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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Hotel Room Evacuation During Fire Alarm

BKeyes : December 15, 2014 6:00 am : Evacuation, Fire Alarm, Hotel, Questions and Answers

Q: We own and operate a hotel on our hospital campus and are revamping our fire plan. Are we required to have all the hotel guests evacuate their rooms upon activation of the fire alarm? Also, we have a marked exit into a courtyard with a 6 foot high fence around it. The gate in the fence then leads to the public way. Must this gate remain unlocked for egress to the public way or can you have an assembly point inside the courtyard?

A: Section of the 2000 Life Safety Code states the fire safety information that is posted in the hotel room is sufficient for the guests to make their own decision as to whether or not they evacuate their rooms and/or building during a fire alarm. In an obvious fire alarm testing situation, I can see that is a legitimate situation where evacuation is not necessary. But other than that, appears to leave that decision up to the guests. However, it would seem logical to want everyone to evacuate whenever a fire alarm is activated.

In regards to the fence surrounding the courtyard, that presents other problems. Since you say it is a marked exit, then the exit discharge is required to extend to the public way. The public way is defined as a street, alley, or other similar parcel of land essentially open to the outside air, which is dedicated or otherwise permanently appropriated to the public for public use. A fenced-in area that has a locked gate does not seem to meet this definition of public way. In my opinion, the gate would have to remain unlocked. The gate would also have to be an obvious point of exit, or it would have to be marked with an illuminated exit sign, and the path of egress to the public way would need to be illuminated with emergency power. Even if you got a local authority having jurisdiction (AHJ) to allow the locked gate in the courtyard, that does not mean other AHJs would see it the same way.

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Ambulatory Surgical Center Waiting Rooms

BKeyes : December 8, 2014 6:00 am : Ambulatory Care Occupancy, Questions and Answers, Waiting Areas

Q: Can an Ambulatory Surgical Center (ASC) have a waiting room that is shared with another physician’s practice that is not associated with the ASC, but is located in the same building?

A: No, it cannot. Section 20/ of the 2000 Life Safety Code states the ambulatory health care occupancy must be separated from other tenants and occupancies with 1-hour fire-rated barriers. The ASC is located in an ambulatory health care occupancy and the physician’s practice is another tenant and is presumably located in a business occupancy. This separation between tenants and occupancies includes waiting rooms and areas.

In addition, the Centers for Medicare & Medicaid Services (CMS) S&C memo 10-20-ASC dated May 21, 2010, specifically states ASC must have waiting areas that are separate from other tenants and occupancies by 1-hour fire-rated barriers. The logic expressed in the CMS memo is patients occupying an ASC waiting area for the purpose of receiving treatment may not be capable of evacuating without assistance; therefore the ASC waiting area needs to comply with all of the fire safety requirements afforded to ambulatory health care occupancies. The CMS memo does say existing ASC that are cited to be non-compliant in regards to the waiting area requirements may submit waiver requests, but waivers will not be allowed for ASC classified as new construction facilities (designed or constructed prior to March 11, 2003). Please be advised that the CMS categorical waivers do not apply to this situation.

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Christmas Decorations

BKeyes : December 4, 2014 6:00 pm : Decorations, Questions and Answers

I have received quite a few questions concerning combustible decorations this season and thought I would run this special Q&A today…


Fire Retardant Spray Web 2

Q: My administration is decorating our hospital lobby and has purchased some decorations that do not have a flame retardant rating or certificate. I have informed them that they are in violation of the Life Safety Code. They have found product that can be sprayed on the decorations to make them meet code. I am not convinced that this meets the intent of the code. They claim it meets the requirements of NFPA 701. Have you heard of this product and if applied will I be compliant with code?

A: Yes, I am familiar with this product, and I do not have any problems with the safety of its proper use. However, how are you going to prove to a surveyor that the decorations have been treated with the flame retardant? Once it is applied, it dries clear and there is no physical evidence that the product has been applied.

The typical surveyor wants proof that the flame retardant has been applied. Work orders identifying the decoration in detail, along with its location and the date of application, may be acceptable. A photograph of the product being applied is even more effective, but you would have to photograph every piece of decoration that it is applied to. Documenting (writing) on the decoration the date of the last application and the work order number may also be effective. The problem is it becomes a nightmare trying to document every decoration. And what about the decorations that may have been missed? How can you tell if it was treated or not?

Can you meet the intent of the Life Safety Code with this flame retardant spray-on solution? Yes… but it is not easy to document.

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Door Hooks

BKeyes : December 1, 2014 6:00 am : Doors, Questions and Answers

Q: With regards to installing a hook on a fire rated door, would an adhesive backed hook be considered a modification to the door?

A: As far as I can tell, NFPA 80 and NFPA 101 (LSC) does not address this specific issue. One could argue that the hook can be applied with the same adhesive that is permitted in section 1-3.5 in NFPA 80 (1999 edition) which discusses signs attached to fire doors, especially since the area of the hook would be presumably less than what is usually provided for signs. The difference is that when you hang a coat on the hook, you now have an additional fuel load.  So even though the hook is not penetrating the door or affecting the integrity of the door itself, the door might not perform the same in a fire because of the unexpected additional fuel load.

It is not unusual for a NFPA code or standard to fail to address all possible considerations. Actually, it is quite common. When the code or standard fails to address a specific issue, then it is up to the authority having jurisdiction (AHJ) to make an interpretation on that issue. If the AHJ has indeed made such an interpretation, then that’s your answer. But, to my recollection, I am not aware if CMS or any accreditation organization has made a written (formal) interpretation on whether or not hooks can be mounted to fire rated doors with adhesive. You could ask them, but then whatever answer they give you would only apply to their inspections. In other words, just because the accreditation organization says it is okay to do something that does not mean it is okay with CMS, or any of your other AHJs.

When an AHJ has not provided a clear interpretation on an issue, then the organization may conduct a risk assessment, considering the pros and cons of such action (i.e. using the adhesive hooks on fire rated doors). However, just because you conducted a successful risk assessment does not mean the AHJ has to accept your conclusions. If they disagree with your findings, they can cite you for safety related violations even though there is no specific standard prohibiting the hooks on the doors. My advice is don’t do it. It’s not worth the hassle of defending yourself to an over-zealous surveyor who just doesn’t agree with your conclusions. Also, once you let one hook on the door, it will invite many others, and now it becomes a nightmare to monitor and enforce.

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Portable Fire Extinguishers

BKeyes : November 24, 2014 6:00 am : Business Occupancy, Fire Extinguishers, Questions and Answers

Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital?

A: The monthly inspection and annual maintenance requirements for the portable fire extinguisher is the same for all occupancies, and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:

  • Make sure extinguisher is in its designated place
  • Make sure the access to the extinguisher is not obstructed
  • Make sure the operating instructions on the nameplate is legible and facing outward
  • Make sure the safety seals and tamper indicators are not broken or missing
  • ‘Heft’ the extinguisher to determine fullness (pick it up and hold it)
  • Examine the extinguisher for obvious damage, corrosion, leakage or clogged nozzle
  • Make sure the pressure gauge (if so equipped) is in the normal operating range
  • For wheeled units, check the condition of the tires, wheels, carriage, hose, and nozzle
  • Make sure the HMIS label is in place

This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable) and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. An annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection is required. A 12 year hydro-test of the extinguisher is also required.

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Quick Response Sprinklers

BKeyes : November 10, 2014 6:00 am : Questions and Answers, Sprinklers

Q: We completed our hospital sprinkler installation in 1994, and most of the sprinklers that were installed were quick response sprinklers. Now I hear at an ASHE conference that we need to replace all of these sprinklers. I thought we had 50 years before we replace them. Why do we need to do that so soon?

A: NFPA 25 (1998 edition), section 2-3.1.1 requires quick response sprinklers to either be replaced or have a sample size tested, 20 years after installation. The sample size is a minimum of 4 sprinklers, or 1% of the individual sprinkler sample installed, whichever is greater. If just one sprinkler in the sample size fails, then all of the remaining sprinklers have to be replaced. If the samples pass, then the quick response sprinkler must be re-tested every 10 years thereafter. Most hospitals find it more cost effective to just remove all the QR sprinklers and replace them with new ones every 20 years. Comparatively, standard response sprinkler do not have to have a sample size tested until 50 years after installation. But the Life Safety Code requires quick response sprinklers (or residential style sprinklers) in smoke compartment containing patient sleeping rooms. Quick response sprinklers and standard response sprinklers are not allowed to be installed within the same four walls (room, area, hallway). You cannot ‘mix’ quick response with standard response sprinklers, because they will not respond the same in the event of a fire. The quick response sprinklers may discharge quicker than the standard response sprinklers, which may actually prevent the standard response sprinklers from activating at all. Surprisingly, I find this problem frequently.

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Smoke Detection

BKeyes : November 3, 2014 6:00 am : Fire Alarm, Questions and Answers

Q: Are we supposed to have smoke detectors in the corridors of our hospital? I see the Statement of Conditions ask if we have smoke detectors in our corridors, which leads me to believe it is a requirement that we need to meet.

A: That depends on other factors. The Life Safety Code does not require smoke detectors in hospital corridors, although it does require them in limited care facilities corridors with some exceptions. However, your local or state authorities may have regulations that require the smoke detectors in corridors. Also, if you have an equivalency approved by an authority having jurisdiction it’s possible that one of the compensating measures was to install smoke detectors in the corridors. So, while the Life Safety Code does not require smoke detectors in the corridors of a hospital, other factors may. That’s why the statement of conditions is interested in knowing if you have them.

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Upgrading from Business to Healthcare Occupancy

BKeyes : October 27, 2014 6:00 am : Business Occupancy, Questions and Answers

Q: We have an attached building that houses an ambulatory surgical center and the building is classified as a business occupancy. We want to convert it from business occupancy to healthcare occupancy so we can have overnight patient care sleeping accommodations. What should we be concerned about?

A: It is classified as business occupancy and you have an ambulatory surgical center in the building? That doesn’t seem right, but I’m glad you’re going to fix that problem. Construction type is one of the many issues that must be dealt with in converting a building from business occupancy to healthcare occupancy, but there are other issues to consider as well. The first thing that needs to be understood is, changing from business to healthcare means the building has to meet new construction requirements found in chapter 18 of the 2000 Life Safety Code, not in chapter 19 which is for existing construction. Therefore, here is a quick summary of the things to investigate to ensure you are in compliance with chapter 18, mainly because these items may not be required in business occupancy. (NOTE: This is not an all inclusive list):

  • Construction Type requirements (as already noted)
  • Occupant load factors are different for healthcare
  • Means of egress components are more restrictive for healthcare, such as fire escape stairs are not permitted
  • Means of egress doors have different locking arrangements that actually favor healthcare
  • Stair width for existing is 44 inches while the business occupancy building may have been constructed to lessor standards
  • Horizontal exits, while not required, if used in the renovated business occupancy cannot have any penetrations (duct, conduit, etc.)
  • Corridor width MUST be 8 feet wherever inpatients are housed or treated, but may be 44 inches wide where inpatients would never be (such as a basement support services or administration).
  • The minimum clear width of the doors in a means of egress is 41.5 inches, which is far wider than what you would find in a business occupancy
  • Healthcare allows the use of suites, both for sleeping arrangements and non-sleeping arrangements which is a great benefit to the hospital
  • Dead-end corridors are only permitted to be 30 feet in healthcare while they are permitted to be 50 feet in business
  • Travel distances to an exit is less in a healthcare occupancy as compared to a business occupancy
  • Emergency lighting is required in healthcare
  • Protection from hazards is more restrictive with healthcare
  • Medical gases must be in compliance with NFPA 99 (1999 edition) which means a Level 1 piped system would have to be installed for a surgery
  • Interior finish requirements are more restrictive, but this is not usually a problem
  • A fire alarm system is required, with more devices and appliances than what a business occupancy would require
  • The entire building would have to be sprinklered with quick response sprinklers
  • Corridors in healthcare are required to be separated from all other spaces, while there is no requirement for corridors in business
  • There are multiple examples where spaces may be open to the corridor in healthcare that the hospital may take advantage of
  • Corridor walls have construction requirements
  • Corridor doors have certain requirements
  • Healthcare requires each floor to be subdivided into at least two smoke compartments and there are specific construction requirements for the compartment barriers and doors
  • Utilities must comply with section 9.1, which includes gas, electrical and emergency power
  • Healthcare facilities must have Level 1 emergency power as described and prescribed in NFPA 99. This requires significant changes to life safety branch and critical equipment branch, which business occupancies would not have to comply with.
  • The healthcare facility must have evacuation plans and relocation plans and fire drills once per quarter per shift
  • Combustible decorations are not permitted in healthcare
  • Portable heating devices are not permitted in patient care areas

That’s just a quick list of things but I’m sure there are more items in greater detail that you would need to comply with as well. As you can see, this is a large undertaking to convert a building that was never intended to be healthcare occupancy into a hospital. Most organizations choose to build a brand new building when they realize the cost in converting an existing building.

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Fire Extinguisher Bar-Code Labels

BKeyes : October 20, 2014 6:00 am : Fire Extinguishers, Questions and Answers

Q:  Our administration wants us to discontinue applying bar-code labels on each extinguisher in our facility, and begin applying the labels on the cabinets and walls where the extinguishers are located. Do you see this being an issue for us down the road?

A: It would be interesting to understand why your administration wants this change made. I have seen bar-coding done both ways: label the extinguisher vs. label the location of the extinguisher. I don’t see it as a problem, either way. NFPA 10 (1998 edition) section 4-3.4.3 says records of the monthly inspection must be kept on a tag or label attached to the extinguisher; on an inspection checklist maintained on file; or in an electronic system (e.g. bar coding) that provides a permanent record. The standard does not say the bar-code label has to be on the extinguisher, so logic says it can be located near the extinguisher. This is subject to state and local authorities’ interpretation of the standard, as they may want the label in a specific location. I personally would want to label the asset rather than the asset location.

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Ambulatory Surgical Center Mixed Occupancies

BKeyes : October 13, 2014 6:00 am : Ambulatory Care Occupancy, Occupancies, Questions and Answers

Q: We have an Ambulatory Surgical Center (ASC) located in a one story nonsprinklered building, and is separated from a physician’s office. The exit access from the ASC leads into a corridor which is within the physician’s practice. Since this corridor is not technically part of the ASC, is the ASC responsible for having the corridor wall opposite from the occupancy separation to be 1-hour fire rated?

A: You raise an excellent point: Once you leave the ambulatory health care occupancy and enter a different occupancy type, does the means of egress have to comply with ambulatory health care requirements? According to sections 20/ of the 2000 edition of the Life Safety Code (LSC), the answer is yes. This section says all means of egress from ambulatory health care occupancies that traverse non-ambulatory health care spaces must conform to requirements of the LSC for ambulatory health care occupancies. The exception to this requirement would be if the barrier between the ambulatory health care occupancy and the contiguous occupancy qualifies as a horizontal exit, then the means of egress in the contiguous occupancy does not have to meet the more rigorous requirements for ambulatory health care occupancy, provided the means of egress is not through a high-hazard area. Horizontal exits are required to be 2-hour fire rated. So, how does this apply to you? If your ASC qualifies as new construction (built after March 11, 2003), then the means of egress in the physician area (outside of the ASC) must have 1-hour fire rated walls that extend from the floor to the deck above (unless they terminate at a ceiling that is also 1-hour fire rated); or if the building is protected with automatic sprinklers throughout; or the barrier between the ASC and the physician’s offices is a 2-hour fire rated horizontal exit. If the ASC qualifies as existing construction (built on or before March 11, 2003) then there are no requirements for the corridors, and what you currently have would be acceptable.

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