Sep 08 2017

Suite Boundary

Category: Questions and Answers,Suites,WallsBKeyes @ 12:00 am
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Q: We have a suite inside of a smoke compartment. We are trying to find out if the dividing wall needs to be the same as the 1-hour smoke barrier.

A: According to section 19.2.5.7.1.2 of the 2012 LSC, the boundary of a suite has to meet the requirements for corridors. This means, if the smoke compartment is not fully protected with sprinklers, then the corridor walls must be 30-minute rated, smoke-resistant, and extend from the floor to the deck above. If the smoke compartment is fully protected with sprinklers then the corridor walls only have to be smoke-resistant and extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke. Therefore, the suite perimeter walls would have to be the same as the corridor walls.

It is possible however, that one wall can serve two purposes, so the suite wall could also be a smoke barrier as long as the wall meets the requirements for both purposes.

Keep in mind that a suite is nothing more than a room, although it is a large room with a lot of smaller rooms inside. Therefore, all corridor entrance doors into the suite must positively latch, and the path of egress cannot take you from a corridor into a suite to get to an exit.


Apr 14 2017

Sleeping Suites

Category: Questions and Answers,SuitesBKeyes @ 12:00 am
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Q: Are recovery rooms and observation units considered sleeping suites or non-sleeping suites? What is the definition of what constitutes a sleeping suite?

A: Recovery rooms, surgical suites and pre-op suites would be considered “non-sleeping suites” because sleeping accommodations are not provided in these areas. The Life Safety Code uses the term “patient sleeping rooms”. If the suite includes patient sleeping rooms, then it is restricted to the requirements for sleeping suites. If the suite does not provide sleeping rooms, then it can be considered non-sleeping suites which have less restrictions.

An observation room can be a patient sleeping room, or it can be an exam room in an ER. Whether it is classified as a “patient sleeping room” depends on the hospital’s definition of an observation room. Remember: If it looks like a duck and quacks like a duck, then it pretty much is a duck. If the observation room looks like a patient sleeping room, then a surveyor can consider it a patient sleeping room even if you call it something else.


Jun 13 2016

Surgery Suites

Category: Questions and Answers,SuitesBKeyes @ 12:00 am
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Q: Are surgery rooms considered to be patient sleeping rooms or non-sleeping rooms? In reference to allowable suite sizes, what is the maximum area of the suite?

A: Surgery rooms are definitely considered non-sleeping rooms. A sleeping room is a room designed and constructed for patient sleeping. Surgery rooms are not designed and constructed for patient sleeping. And by the way, (you didn’t ask, but….) neither are sleep labs. A sleep lab sleeping room is not a patient sleeping room, but is an exam room, and can qualify to be classified as business occupancies. Since it is a non-sleeping area, a surgery suite is permitted to be 10,000 square feet in size. However, if you had a patient sleeping suite, the 2000 Life Safety Code limits the size to 5,000 square feet. The 2012 Life Safety Code does permit patient sleeping suites to extend to 10,000 square feet but specific additional requirements have to be met. There are CMS categorical waivers that would allow a hospital to utilize the 2012 edition pertaining to patient sleeping suites.


Aug 11 2014

Suite Entrance Doors

Category: Doors,Questions and Answers,SuitesBKeyes @ 6:00 am
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Q: Are there any NFPA regulations which require doors serving as exits from suites must swing in the direction of egress? I have identified smoke barrier double doors in corridors which seem to fit the description of “cross corridor doors” and found to swing in the same direction. Upon review of NFPA 18.3.7.5 it seems as though they must swing in opposite directions. Will these doors have to be replaced or modified to swing in opposite directions?

 A: Yes, there are NFPA regulations that address door swings in the direction of travel, but it depends on different factors and not all suite entrance/exit doors would have to comply. Section 7.2.1.4.2 of the 2000 edition of the Life Safety Code specifically says doors required to be of the side-hinged or pivoted-swinging type shall swing in the direction of egress travel where serving a room or area with an occupant load of 50 or more. An exception to this requirement says smoke barrier doors shall not be required to swing in the direction of egress travel as provided in Chapter 19. So this section only requires doors to swing in the direction of egress where the occupant load is 50 or more. As far as the Life Safety Code is concerned, the occupant load is calculated by the defined occupant load factor and the area of the space involved. So, an inpatient treatment suite such as an ICU, which has a maximum area of 5,000 square feet and the occupant load factor for healthcare sleeping area is 120 square feet per person (see Table 7.3.1.2), would have an occupant load of 41 persons. So, based on those factors an entrance/exit door from an ICU suite would not have to swing in the direction of egress travel. The exception to 7.2.1.4.2 permits existing smoke compartment barrier doors to be exempt from this requirement, so if the cross-corridor doors that you have identified were installed prior to March 11, 2003, then they are considered existing and are exempt from having to swing in the direction of egress travel. Why March 11, 2003? That’s the date CMS adopted the 2000 edition of the LSC. It is important to point out section 7.2.1.4.3 which requires the door to swing in the direction of egress travel where used in an exit enclosure. Therefore, a door leading into an exit stairwell would have to swing in the direction of egress travel regardless of how few occupants it serves. You are correct that 18.3.7.5 does require new smoke compartment barrier cross-corridor doors to be a pair of opposite swinging doors, but that just for new construction, or anything built on or after March 11, 2003. If by chance the smoke compartment barrier cross-corridor doors in question are new (installed on or after March 11, 2003) and they are not double egress, then that would be a LSC deficiency. The organization could choose to replace the doors with compliant ones; or request a waiver or an equivalency from CMS which probably would not be approved. My suggestion is that you just repair the doors and make them double egress swing.


Feb 28 2013

Oversized Suites of Rooms

Category: Equivalencies,Questions and Answers,SuitesBKeyes @ 5:00 am
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Q: Can an FSES equivalency be written for an oversized ER suite? Our ER was constructed in 2005 and the designer made it 13,450 square feet, which is more than the maximum allowable amount.  We have exam rooms without doors and a surveyor said that was not allowed if the ER is not a suite.

 A: Yes, a Fire Safety Evaluation System (FSES) equivalency may be conducted and submitted to your authority having jurisdiction, but you have to make sure of a few issues. First, the deficiency for an over-sized ER suite has to address the fact that the exam rooms do not have doors. The surveyor is correct in saying that a room providing care or treatment to a patient has to be separated from the corridor by a door that latches.  Secondly, since you do not qualify for a suite (because you are 3,450 square feet over the limit), you have to assess the ER as if it has an exit access corridor, and all the exam rooms are open to the corridor. The FSES document is a NFPA 101A Guide on Alternative Approaches to Life Safety (2001 edition), and the worksheet to use is form 4.7.6. The value for Safety Parameter #5 has to be -10 points for no doors to the corridor. Make sure you travel distances are no more than 100 feet or 50 feet if through two intervening rooms. If the plans to construct the ER department were approved by the local authority on construction after March 11, 2003, then you must assess the area on the FSES worksheet as new construction, which makes it harder to get the numbers to work. The logic on that issue is a new building should not have any life safety deficiencies. If the numbers do not work out on the FSES equivalency, you can always consider cutting the ER into two, smaller suites by adding doors and walls in strategic areas. That may not be desirable, but it may be your only solution if the FSES does not work.


Nov 19 2012

Means of Egress Widths in Suites

Category: Corridors,Questions and Answers,SuitesBKeyes @ 5:00 am
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Q: During a recent survey, we were cited for not maintaining at least 36 inches of clear width in our suites for exiting purposes. I thought one of the advantages of suites is corridor widths are not required to be maintained, according to section 19.2.3.3 (exception #2) in the 2000 edition of the Life Safety Code (LSC). Why would we have to maintain 36 inches clearance?

A: You are correct when you say corridor widths are not required to be maintained in a suite-of-rooms, however, the surveyor was basically correct in that aisle widths must be maintained in all areas of the means of egress. Let’s review the basic concept of a suite: A suite is just a large room with a lot of smaller rooms inside it. There are constraints on the size of the suite and limitations on the travel distances from inside the suite to the corridor door. One of the advantages of a suite is what looks like a corridor inside the suite is actually just a common space, and the width does not have to be maintained to 8 feet clearance, as you pointed out. However, the means of egress must meet minimum clearances according to section 7.3.4.1 which is at least 36 inches clearance for new conditions and 28 inches for existing. The means of egress is defined in section 3.3.121 as “A continuous…way of travel from any point in the building…to a public way…” The means of egress applies to all rooms including suites even if there are no corridors in that area, so you would have to comply with section 7.3.4.1 and allow a minimum aisle width of 36 inches for new construction, or 28 inches for existing conditions.


Sep 17 2012

Storage in a Patient Sleeping Suite

Category: Questions and Answers,Storage,SuitesBKeyes @ 5:00 am
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Q: Can we install shelving along the walls within a patient sleeping suite? This shelving would not be limited to a supply room, but would be permanently affixed to the walls inside the main room in the suite and would not obstruct sprinkler heads or visual contact with the fire alarm notification strobe.

A: It all depends on what you put in the shelves. Since you are making a modification of the suite, you would have to comply with new construction requirements found in chapter 18 of the 2000 edition of the LSC. Take a look at section 18.3.2.1 on hazardous areas. It describes a room that is greater than 100 square feet and stores combustible material as a hazardous area. Section 18.2.5.5 does not allow intervening rooms to be hazardous areas, and the main room inside the suite would definitely be an intervening room, and would be greater than 100 square feet. If the supplies that are placed on these shelves are combustible, then it is not allowed in a patient sleeping suite. Most supplies used in patient care are packaged in combustible material, such as cardboard boxes, plastic, paper or linen. Even if you think staff won’t place combustibles on these shelves, I would strongly suggest that you do not go this route. You can never be sure what staff will place there after the shelves are installed.


Dec 06 2011

Magnetic Latches on Suites

Category: Door Locks,Doors,Questions and Answers,SuitesBKeyes @ 4:17 am
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Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?

A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.

In new healthcare occupancy, section 18.3.6.3.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).

However, for existing healthcare occupancies, section 19.3.6.3.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception. When locks are permitted on egress doors, they must meet the requirements found in 19.2.2.2.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.

Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.


Feb 01 2011

Suites of Rooms Used as Hazardous Rooms

Category: Hazardous Areas,Questions and Answers,SuitesBKeyes @ 7:24 pm
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Q: Can the entire patient sleeping suite of rooms, such as an ICU, be considered a hazardous room? This would allow us to store supplies in the common area of the suite rather than in a separated hazardous room.

A: No, and the reason why is section 19.2.5.5 of the 2000 edition of the LSC says intervening rooms must not be hazardous areas. The common area in the suite would be an intervening room for anyone exiting from the patient sleeping room. Now, that doesn’t mean you are not allowed to have small quantities of supplies packaged in combustible paper or plastic containers in the common room of the suite. The issue here is whether or not the AHJ would deem the quantity of supplies hazardous. My suggestion is to ask the local AHJ take a look and render an opinion as to whether or not the quantity of supplies is hazardous. If he/she says it is OK, then this constitutes as a risk assessment and could be used as an explanation if the subject comes up during a survey or inspection by another AHJ.


May 01 2010

Suites Used as a Smoke Compartment

Category: Questions and Answers,SuitesBKeyes @ 4:03 pm
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Q: We want to relocate a smoke compartment barrier to the entrance of our OR Surgery, in order to make the OR Surgery a suite of room. Do you see any problem why we cannot do this?

A: Yes, there are a few issues you need to be sure to address before you proceed. First let me say that there is nothing wrong in a single wall having several functions. A wall that serves as a barrier for a suite-of-rooms and a smoke compartment is actually quite common and normally not a problem. You just have to be sure that the wall, and all the openings in the wall, meet the requirements for each purpose. Since your question said you are relocating a wall, then that means you need to meet new construction requirements, found in chapter 18 of the Life Safety Code (LSC). Section 18.3.7.3 requires the new wall to be 1-hour fire rated from floor to deck, and section 18.3.5.1 requires the area where the new wall is installed to be protected with automatic sprinklers. All the doors in the wall have to be substantial, such as 1¾ inches thick solid-bonded, wood core, or of construction that resists fire for not less than 20 minutes. The doors will have to be self-closing, and since they also serve as an entrance to the OR suite, they will have to positively latch. The position of the relocated wall is important as well. Section 18.2.5.10 limits a dead-end corridor to 30 feet, so make sure the relocation does not exceed this distance. Also, since you are relocating a smoke compartment barrier, that will change compartment size (limited to 22,500 sq. ft.), travel distances to a smoke compartment door (limited to 200 feet), and a net area of 30 sq. ft. per patient from adjoining compartments. The size and travel distances inside the OR suite are limited as well (see 18.2.5 for limitations). Cross corridor doors must be a pair of swinging doors that open in opposite directions, not contain a center mullion, and each leaf must have a clear width of at least 41½ inches. There are a few other exceptions that you may qualify for in section 18.3.7. So, consider all of these requirements before you begin construction, and check with your local and state authorities to see if they have any other restrictions.


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