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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Evacuation Route Maps

BKeyes : May 18, 2015 1:00 am : Evacuation, Maps, Questions and Answers

Q: Are evacuation route drawings required to be posted at nurse stations or anywhere else per Joint Commission or CMS requirements?

A: No. There is no Joint Commission standard or requirement and there is no CMS standard or requirement for evacuation route plans to be posted on units or in corridors. Although, having them in strategic locations are valuable teaching aids during routine fire drills. This is one of those great surveyor myths that seems to have been started decades ago by an misinterpretation by an official from CMS (or as it was called back then, HCFA). You may want to check with your local and state authorities to see if they have any requirements on this issue.

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Compressed Flammable Gas

BKeyes : May 11, 2015 1:00 am : Cooking Appliances, Flammable Liquids, Gas Cylinders, Questions and Answers

Q: Can we store compressed butane gas cylinders used for food-warming and heating in the kitchen or do they require special storage?

 A: NFPA 30 requires all flammable gases and liquids exceeding 1 gallon (aggregate total) must be stored in a proper fire rated cabinet, or in a hazardous room with 1-hour fire rated barriers. You are not allowed to store mixed substances, such as combustibles with flammable liquids and gasses. For quantities less than 1 gallon, they must be stored in their original container, or in a special safety can. Joint Commission does have a standard (EC.02.01.01) whereby they could cite you for having any flammable liquid or gas stored outside a fire rated cabinet regardless of the quantity.  

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Staff On-Call Sleeping Rooms

BKeyes : May 4, 2015 1:00 am : On-Call Sleeping Rooms, Questions and Answers

Q: Does the Life Safety Code require hospital staff sleeping rooms have smoke detection inside the room and door closers installed? We have an on-call sleeping room for physicians in our Labor & Delivery unit and a consultant said we need smoke detectors and a closer on the door.

A: The answer is yes, the Life Safety Code (2000 edition), does require it. Section says where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards must comply with the most restrictive life safety requirements of the occupancies involved. This means where there is a dominate occupancy (such as healthcare occupancy in the Labor & Delivery unit) that also has a small portion of a different occupancy (such as the staff on-call sleeping room which is actually hotels and dormitories occupancy) and these two occupancies are not separated by a 2-hour fire rated barrier, then this means the two occupancies are mixed, and the most restrictive requirements of both occupancies apply. As you indicated, hotel and dormitory occupancy does require single station smoke alarm and a closure on corridor doors to sleeping room (see sections and However, there is an exception to section which says where incidental to another occupancy, buildings used as follows shall be permitted to be considered part of the predominant occupancy and subject to the provisions of the Code that apply to the predominant occupancy:

  1. a) Mercantile, business, industrial, or storage use;
  2. b) Nonresidential use with an occupant load fewer than that established by Section 6.1 for the occupancy threshold.

This exception is allowing small incidental use of one occupancy to not have to comply with the requirements of that particular occupancy, and instead may comply with the requirements of the predominant occupancy, which in your case would be healthcare occupancy. There is only one catch, though. The phrase ‘incidental’ is ambiguous and is not defined. Therefore, the authority having jurisdiction (AHJ) gets to answer the question: What does incidental mean? I do not know what state and city you are located in, so I do not know who your AHJs are, but it’s a sure bet you have 5 or 6 AHJs who enforce the Life Safety Code, and it is likely that not all of them would make this interpretation the same way:

  • Joint Commission (or one of the other accreditation organizations)
  • CMS
  • State fire marshal
  • State public health
  • Local fire inspector
  • Insurance company

Since you have so many AHJs who have the right to interpret the phrase ‘incidental’, my advice is to take a very conservative approach and do not consider the exception, and go with installing a single station smoke alarm and a closure on the door to the corridor for the sleep room. By the way, most of the AHJs accept the fact that a smoke detector connected to the building fire alarm system in a hospital is equivalent to a single station smoke alarm, so you may be okay by just installing a smoke detector, rather than a single station smoke alarm. That’s your call.

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Helium Tank/ ABHR Dispenser Location

BKeyes : April 27, 2015 6:00 am : Alcohol Based Hand-Rub Dispensers, Gift Shops, Helium, Questions and Answers

Q: Can we have a helium tank if secured properly in gift shop? And what are requirements for hand sanitizer locations- location to switches or outlets?

A: Provided the tank is secured properly, and there is less than 300 cubic feet of compressed gas total in the Gift Shop, you may have a helium tank in the shop. The typical ‘H’ tank (which is approximately 9 inches in diameter and about 55 inches tall) contains 250 cubic feet, so 1 ‘H’ tank properly secured in the gift shop would be permissible (but only one tank). Joint Commission has changed their requirements to allow the Alcohol Based Hand Rub (ABHR) dispensers to be mounted no less than 1 inch side-to-side to an electrical outlet or an electrical switch. However, CMS is still on the definition of no less than 6 inches center-to-center between an ABHR dispenser and an electrical outlet or switch. Once the new 2012 edition of the Life Safety Code is adopted, then CMS will be on the same page as Joint Commission

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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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