Fire Door Inspector

Q: My accreditation organization has a standard that says “testing and inspection of fire door assemblies needs to be conducted by a qualified person.” By what specifically do they mean when they say “qualified” and where are we able to find where they define their interpretation of what qualified is?

A: You will find the interpretation of what ‘qualified’ means under section of NFPA 80-2010, which says functional testing of fire doors and window assemblies must be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. You may hire this responsibility out to a contractor with this knowledge and understanding, or you may assign the responsibility to test the fire doors to one of your own staff individuals, provided you ‘qualify’ them by determining they have the knowledge and understanding to perform this test.

If you decide on the latter, you need to document this decision by describing why you believe this individual has this knowledge and understanding of fire door operating components, and retain that document in case the surveyor asks to see how you qualified that individual. Your own staff individual could be qualified based on a certification course they may have taken (please understand there is no requirement that the person conducting the fire door inspections be certified, but it can be a good source of education), or the individual may be qualified simply because they have worked on doors for years and have accumulated this knowledge and understanding. The key is you may need to defend this decision, so it is best to document the decision and retain that to show to a surveyor.

Time Allowed for Repairs

Q: What are the time frames for repairing life safety deficiencies found during routine inspections? How much time would be allowed to repair emergency exit signs, or failed smoke detectors?

A: Well… if you’re talking about resolving a deficiency that was cited on a survey report, you have 60-days from the time you receive the report. This is actually a mandate from CMS under CFR 488.28(d). But CMS (and the accreditation organizations, or AO) understand if additional time is required, due to the need of obtaining approval from your governing body, or engaging in competitive bidding, as examples.

If you need more time and the deficiency is a LSC deficiency, then you have the option of requesting a Time-Limited Waiver, a Standard Waiver, or a FSES Equivalency. Each AO has their own instructions and procedures for you to follow when requesting one of these.

But if you conduct your own assessment and find certain items deficient, then you are not obligated to resolve the deficiency within the 60-day window. Most AOs will expect you to resolve the deficiency in a reasonable amount of time.

If all you need to do is install four new ‘Exit’ signs, then a month or so is reasonable. But a year would not be considered reasonable.  A failed smoke detector should not take more than a month or so, unless it is such a special item that delivery time is excessive.

Other than the 60-day window after a survey, I’ve never seen a set time-limit for life safety repairs. All of the AHJs I’ve worked with are willing to work with you. If you need extra time due to extenuating circumstances, they will be understanding.

Whatever is reasonable… Most AHJs will work with you on this, as long as the time-frame is reasonable.

Emergency Department Corridor Width

Q: What is the minimum acceptable clearance required in an Emergency Department corridor? Currently there is a crash cart stored for rapid accessibility and the distance directly in front of it is effectively reduced to slightly over 72-inches allowing enough room for a stretcher still to pass. The cart is on wheels and can be quickly easily rolled out of the way as might be needed.

A: Is the Emergency Department a suite of rooms? If yes, then you have nothing to worry about. There are no corridors inside a suite of rooms, even though what looks like a corridor is actually a communicating space. But you do have to maintain aisle width clearance and section of the 2012 LSC says the minimum aisle width is 36-inches. So it looks like you have that covered with the 72-inches clearance.

However, if the Emergency Department is not a suite, then you must maintain corridor width requirements. But how wide is the corridor required to be in the Emergency Department? Well… that depends, based on the occupancy classification of the Emergency Department, and whether or not you have any inpatient sleeping rooms in the area. Section (1) permits the clear width of a corridor to be 44-inches if the corridor is not intended for the housing, treatment or use of inpatients.

Now, before you say you don’t have any inpatients in the Emergency Department, remember that CMS has interpreted all Emergency Departments that provide observation beds must be healthcare occupancies, as they consider observation beds to be sleeping accommodations and therefore must meet inpatient requirements. So, if you have observation beds in the Emergency Department, then you must maintain corridor width of 8-feet.


But if you don’t have any observation beds in the Emergency Department, then 44-inches is your clear width requirement and it looks that you’ve made that.

Battery Powered ‘Exit’ Signs

Q: Do ‘Exit’ signs with battery backup require the same testing as emergency lighting in the path of egress as indicted in section of the 2012 Life Safety Code?

A: Well… yes, but not exactly. Section of the 2012 Life Safety Code requires all ‘Exit’ signs to be visually inspected for operation of the illumination sources at intervals not to exceed 30 days. That is a visual inspection and is not a 30-second test or an annual 90-minute test that you’re alluding to.

But section says ‘Exit’ signs connected to, or provided with, a battery-operated emergency illumination source must be tested and maintained in accordance with 7.9.3, which is the section that requires a 30-second monthly test and a 90-minute annual test of the battery system. So, you’re correct in that battery powered ‘Exit’ signs need to be tested monthly and annually just like battery powered emergency lights, but you just had the wrong code reference.

Fire Extinguisher Signs

Q: I was wondering if there was a specific regulation that states exactly where fire extinguisher signs need to be located. Is there a difference between patient area and staff area? Looking over the new Life Safety Code regulations I have not been able to get a specific answer on where signage location is mandatory.

A: The only thing I can find is section of NFPA 10-2010, which says where visual obstructions of fire extinguishers cannot be completely avoided, means shall be provided to indicate the extinguisher location. The Annex section says acceptable means of identifying the fire extinguisher locations include arrows, lights, signs, or coding of the wall or column.

 So, while there is no direct requirement to install signs over fire extinguishers, you may do so. However, be aware: Some AHJs will expect signs identifying the locations of all extinguishers once you start using signs. Their logic is, if you use signs to identify the location of some extinguishers, then your staff will expect to see signs for all extinguishers.

The AHJs do have the right to interpret the code as they see fit. I suggest you ask your AHJs to see if they would require all of the extinguishers have signs.

Occupancy Separation

Q: I am a consultant hired by a health system to review a potential building they want to purchase. The architect on this project tells me that the building is NFPA 220 construction type II (111) which is basically a 1-hour rated assembly. The building is a fully sprinklered three story building, and has a mixed use including business and ambulatory healthcare occupancies. The health system is planning on buying the building and is looking to put a free-standing emergency clinic on the first floor which you’ve said needs to be healthcare occupancy. The second floor is a business occupancy. Here’s where it gets strange and I want to make sure I’m not crazy. The floor separation between the first and second floors in this case (business and healthcare) would need to be two-hour fire rated. But Type II (111) buildings have one-hour fire rated floors. I’ve received a drawing from the architect that states the construction type as II (111), but it shows the floors being upgraded to two-hour fire rated construction. The question is, can we have a two-hour floor supported by a one hour steel frame?

A: From my point of view, if they can document that the floor is 2-hour fire rated, then that should be enough for an AHJ to approve the separation between healthcare and business occupancies. I would view it as this: The floor is 2-hour fire rated, and it meets the requirements for a separation between healthcare and business occupancies, and it meets the requirements for Type II (111) construction type. Now, my opinion does not count, so I suggest they get an interpretation from their AHJs, including their accreditation organization.

By the way… CMS was the one who said in late 2016 that Emergency Departments need to be healthcare occupancies. Since then, they have modified their position a bit. Now they are saying an ED must be healthcare occupancy if they provide patient observation rooms. CMS’ rationale is if the patient is sleeping in an observation bed, then that should qualify it as healthcare occupancy. (I don’t agree, but my opinion does not count.) CMS does concede that an ED may be classified as ambulatory healthcare occupancy provide there are no observation beds.

Cords on Nurse Call Stations

Q: We have a behavioral health unit and want to know if pull-cords are required on the nurse-call system in the patient bathroom? Is there an alternative to cords so this type patient can’t hang themselves?

A: The NFPA codes and standards do not address this issue, but the FGI Guidelines do. CMS and the accreditation organizations expect you to follow the FGI Guidelines for new construction, unless there are other more restrictive requirements for other authorities, such as state health departments or local building codes.

Section 2.5- of the 2010 FGI Guideline says a nurse call system is not required in psychiatric nursing units, so you do not have to provide cords on the call-buttons. Also, section 2.5- says call cords or strings in excess of 6 inches are not permitted. Now, the latter section is for geriatric, Alzheimer’s, or dementia units, but the concept can carry-over to your behavioral health unit.

ABHR Dispensers

Q: We currently have ABHR installed on the outside of our patient bays and would like to install an additional dispenser in the patient bay itself (at the point of use). If an ABHR container is installed on the wall on the outside of the patient bay next to the door, can a dispenser be installed on the other side of the wall on the inside of the bay next to the door (they would mirror each other; one interior and one exterior). I did measure the distance between the two from interior to exterior and it is only 1 ft. wrapped around. What is the interpretation of the 4-foot dispenser separation requirement? Just want to make sure we are in compliance with LSCs!

A: The interpretation I received is the ABHR dispensers need to be separated by 4 feet (horizontally), including a wrap-around a door frame. So, what you described (ABHR dispensers separated by only 1-foot, but on separated sides of the wall) would not be permitted.

Temperature & Humidity Monitoring

Q: Where do I find in the code that tells me where required temperature and humidity must be monitored? We have our accreditation organization here, and they mentioned our Sterile Processing and Clean Utility rooms require this monitoring. I have looked at the FGI manual and looked at AHSRAE 170-2008 table which have the guideline perimeters, and this list has several locations with temperature and humidity perimeters. Are these all required to be monitored? I haven’t found any specific reference in the Life Safety Code that says which areas are required to be monitored. Any help would be appreciated.

A: You won’t find it in the Life Safety Code, because it does not directly regulate air temperature, humidity, or air pressure relationships. This is left to other standards, guidelines and regulations. For instance; CMS has a standard for acute-care hospitals under §482.41(c)(4) that says “There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.” In the Interpretive guidelines section for this standard it says acceptable standards such as AORN and FGI should be incorporated into hospital policy. The accreditation organizations will have standards of their own that compliment what CMS is saying. So, some sort of standard must be used by the hospital. If not the FGI Guidelines (which references the ASHRAE 170 standards on design of ventilation), then some other standard must be used. This means if the state or local AHJ had more restrictive requirements you would have to comply with those requirements. It appears your AO is expecting the hospital to meet at a minimum, the FGI requirements for ventilation.  To answer your question, yes these other locations must be monitored to ensure you have the proper HVAC ventilation. If you don’t monitor them, then how do you know if they are correct? But you won’t find this information referenced in the Life Safety Code.

Receptacle Testing

Q: Is there a code in the 2012 LSC about testing electrical receptacles around hospital beds?

A: Well… actually, that would be in the NFPA 99-2012 code/standard, and the answer is yes, all receptacles in patient care rooms must be tested. But the frequency of that test is different, depending on whether the receptacle is a hospital-grade receptacle or not.

Section says hospital-grade receptacles must be tested after initial installation, replacement, or servicing of the device.

Then section says receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, must be tested at intervals not exceeding 12 months.

But section does say additional testing of receptacles (including hospital-grade receptacles) in patient care rooms shall be performed at intervals defined by documented performance data. This means you do have to test hospital-grade receptacles at a frequency determined by the healthcare organization based on information such as historical data, risk assessments, or manufacturer’s recommendation.

So, if you do install hospital-grade receptacles in the above locations, then you do have to test them after the initial installation, but at intervals that you get to determine.

Non-Patient Care Electrical Equipment

Q: What required inspections are needed for non-patient care electrical equipment and at what intervals should they be completed in. I cannot find anything definitive in NFPA 99 – 2012.

A: CMS will expect that you conduct the maintenance activities (i.e. PM’s) as recommended by the manufacturer, for all electrical equipment regardless if it is considered patient care or non-patient care equipment. In addition, this electrical equipment must be on the facility’s inventory of equipment.

This is based on CFR §482.41(c)(2) which is also known as A-0724 in the State Operations Manual (SOM) Appendix A. This document is available at no charge by searching “CMS SOM Hospitals”. Since it is a CMS standard, then all of the accreditation organizations and state agencies must have standards that are equal to that.

So, the answer to your question is: Whatever the manufacturer recommends, you must comply. And this is based on a CMS requirement, not an NFPA 99 requirement.

CMS does offer an Alternative Equipment Management (AEM) program that would allow you to conduct PM activities that differ from the manufacturer’s recommendations, but there are a lot of challenges to this AEM program and it is not for everyone. You can read all about it in CFR §482.41(c)(2).

Elevator Shaft Construction

Q: We have a hospital that was built in 2008. We believe there is an elevator construction issue. When they built the elevator shafts they put smoke detectors inside at the top but no sprinklers. On the three exterior sides of the shaft (non-door side) they have cinder block wall. On the interior wall (door side) they have some cinder block construction but they also have in sporadic places two pieces of plywood with glue creating a 2-hour fire rated wall. The other issue is in between the glue there are holes or air pockets. Is this acceptable to use plywood to create a 2-hour fire rated wall or does it have to be cinder block top to bottom? Our construction type is Type II (222) and the elevator shaft serves 8 stories.

A: No… it is not acceptable to use plywood as part of the construction of a 2-hour fire-rated wall. First of all, Type II buildings are not permitted to have combustible construction on their structural members. NFPA 220-2012, section 4.3.1 says Type I and Type II construction must be those types in which the fire walls, structural elements, walls, arches, floors, and roofs are of approved noncombustible or limited combustible materials. Plywood is combustible, even if it is fire-retardant. So, the plywood has to go, and must be replaced with non-combustible materials in order to complete the 2-hour fire rated elevator shaft. NFPA 13 does not require sprinklers in a non-combustible elevator shaft that does not use hydraulic fluids. Assuming it is a traction elevator (i.e. cables and pulleys), then the elevator shaft is not required to be sprinklered. But to answer your question, the plywood is a problem and should not be there.

Dead-Bolt Locks on Entrance Doors

Q: A while ago, you made a posting that said a deadbolt lock on a door in the means of egress (such as an aluminum-framed glass sliding door at the entrance of the hospital) would be permitted as long as the door is not a fire-rated door and has no other releasing devices such as a lever, knob or crash-bar. I do not believe that is true, as a deadbolt lock with a thumb-turn should not be permitted in the mean of egress. Please advise…

A: After reconsideration, I believe you are correct. I looked up the commentary under in the 2012 LSC Handbook, and it says this about the releasing device on the door:

“Examples of devices that might be arranged to release latches include knobs, levers, and bars. This requirement is permitted to be satisfied by the use of conventional types of hardware, whereby the door is released by turning a lever, knob, or handle or by pushing against a bar, but not by unfamiliar methods of operation, such as a blow to break glass…. The operating devices should be capable of being operated with one hand and should not require tight grasping, tight pinching, or twisting of the wrist to operate.”

It is rather obvious that a standard deadbolt lock with a thumb-turn device does require a tight grasping, twisting of the wrist to operate. So, I agree with you that it would not be permitted in the arrangement as described.

Thanks for bringing this to my attention… I do apologize for the confusion and misinformation.

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.

Medical Gas Shutoff Valves

Q: As a hospital security assessor, I am concerned about the availability of hospital gases in Behavioral Health Units. It would be easy for a patient to pull the tab off the plastic covering on the window and tamper with the gases. Would it be permissible to install a clear locking door with hardened glass in place of the plastic panel and provide access to the locked box via scan card with the caveat that the door would automatically unlock open during a fire event?

A: One has to ask why would there be medical gases on a behavioral health unit? Do you treat acute-care patients there? However, if you have them there, then you need to deal with them.

Your question appears to address the medical gas shutoff valves, or zone valves as they are often called. According to NFPA 99-2012, section, zone valves have to be visible, accessible and readily operable from a standing position in the corridor. NFPA 99-2012 does not prohibit the use of special locking arrangements for access to the zone valves.

I think you have a legitimate concern, especially if you document this concern in a risk assessment. But I suggest you contact your authorities having jurisdiction, and ask them if it would be permitted. At a minimum, I suggest you ask:

  • Your accreditation organization
  • Your state agency in charge of hospital design and construction
  • Your local building authorities
  • Your state or local fire marshal