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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Evacuation Chairs

BKeyes : March 2, 2015 6:00 am : Evacuation, Questions and Answers

Q: Are stairway evacuation chairs required in all high rises, or business occupancies in general?

A: According to the Life Safety Code, there is no requirement to provide stairway evacuation chairs in any specific occupancy, hi-rise or otherwise. However, the Life Safety Code (as well as any of the Accreditation Organizations, such as Joint Commission, HFAP, and DNV) requires you to have a fire safety plan that includes plans for evacuation. If your organization chooses not to use stairway evacuation chairs to evacuate your patients, then you must have an alternative method to evacuate patients. Incidentally, the Life Safety Code does not restrict the storage of evacuation chairs inside a stairwell, as long as it does not interfere with egress. The only place that qualifies for ‘not interfering with egress’ is usually at the top of the typical stairwell. As always, please check with your state and local authorities to determine their regulations concerning evacuation chairs.

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Fully Ducted HVAC System

BKeyes : February 23, 2015 6:00 am : HVAC, Questions and Answers, Smoke Compartment

Q: I have never been able to understand what a fully ducted heating system is and when a damper is not required. Can you explain this matter to me?

A: ‘Fully ducted’ HVAC systems are those in which the air in the HVAC system travels from the air handler to the room diffuser in ducts. The alternative is open return-air plenum ceilings or open supply-air plenum ceilings. Those types involve the open space above the ceiling for the movement of air, and there is no HVAC duct in that area. The return-air plenum ceilings are much more common than supply-air plenum ceilings, and would have an opening at the smoke compartment barrier (above the ceiling) to allow the movement of ventilation air without being inside ducts. What the Life Safety Code is saying is if you have ‘fully ducted’ HVAC system from the air handler all the way to the room diffuser on both the supply and return sides, and it penetrates a smoke compartment barrier, then the LSC does not require that you have a smoke damper in this barrier if the smoke compartments on both sides of the barrier are protected with sprinklers. While this is a huge benefit for facility managers, if you are required to comply with the International Building Code (IBC), they do not allow this exception, and you would have to have smoke dampers at the barrier.

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Force to Open a Fire Door

BKeyes : February 16, 2015 6:00 am : Doors, Fire Doors, Questions and Answers

Q: What is the permitted force to open a fire door? What kind of means can be used to test this onsite?

A: The answer to your question is found in section of the 2000 edition of the Life Safety code, which says: “The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width. Opening forces for interior side-hinged or pivot-swinging doors without closers shall not exceed 5 lbf. These forces shall be applied at the latch stile. Exception #1: The opening force for existing doors in existing buildings shall not exceed 50 lbf applied to the latch side. Exception #2: The opening forces for horizontal sliding doors shall be as provided in Chapters 22 and 23. Exception #3: The opening forces for power-operated doors shall be a provided in” I am not an expert in the available tools to measure lbs. of force, but a good-old fashion fish scale should do the job. Since you asked specifically for fire doors, I looked at NFPA 80 but did not find anything that would contradict the above section.

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Medical Records

BKeyes : February 9, 2015 6:00 am : Medical Records, Questions and Answers

Q: Do medical records in an off-site, business occupancy building have to be fire protected? This was not cited during our survey, but I heard from another hospital that this was cited at their clinics. Our clinics are not protected with automatic sprinklers since it is not a requirement for business occupancies.

A: Many accreditation organizations have specific standards that require the medical records to be protected from fire. This is based on the CMS Condition of Participation standard §482.24(b) which says in the Interpretive Guideline section: “Medical records must be properly stored in secure locations where they are protected from fire, water damage and other threats.” This may be accomplished in various methods, such as placing the medical records in vaults, fire-rated cabinets, or in a room that is fire-rated. Fire protection may be installed in the form of sprinklers or clean agent suppression systems. Please note that the presence of sprinklers and associated piping does not constitute a threat from water damage. The Life Safety Code says hazardous areas in business occupancies include areas used for general storage, which would apply to the storage areas for medical records. Therefore, if the medical records are not stored in a fire-rated cabinet, then you would have to do one of the following:

  1. Enclose the area with 1-hour fire resistive construction, or;
  2. Protect the area with automatic sprinklers.

You indicated that these areas are not protected with automatic sprinklers, so it appears to me that you would have to enclose the medical record storage area with 1-hour fire resistive construction, or install fire-rated cabinets.

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Single Station Battery Powered Smoke Alarms

BKeyes : February 2, 2015 6:00 am : Fire Alarm, Questions and Answers

Q: I am having trouble with locating in the 2000 edition of the Life Safety Code where single station battery powered smoke alarms are being addressed for maintenance. I know they are supposed to be in compliance with the manufacturer’s specifications, but the LSC does not really address this. I would greatly appreciate any input on this you can give me.

A: I would say that section of the 2000 LSC does address this issue, as single-station smoke alarms are considered part of the fire alarm system, even if the device is not connected by wire to the fire alarm control panel. Where the codes and standards are not specific, the authority having jurisdiction (AHJ) has to make an interpretation on how the devices should be maintained.

I would say a single-station smoke alarm must meet all the requirements of NFPA 72, and NFPA 72 (1999 edition), Table 7-3.2, line 15(h) says “All Smoke Detectors” must be tested annually. This would include single-station battery powered smoke alarms as well. Taking this a bit further, looking at Table 10.4.3 of NFPA 72 (2002 edition), line 15(j) says “Single and multiple station smoke alarms” must be tested annually. Whether or not the battery powered single-station smoke alarm is required by the Life Safety Code, section says the mere fact that it is there, the organization must maintain it.

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Portable Heaters

BKeyes : January 26, 2015 6:00 am : Portable Space Heaters, Questions and Answers

Q: As the cold weather starts to creep up on us I’m continuously asked by staff if they can have a personnel heater in their office space (not patient care areas). What kind of heaters are permitted and where?

A: Portable space heaters whose heating element does not exceed 212°F (100°C) are permitted in non-patient care or non-patient treatment areas in healthcare occupancies. These portable heaters would have to be inspected upon purchase and be accounted for in the organization’s equipment utility equipment inventory.

Patient care areas area loosely defined as a smoke compartment which contains patient care or treatment activities. This is in accordance with the 2000 edition of the Life Safety Code, section 19.7.8. You should conduct a risk assessment for the use of portable space heaters even if they are compliant and not used in patient care areas. The presence of a portable heater implies the HVAC system is not performing adequately to meet the requirements of the building. That is a “red flag” for a surveyor who can investigate and determine what corrective action that you have taken, other than placing a portable heater there. Also, the facility’s electrical distribution system may not be able to handle additional heating appliances. Portable heating appliances should only be used as a short-term solution, rather than a final fix.

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BKeyes : January 19, 2015 6:00 am : Curtains, Questions and Answers

Q: Are there any requirements regarding outer hospital windows to have curtains or blinds? Some seem to think that they are required in case of severe weather as curtains are closed to prevent flying glass. I can’t seem to find anything in the Joint Commission or NFPA standards.

A: No, I’ve never seen or heard of any codes or standards that require them. However, without them, the patient may be at risk of flying glass as you suggested, and that risk would need to be assessed and documented. Therefore, a surveyor may expect to see curtains or blinds, and if there are none, the surveyor has the right to inquire if you have conducted a risk assessment. If no risk assessment is available to review, they then have the option to cite you if they feel it is significant. Check with your state and local authorities to determine if they have any regulations that would require them.

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Outpatient Centers and Clinics

BKeyes : January 12, 2015 6:00 am : Ambulatory Care Occupancy, Business Occupancy, Clinics, Questions and Answers

Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business?

A: The Life Safety Code defines different occupancies by the level of care and/or activities that take place in them. A hospital may have many different occupancy classifications, or it may have only one… it’s the organization’s decision. Here is a run-down on the most common occupancy classifications found in healthcare today, and their requirements:

Healthcare Occupancy

An occupancy used for purposes of medical care or other treatment where four or more persons are incapable of self-preservation; and provides sleeping accommodations for those patients.

Ambulatory Care Occupancy

An occupancy used for purposes of medical care or other treatment on an outpatient basis, where four or more persons are incapable of self-preservation, and does not provide sleeping accommodations.

Business Occupancy

An occupancy used for the transaction of business other than mercantile.

So, to answer your question, an outpatient center and clinic could very well be ambulatory care occupancy or it may be business occupancy; it all depends on what level of care and treatment is provided. It is permissible to have more than one occupancy in the same building, provide appropriate fire rated barriers separates the occupancies. A 2-hour fire rated barrier is required to separate a healthcare occupancy from any other occupancy, and a 1-hour fire rated barrier is required to separate different occupancies that are not healthcare.

There are distinct requirements for each occupancy, but the requirements are less for ambulatory care compared to healthcare, and they are even less for business as compared to ambulatory care. So there is an advantage to the organization if the clinic was classified entirely as business occupancy. However, you may not have 4 or more persons incapable of self-preservation in a business occupancy, so make sure you are in synch with that.

Also, CMS considers all ambulatory surgical centers (ASC) to be ambulatory care occupancies regardless of the number of patients incapable of self-preservation, and they also consider end stage renal disease (ESRD) dialysis centers to be ambulatory care occupancies if they are located on a floor other than the level of exit discharge, or if they are contiguous to a high-hazard occupancy. Be aware that in their proposed rule to adopt the 2012 Life Safety Code, CMS has indicated that they intend to classify facilities that have 1 or more patients incapable of self-preservation as an ambulatory care occupancy. Whether they will adopt that as a final rule is unclear, but you should be aware of the possibility.


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Main Lobby Locked Doors

BKeyes : January 5, 2015 6:00 am : Door Locks, Questions and Answers

Q: We have a separate building on our campus that includes our behavioral health unit, along with related offices and meeting rooms for the support staff. The behavioral health unit is segregated from the offices and meeting rooms and patients would never be in these offices or meeting rooms. There are secured doors preventing the patients from entering the main lobby area. The path of egress for the offices and meeting rooms is through the main lobby. This is a secured facility, so much so that the egress doors from the main lobby of the facility are locked with the use of electronic mag-locks. The only way the doors will release is through one of the three methods: Swipe an employee badge to release the mag-locks; a person in the cubicle to push a button to release the mag-locks; or when the fire alarm system is activated. Are we in compliance with the Life Safety Code with our mag-lock doors for egress concerns in our lobby?

A: It does not appear that you are. As you state, the behavioral health unit is segregated from the rest of the facility by secured doors and the path of egress for the offices and meeting rooms is through the main lobby, so locking those egress doors would not be permitted. Section of the 2000 Life Safety Code does not allow doors in the path of egress to be locked. The exceptions to allow delayed egress locks and access-control locks, but in this case, it does not appear that you could use clinical needs locks on doors in the path of egress that are shared by the offices and meeting rooms.

Typically, authorities having jurisdiction do not allow clinical needs locks on more than one set of doors in the path of egress for behavioral health units. You could install delayed egress locks on the main lobby egress doors as long as the entire facility is either sprinklered or protected with detectors. A card-swipe reader could be installed to deactivate the delayed egress function so people could exit without activating the delayed egress alarm. Or, you could install access-control locks on the doors, although they really are not locks for people egressing. Follow the requirements for delayed egress and access-control locks found in sections and of the 2000 Life Safety Code.

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Electric Blankets

BKeyes : December 29, 2014 6:00 am : Electric Blankets, LSC, Questions and Answers

Q: Are electric blankets permitted to be used by patients in long term care facilities? I cannot find any references to electric blankets in any NFPA codes or standard.

A: Technically, you are correct: There is no specific NFPA code or standard that prohibits the use of electric blankets in healthcare. However, there are significant risks to the patient and staff if you do use them, and before you allow the use of electric blankets, you need to conduct a risk assessment. At a minimum, the risk assessment needs to address to following issues:

  • Could the heat generated from the blanket cause epidermal damage to the patient?
  • Could the electrical portion of the blanket become damaged due to abuse or spillage, and cause harm to the patient?
  • Could the electrical cord become damaged (frayed) by other wheeled equipment rolling on top of the cord?
  • Could the electrical cord become a tripping hazard to the patient or staff?
  • Could the patient accidentally set the temperature control too high and cause damage to their body?
  • How will the electric blankets be maintained and inspected, and who will perform this task?

Another issue that you need to address… Why do you want to use electric blankets? Is the patient room too cool for the patient’s comfort level? There are minimum temperature levels that the organization must meet. If a surveyor observes the use of electric blankets, they have the right to investigate to determine if you did a risk assessment that addresses all of the above issues, and more. They have the right to review your risk assessment and they have the right to disagree with the conclusions in the risk assessment. In other words, no matter how you justify their use, a surveyor can still cite you for an unsafe environment for using electric blankets if they want. My advice: Stay away from electric blankets, and do not allow them. They become more problems than they are worth. Check with your state and local authorities to determine if they have regulations that would prohibit their use.

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