Mar 16 2017

Distance to a Storage Shed

Category: Construction,Questions and Answers,StorageBKeyes @ 12:00 am
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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 7.2.2.5.2 and 7.2.2.6.3 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
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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:

CAUTION:

OXIDIZING GAS(ES) STORED WITHIN

NO SMOKING

This requirement is found in NFPA 99-2012, sections 11.3.4.1 and 11.3.4.2, 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
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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
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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 8.2.3.2.3.1 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 4-3.1.1.2 (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 5.1.3.3.2(4). 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
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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 7.2.2.5.3 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
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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 18.3.2.1 for new construction and 19.3.2.1 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
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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 18.3.2.1 or 19.3.2.1 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.


Jun 30 2014

Oxygen Storage in Business Occupancies

Q: Our hospital has an offsite building for our cardiac rehab, physical therapy, and pulmonary rehab programs. It also houses our business office and some physician offices. The building is classified as a Business Occupancy. What are the requirements for storing oxygen cylinders in a non-rated storage room?

A: A business occupancy that provides services for cardiac rehab, physical therapy, and pulmonary rehab programs is considered to be a health care facility. Assuming you are either Joint Commission accredited, or receive federal reimbursement monies for Medicare or Medicaid services, you are required to comply with NFPA 99 (1999 edition) Health Care Facilities standard. According to section 1-2, NFPA 99 (1999 edition) applies to all health care facilities, and section 2-1 defines a health care facility where medical care is provided. Chapter 13 in NFPA 99 is the chapter for “other” health care facilities which are not hospitals, nursing homes and limited care facilities. Section 13-3.8 requires all gas equipment to conform to chapter 8. Section 8-3.1.11 lists the storage requirements for nonflammable gases greater than 3,000 cubic feet and quantities less than 3,000 cubic feet which are similar (but not the same) as those requirements for hospitals. For storage of quantities of nonflammable gas greater than 3,000 cubic feet, the requirements are the same as those for hospitals, which are found in section 4-3.1.1.2 of NFPA 99. However, for quantities less than 3,000 cubic feet, there is a difference in storing nonflammable gas in quantities of 300 cubic feet or less. Hospitals have the advantage of having a special dispensation granted by The Centers for Medicare & Medicaid Services (CMS), in the form of S&C Letter 07-10, published January 12, 2007. In this letter, CMS allows hospitals (but not medical offices or clinics) the advantage of following the 2005 edition of NFPA 99, which permits quantities up to 300 cubic feet of nonflammable gas to not be stored in any special rooms or areas. This exception for ‘up to 300 cubic feet’ is not found in the 1999 edition of NFPA 99. Therefore, your business occupancy must store all nonflammable gas cylinders in quantities from 0 to 3,000 cubic feet in accordance with section 8-3.1.11.2, which requires a specially designated room which has a door capable of being locked, and all oxidizing gases in this room must be separated from combustibles by 20 feet (or 5 feet if the room is protected with automatic sprinklers), or the oxidizing gases are to be stored in a flammable cabinet with a fire rating of at least 30 minutes.


Jun 23 2014

Storage in Generator Rooms

Category: Generators,Questions and Answers,StorageBKeyes @ 5:00 am
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Q: I cannot find a code reference that prohibits storage in the generator enclosure. Is there a specific reference for this in the 2000 edition of the Life Safety Code?

A: Sections 19.5.1 and 9.1.3 of the Life Safety Code (2000 edition) references NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, section 5-2.1, which requires the generator to be installed in a separate room for Level 1 installations, which applies to hospitals. NFPA 110 does require a minimum 2-hour fire rating or the generator must be located in an adequate enclosure located outside of the building capable of resisting the entrance of snow and rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, is permitted in this room. In addition, section 5-2.2 of NFPA 110 does not allow generators to be installed in the same room where normal electrical equipment service is installed. These two sections are being interpreted by many national authorities whereby absolutely nothing is allowed in the same room as the generator. The good news (if there is any), the most recent edition of NFPA 110 (2010 edition) does allow small repair parts, tools and manuals in this generator room, but that edition will not be part of our accreditation process until CMS adopts the 2012 edition of the Life Safety Code. So for now, we must comply with the 1999 edition of NFPA 110.


May 26 2014

Flammable Liquids

Category: Flammable Liquids,Questions and Answers,StorageBKeyes @ 5:00 am
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Q: Are there any special storage requirements for flammable liquids and flammable aerosol cans in the work area?

A: Yes, flammable liquids in all forms and capacities must be stored in compliance with section 8.4.3.1 of the 2000 edition of the Life Safety Code, which in turn requires compliance with NFPA 30, 1996 edition. According to NFPA 30, class IA flammable liquids are permitted to be stored outside of a protected cabinet as long as the container is not greater than 1 gallon. As long as the aerosol can is less than 1 gallon, you should not have a problem with keeping it in a regular cabinet. Once you reach an aggregate total of 5 gallons of class IA flammable liquids, then they need to be stored in a fire-rated cabinet.


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