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 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. NFPA codes and standards do not prevent storage in electrical rooms as long as it does not obstruct access to the electrical equipment. 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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Walk-In Coolers

BKeyes : July 14, 2014 12:30 pm : Questions and Answers, Sprinklers

Q: During a recent survey, the life safety surveyor wrote a finding that my refrigerator and freezer walk-in coolers are not in compliance with the building having full sprinkler coverage. The walk-In coolers were installed prior to 1982, and two units do have sprinklers, but three do not. The state fire marshal reviewed us and said we’re okay. What do you think?

 A: It appears to me that it is an issue of whether you’re taking credit for the building being fully sprinklered. If you have a certain Construction Type (see Table of the 2000 Life Safety Code) that requires sprinklers; or you have equivalencies or waivers that requires the building being fully sprinklered; or if you have performed any renovation or alterations in the walk-in coolers since March 11, 2003; or if you have delayed egress locks located anywhere in the building, then yes, the walk-in coolers must be protected with sprinklers.

But if none of that has occurred and there is no apparent requirement for the smoke compartment where the walk-in coolers are located (or the entire building) is required to be sprinklered, then you should be okay. Keep in mind that it doesn’t matter that one of your authorities having jurisdiction (AHJ) approved this installation. If another AHJ disagrees, it is their privilege to enforce the codes and standards as they understand them; they are not bound by what the state fire marshal says. Installing dry-head type sprinklers in freezing environments is not that difficult, nor costly. I would consider upgrading and installing dry-heads.

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Main Drain Tests

BKeyes : July 7, 2014 5:00 am : Main Drain, Questions and Answers, Sprinklers, Testing

Q: Where are main drain tests required to be done? This is a large medical facility with nine story towers. Several fire mains feed the various campus buildings. Is the main drain test required to be done only where the fire mains supply the system risers, or does it also need to be done on each floor at the riser as well? Would you please supply your rationale for your answer?

A: According to the 2000 edition of the Life Safety Code, main drain tests are regulated by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. Section 1-5 of NFPA 25 defines a main drain as the primary drain connection on the system riser and also is utilized as a flow test connection. Section 9-2.6 requires a main drain test must be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply and control valves. NFPA 25 does not adequately define what a ‘system riser’ is, so we turn to the Handbook for NFPA 13 Standard for the Installation of Sprinkler Systems which identifies a ‘system riser’ as the above ground horizontal or vertical pipe between the water supply and the mains (cross or feed) that contains a control valve (either directly or within its supply pipe) and a waterflow alarm device. A system riser is more than just a subset of the term riser, which is broadly defined as any vertical piping within the sprinkler system. As indicated by the definition, a system riser can be any aboveground pipe in a vertical or horizontal orientation installed between the water supply and the system mains that contain specific devices. By this definition it appears one could loosely define the locations of a main drain test to be conducted wherever there is a control valve and waterflow alarm switch. In a large multi-story facility such as yours, that would most likely require a main drain test at least on every floor, possibly more. The Accreditation Organizations (AOs, such as Joint Commission, HFAP and DNV) typically do not seek this level of compliance. Most of the AOs only expect main drain tests to be conducted at the base of the risers of the sprinkler system, not at every floor. However, depending on your state agency surveyors who conduct CMS validation surveys, it is very reasonable and possible that they will expect the main drain tests to be conducted at every floor. To continue with additional information, the purpose of a main drain test is covered in the Annex section A-9-2.6, which says main drain tests are used to determine whether there is a major reduction in waterflow to the system, such as might be caused by a major obstruction, a dropped gate, a valve that is almost fully closed, or a check valve clapper stuck to the valve seat. A large drop in the full flow pressure of the main drain (as compared to a previous test) normally is indicative of a dangerously reduced water supply caused by a valve in an almost fully closed position or other type of severe obstruction. After closing the drain, a slow return to normal static pressure is confirmation of the suspicion of a major obstruction in the waterway and should be considered sufficient reason to determine the cause of the variation. A satisfactory drain test (i.e., one that reflects the results of previous tests) does not necessarily indicate an unobstructed passage, nor does it prove that all valves in the upstream flow of water are fully opened. The performance of drain tests is not a substitute for a valve check on 100 percent of the fire protection valving. The main drain test is conducted in the following manner:

  1. Record the pressure indicated by the supply water gauge [Static Pressure]
  2. Close the alarm control valve on alarm valves
  3. Fully open the main drain valve
  4. After the flow has stabilized, record the residual (flowing) pressure indicated by the water supply gauge
  5. Close the main drain valve slowly
  6. Record the time taken for the supply water pressure to return to the original static (nonflowing) pressure
  7. Open the alarm control valve
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Oxygen Storage in Business Occupancies

BKeyes : June 30, 2014 5:00 am : Business Occupancy, Oxygen Cylinders, Questions and Answers, Storage

Q: Our hospital has an offsite building for our cardiac rehab, physical therapy, and pulmonary rehab programs. It also houses our business office and some physician offices. The building is classified as a Business Occupancy. What are the requirements for storing oxygen cylinders in a non-rated storage room?

A: A business occupancy that provides services for cardiac rehab, physical therapy, and pulmonary rehab programs is considered to be a health care facility. Assuming you are either Joint Commission accredited, or receive federal reimbursement monies for Medicare or Medicaid services, you are required to comply with NFPA 99 (1999 edition) Health Care Facilities standard. According to section 1-2, NFPA 99 (1999 edition) applies to all health care facilities, and section 2-1 defines a health care facility where medical care is provided. Chapter 13 in NFPA 99 is the chapter for “other” health care facilities which are not hospitals, nursing homes and limited care facilities. Section 13-3.8 requires all gas equipment to conform to chapter 8. Section 8-3.1.11 lists the storage requirements for nonflammable gases greater than 3,000 cubic feet and quantities less than 3,000 cubic feet which are similar (but not the same) as those requirements for hospitals. For storage of quantities of nonflammable gas greater than 3,000 cubic feet, the requirements are the same as those for hospitals, which are found in section 4- of NFPA 99. However, for quantities less than 3,000 cubic feet, there is a difference in storing nonflammable gas in quantities of 300 cubic feet or less. Hospitals have the advantage of having a special dispensation granted by The Centers for Medicare & Medicaid Services (CMS), in the form of S&C Letter 07-10, published January 12, 2007. In this letter, CMS allows hospitals (but not medical offices or clinics) the advantage of following the 2005 edition of NFPA 99, which permits quantities up to 300 cubic feet of nonflammable gas to not be stored in any special rooms or areas. This exception for ‘up to 300 cubic feet’ is not found in the 1999 edition of NFPA 99. Therefore, your business occupancy must store all nonflammable gas cylinders in quantities from 0 to 3,000 cubic feet in accordance with section 8-, which requires a specially designated room which has a door capable of being locked, and all oxidizing gases in this room must be separated from combustibles by 20 feet (or 5 feet if the room is protected with automatic sprinklers), or the oxidizing gases are to be stored in a flammable cabinet with a fire rating of at least 30 minutes.

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