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Closers on Doors to CT Scan

BKeyes : December 13, 2017 12:00 am : Doors, Hardware, Questions and Answers

Q: Do entrance doors to x-ray rooms and CT scanner rooms have to be controlled by door closers?

A: According to the Life Safety Code, they only need closers if they are considered to be hazardous rooms (normally not) or if the door in question is also part of the smoke compartment barrier wall. However, other codes and standards may apply. Be sure to check with your state and local authorities.

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Office Door Holiday Decorations

BKeyes : December 12, 2017 12:00 am : Decorations, Doors, Fire Doors, Questions and Answers

Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape for the holidays. Are there specific prohibitions against this? We don’t want to be a Grinch unless necessary. thanks!

A: Section 7.1.10.2.1 of the 2012 LSC says decorations cannot obstruct the function of the door or the visibility of the egress components. So, the decorations cannot obstruct the door in any way.

Section 4.1.4.1 of NFPA 80-2010 says signage on fire-rated doors cannot be more than 5% of the door surface. Now decorations may not be considered signage by most individuals, but the intent is to keep the fire-load on the door to a minimum so it can function properly in the event of a fire. I can see where a surveyor would have a serious issue with decorating fire-rated doors with wrapping paper and bows, because it adds fuel to the door that was not present during the UL testing of the doors.

Sorry, but I suggest you be the Grinch and tell them to remove wrapping paper and bows from the fire-rated doors.

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Generator Testing

BKeyes : December 11, 2017 12:00 am : Generators, Questions and Answers, Testing

Q: In a business occupancy and an ambulatory occupancy do we need to test our generator on load each month or can we do a load bank test once per year?

A: Yes… Monthly load tests are required for emergency power generators at ambulatory healthcare occupancies and business occupancies. According to the 2012 Life Safety Code, sections 20/21.5.1.1 for ambulatory healthcare occupancies and 38/39.5.1 for business occupancies, compliance with section 9.1 on utilities is required (just like healthcare occupancies).

Section 9.1.3 requires compliance with NFPA 110-2010 regarding emergency power generators, and section 8.4.1 of NFPA 110 requires monthly load tests.

Now… there is an exception to all of these testing requirements…. Section 9.1.3 says emergency generators, where required for compliance by the LSC, must be tested and maintained in accordance with NFPA 110-2010. So, if you are not required to have emergency power generators at the ambulatory healthcare occupancy or the business occupancy, then you do not have to maintain them according to NFPA 110.

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Separation of Different Occupancies

BKeyes : December 8, 2017 12:00 am : Occupancies, Questions and Answers, Separation

Q: There is an existing clinic which is classified as business occupancy that leases space within a rehabilitation and nursing center. Does this need to be separated by a 2 hour rated partition? Does the egress corridor from the clinic to the exterior need to be rated?

A: Uhm… my answer is … it depends. You state the clinic is a business occupancy, but you did not state what occupancy the rehabilitation and nursing center is. I’m not sure what you mean by a ‘nursing center’… is that a hospital, a nursing home, or is it something else? Is the rehabilitation center classified as a hospital or a nursing home? Or is it outpatient only? Are there any patients in the rehabilitation center that are incapable of self-preservation? If so; how many?

If the rehabilitation center and the nursing center is a different occupancy than the clinic (which you say is a business occupancy), then yes, the different occupancies must be separated by fire rated barriers. The fire rating of these barriers depends on whether or not the occupancy (other than the business occupancy) is healthcare occupancy. Where healthcare occupancy is separated from any other occupancies, the fire rating on the barrier must be 2-hours. However, if the occupancy of the rehabilitation and nursing center is not healthcare occupancy, then the fire rating on the barrier separating the occupancies is only required to be 1-hour rated.

Corridors in new construction business occupancies must be constructed with 1-hour fire rated walls, according to section 38.3.6.1 of the 2012 LSC. But the exceptions to 38.3.6.1 say the requirement for 1-hour fire rated walls does not apply:

  • Where exits are available from an open space;
  • Within a space occupied by a single tenant;
  • Within buildings protected throughout by an approved sprinkler system.

If the business occupancy is considered existing construction, then there are no requirements for the corridor walls. If the rehabilitation and nursing center exits into and through the business occupancy, then the corridor in the business occupancy must meet the requirements for corridors in the occupancy where the rehabilitation and nursing center is located.

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Business Occupancy Fire Drills

BKeyes : December 7, 2017 12:00 am : Business Occupancy, Fire Drills, Questions and Answers

Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party during a routine fire drill? We have documented staff participation with each drill. The building fire alarm system including communication with the third party is also completed during the year per standard. The clinic (business occupancy) may be located in a building with many other types of businesses.

A: I don’t think so. If you look at the healthcare occupancy chapter section 18/19.7.1.4 (2012 LSC), it says fire drills shall include the transmission of the fire alarm signal. However, there is no comparative section in chapters 38 & 39 for business occupancy. Since the business occupancy chapter does not specifically require the activation of the building fire alarm system for a fire drill, then I would say it is not a Life Safety Code requirement. It would be best practice, but not a requirement.

Sections 38/39.7.2 (2012 LSC) says fire drills in business occupancies (where required) must comply with section 4.7. Section 4.7 discusses many requirements regarding fire drills but activating the fire alarm system is not one of them. Please review your accreditation standards to determine if they require activation of the fire alarm system during a fire drill in a business occupancy.

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Alcohol Based Hand-Rub Solution Storage

BKeyes : December 4, 2017 12:00 am : Alcohol Based Hand-Rub Dispensers, Questions and Answers, Storage

Q: Our hospital bulk stores alcohol based hand-rub (ABHR) sanitizer containers of 1000 ML (33.8 fl. oz.) per container & 750 ML (25 fl. oz.) per container in its housekeeping department for future placement on the units. The 1000 ML containers have 62% ethyl alcohol, which the 750 ML containers have 70% ethyl alcohol. The 1000 ML containers come 8 to a box and we have 25 boxes on pallets, while the 750 ML containers come 6 to a box and we can have up to 180 boxes on pallets at one time in the warehouse/storeroom, which is quite large and is open to the deck above. This room is located in the basement of a high rise that has an ED on the floor above, ORs on the 2nd floor and inpatient sleeping floors above that. The room and whole building have both smoke detectors and sprinklers and was constructed in 2011. Half of the room where the sanitizer is bulk stored is surrounded by a 2-hour fire/smoke barrier, while the other half has 1-hour fire resistive construction. My questions are this: Is the storage of this much ABHR sanitizer acceptable? If not, what would be required? We do have a room off this one that is totally surrounded by a 2-hour fire/smoke barrier. If the room in question is not acceptable, would this room be okay?

A: The storage of what you described is over 33,000 fluid ounces which is more than 263 gallons of flammable Class IC liquids. Hand sanitizer solution is considered a Class IC flammable liquid according to NFPA 30-2012, Flammable and Combustible Liquids Code. This is also based on the Safety Data Sheets of most brand-name hand sanitizers which state the flash point is 73 degrees F, and some of them have a boiling point of 176 degrees F. According to NFPA 30, this makes it a Class IC flammable liquid.

According to NFPA 30, you are permitted to store 263 gallons in one location (actually, you can store up to 2750 gallons of Class IC flammable liquids in one location, but there are limitations:

  • The maximum height of the pile (i.e. pallets) is 5 feet
  • The storage of the liquids cannot obstruct access to egress in the room. A fire in the liquid storage cannot prevent egress from the room.
  • Storage cannot be in a basement
  • An inside storage room with a total floor area less than 150 square feet is required to be protected with fire-resistant construction of 1-hour (walls, ceiling floors)
  • An inside storage room with a total floor area more than 150 square feet but less than 500 square feet is required to be protected with fire-resistant construction of 2-hours (walls, ceiling floors)
  • Inside storage rooms with a total floor area 500 square feet or more are not permitted.
  • Containment or drainage protection is required.

So…based on your comments I would say you need to move the stored items out of the basement and into a room that is less than 150 square feet and is 1-hour fire rated protected, and you need to provide containment or drainage protection.

To be honest… most hospitals that I visit do not store this much of the hand sanitizer liquids in their facility. They store much less, and keep them in flammable cabinets which would not require 1-hour fire rated rooms. I know why your people want so much as it comes cheaper in bulk…. But the cost to properly store this stuff far outweighs the savings of buying in bulk.

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Locks and Latches on Doors

BKeyes : December 1, 2017 12:00 am : Door Locks, Questions and Answers

Q: In follow up to your articles on locks on doors, we are a mental health facility and have mag-locks operated by swipe cards / fobs. The same doors also have latching hardware operated by push bars and thumb releases. Is this in conflict with “no more than one releasing operation to operate the door”?

A: That is a good question… I would say a door that is equipped with magnetic locks and has basic latching hardware does qualify as a door with more than one action to operate the door. But, as I said many times, it doesn’t matter what I say… it matters what your authorities having jurisdiction (AHJ) say. While 7.2.1.5.10.4 of the 2012 LSC does allow two additional releasing operations for security devices, that only applies to individual living units and guest rooms of residential occupancies. That does not seem to apply to your situation.

Section 19.2.2.2.5.1 of the 2012 LSC allows doors in the path of egress to be locked where the clinical needs of the patients require specialized security measures. These sections of the LSC have been interpreted by most AHJs to be used only for psychiatric patients, or Alzheimer and dementia patients; It is not available for use in other areas of the hospital. So, the use of magnetic locks in the situation that you describe appears to be acceptable, but there is nothing in section 19.2.2.2.4 that allows more than one releasing action to operate the door. Therefore, I would say the combination locks and latches that you describe would not be permitted.

However, I encourage you to contact your state and local AHJs, and your accreditor and ask them if they would permit the arrangement that you describe. If all of them will allow it then you are good to go. But if any one AHJ does not allow it, then you cannot have the locks and latches on the door. Make sure you maintain all the replies from the AHJs in writing for future reference.

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Carpeting in Stairwells

BKeyes : November 30, 2017 12:00 am : Carpeting, Questions and Answers, Stairwells

Q: I have several hospitals that have been cited by surveyors for having carpet in the stairwells. Can you tell me if there is any code requirement that states that carpet is not allowed in the fire exit stairwell?

A: Excellent question. No… as far as I know, there is no direct standard that prohibits carpeting in exit enclosure stairwells. However, there are a few sections of the LSC that could shed light on this issue.

Section 7.1.6.4 of the 2012 LSC says walking surfaces must be slip resistant. If a surveyor believes the carpet can be slippery, then that would be a problem. Section 7.2.2.3.3.2 of the 2012 LSC says stair treads and landings must be free of projections that could trip stair users. This may be a bit of a stretch, but if the surveyor believes a carpet could become loose, it may trip the people using the stairs.

Annex section A.7.2.2.3.5 of the 2012 LSC says carpeting over the nose of a stair can create an unstable surface. “Any horizontal projections of resilient covering materials beyond the tread nosing and riser, such as carpet and underlayment, can interfere with user’s feet and thereby reduce usable tread depth.”

I think it is safe to say that carpeting is not prohibited, but in the opinion of the NFPA 101 technical committee, carpeting can interfere with the user of the stairs. If the technical committee fully believed carpeting on stairs was a serious impediment to exiting, they definitely would have banned it. It is important to understand that the Annex section is not part of the enforceable code, but rather is explanatory information provided by the technical committee for users of the Life Safety Code to understand what the technical committee was thinking when they wrote the standards.

Therefore, it is perfectly acceptable for an authority having jurisdiction (AHJ) to follow the recommendations provided in the Annex section… or not. It is just advisory information to help the AHJ interpret the LSC. The AHJ can use the information in the Annex section… or they can choose to ignore the information. I can’t say that I disagree with the surveyor… although I can’t remember the last time I saw carpeting in exit access stairwells.

 

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Removal of a Water-Flow Switch

BKeyes : November 29, 2017 12:00 am : Questions and Answers, Sprinklers, Standpipe Flow Tests

Q: We have a water-flow switch on the line that rises through a nursing wing stairwell and feeds the hose cabinets. There are no longer any hoses in the cabinets. Can we remove the flow switch? I don’t know if it’s relevant but our pump test manifold is also on this riser.  I am going on the fact that if the fire department hooks up to the hose riser hopefully we will know there is a fire!

A: I do not believe you are permitted to remove the waterflow alarm switches from the standpipes, and you still need to maintain them and test them. According to NFPA 14 (standard for the installation of standpipes), 2010 edition, says you must have waterflow alarms on standpipes required by the AHJ. The presumption here is the installation of the standpipe was required by some AHJ, or they would not have been installed. In hospitals, only high-rise buildings are required to have standpipe system, so if your facility qualifies as a high-rise, then I would say no. If you want to pursue this issue, you would need to have written approval from all the AHJs who govern your hospital, such as CMS, Joint Commission, the local AHJ, the state AHJ, and the insurance company. Not likely that they would all agree to let you remove the devices.

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Security Cameras in Stairwells

BKeyes : November 27, 2017 12:00 am : Questions and Answers, Stairwells

Q: Can I install security cameras in stairwells

A: You can…. But be prepared to remove them. Many Accreditation Organizations (AOs) and most states who survey on behalf of CMS do not allow cameras in stairwells. The reason for this is two-fold: 1) Section 7.1.3.2.1(10) of the 2012 Life Safety Code does not permit new penetrations into the exit enclosure that does not serve the exit enclosure (with some exceptions). Many AHJs believe security cameras serve the facility and not just the exit enclosure; and 2) The concept of exit enclosures is to provide a clean environment that is free of any device that does not serve the purpose of the stairwell. The purpose of the stairwell is to evacuate people from the building in the event of an emergency. The security camera does not serve that purpose… a security camera monitors the activity of the people.

Anyway… I’m in favor of security cameras in stairwells, but my opinion does not matter, and many AHJs do not permit them. So, perhaps it would be best to not install them.

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