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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Storage in Stairwells

BKeyes : March 23, 2015 6:00 am : Questions and Answers, Stairwells, Storage

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 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.

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Oxygen Storage

BKeyes : March 16, 2015 6:00 am : Oxygen Cylinders, Questions and Answers

Q: A local fire inspector approved our outdoor storage shed for full oxygen cylinders. Now a surveyor says it is not compliant because the shed is made of wood, and the accumulative total of oxygen stored exceeds 20,000 cubic feet and must meet NFPA 50 for bulk oxygen storage. Who is correct?

A: Sometimes it doesn’t matter who is correct, but more importantly what the standards and regulations require. First, I would disagree that oxygen stored in cylinders in quantities exceeding 20,000 cubic feet requires compliance with NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites. NFPA 50 is for a bulk oxygen system which is defined as an assembly of equipment, including cylinders, pressure regulators, safety devices, vaporizers, manifold, and interconnecting piping. It does not appear that you have that assembly; just the full cylinders of oxygen. However, oxygen stored inside the building in quantities exceeding 3,000 cubic feet must be stored in 1-hour fire rated enclosures that are constructed with non-combustible materials, according to NFPA 99 (1999 edition), section 4- But a storage shed outdoors that is at least 10 feet from the healthcare facility is not required to be fire-rated.  Keep in mind that just because a local AHJ approved this arrangement, that does not mean it will be (or must be) acceptable to all AHJs. Each authority has the right to interpret the situation to his or her own understanding, and you need to comply with the most restrictive..

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Engine Block Heaters

BKeyes : March 9, 2015 6:00 am : Generators, Questions and Answers

Q: A consultant told me that emergency generator rooms are required to be maintained at least 40 degrees F. Do I need to maintain that temperature if I have block heaters on the engine?

A: Yes, you do need to maintain at least 40° F ambient room temperature especially when you have engine water jacket heaters that maintains the temperature of the engine water at a minimum of 90° F. Section 5-6.7 of NFPA 110 (1999 edition) clearly states that the emergency power supply (EPS) room temperature must be at least 70° F unless you have water jacket heaters that maintains the water temperature of the engine at 90°F; then you are allowed to lower the EPS room temperature to 40°F. So, this would mean the room needs to be maintained at a minimum of 40°F.

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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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