section 4-3.3 has detailed information on how storage cabinets must be constructed, and cabinets with a listing as meeting the NFPA 30 requirements are acceptable;
  • Section 4-3.4 says storage cabinets are not required to be vented, but if they are vented to they have to be vented to the outdoors;
  • Section 4-4.2.1 says interior storage rooms containing more than 5 gallons of class IB liquids (in lieu of listed storage cabinets) up to 150 square feet are required to be 1-hour fire rated, and from 150 square feet up to 500 square feet are required to be 2-hour fire rated (rooms larger than 500 square feet are not permitted to be used for storage of class IB liquids);
  • Sections 4-4.3.5 and 4-5.1.5 says class I liquids are not permitted to be stored in the basement of a facility;

Not all hazardous areas are actually 1-hour fire rated, so care must be taken when deciding to store ABHR solution in hazardous areas. You say your hazardous area is 2-hour fire rated, which seems a bit odd, since hazardous areas are not required to be more than 1-hour fire rated. But it is what it is, and you would be permitted to store ABHR solution in quantities larger than 5 gallons if the 2-hour fire rated room is not larger than 500 square feet. Also, that room would not be permitted to be in the basement.

Jun 28 2017

Converting a Cath Lab Procedure Room to Storage

Category: Questions and Answers,StorageBKeyes @ 12:00 am

Q: I have a procedure room in our Cath Lab that Administration wants to convert to a storage room. The building is fully sprinkled and as I look at NFPA of the 2012 LSC, it refers me to section 8.7. It would seem that I could use this room for hazardous storage (combustibles) as long as I have a smoke barrier and a self-closing 20-minute door, because that is what section 8.7 permits. The room is over 100 square feet. Other storage rooms in this building are protected with a 1-hour fire rated wall system, that includes a 45-minute fire rated door assembly… so, can I or can’t I use non-rated smoke partitions for this new storage room?

A: Well… not quite. You have the right idea, but section of the 2012 LSC over-rides section 8.7. Take a look at which says any hazardous area shall be protected in accordance with section 8.7, and the areas described in Table shall be protected as indicated. Table says storage rooms larger than 100 square feet and storing combustible material requires 1-hour fire rated barriers. You state your former Cath lab procedure room is more than 100 square feet, so by the looks of things, this is the governing statement on new hazardous rooms.

However, there may be an exception that might apply to your situation. There is a new chapter in the 2012 LSC that was not in the 2000 edition: Chapter 43, which is on building rehabilitation. Take a look at which says a change of use that does not involve a change of occupancy classification shall comply with the requirements applicable to the new use in accordance with the applicable existing occupancy chapter, unless the change of use creates a hazardous contents area as addressed in

Looking at (2), it says for existing healthcare occupancies protected throughout by an approved, supervised automatic sprinkler system in accordance with (1), where a change in use of a room or space not exceeding 250 square feet results in a room or space that is described by (7), the requirements for new construction shall not apply, provided that the enclosure meets the requirements of through

Okay… what this is saying is the change in use of the Cath lab procedure room to a storage room that is a hazardous room, does not have to meet new construction requirements for hazardous rooms (i.e. 1-hour fire rated barriers and ¾ hour fire rated door assembly), but may comply with existing construction requirements for hazardous rooms (i.e. smoke partitions and non-rated self-closing door), PROVIDED:

  • The room does not exceed 250 square feet
  • The entire building is protected with sprinklers.

Measure the area of the old Cath lab procedure room. If it does not exceed 250 square feet, then you do not have to meet 1-hour fire rated barrier requirements. However, if it does exceed 250 square feet, then I’m sorry to say, you do have to meet 1-hour fire rated barrier requirements, with a ¾ hour fire rated door assembly.

Mar 16 2017

Distance to a Storage Shed

Category: Construction,Questions and Answers,StorageBKeyes @ 12:00 am

Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any minimal distance that the out-building must be away from the protected facility?  The number that I keep hearing from people is 10 feet of clearance from the protected building but I have not been able to confirm that as a requirement or a best practice.

A: No… there does not seem to be a set number of feet for a non-compliant outbuilding that needs to be from a healthcare occupancy, written into the Life Safety Code. I was at a seminar recently where that question came up and the instructor admitted there was no definite set-back required. But… like everything else that is not definitive in the Life Safety Code, the AHJ can interpret (decide) what the set-back should be. I too have heard 10 feet is the distance a non-compliant building needs to be from a healthcare occupancy without a 2-hour fire rated separation. That is actually a sound interpretation, based on other Life Safety Code requirements. Take a look at section and of the 2012 LSC which discusses the need for a 10 foot section of wall to be 1-hour fire rated when the fire rated wall intersects with an outside barrier at an angle less than 180 degrees. While that does not specifically refer to a set-back of a non-compliant building, it does provide you with a distance to go on.

Feb 22 2017

Signs on Doors to Rooms Used for Storage of Cylinders of Oxygen

Category: Oxygen Cylinders,Questions and Answers,Signs,StorageBKeyes @ 12:00 am

Q: If there are oxygen tanks stored on a unit that does not exceed the 12 tank threshold, does the door to the storage area where the tanks are stored need to have a sign indicating that tanks are stored within?

A: No. Rooms with less than 300 cubic feet of oxidizing gases (or about 12 E cylinders) does NOT have to have a sign warning of oxidizing gases stored within. However, the door to a storage room containing oxidizing gases in quantities of 300 cubic feet or more  must have a precautionary sign, readable from a distance of 5 feet, and must be displayed on each door or gate of the storage room or enclosure. The sign must include the following wording as a minimum:




This requirement is found in NFPA 99-2012, sections and, and applies to all healthcare organizations, new and existing. On this particular section of NFPA 99, there is no exception in having this sign if the facility is posted as being a NO SMOKING facility. That applies to other sign requirements where oxygen therapy is in use on a patient, but that exception does not apply to a storage room containing oxidizing gases.

So, as you are conducting your routine building tour, please keep an eye out for the required signs on any door where oxidizing gases are stored in quantities of 300 cubic feet or more.

Jan 25 2017

Under Sink Storage

Category: Questions and Answers,Storage,Under SInkBKeyes @ 12:00 am

Q: What standard in the Life Safety Code prohibits storage under sinks?

A: There is no direct standard in the Life Safety Code or any of the standards the LSC references that addresses under-sink storage.

The issue is a concern of Infection Control as waste water that drips from the sink drain pipes would contaminate any clean items stored under the sink. This is strictly an Infection Control issue… not a Life Safety Code issue. Surveyors often cite their own physical environment standards for under sink storage, because it addresses building safety, which is appropriate since contaminated waste water dripping onto clean supplies would be a safety issue.

May 25 2015

Door to Medical Gas Storage Room

Category: Doors,Medical Gas,Questions and Answers,StorageBKeyes @ 1:00 am

Q: I have an existing medical gas storage room in an outpatient surgery center that was constructed with 1-hour barriers and ¾ hour fire rated door. A surveyor cited me because he says the door has to be constructed of non-combustible or limited combustible materials. The door that is installed is a high pressure decorative laminate with a bonded agri-fiber core with a 45 minute fire resistance rating. I maintain that doors are exempted from the noncombustible/limited-combustible provision. Who’s correct?

A: One scenario that the surveyor may hold you accountable to is medical gas systems in ambulatory care occupancies are regulated by the Life Safety Code, and not by NFPA 99. The Life Safety Code (2000 edition) would look at medical gas room as a hazardous room, and for ambulatory care occupancies, a hazardous room compares their level of hazard to their surrounding area. The section that regulates hazards in ambulatory care occupancies is section 20/21.3.2 which refers you to 38/39.3.2, which in turn refers you to section 8.4. Section 8.4 essentially says any area with a higher level of hazard than the surrounding area needs to be protected with fire protection sprinklers, or 1-hour fire rated barriers. Section requires a 1-hour fire rated barrier to have at least a ¾ hour fire rated door as long as the fire barrier is not used as a vertical opening (such as a rated shaft) or an exit enclosure (such as a stairwell). Hopefully, you don’t have the med gas room in a stairwell, so a properly labeled ¾ hour rated doors is acceptable, and in this scenario I would say the surveyor is mistaken. However, if the surveyor requires that you comply with NFPA 99 in regards to medical gas systems, then that is an entirely different situation. Section 4- (a) 11 (a) of the 1999 edition of NFPA 99 requires doors to be constructed of non-combustible or limited combustible materials. If the 45-minute fire rated door that you have is laminated with limited combustible materials, then it would not be compliant with NFPA 99 (1999 edition), and I would say the surveyor is correct. Section 3.3.118 in the Life Safety Code defines what limited combustible materials are. I suggest you contact the manufacturer of the door and ask them to produce documentation whether or not the door meets the heat values stipulated in section 3.3.118, that may qualify the door as being constructed with limited combustible materials. Now, on another point of view, if the surveyor requires you to comply with NFPA 99, 2005 edition, the door to this room still has to be constructed from non-combustible or limited combustible materials, but it is no longer permitted to be ¾ hour fire rated, but must be 1-hour fire rated, according to section The 2012 edition of NFPA 99 has the same requirement.

Mar 23 2015

Storage in Stairwells

Category: Questions and Answers,Stairwells,StorageBKeyes @ 6:00 am

Q: Is there any specific regulation that addresses storing items under stairwells and if so does it differentiate between public stairs and stairs which are utilized to access areas not open to the public?

A: Yes, section of the 2000 edition of the Life Safety Code specifically says there must be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. There is an exception that says enclosed usable space is permitted under the stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure, and entrance to that enclosed usable space is not from within the stair enclosure. The common conclusion of this (and other sections) is general storage is prohibited in stairwells. The concept of an exit enclosure is to provide an egress environment which is sterile from safety hazards. It is recognized that general storage usually ends up (or has the potential of) being a hazardous area, and exiting through a hazardous area is not permitted. From that point of view, this makes perfect sense. However, the LSC does not prohibit safety items stored in the stairwell as long as they do not interfere with the egress. As mentioned in a posting on March 2,  evacuation chairs stored at the top of the stairwell could be considered to not interfere with egress.  Hospitals have such a difficult time finding adequate useful storage space I believe a safety item (such as patient evacuation chairs) should be permitted inside an exit enclosure provided it does not interfere with egress in any way.

Sep 15 2014

Equipment Room Storage

Category: Mechanical Rooms,Questions and Answers,StorageBKeyes @ 6:00 am

Q: I was always under the impression that no storage was allowed in mechanical rooms within hospitals. Now I work at a hospital that allows ladders and supplies to be stored in mechanical rooms. Is this allowed?

A: All I can say is it is not a NFPA violation to store items in mechanical rooms, as long as it is done properly. Obviously, storing combustible or flammable items must be accomplished in approved storage rooms, and the typical mechanical room may not qualify for these hazards. But then again, perhaps a mechanical room could qualify to store combustibles. Sections for new construction and for existing conditions of the 2000 edition of the LSC describe the requirements for storing combustibles. It does not make sense to store a bunch of cardboard boxes full of paper filters in a mechanical room that also houses fuel-fired equipment. But why can’t you store those same boxes of filters in a mechanical room for air handlers that does not have any fuel-fire equipment, and qualifies as a hazardous room under the code sections referenced? The NFPA codes and standards do not prohibit it. Where hospitals get ‘pinched’ on this issue, is they don’t do their homework. A mechanical room that was never designed to double up as a storage room may not qualify as a storage room for combustibles. If you alter (or change) the use of a room or area, the room or area must comply with the requirements for new construction. This means if a hospital decides to start storing combustibles in an AHU mechanical (with no fuel-fired equipment), now the room must be protected with 1-hour fire rated barriers, and also be protected with automatic sprinklers. If the room in question does not meet these requirements, then the hospital is exposed for a citation. Another issue is access. Even if the same AHU mechanical room described above qualifies as a hazardous room, if there are so many items stored in the mechanical room that obstructs access to the mechanical equipment, then that is a problem and the hospital could be cited as well

Sep 01 2014

Storage in Electrical Rooms

Category: Electrical Rooms,Questions and Answers,StorageBKeyes @ 6:00 am

Q: Can cardboard boxes be stored in an electrical room that is over 50 square feet, fully sprinklered, and has only dry transformers under 112 1/2 kVA?

 A: Yes, only if the room qualifies as a hazardous room under sections or of the 2000 edition of the Life Safety Code, depending if the room is considered new construction or existing conditions. With the exception of NFPA 1 (2012 edition) NFPA codes and standards do not prevent storage in electrical rooms as long as it does not obstruct access to the electrical equipment. Since NFPA 1 is NOT a referenced standard by the Life Safety Code, the restrictions found in that standard does not apply.  You must maintain at least 36 inches clearance in front of all electrical panels, and at least 30 inches clearance to the side of electrical panels. Now, other authorities having jurisdiction may have their own rules and interpretation, so I would suggest you check with your accreditation organization, state and local authorities to see if they have any issues with that.

Next Page »