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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Soiled Utility Room Door Signage

BKeyes : April 20, 2015 6:00 am : Doors, Questions and Answers, Signs, Soiled Utility Rooms

Q: Are you aware of any door signage requirements for soiled utility rooms and/or trash rooms?

A: There is no Life Safety Code requirement for signs on a soiled utility room door or a trash collection room door, unless the door could somehow be confused with an exit door. Then a ‘NO EXIT’ sign will have to be posted on the door, with the word ‘NO’ 2 inches tall, and the word ‘EXIT’ 1 inch tall, and the word ‘NO’ has to be on top of the word ‘EXIT’. If the doors to the soiled utility room or the trash collection room are fire-rated doors, then the sign must be no larger than 5% of the overall surface area of the door, and can only be attached to the door with adhesives. Nails and screws are not permitted to attach a sign to a fire rated door. Perhaps you may be thinking of a state regulation whereby every door must have a number or name assigned to it. I have seen this regulation in many states. However, I am not aware of any CMS, Joint Commission, HFAP or DNV requirement for signs on these doors.

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Handrails in Corridors

BKeyes : April 13, 2015 6:00 am : Corridors, Handrails, Questions and Answers

Q: I am working on an aesthetic corridor remodel for a hospital. Can you please tell me if there are specific requirements as to handrail locations (i.e- one side of the wall vs. both sides, at what locations, for what amount of distance, etc.)?

A: In regards to healthcare occupancies, and specifically hospitals, there is no Life Safety Code requirement for handrails in an exit access corridor. There are requirements for stairs, exit enclosures, ramps and exit passageways to have handrails, but the LSC does not have any requirements for corridors. However, there are other codes and standards to consider. The Facility Guidelines Institute requires hospitals to comply with ADA requirements in regards to handrails in corridor, unless the functional program narrative specifically decides against them. What this means, if the hospital has a written program that describes the use and activities that the corridor serves is not consistent with handrails, then it is permissible not to install them. An example of this may be a Psychiatric unit where a handrail could possibly be removed and used as a weapon. In essence, the hospital gets to decide if there will be handrails, but the reason needs to be plausible and written down in a program narrative. Also, compliance with ADA requirements is required whenever new construction or renovation of an existing area is conducted. I do not believe just installing new wallpaper qualifies as renovation, so compliance with ADA would not be required. I strongly recommend that you contact the local and state authorities to determine if they have regulations that would require handrails.

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Sprinklers in Construction Projects

BKeyes : April 6, 2015 6:00 am : Construction, Questions and Answers, Sprinklers

Q: We have a construction project that involves removing all of the ceiling tiles in the area. Do we have to relocate the sprinklers heads to within 12″ from the deck above? Do you have any guidance on what’s required for fire protection in the construction area?

A: If your organization is required to be in compliance with the 2000 edition of the Life Safety Code, then sections 18/ requires compliance with the provisions of NFPA 241 Standard for Safeguarding Construction, Alteration and Demolition Operations, (1996 edition) during renovation and construction that includes a means of egress. The phrase ‘means of egress’ pretty much covers everything, so it would be a safe bet that NFPA 241 applies whenever any construction or renovation is underway. The 1996 edition of NFPA 241 does not require an active water-based sprinkler fire protection system to be installed and operating during the construction phase, but if there is one, it must comply with NFPA 13 Standard for Installation of Sprinkler System, which means sprinkler heads would have to be mounted within 12 inches of the deck if the suspended acoustical tile ceiling had been removed. The 1996 edition of NFPA 241 also only requires fire resistant and smoke resistant temporary construction barriers, rather than 1-hour fire rated barriers. Now, the 2012 edition of the Life Safety Code requires compliance with the 2009 edition of NFPA 241, which did undergo a change in regards to temporary construction barriers. The requirement for temporary construction barriers changed to be either 1-hour fire rated, or non-rated fire resistant if the construction area is fully protected with automatic sprinklers. Again, sprinklers are not mandatory, but if you have them, they must comply with NFPA 13. If the decision for temporary construction barriers is to go with 1-hour fire rated walls, then a ¾ hour fire rated door, which is self-closing and positive latching must be provided. To answer your question directly, I would say ‘No’, there is no requirement whereby you must relocate the heads to within 12 inches of the deck. However, if you do, it may save you with considerable expenses in other areas. If the area is properly sprinklered according to NFPA 13, then a fire watch would not have to be implemented, and the temporary construction barriers would not have to be 1-hour fire rated. This may become a significant expense which could be avoided. If this construction area is located underneath an occupied inpatient unit, then it makes much more sense to provide properly installed sprinklers in the construction project for added protection, which should reduce the risk of the renovation to the inpatients.

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Temporary Signs on Fire Doors

BKeyes : March 30, 2015 6:00 am : Doors, Fire Doors, Questions and Answers, Signs

Q: Are hand-made temporary directional signs permitted to be taped to fire doors? We had a surveyor tell us that nothing can be taped to a fire door.

A: Yes, temporary signs are permitted to be taped to a fire door, but they are limited in size. NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition, section 1-3.5, says informational signs installed on the surface of fire doors are permitted. The total area of the attached signs is not to exceed 5 percent of the area of the face of the fire door to which they are attached. Signs are required to be attached to fire doors using an adhesive. Mechanical attachments such as screws or nails are not permitted. Signs are not to be installed on glazing material in fire doors, and signs are not to be installed on the surface of fire doors so as to impair or otherwise interfere with the proper operation of the fire door. With a fire door size of 80” x 32” (approximate guess of the fire door in question), a single 8½ x 11 sheet of paper is well below the 5 percent maximum which the code permits. You state that the paper sign was observed to be attached to the door with adhesive, so it appears it meets the requirements for signage on fire doors. Sounds like a case for an appeal or clarification.     

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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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