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Signs on Doors to Rooms Used for Storage of Cylinders of Oxygen

BKeyes : February 22, 2017 12:00 am : Oxygen Cylinders, Questions and Answers, Signs, Storage

Q: If there are oxygen tanks stored on a unit that does not exceed the 12 tank threshold, does the door to the storage area where the tanks are stored need to have a sign indicating that tanks are stored within?

A: Yes… the door to a storage room containing oxidizing gases regardless of the quantity of gas stored (i.e. less than 300 cubic feet, or 12 E cylinders of oxygen) must have a precautionary sign, readable from a distance of 5 feet, and must be displayed on each door or gate of the storage room or enclosure. The sign must include the following wording as a minimum:




This requirement is found in NFPA 99-2012, sections and, and applies to all healthcare organizations, new and existing. On this particular section of NFPA 99, there is no exception in having this sign if the facility is posted as being a NO SMOKING facility. That applies to other sign requirements where oxygen therapy is in use on a patient, but that exception does not apply to a storage room containing oxidizing gases.

So, as you are conducting your routine building tour, please keep an eye out for the required signs on any door where oxidizing gases are stored.

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Medical Office Building Occupancy Classification

BKeyes : February 21, 2017 12:00 am : Blog, Occupancies, Questions and Answers

Q: A Hospital System that I do work for is in the process of constructing a Medical Office Building off-campus (over 250 yards from the Hospital). The building will house exam rooms, treatment rooms, and procedure rooms for a Provider Based Physician. In the past, we would consider this a Business Occupancy. We have heard that for an off-campus Provider Based Physician we will need to use a more restrictive code. Is this true, and if so, do we use the Healthcare Occupancy or the Ambulatory Healthcare Occupancy for this building type?

A: On June 30, 2016, CMS issued a correction to their Final Rule to adopt the 2012 Life Safety Code. This correction specifies that all ‘hospital outpatient surgical departments’ have to meet Ambulatory Health Care Occupancy (AHCO) requirements regardless how many outpatients are incapable of taking action for self-preservation.

One of the confusing issues in this CMS communication is the phrase ‘hospital outpatient surgical departments’. Initially, most people would think that phrase describes Ambulatory Surgical Centers (ASC) because the word ‘surgical’ is used. But in follow-up communications with CMS, they described this phrase ‘hospital outpatient surgical departments’ to mean any service that qualifies under the definition of AHCO.

Section of the 2012 LSC describes AHCO as:

  • Outpatient treatment for patients that renders the patient incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Emergency or urgent care for patients who, due to the nature of the injury or illness are incapable of taking action for self-preservation under emergency conditions without the assistance of others.

This description is beyond just ASC; it includes all sorts of procedures, such as:

  • Endoscopy
  • Bronchoscopy
  • Colonoscopy
  • MRI / CT Scan
  • Cath Labs
  • Some therapy units, such as Aqua-Therapy
  • Etc.

Since the 2012 LSC says four or more outpatients in order to qualify for AHCO, CMS felt the need to issue a correction to their Final Rule to say now it is 1 or more outpatients to qualify as an AHCO.

What this means, if the physician’s office was doing a minor procedure and it only involves one outpatient at a time, and that minor procedure qualifies under as being an AHCO, then the building (or story) must meet AHCO occupancy requirements even if there is only one outpatient involved in the entire facility. Under the 2012 LSC definition, that physician office would qualify as being a Business Occupancy, but with the new CMS correction to the Final Rule, it now must be AHCO.

And this is retroactive to existing conditions.

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Endoscopy Ventilation Requirements

BKeyes : February 20, 2017 12:00 am : Endoscopy, Questions and Answers, Ventilation

Q: What are the ventilation requirements for the scope room in endoscopy? This is the room where the clean instrumentation is kept.

A: It all depends if you’re talking about existing conditions or new construction. If you’re talking about existing conditions, then you need to find out what regulations and standards were in effect when the unit was designed. Once the room is constructed to a particular set of ventilation requirements, then they stay that way until you renovate the unit. In other words, you do not have to meet new construction requirements.

If you are talking about new construction requirements, then the 2014 FGI guidelines have the following requirements:


  Air Pressure Relationship Surrounding Areas Minimum Outdoor ACH Minimum Total ACH Room Air Exhausted to Outdoors? Room Unit Recirculation? Relative Humidity Design Temperature Design
Clean Workroom Positive 2 4 NR No Max 60 72-78
Sterile Storage Positive 2 4 NR NR Max 60 72-78
Endoscopy Procedure Room NR 2 6 NR No 20-60 68-73

NR = No Requirement

ACH = Air Changes Per Hour

These are only guidelines. You need to find out if your state or local authorities have more restrictive requirements.

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Evacuation Chairs Stored in Stairwells

BKeyes : February 17, 2017 12:00 am : Evacuation, Questions and Answers, Stairwells

Q: I understand it would be best to not place something affixed to the walls of the exit stairwell that protrudes in to the path of egress, which in turn, may interfere with egress. But we have two sets of stairwells, that in the middle of each floor, is a landing which has about a 7’ alcove going away from the path of egress on the landing, and the path of egress does not use this alcove.

So my question is, can we store evacuation chairs in these alcoves? I can understand affixing these items in the path of egress within the stairwell, can interfere with egress, but these alcoves are clearly out of the way and not in the path of egress.

A: To answer your question, let’s first take a look at section of the 2012 Life Safety Code (LSC), which says there shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

What this section appears to say is you may store your evacuation chairs in the alcove of your stairwell since the alcove is not part of the egress, and the stored evacuation chairs would not interfere with egress. But there are surveyors and AHJs that take a much more severe look at this issue, based on section of the 2012 LSC, which says an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

Some AHJs take a very strong stand against anything being stored in the stairwells, but the Annex section of explains this requirement a bit further, and says the provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be ‘sterile’ with respect to fire safety hazards.

The above reference is in the Annex section of the LSC which means it is not part of the enforceable section of the code, but it is an explanatory section to help authorities understand the intent of the technical committee who wrote the code. Most AHJs follow what the Annex section says, although they do not have to. The Annex section for does prohibit storage in the stairwell that is “not necessary for safety”, but one could make the point that evacuation chairs are necessary for safety and therefore are permitted to be stored in the stairwell, as long as they do not interfere with egress.

The bottom line is it is apparent to me that the Life Safety Code does permit the storage of evacuation chairs in an exit stairwell, as long as the chairs are stored in such a way as to not interfere with egress. However, not all AHJs actually agree with this and some do cite hospitals if they have anything stored in the stairwells. If you want to pursue this and store the evacuation chairs in the alcove of your stairwells, I suggest you document these sections of the Life Safety Code and show them to any surveyor who questions the practice. It may prevent you from having a citation, or it may not.

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Fire Extinguisher Inspections

BKeyes : February 16, 2017 12:00 am : Fire Extinguishers, Questions and Answers

Q: I work in a 420 bed Hospital and during a recent survey we got cited for our yearly inspection dates on our fire extinguishers, which I understand. But on the monthly inspection dates, does the inspector put the date they do the inspection or the date of the next month?

A: For monthly inspections of portable fire extinguishers, NFPA 10 (2010 edition) section says at a minimum of 30 day intervals, the date the inspection was performed and the initials of the person performing the inspection must be recorded. So each month, the person making the inspection must record the date that the inspection is made, on the extinguisher tag. Most authorities want to see an actual date, written in a month/day format provided the year is clearly identified on the tag. Initials of the individual conducting the inspection are usually accepted over actual signatures.

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Creating Separated Occupancies

BKeyes : February 15, 2017 12:00 am : Occupancies, Questions and Answers, Separation

Q: I have a 3 story hospital and I would like to have a mixed occupancy classifications for different floors. The basement floor is for support – no patients are ever on this floor for any reason. The top floor is administration. Patients are occasionally on this floor if they are being transported to the adjacent hospital – always in the company of nursing staff and only for 1-2 minutes at a time during transport. No treatments and no overnight stays on this floor. Can I declare the main floor to be healthcare occupancy and the other two floors to be business occupancy? If so, what are the proper steps to make this happen; do I need to involve an architect, do the life safety plans need to be retitled, can I make this decision myself or do I need approval of some sort?

A: You should not make this decision by yourself. You need to employ an architect who has healthcare experience and a good working knowledge of the Life Safety Code.

You did not mention what your facility construction type is (according to NFAP 220). Take a look at of the 2012 LSC… there is a Table that lists all of the approved constructions types for existing hospitals. It is important to know because you will need a 2-hour fire rated barrier between the floors where you want separated occupancies in your facility.

It appears you should not have any issues in making the lower level a business occupancy, and there may be some possibility for the upper level as well. But the experienced architect needs to conduct a field review to ensure exiting, construction type and other factors are correct to allow separated occupancies in your facility.

Once the review has determined you can make these changes, then your Life Safety drawings need to be updated and perhaps your state or local AHJ may want to review this change as well.

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Eyewash Station Locations

BKeyes : February 13, 2017 12:00 am : Eyewash Stations, Questions and Answers

Q: Where are eyewash stations required in a hospital/ambulatory care facility?

A: They are required in areas where corrosive or caustic materials (i.e. chemicals) are used, stored or handled and could be splashed into the eye. A risk assessment must be made to determine where (if any) eyewash stations are necessary. The place to start is by looking at the Safety Data Sheet. If the SDS says rinse eyes for 15 minutes, then that is your first clue that an eyewash station may be required. The next step is to determine if the use, handling, or storage of the material could be splashed into the eyes. Note: When you evaluate this step you have to evaluate the process as if people are not wearing any PPE. If you conclude you need an eyewash station, then it has to meet the requirements of ANSI Z358.1-2014 which means it has to be plumbed and maintained, although there are some units that are self-contained that do qualify.

It is interesting to note that blood and body fluids are not considered corrosive or caustic.

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Emergency Department Classification

BKeyes : February 10, 2017 12:00 am : Emergency Department, Questions and Answers

Q: Should Emergency Departments be classified as healthcare, ambulatory healthcare, or business occupancies?

A: According to the 2012 Life Safety Code, a typical Emergency Department (ED) may be classified as healthcare or ambulatory care occupancies, but never business occupancy. The patients brought to a typical ED are not necessarily ambulatory or put in the NFPA vernacular, “capable of self-preservation”. So that would eliminate the business occupancy as a choice.

But informal communications from CMS reveals that they do not agree with this interpretation, entirely. While the typical ED does not provide sleeping rooms, it is understood that the ED may have 24-hour observation beds. In the way that CMS thinks, they consider these 24-hour observation beds as sleeping accommodations, so the designation of healthcare occupancy is mandatory.

Now, if your ED does not have 24-hour observation beds, then it is clear the ED could be classified as ambulatory healthcare occupancy.

Other issues that hospitals may have in deciding whether to classify the ED as ambulatory care or healthcare occupancy are:

  • A 2-hour fire rated barrier is necessary to separate ambulatory care occupancy from the rest of the hospital that is classified as healthcare occupancy;
  • Exiting from the healthcare occupancy through the ambulatory has to meet all of the requirements for healthcare occupancy, unless there is a horizontal exit involved;
  • Suites are permitted in ambulatory occupancies, and according to the 2012 Life Safety Code, they are allowed to be unlimited in size, but still have certain travel distance limitations;
  • Corridors in ambulatory care occupancies are only required to be 44 inches wide in clear width;
  • As long as the ambulatory care occupancy is a single tenant, or as long as the ambulatory care occupancy is fully protected with automatic sprinklers, rooms are not required to be separated from the corridors. Therefore, there are no requirements for doors to ED exam rooms, and if they do have doors, they are not required to positively latch.

Most of the times that I have observed organizations classify their EDs as ambulatory care occupancies, it was due to the fact that the ED did not qualify as a suite as described in the healthcare occupancy chapters, but they wanted to take advantage of the 44 inch wide corridors issue, and the no-door issue permitted in the ambulatory care occupancy. That would allow them to pretty much maintain the ED similarly to a suite, with some limitations.


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Life Safety Inspections at Offsite Locations

BKeyes : February 9, 2017 12:00 am : Documentation, Questions and Answers, Testing

Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher inspections required? We have several off-site laboratories and other services in buildings that we do not own.

A: Yes… you must maintain all of the features of Life Safety at the offsite locations, even those that you do not own; the same as you would at the main hospital. Just because you do not own the fire extinguishers, fire alarm system, sprinkler system, fire dampers, exit signs, generator, elevators, medical gas systems, and fire doors does not give you a pass on not properly maintaining them. I understand that landlords rarely conduct the same level of testing and inspection of their building’s fire safety features as you would at the hospital, but the rules for testing and inspection apply evenly across all facilities where you have staff and patients, regardless who owns it. Your survey team may not always ask to see the documentation for testing and inspecting these systems at the offsite locations, but it is a requirement found in the core chapters and occupancy chapters of the Life Safety Code.

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Corridor Door Louver

BKeyes : February 8, 2017 12:00 am : Corridors, Doors, Questions and Answers

Q: Is there a code that says anything about adding a vent through a door that is in the corridor of our hospital?

A: Well… you might be able to do that legally on a very few specific corridor doors (i.e. bathroom doors, toilet rooms doors, shower room doors), but no, you cannot install a louver in a typical corridor door in a hospital because section of the 2012 LSC says corridor doors have to resist the passage of smoke. Therefore, a louver in a door would not resist the passage of smoke.

Now, a very few specific corridor doors do not have to resist the passage of smoke as described in section (1), and you would be permitted to install a louver in those doors.

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