Questions and Answers

The following Questions and Answers were previously published in the Healthcare Life Safety Compliance newsletter, and all answers were provided by Brad Keyes.

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Hospital Owned Appliances

BKeyes : September 22, 2014 6:00 am : Appliances, Consumer, Questions and Answers

Q: How does CMS and the accreditation organizations look at preventive maintenance of household electrical items, such as lamps and coffee makers used by staff in the hospital? Do I need to remove them from the facility?

 A: No, you do not need to remove those items from your facility, but CMS and the accreditation organizations will expect that you follow accepted practices of conducting initial electrical checks on all equipment used in the hospital, but additional follow-up preventive maintenance (PM) activities would be up to you. NFPA 99 Health Care Facilities (1999 edition) has guidance on this issue under section 7-, which requires the leakage current for facility owned appliances (e.g. housekeeping or maintenance appliances) that are used in a patient care vicinity and are likely to contact the patient must be measured. The leakage current shall be less than 500 microamperes. Household or office appliances not commonly equipped with grounding conductors in their power cords shall be permitted provided they are not located within the patient care vicinity. For example, electric typewriters, pencil sharpeners, and clocks at nurses’ stations, or electric clocks or TVs that are normally outside the patient care vicinity but might be in a patient’s room, are not required to have grounding conductors in their power cords. The patient care vicinity is defined as a space for the examination and treatment of patients which extends 6 feet beyond the normal location of the bed, table, chair, treadmill, or other device that supports the patient during examination and treatment, and extends to 7 feet 6 inches above the floor. After the initial electrical current check, conduct a risk assessment to determine if these household types of equipment are required to have periodic planned maintenance activities or only be addressed on an as-needed basis.

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Equipment Room Storage

BKeyes : September 15, 2014 6:00 am : Mechanical Rooms, Questions and Answers, Storage

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

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Door Locks

BKeyes : September 8, 2014 6:00 am : Door Locks, Questions and Answers

Q: We have been asked to install a lock on a door in the path of egress through an office. For security reasons they would like to lock the doors to and from this area. We are thinking of using an electric strike fail safe connected to fire alarm on both doors. This is not in a patient care area, and the doors would only be used by staff.

A: In a hospital, there are only three permissible methods to lock a door in the path of egress: 1) Delayed egress; 2) Access-control; and 3) Clinical needs. Let’s eliminate clinical needs right off the bat, as that refers to a behavioral health unit or an Alzheimer’s unit. Delayed egress may be a possibility, but the hospital needs to be fully sprinklered or fully smoke detected, and you cannot have more than one delayed egress lock in the path of egress to the public way. Delayed egress does not provide true security for the doors, just a 15 second delay which if activated can be very annoying to the staff. I don’t see this as a suitable arrangement.  The more logical approach is the access-control locks, which allows you to provide security to prevent unauthorized individuals from entering the space, but it does not prevent anyone from exiting the space. Section of the 2000 edition of the Life Safety Code describes the requirements for access-controlled egress:

  • A sensor must be installed on the egress side of the door to detect an occupant approaching the door and automatically unlock the door. This sensor must also be wired where a loss of power to the sensor unlocks the door.
  • A loss of power to the access-control system must unlock the door.
  • A manual release ‘Push to Exit’ button must be installed on the egress side of the door, 40 – 48 inches above the floor, and within 5 feet of the door. The manual release button must be labeled with a sign that reads ‘Push to Exit’. When operated, the manual release button must directly interrupt power to the lock independent of the access-control system, and the door must remain unlocked for a minimum of 30 seconds.
  • Activation of the building’s fire alarm system and/or sprinkler system must unlock the door, and remain unlocked until the fire alarm system has been manually reset.

Access-control locks do not provide any security in the path of egress. In your question, you stated that the door in question is in the path of egress. If that is truly the case, then there is no way you can legally lock this door. I would advise the hospital to re-configure their walls and path of egress to allow the office space they desire without locking a door in the path of egress. Another issue to consider: Is the door in question required to latch? If so, then access-control locks cannot be used in lieu of latching. Even though the door may be locked by a mag-lock, it still needs to latch (if required). The phrase “fail safe” means different things to different people. Typically, for locksmiths ‘fail safe’ means when power is removed, the locks remain locked, but for fire safety people the phrase ‘fail safe’ means the lock remains unlocked.

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Storage in Electrical Rooms

BKeyes : September 1, 2014 6:00 am : Electrical Rooms, Questions and Answers, Storage

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.

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O2 Cylinders in Ambulatory Surgical Centers

BKeyes : August 25, 2014 6:00 am : Ambulatory Care Occupancy, Oxygen Cylinders, Questions and Answers

Q: Since the Life Safety Code addresses ambulatory surgery centers in chapters 20-21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage of compressed gas cylinders?

 A: According to the CMS S&C-07-10 memo dated January 12, 2007, Ambulatory Surgical Centers (ASC) are included in the scope of that interpretation memo and ASC are required to abide by the 2005 edition of NFPA 99, section 9.4.3. This allows them the same advantage as hospitals with no storage requirements for 300 cubic feet and less of non-flammable compressed gas per smoke compartment. For storage of non-flammable compressed gas over 300 cubic feet and less than 3,000 cubic feet per smoke compartment, the ASC needs to comply with Chapter 13 of NFPA 99, section 13-3.8 which refers back chapter 8. Section 8- provides the requirements for storage of non-flammable compressed gas in quantities less than 3,000 cubic feet, which do not include 1-hour fire rated barriers. However, since the CMS S&C memo grants a special dispensation for ASC to follow the 2005 edition of NFPA 99, for 300 cubic feet and less of compressed gas, then they are the same as hospitals in regards to storage of compressed gas. According to the CMS S&C memo, cylinders in use are not to be counted as cylinders in storage. Therefore, they are not included in the calculation of cubic feet of compressed gas when considering storage requirements.  NFPA 99 requires full compressed gas cylinders to be segregated when stored with empty compressed gas cylinders.

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Special Fire Extinguisher Placard

BKeyes : August 18, 2014 6:00 am : Fire Extinguishers, Kitchens, Questions and Answers

Q: Do we have to have a special placard on our fire extinguishers in our kitchen, alerting people to activate the cooking hood fire suppression system first, before using the fire extinguishers? We received a citation from a surveyor on this issue.

 A:  The answer is yes, but I admit I was not aware of this requirement until recently. A hospital-client of mine was cited by their state surveyor for not having a placard near the Class K fire extinguishers informing the staff not to use the fire extinguisher until the cooking hood fire suppression system had been activated. I had never heard of this, so I contacted the surveyor at the state agency and asked what code or standard required this. He said it was in NFPA 96 (1998 edition), and sure enough, there it was in section 7-2.1.1: “A placard identifying the use of the extinguisher as a secondary means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.” Now, the standard says ‘each portable fire extinguisher in the cooking area’, but the state surveyor cited just the Class K extinguishers. I learned something new that day, so I considered it a successful day. If you don’t have those placards near all of your extinguishers in the cooking areas of your establishment, then I suggest you consider them, before you get cited.


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Suite Entrance Doors

BKeyes : August 11, 2014 6:00 am : Doors, Questions and Answers, Suites

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 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 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, 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 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 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 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.

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Operating Room Entrance Doors

BKeyes : August 4, 2014 6:00 am : Doors, Operating Room, Questions and Answers

Q: Concerning latching hardware for a surgical suite, I could not locate any exceptions in the Life Safety Code to the positive latching requirements concerning operating room doors. From an infection control standpoint, the doctor having to handle a lever after scrubbing would not be desirable. Since the operating room is positive pressure, and the doors swing into the room, the positive pressure keeps the doors in a closed position full time. Are there waivers issued for these situations?

 A: Entrance doors to operating rooms that positively latch can have hardware devices that resemble ‘paddles’ and are easily actuated by elbows, hips or shoulders. The physicians and nurses do not have to touch the paddles with their hands, which may be considered sterile from scrubbing. The bigger question to consider in this scenario is do the entrance doors to the operating room actually have to positively latch? This can be easily answered by determining if the Surgical OR area is a suite of rooms or not. If the OR area is a suite, then the entrance doors to the operating rooms do not have to latch. However, if the OR area is NOT a suite, then the entrance doors to the operating rooms must latch since they are doors that open onto an exit corridor. The OR area is either a suite or it is a series of exit access corridors. The advantage of a suite is there are no requirements for corridors inside the suite because it is a room. Therefore, what looks like a corridor is actually a communicating space and the minimum widths pertaining to aisles in a communicating space (see section of the 2000 LSC) are required to be maintained (28” for existing and 36” for new). That means the restrictions about storing items (such as medical equipment and non-combustible supplies) in the corridors no longer applies. Also since there are no corridors, there are no requirements for corridor doors, which means if there are doors to the inner-rooms (other than doors to exits or hazardous rooms), they do not have to latch. This is a huge advantage for those high-acuity areas such as ERs and ICUs where staff needs to have access to their patients quickly. As far as waivers are concerned, it would be very unlikely that the Centers for Medicare & Medicaid Services (CMS) would grant a waiver for a corridor door to an operating room that is required to latch. All waivers and equivalency requests must be submitted through your accreditation organization or state agency, who then submits them to the appropriate CMS regional office for approval. Only CMS is able to approve waivers or equivalency request, according to the recent proposed rule on the adoption of the 2012 edition of the LSC.

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Emergency Lighting

BKeyes : July 28, 2014 6:00 am : Emergency Lights, Questions and Answers

Q: Is there a NFPA standard for emergency lighting placement in an anesthetizing location? A specific requirement where on the wall or ceiling it must be mounted? Do the self-check devices still require a manual 30 second and 90 minute test?

 A: NFPA 99 (1999 edition) section 3- discusses electrical needs in anesthetizing locations. Basically, all it says is one or more battery-powered emergency lighting units must be installed in accordance with NFPA 70, article 700-12 (e), which describes the electrical requirements for an emergency lighting fixture, such as:

  • A rechargeable battery
  • A battery charging means
  • Provisions for one or more lamps mounted on the equipment
  • A relay device to energize the emergency lighting upon loss of normal power

Article 410 of NFPA 70 discusses lighting fixtures and locations in general. Basically, they address wet, damp, corrosive locations, and mounting fixtures in closets, ducts and hoods, showers and near combustible materials, but does not address on where they need to be mounted for anesthetizing locations. A further review of NFPA 99 does not reveal anything about location of emergency lighting. Neither NFPA 110 nor NFPA 111 addresses emergency lighting locations. Section 7.9 of the 2000 edition of the LSC does discuss emergency lighting, and it uses the term ‘means of egress’ to describe where emergency lighting needs to be located, but specific as to walls or ceiling mounting.

Ironically, this section does not require battery-powered fixtures for emergency lighting needs and references NFPA 110 if emergency lighting is powered by generators. Therefore, in this case, NFPA 99 would supersede the LSC and you would need to install battery-powered emergency lighting in anesthetizing locations, even if you had generator powered emergency lighting. But section 7.9.3 of the LSC does require 30 second testing of battery-powered emergency lighting fixtures at 30-day intervals, and 90 minute tests annually. However, in lieu of the regular monthly 30-second tests, the exception to 7.9.3 does allow self-diagnostic battery powered emergency lighting equipment which automatically performs a test for not less than 30 seconds not less than every 30 days and indicates failures by a status indicator is exempt from the 30-day functional test, provided a visual inspection is performed at 30-day intervals.

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Clinic: Business Occupancy

BKeyes : July 21, 2014 6:00 am : Business Occupancy, Questions and Answers

Q: Our new clinic integration program has made us look closely at the clinic’s life safety process. The clinic is classified as a business occupancy. Is the assessment for life safety compliance different than an acute care hospital?

 A: While the clinic is classified as a business occupancy, the approach to a life safety assessment would be similar as conducting a life safety assessment for a healthcare occupancy (hospital), but you do not assess the clinic to the same set of standards as you would the hospital. Healthcare occupancies must comply with the core chapters of the 2000 Life Safety Code (LSC), which are chapters 1-4, and 6 – 11, and they have to comply with the occupancy chapters 18 and 19. Business occupancies likewise have to comply with chapters 1 – 4, and 6 – 11, but they have a different set of occupancy chapters to comply with; chapters 38 & 39. Chapter 38 is for new construction and chapter 39 is for existing construction. A facility is considered new construction if its construction plans and documents were approved by the local authorities after March 11, 2003. A facility is considered existing construction if its construction plans and documents were approved by the local authorities on or before March 11, 2003. Also, any renovation conducted in existing construction buildings on or after March 11, 2003 must comply with new construction requirements.

Why the date of March 11, 2003? Because that is the date that the Centers for Medicare & Medicaid Services (CMS) adopted the 2000 edition of the LSC. Assuming your clinics qualify for existing construction occupancy, you must assess the building for compliance with chapter 39. You will find that the life safety requirements are far less restrictive for business occupancies as compared to healthcare occupancies. Examples where there will be significant differences (and leniencies) in compliance, are:

  • Construction Type                     (39.1.6)
  • Overhead Rolling Fire Doors     (
  • Means of Egress Arrangement   (39.2.5)
  • Emergency Lighting                  (39.2.9)
  • Hazardous areas                                    (39.3.2)
  • Fire alarm systems                     (39.3.4)
  • Sprinkler systems                       (39.3.5)
  • Corridor walls                           (39.3.6)
  • Smoke compartments                (39.3.7)
  • Fire Drills                                  (39.7.1)
  • Fire Extinguisher Training          (39.7.2)

While fire damper testing in healthcare occupancies enjoys a 6-year cycle, that is not the case in business occupancies, which requires a 4-year testing interval. You will have to research each issue individually to determine your level of compliance.

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