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Emergency Illumination in Mechanical Rooms

BKeyes : March 24, 2017 12:00 am : Emergency Lights, Mechanical Rooms, Questions and Answers

Q: Is emergency lighting required for mechanical rooms?

A: The answer depends on whether the mechanical room has a designated aisle, the occupancy classification of the building, and whether it is an underground or widow-less structure. According to section 7.8 of the 2012 Life Safety Code the means of egress is required to be illuminated in the following locations in any occupancy:

  • Designated stairs
  • Designated aisles
  • Designated corridors
  • Designated ramps
  • Passageways leading to an exit.

As far as a mechanical room is concerned, if the room is large enough that there would be a designated aisle in the room, then it would require illumination.

But does the illumination in the mechanical room need to be connected to emergency power? According to section 7.9, emergency illumination room is dependent upon any one of the following:

  • If required by the occupancy chapter;
  • If the building is an underground or windowless structure;
  • If the building is a high-rise building;
  • At doors equipped with delayed egress locks;

Healthcare occupancies and ambulatory healthcare occupancies do require emergency illumination (see 18/19/20/, but business occupancies only require emergency illumination if the building is two or more stories in height above the level of exit discharge; if the occupancy is subject to 100 or more persons above or below the level of exit discharge; and if the occupancy is subject to 1,000 or more persons.

If the mechanical room is located inside a healthcare occupancy, then it would have to be connected to a Type 1 essential electrical emergency power system, which means the emergency illumination must be provided by onsite generators.

So, it depends where the mechanical room is located. But if it is located inside a hospital, and the mechanical room is large enough to have an aisle, then yes, emergency illumination would be required.

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Quarterly Fire Drills

BKeyes : March 23, 2017 12:00 am : Fire Drills, Questions and Answers

Q: We are required to conduct a fire drill every quarter. If I did one on March 22, when is the earliest and the latest dates that I can do the next one?

A: It depends on who your AHJ is. CMS would allow it to be conducted anytime during the quarter so the next drill could be done as soon April 1 or as late as June 30.

HFAP requires 3 months from the previous activity, with the next drill performed during the third month. So 3 months from March 22, is June 22, the 3rd month would be June, so the next fire drill should be conducted anytime in June.

Joint Commission requires 3 months from the previous activity plus or minus 10 days. But they have a different interpretation on how this is calculated: Three months from March 22, is June. Plus 10 days is July 10, and minus 10 days is May 22, so according to their interpretation, the next quarterly fire drill can be between May 22 to July 10.

But be aware: CMS does not like the idea that a quarterly fire drill could be conducted beyond the quarterly time period. Since the March 22 fire drill was conducted during the first quarter, they would want the second fire drill conducted during the second quarter, and July is not in the second quarter.

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Temporary Construction Barriers

BKeyes : March 22, 2017 12:00 am : Construction, Questions and Answers

Q: Per NFPA 101 2012 edition: are plastic barriers (w/zippers) no longer acceptable around construction areas though the facility is fully sprinkled?

A: No… I wouldn’t say that. But the issue is being reviewed by NFPA Healthcare Interpretations Task Force (HITF) and a change may occur later this year.

Section of the 2012 LSC says the means of egress of any area undergoing construction, repair, or improvements must comply with NFPA 241, which is the standard for safeguarding during construction operations. Section 8.6.2 of NFPA 241-2009 says temporary construction barriers are required to be 1-hour fire rated, with ¾ hour fire rated doors assemblies if the construction area is not full protected with sprinklers. 1-hour barriers are typically steel studs with 5/8 inch thick gypsum board on both sides, with all seams taped and mudded and all screws heads mudded. If the construction area is protected with sprinklers, then the temporary construction barrier is permitted to be non-rated, but construction ‘tarps’ are not permitted as the non-rated barrier. At this time flame retardant plastic sheeting (i.e. Visqueen) will be permitted as a temporary construction barrier where the construction area is fully protected with sprinklers.

However, this issue is being reviewed by HITF of the NFPA. At the June, 2016 meeting of HITF, the members discussed whether or not flame retardant plastic sheeting was acceptable or if it was the same as ‘construction tarps’. At that time there was not a clear consensus so no decision was made. The committee said they would review it again next year.

Unless your AHJ has specifically ruled on this issue, the HITF seemed to say that flame retardant plastic sheeting would be permitted when the construction area is fully protected with sprinklers. But, of course, that is not in writing so it is not official.

I would say continue to use flame retardant plastic sheeting until you learn otherwise.

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Interior Finish

BKeyes : March 20, 2017 12:00 am : Interior Finish, Questions and Answers

Q: I would like to know the 2012 Life Safety Code requirements for an audio testing room in a high rise hospital building. The floor, wall and ceilings are covered with cloth materials similar to carpet. The room has been protected by smoke detector and sprinkler.

A: The wall coverings that you describe would not be considered decorations, but rather interior finish. Section of the 2012 LSC requires interior finish to meet section 10.2 and limits them to Class A or Class B materials. Class A materials have a flame spread of 0 – 25 and Class B materials have a flame spread of 26 – 75. Both Class A and Class B have smoke development index of 0 – 450. So, make sure your wall coverings in the audio room meet these flame spread and smoke development ratings. These rating are not dependent on the presence of smoke detectors or sprinklers.

You may also want to discuss this issue with your Infection Control individual as cloth material would be difficult to clean.

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Sprinklers in Air Handlers

BKeyes : March 17, 2017 12:00 am : Air Handlers, Questions and Answers, Sprinklers

Q: Does a roof top air handler require sprinkler heads if it is unoccupied? We have large walk-in style air handlers on the roof of our hospital and they are not protected with automatic sprinklers.

A: Well… section of the 2012 Life Safety Code requires buildings containing health care facilities to be protected throughout with automatic sprinklers. Initially, one could make the case that mechanical equipment sitting outside the building (although on top of the building) is not part of the building and therefore is not included in this requirement. Taking a look at NFPA 13 (2010 edition), I see sprinklers are required in elevator equipment rooms, and sprinklers are required in electrical rooms (with some exceptions). But these rooms are actually inside the building and would be required to be protected with sprinklers according to section of the 2012 LSC.

So it depends: Is the roof-top air handler room considered outside the building, or is it considered part of the building? That’s going to be the deciding factor, and who makes this decision? The authority having jurisdiction (AHJ) does. Even though accreditation organizations like The Joint Commission, HFAP and DNV are AHJs, they typically leave the construction interpretations to the local and state AHJs. So, if your state or local AHJ has made the determination that the air handler on top of the hospital roof does not require sprinklers, that may be enough to convince the accreditation organizations.

Or it may not. You never know if the accreditation organizations will make a different interpretation while a surveyor is onsite. If you do not want to install sprinklers, then I suggest you get it in writing from your state and local AHJs that sprinklers are not required in the air handler, and keep that document on file. If an accreditation surveyor thinks you should have sprinklers, pull that document out and see if that stops them from writing a citation. However, if you start storing combustible items in the air handler (like cardboard boxes of clean filters) then that will likely prompt the surveyor to write a finding.

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Distance to a Storage Shed

BKeyes : March 16, 2017 12:00 am : Construction, Questions and Answers, Storage

Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any minimal distance that the out-building must be away from the protected facility?  The number that I keep hearing from people is 10 feet of clearance from the protected building but I have not been able to confirm that as a requirement or a best practice.

A: No… there does not seem to be a set number of feet for a non-compliant outbuilding that needs to be from a healthcare occupancy, written into the Life Safety Code. I was at a seminar recently where that question came up and the instructor admitted there was no definite set-back required. But… like everything else that is not definitive in the Life Safety Code, the AHJ can interpret (decide) what the set-back should be. I too have heard 10 feet is the distance a non-compliant building needs to be from a healthcare occupancy without a 2-hour fire rated separation. That is actually a sound interpretation, based on other Life Safety Code requirements. Take a look at section and of the 2012 LSC which discusses the need for a 10 foot section of wall to be 1-hour fire rated when the fire rated wall intersects with an outside barrier at an angle less than 180 degrees. While that does not specifically refer to a set-back of a non-compliant building, it does provide you with a distance to go on.

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Combustible Decorations

BKeyes : March 15, 2017 12:00 am : Decorations, Questions and Answers

Q: We have a large wall 15 ft. x 12 ft. in our public cafeteria in the hospital that gets decorated with a different theme every quarter. This was started early this year and everyone seems to love it. Materials used varies from papers, pictures, plastics, cardboard, etc. Should this be a concern or a violation of the Life Safety Code?

A: Yes… it should be a concern. Section of the 2012 LSC discusses the limitations of combustible decorations on wall and ceiling surfaces. You are only allowed to cover 20% of the wall surface in non-sprinklered areas, and only 30% in sprinklered areas. Keep an eye on the quantity of wall surface covered to make sure they do not cover more than the allowed amount.

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Labeling Walls with Fire Rating

BKeyes : March 14, 2017 12:00 am : Questions and Answers, Walls

Q: Is there an NFPA code requirement for labeling fire / smoke rated walls above ceiling and if so what is it?

A: No… there is not a NFPA code or standard requirement to label the walls above the ceiling. But I’ve been told there is an IBC requirement, but I cannot provide you with any confirmation of that. I’m not a big fan of labeling the walls above ceiling with their hourly ratings, or even whether or not they are fire-rated walls or smoke barriers, etc. The reason why; it often can be labeled incorrectly… then what does a surveyor do if the walls are labeled one way and the LS drawings show something different? It creates confusion and opens the door for a finding by the surveyor. If you don’t have to do it, I suggest you do not.

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Waste Containers

BKeyes : March 13, 2017 12:00 am : Questions and Answers, Waste Containers

Q: The 2012 Life Safety Code allows for 96 gallon containers outside a hazardous area for clean waste.  Unfortunately, our vendor that handles recycling does not have a 96 gallon container that meets the fire rating to take advantage of the LSC specifications (FM Approval 6921 labeling).  Hence, how many 32 gallon containers can be stored in an area and is there a requirement to space them apart?

A: The Life Safety Code does address this issue. The 2012 LSC, section limits soiled linen and trash containers to 32 gallons capacity. Mobile containers that exceed 32 gallon capacity are required to be stored in a room designed as a hazardous area when not attended. An aggregate of containers with a total accumulated capacity of 32 gallons must not exceed a 64 square foot area. So, technically, you could have many 32 gallon containers as long as they are in their own 64 square foot area.

Section of the 2012 LSC has the additional provision of allowing the 96 gallon container used for recycling clean waste and patient records waiting destruction are excluded from the conditions in provided the container does not exceed 96 gallons capacity and are labeled and listed as meeting the requirements of FM Approval standard 6921. If your container does not meet the FM Approval standard 6921 (or comparable listing) then you do not qualify for section You would then have to follow section

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Portable Fire Extinguishers

BKeyes : March 10, 2017 12:00 am : Fire Extinguishers, Mechanical Rooms, Questions and Answers

Q: Are fire extinguishers required to be placed in mechanical rooms in our hospital? I’ve searched NFPA 10 and the Life Safety Code and haven’t found anything concrete. The mechanical rooms in our facility are strictly boiler rooms, electrical control panel rooms, and so on. They are considered restricted areas and are always kept locked, with access granted to just the facilities staff and the security staff. Any help you can provide is greatly appreciated.

A: Yes, according to sections and of the 2012 Life Safety Code, you must be in full compliance with NFPA 10 (2010 edition) for maximum travel distance to the location of a portable fire extinguisher, in all areas of your facility. Each classification of extinguishers has their own different requirements, as follows:

Class A Extinguishers

Maximum travel distance to extinguisher:                  75 feet

Maximum floor area for each extinguisher:               11,250 sq. ft.

Maximum floor rating per unit of ‘A’:                       3,000 sq. ft. for Light (Low) Hazard

1,500 sq. ft. for Ordinary (Moderate) Hazard

1,000 sq. ft. for Extra (High) Hazard


Class B Extinguishers

Light (Low) Hazard:

5-B                  30 feet maximum travel distance

10-B                50 feet maximum travel distance

Ordinary (Moderate) Hazard:

10-B                30 feet maximum travel distance

20-B                50 feet maximum travel distance

Extra (High) Hazard:

40-B                30 feet maximum travel distance

80-B                50 feet maximum travel distance

Class C Extinguishers

Class C fires are started with electrical current, but the actual fuel that burns is either a Class A or a Class B hazard. Therefore, Class C extinguishers should be mounted and located according to either Class A or Class B requirements, depending on the potential fire.

Class K Extinguishers

Maximum travel distance is 30 feet.

Even mechanical rooms where very few people have access are required to be protected with portable fire extinguishers, so make an assessment of what the potential fuel that could catch on fire, and obtain the classification of extinguisher(s) that meets that potential fuel, and space them out accordingly.

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