Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised as to whether or not this Endo Unit needs a firewall separation. Where does the Life Safety Code discuss the requirements for Endo Units? What options do we have if we do not have the requisite fire barriers?
A: You won’t find the phrase Ambulatory Endoscopy Unit (or Endo unit) in the Life Safety Code, because the code deals with different occupancy designations, not different uses within those specific occupancies. You didn’t say, but I’m guessing the Endo Unit is classified as an ambulatory healthcare occupancy, as I suspect the patient is sedated and incapable of self-preservation. Another assumption is made that this unit is an outpatient unit, thereby supporting the thought it is an ambulatory healthcare occupancy. It appears you have an outpatient endoscopy unit that serves 4 or more patients that are incapable of self-preservation. That makes it an ambulatory healthcare occupancy designation. Ambulatory healthcare occupancies are required to be subdivided into at least 2 separate smoke compartments with a 1-hour fire rated barrier. The 1-hour fire rated barrier must extend from the floor to the floor or roof slab above, and openings (i.e. doors) must be at least 1¾ inch thick, solid-bonded wood core and be self-closing. Exceptions to the subdivision into two smoke compartments are if the ambulatory healthcare occupancy is less than 5,000 square feet and fully protected with smoke detectors; or if the ambulatory healthcare occupancy is less than 10,000 square feet and protected throughout by automatic sprinklers. Ambulatory healthcare occupancies must be separated from other occupancies (i.e. business occupancies) by a 1-hour fire rated barrier that extends from the floor to the floor or roof slab above. Doors in this barrier must be ¾ hour fire rated, self-closing, and positive latching. There are other fire barriers that could be part of the Endo Unit, such as fire barriers separating hazardous areas from occupied areas, and barriers separating exit enclosures from occupied areas.
Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.
A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section 184.108.40.206 of the 2000 edition of the LSC requires compliance with section 9.6. Section 220.127.116.11 requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.
Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors. Is this permitted?
A: Actually, dead-bolt locks with a thumb-turn on the inside would be permitted on restroom doors, provided the doors to the restrooms are not positive latching. Restroom doors are not required to latch, therefore the larger restrooms rarely have positive latching hardware. Section 18.104.22.168.4 of the 2000 Life Safety Code© says doors in the means of egress are not permitted to have more than one action to operate the door. If the door had a latch-set and a dead-bolt lock then that would not be permitted since it takes two actions to operate the door (unlock the dead-bolt and turn the latch-set). But since the bathroom door does not require a latch-set, then a dead-bolt lock that can be unlocked from the egress side would be permitted.
Q: There appears to be many different ways a hazardous room is maintained: If it is sprinklered, does it have to be 1-hour rated? If it is existing construction, does it have to be sprinklered? What rules apply if there is a lay-in ceiling? What are the basic requirements for a hazardous room?
A: A hazardous room in a hospital includes a room larger than 50 square feet used for the storage of combustible supplies. How many combustible supplies are needed to make it a hazardous room? Not much, but it is a judgment call by the surveyor. If the room is designated ‘existing conditions’ (created prior to March 11, 2003) then there are two options on how it has to be maintained:
- If there are no sprinklers in the room, then the walls need to be one-hour fire rated and extend from the floor to the deck above, and the door to the room needs to be ¾-hour fire rated, self-closing and positive latching.
- If there are sprinklers in the room, then the walls only have to be smoke resistant, and extend from the floor to the ceiling, as long as the ceiling also resists the passage of smoke. The door to the room may be non-rated, but must be self-closing and positive latching.
If the room is designated ‘new conditions’ (created on or after March 11, 2003) then there is only one option for the room: The room must be sprinklered, and the walls must be one-hour fire rated and extend from the floor to the deck above, and the door must be ¾-hour fire rated, self-closing and positive latching. Also, if the supply room was originally constructed to ‘new conditions’, but before March 11, 2003, it cannot be down-graded to ‘existing conditions’, but must be maintained as ‘new conditions’. Any ceiling that has sprinklers or smoke detectors must be maintained to resist the passage of smoke. This is because smoke and heat will migrate above the ceiling if there are cracks, voids or missing tiles, and the detectors and sprinklers may not activate properly.
Q: Why does the escutcheon plate on a sprinkler need to be required when the ceiling is not rated and the corridor walls extend to the deck? If a basement can have sprinklers and no ceilings why are the sprinklers on the floors above required to have these plates when the ceiling is not rated?
A: The escutcheon plates are required on sprinkler heads which are mounted in ceilings to fill the gap between the head and the ceiling. Many times a sprinkler installer will use a hole saw larger than necessary to make the opening for a sprinkler head. Any gap over 1/8 inch must be sealed, so the escutcheon plate serves as a gap sealer and as an attractive trim plate. Without sealing this gap, heat and smoke will rise up above the ceiling and activation of the sprinkler head (and smoke detector, if so equipped) will be delayed. They are very important, and an easy deficiency for a surveyor to find.
Q: We have an old dark room that was converted into an air handler room. What’s the requirement for a door to this room?
A: It all depends where this former dark room is located. First of all, what is the occupancy designation for the building or area where this air handler is located? If it is business occupancy and the air handler does not include a gas-fired furnace, then it is very likely that no door is actually required to this room. However, if the building or area is designated as a healthcare occupancy, then it depends whether or not the room opens up onto a corridor. In healthcare occupancies, all corridors must be separated by walls and doors from all other areas. Now, there are some exceptions to this requirement, but an air handler room will not qualify for any of these exceptions. If the former dark room/air handler room does not open onto a corridor, but opens onto another room, then it is likely that a door would not be required, provided the air handler room does not contain anything to make it a hazardous room, such as fuel-fired equipment, or storage of combustibles of flammables. If the air handler room somehow qualifies as a hazardous room (see sections 22.214.171.124 of the 2000 edition of the LSC) then the room will need to be protected with automatic sprinklers, and the walls will be required to be 1-hour fire rated, and the doors will be required to be ¾-hour rated, self-closing and positive latching. All of that would be required even if the room does not open onto the corridor. If the air handler room is not considered to be a hazardous area, and the room opens onto a corridor, then the door is only required to resist the passage of smoke, or if the corridor is located in a non-sprinklered smoke compartment then a substantial door such as 1¾ inch thick, solid-bonded, wood-core door, or be of such construction to resist fire for at least 20 minutes. Notice it did not say the door had to be 20-minute fire rated. That is a common misunderstanding.
Q: The Joint Commission standard for weekly testing of the fire pump only requires us to record the test date of the inspection. We were cited for not recording the suction and discharge pressures. Is this a requirement?
A: Yes, recording the suction and discharge pressures, along with the amount of time required to start the weekly test (by lowering the water pressure) are required documentation for each weekly fire pump test. Even though these requirements are not specifically identified in the EC standards, they are identified in the NFPA 25 (1998 edition) which is referenced by the Joint Commission standards.
Get a copy and read the NFPA 25 (1998 edition) as it has a lot of testing requirements of the sprinkler system which are not identified in the Joint Commission standards, but are required.
Q: Can a sterile supply corridor that feeds the back of Surgical OR’s have a corridor of less than 8′ if the patient access is from the front of the OR? This front patient access provides the required exit access for inpatients to two exits.
A: Maybe. It all depends on whether or not the sterile supply corridor that feeds the back of the Surgical ORs could in any way be considered a path of egress for the inpatients receiving treatment in the OR. Is this path marked with ‘Exit’ signs? That is usually a dead-giveaway since it marks the path of egress through the sterile corridor as a means of egress for the occupants of the ORs. But, that is not the only indication. Even if the path is not marked with an ‘Exit’ sign, it could still be considered a required path of egress from the ORs. You mentioned that the front patient access provides the required exit access for inpatients to two exits. If that is true (and I have no reason to doubt you), then that may possibly make the sterile corridor to NOT be a required means of egress, and then it would not have to comply with section 126.96.36.199 (2000 edition) for 8 foot corridor widths for new construction. For existing construction, section 188.8.131.52 says 4 foot width is required, but if the corridor is already constructed to a width greater than 4 feet, then you must maintain to corridor to 8 feet of width if you make any alterations or renovations. Parking equipment in a corridor would be considered an alteration.
Before you make any changes to your facility, you need to discuss this issue with the architect who designed the egress routes from the ORs, if that person is still available. It is important that any change in function be reviewed by the proper individuals, which may also include your local or state authorities.
Q: Does NFPA 72-1999 edition specifically state that annual fire system inspection documentation include an itemized inventory of each system device as passed or fail? Does a report stating that (i.e. 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed) satisfy the requirement?
A: Specifically? I would say it does, but if you want to see the words: “Every annual fire alarm system documentation must include an itemized inventory of each device as passed or failed” … you will not find those words in NFPA 72, 1999 edition.
What it does say is this: Section 7-5.2.2 requires documentation of the fire alarm test to comply with all the applicable information found in Figure 7-5.2.2. On page 3 (of 4) of figure 7-5.2.2, the documentation required by NFPA 72 includes:
- Location of the device
- Serial number of device
- Device type
- Visual check
- Functional test
- Factory setting
- Measured setting
- Pass of Fail
In addition to that requirement for annual testing, section 7-184.108.40.206 requires all components affected by a change to the system to be 100% tested. This is in regards to a change to the system, like the addition of an initiating device all the devices on the circuit for the new device must be tested.
So, I would say NFPA 72 (1999 edition) does specifically require the documentation of whether or not each device passed or failed its test. Also, it is now an interpretation by many of the national AHJs for healthcare organizations that each test report has this information documented. The logic for this requirement is solid; how does the facility manager know that the fire alarm testing technician actually tested each and every device in their building, if you do not know where they are, and document the results of each test?
A report stating that 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed their inspection would NOT satisfy the reporting requirement, as I understand it. There needs to be an inventory list showing each device location and whether or not it passed or failed its test.
It makes good sense.
Q: My question is in regards to illumination of the means of egress, specifically, illumination provided outside the building to a public way. I was told by a consultant that the only means of egress requiring illumination are the “designated” egress paths. We were cited for no illumination for the exit path to the public way, and it was not marked by Exit signs. Is emergency lighting required for illumination outside the building?
A: I agree that only the portions that are designated as the path of egress on the exit discharge are required to be illuminated. The exit discharge becomes a ‘designated path of egress’ when the exit from the building discharges onto the walkway outside the building. I have seen many paths outside the building that are confusing and unsure which path to follow to the public way. In those situations, outdoor ‘Exit’ signs need to mark the path of egress, even though it is outside. Section 220.127.116.11 of the 2000 edition of the LSC clearly states that the exit discharge only includes ‘designated’ stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. If you were cited for not having illumination on an outside sidewalk that lead to a dumpster or other such area that does not serve as a means of egress, then I would say that was an incorrect finding and should be appealed. However, if the finding was for lack of illumination for an outside walkway that does serve as a means of egress from an exit of the building, then that would seem to be a correct finding.
Your question: “Is emergency lighting required for illumination outside the building?” depends on what type of building it is. If the building is healthcare occupancy or ambulatory care occupancy, then yes, emergency lighting is required. According to section 18.104.22.168 (and 22.214.171.124 for ambulatory care) of the 2000 edition of the LSC, emergency lighting must be provided according to section 7.9. Section 7.9.1 says the exit discharge is included in this emergency lighting requirement. You are permitted to utilize battery back-up lighting (as long as it meets the requirements), or generator power for the emergency lighting. Most hospitals use generator power for their emergency lighting since they already have the generator. Battery back-up emergency lights take much more maintenance in monthly and annual testing.
If the building is a business occupancy, then section 126.96.36.199 states emergency lighting is only required in a building that has two or more stories above the level of exit discharge; in a building that is subject to an occupant load of 100 or more persons, above or below the level of exit discharge; or in a building that is subject to 1000 or more total occupants.