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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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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NFPA 110

BKeyes : December 22, 2014 6:00 am : Generators, LSC, Questions and Answers

Q: Which edition of NFPA 110 are we expected to follow? I read that we’re expected to comply with the 1999 edition, the 2005 edition and now the 2010 edition. Which is correct?

A: The 2000 Life Safety Code references the 1999 edition of NFPA 110. The 1999 edition of NFPA 99 also references the 1999 edition of NFPA 110. Since CMS is still on the 2000 LSC, then the 1999 edition of NFPA 110 governs. However, Joint Commission standards references the 2005 edition of NFPA 110 for the 3-year, 4-hour load test, because this load test is not required in the 1999 edition of NFPA 110. Apparently, the accreditor feels the 3-year, 4-hour load test has value and wants their clients to comply with the load test. Joint Commission can do this since the addition of the 3-year, 4-hour load test is not in difference to the 1999 edition of NFPA 110; it is just an addition, so CMS allows it. HFAP and DNV have written similar standards that reference the 3-year, 4-hour load test found in the 2005 edition of NFPA 110.

But last year, CMS issued categorical waivers in their S&C memo 13-58 that will permit hospitals, critical access hospitals, long-term care facilities, ambulatory surgical centers, and inpatient hospices to use the provisions found in the 2010 edition of NFPA 110 immediately without waiting for the new LSC to be adopted. The 2010 edition of NFPA 110 will allow you to reduce the annual load test from 2-hours down to 90-minutes when the monthly load tests do not meet the 30% load capacity of the nameplate value. All of the accreditation organizations recognize and support this CMS position, but be aware that some state agencies do not.

The 2010 edition of the NFPA 110 is referenced by the 2012 edition of the Life Safety Code and will become the rule once the 2012 LSC is adopted. So, for the most part, the 1999 edition of NFPA 110 is the one to use, unless you’re Joint Commission or HFAP accredited, then you must also follow the 2005 edition of NFPA 110 for the 3-year, 4-hour load test. Also, you have the option to use the 2010 edition of NFPA 110 for the annual load test through the use of the CMS categorical waivers. Sounds confusing, but everyone will be on the 2010 edition of NFPA 110 once CMS adopts the 2012 edition of the LSC.

To download your own copy of the CMS S&C memos, go to:

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Hotel Room Evacuation During Fire Alarm

BKeyes : December 15, 2014 6:00 am : Evacuation, Fire Alarm, Hotel, Questions and Answers

Q: We own and operate a hotel on our hospital campus and are revamping our fire plan. Are we required to have all the hotel guests evacuate their rooms upon activation of the fire alarm? Also, we have a marked exit into a courtyard with a 6 foot high fence around it. The gate in the fence then leads to the public way. Must this gate remain unlocked for egress to the public way or can you have an assembly point inside the courtyard?

A: Section of the 2000 Life Safety Code states the fire safety information that is posted in the hotel room is sufficient for the guests to make their own decision as to whether or not they evacuate their rooms and/or building during a fire alarm. In an obvious fire alarm testing situation, I can see that is a legitimate situation where evacuation is not necessary. But other than that, appears to leave that decision up to the guests. However, it would seem logical to want everyone to evacuate whenever a fire alarm is activated.

In regards to the fence surrounding the courtyard, that presents other problems. Since you say it is a marked exit, then the exit discharge is required to extend to the public way. The public way is defined as a street, alley, or other similar parcel of land essentially open to the outside air, which is dedicated or otherwise permanently appropriated to the public for public use. A fenced-in area that has a locked gate does not seem to meet this definition of public way. In my opinion, the gate would have to remain unlocked. The gate would also have to be an obvious point of exit, or it would have to be marked with an illuminated exit sign, and the path of egress to the public way would need to be illuminated with emergency power. Even if you got a local authority having jurisdiction (AHJ) to allow the locked gate in the courtyard, that does not mean other AHJs would see it the same way.

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Ambulatory Surgical Center Waiting Rooms

BKeyes : December 8, 2014 6:00 am : Ambulatory Care Occupancy, Questions and Answers, Waiting Areas

Q: Can an Ambulatory Surgical Center (ASC) have a waiting room that is shared with another physician’s practice that is not associated with the ASC, but is located in the same building?

A: No, it cannot. Section 20/ of the 2000 Life Safety Code states the ambulatory health care occupancy must be separated from other tenants and occupancies with 1-hour fire-rated barriers. The ASC is located in an ambulatory health care occupancy and the physician’s practice is another tenant and is presumably located in a business occupancy. This separation between tenants and occupancies includes waiting rooms and areas.

In addition, the Centers for Medicare & Medicaid Services (CMS) S&C memo 10-20-ASC dated May 21, 2010, specifically states ASC must have waiting areas that are separate from other tenants and occupancies by 1-hour fire-rated barriers. The logic expressed in the CMS memo is patients occupying an ASC waiting area for the purpose of receiving treatment may not be capable of evacuating without assistance; therefore the ASC waiting area needs to comply with all of the fire safety requirements afforded to ambulatory health care occupancies. The CMS memo does say existing ASC that are cited to be non-compliant in regards to the waiting area requirements may submit waiver requests, but waivers will not be allowed for ASC classified as new construction facilities (designed or constructed prior to March 11, 2003). Please be advised that the CMS categorical waivers do not apply to this situation.

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Christmas Decorations

BKeyes : December 4, 2014 6:00 pm : Decorations, Questions and Answers

I have received quite a few questions concerning combustible decorations this season and thought I would run this special Q&A today…


Fire Retardant Spray Web 2

Q: My administration is decorating our hospital lobby and has purchased some decorations that do not have a flame retardant rating or certificate. I have informed them that they are in violation of the Life Safety Code. They have found product that can be sprayed on the decorations to make them meet code. I am not convinced that this meets the intent of the code. They claim it meets the requirements of NFPA 701. Have you heard of this product and if applied will I be compliant with code?

A: Yes, I am familiar with this product, and I do not have any problems with the safety of its proper use. However, how are you going to prove to a surveyor that the decorations have been treated with the flame retardant? Once it is applied, it dries clear and there is no physical evidence that the product has been applied.

The typical surveyor wants proof that the flame retardant has been applied. Work orders identifying the decoration in detail, along with its location and the date of application, may be acceptable. A photograph of the product being applied is even more effective, but you would have to photograph every piece of decoration that it is applied to. Documenting (writing) on the decoration the date of the last application and the work order number may also be effective. The problem is it becomes a nightmare trying to document every decoration. And what about the decorations that may have been missed? How can you tell if it was treated or not?

Can you meet the intent of the Life Safety Code with this flame retardant spray-on solution? Yes… but it is not easy to document.

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Door Hooks

BKeyes : December 1, 2014 6:00 am : Doors, Questions and Answers

Q: With regards to installing a hook on a fire rated door, would an adhesive backed hook be considered a modification to the door?

A: As far as I can tell, NFPA 80 and NFPA 101 (LSC) does not address this specific issue. One could argue that the hook can be applied with the same adhesive that is permitted in section 1-3.5 in NFPA 80 (1999 edition) which discusses signs attached to fire doors, especially since the area of the hook would be presumably less than what is usually provided for signs. The difference is that when you hang a coat on the hook, you now have an additional fuel load.  So even though the hook is not penetrating the door or affecting the integrity of the door itself, the door might not perform the same in a fire because of the unexpected additional fuel load.

It is not unusual for a NFPA code or standard to fail to address all possible considerations. Actually, it is quite common. When the code or standard fails to address a specific issue, then it is up to the authority having jurisdiction (AHJ) to make an interpretation on that issue. If the AHJ has indeed made such an interpretation, then that’s your answer. But, to my recollection, I am not aware if CMS or any accreditation organization has made a written (formal) interpretation on whether or not hooks can be mounted to fire rated doors with adhesive. You could ask them, but then whatever answer they give you would only apply to their inspections. In other words, just because the accreditation organization says it is okay to do something that does not mean it is okay with CMS, or any of your other AHJs.

When an AHJ has not provided a clear interpretation on an issue, then the organization may conduct a risk assessment, considering the pros and cons of such action (i.e. using the adhesive hooks on fire rated doors). However, just because you conducted a successful risk assessment does not mean the AHJ has to accept your conclusions. If they disagree with your findings, they can cite you for safety related violations even though there is no specific standard prohibiting the hooks on the doors. My advice is don’t do it. It’s not worth the hassle of defending yourself to an over-zealous surveyor who just doesn’t agree with your conclusions. Also, once you let one hook on the door, it will invite many others, and now it becomes a nightmare to monitor and enforce.

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