Jan 08 2016

Door to Storage Room

Category: BlogBKeyes @ 12:00 am

Q: We have an Urgent Care facility that is classified as business occupancy. Do I need to lock the door to a storage room?

A: The Life Safety Code does not require a door to a storage room to be locked, in an occupancy classification used by healthcare providers, including business occupancy.

However, one of your authorities having jurisdiction (AHJ) may require the door to be locked, depending on the risk to safety for your patients and staff. If you are accredited by a national accreditation organization, they usually have a standard that requires the healthcare provider to assess the safety and security risks in the environment to your patients and staff. Depending on the contents and layout of the storage room, there may be a significant risk to unauthorized individuals (especially children and behavioral health patients). You may be required to assess the perceived risk in all areas, including the storage room and determine the best course of action to mitigate that risk. The easiest and safest decision may be to lock the door.

Also check with your state and local AHJs as well. They may have regulations that require the door to be locked.

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Jan 29 2015

Frames for Fire Rated Door Assemblies

Category: BlogBKeyes @ 6:00 am

Label for Fire Door FrameDuring the building tour a surveyor observed a label on a frame for a fire rated door assembly that read “Fire Resistant Frame – This frame is identical in construction to a listed frame.  This frame does not bear a listing mark of a testing laboratory because of size, hardware preparation or other limiting factors specified by the user/owner”.  The surveyor initially decided to cite the organization for not having a frame that has  an hourly fire rating on the fire rated door assembly.

Before the survey report could be finalized, it was brought to the surveyor’s attention that NFPA 80 does not require an hourly rating on fire rated door assembly frames. According to NFPA 80, frames in a fire rated door assembly need to be identified that they are fire rated frames, but they do not have to be listed with a specific fire rating. NFPA 80 requires the door frame to be labeled as a fire rated frame, but it does not require the hourly rating to be on the label. It is apparent that a label that says it is a fire rated frame (but with no hourly rating) is good for up to and including 3-hour fire rated door assemblies. After that, the hourly rating needs to be inserted on the frame label.

In this situation the surveyor relented and the finding was not included in the survey report. Another example where a tactful approach explaining the codes and standards to the surveyor can lead to a successful outcome.

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Oct 23 2014

Infant Abduction Locks

Category: BlogBKeyes @ 6:00 am

Hospitals want to keep their nurseries, mother/baby units, and pediatric units secure, so they lock the doors. This causes a problem with the Life Safety Code because you can’t lock the doors in the path of egress in a hospital, other than three exceptions: 1) Clinical needs locks, which nurseries, mother/baby units, and pediatric units do not qualify; 2) Delayed egress locks; and 3) Access-control locks. Access-control locks really do not lock the door in the path of egress because a motion sensor will automatically unlock the door as a person approaches. So, in this situation the doors can only be locked using the delayed egress provision (found in section of the 2000 Life Safety Code).

But hospitals want the infant security systems used on the babies. These systems have a bracelet that is attached to the baby, and some have bracelets to attach to the mother as well. If the bracelet gets too close to the exit door, an alarm will sound and the door will lock. The problem is, these infant security systems do not comply with any of the three exceptions for locking the doors in the path of egress, listed above. Even if the doors will unlock on a fire alarm the hospital says, that is still not enough to qualify for the any of the three exceptions.

But then the hospital says their accreditation organization approved this door locking arrangement. Why should it be considered non-compliant if the accreditor allows it?  Sorry… just because the accreditation organization says it is okay, still does not make it compliant with the requirements of the Life Safety Code. When the state agency who surveys on behalf of CMS takes a look at it, they will not be as benevolent as the accreditor, and they will cite it as a deficiency.

So, to be compliant with the Life Safety Code, when the doors lock because the bracelet gets too close to the door sensor, the doors should lock into a delayed egress mode (again… see section in the 2000 Life Safety Code). Then it would be legal. But the 2012 LSC has made a change in this area and will allow locks on doors for the specialized protective measures for the safety of the occupants (see section 18/ in the 2012 LSC). This will allow you to lock the doors without delayed egress, provided you meet the requirements listed in that section. CMS has already approved categorical waivers to allow hospitals to begin using this new section of the 2012 LSC before they adopt it.

Take a look at your locks that are used on the nurseries, pediatric, mother/baby units, and even the ICUs and the ERs. If they are not delayed egress, then take a look at the CMS categorical waivers and consider modifying the doors to meet those requirements.

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Aug 14 2014

Corridor Doors vs. Cross-Corridor Doors

Category: BlogBKeyes @ 6:00 am

Cross Corridor door web 2I have seen many facility managers (and surveyors for that matter) incorrectly refer to a door as a ‘corridor door’. It appears that they believe as long as the door is accessible from the corridor, then it must be a corridor door. That is not always the case, but it is understandable as corridor doors may be confusing.

A corridor door is a door that separates a room from a corridor, and they are usually mounted parallel to the corridor. Corridor doors are often found on entrances to patient rooms, utility rooms, offices, dining rooms, and the like. Corridor doors are often (but not always) a single-leaf door.

A cross-corridor door is a door that separates a corridor from another corridor, and they usually are mounted perpendicular to the corridor. They are typically used as privacy doors, smoke compartment barrier doors, and fire-rated doors in a horizontal exit or an occupancy separation. Cross corridor doors are usually (but not always) double-leaf doors, and if considered new construction, must be double egress, meaning one leaf swings in one direction and the other leaf swings in the opposite direction.

In reviewing accreditation organization survey reports, I have read where surveyors often refer to ‘corridor doors’ when they really mean something else. According to the Life Safety Code, a corridor door is not required to have a self-closing device (closer), unless it also doubles as a door to a hazardous room, a smoke compartment barrier door, or a fire-rated door. Also, a corridor door must latch, while a smoke compartment barrier door does not have to latch. If a door serves more than one purpose, then the most restrictive requirements must apply.

When referring to the many different types of doors that are accessible from the corridors, always refer to them by their most restrictive requirements:

  • Fire-rated doors to hazardous rooms, exit enclosures, horizontal exits, and occupancy separations
  • Smoke compartment barrier doors
  • Corridor doors to hazardous rooms, or non-hazardous rooms
  • Privacy doors

A privacy door that is a cross-corridor door is not required to latch, or be self-closing; but a privacy door that is a corridor door would be required to latch, since the requirements for a corridor door are more restrictive.

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Jul 31 2014

Smoke Compartment Barrier Door Gaps

Category: BlogBKeyes @ 6:00 am

Smoke compartment barrier doorsI want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor doors that are not fire-rated or used in a smoke compartment barrier are permitted to have gap clearances up to ½-inch in smoke compartments that are protected with sprinklers. In this memo they have conflicting points; the subject line of the memo stated: “Permitted Gaps in Corridor Doors and Doors in Smoke Barriers”, but in the content of the memo they say “This information does not apply to doors in smoke barriers, which have other requirements.”

Click on this link to access this CMS memo:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/CMS1198675.html?DLPage=1&DLFilter=07-18&DLSort=3&DLSortDir=ascending

To be clear, the maximum gap for the proper clearance of smoke compartment barrier doors is 1/8 inch; not ½ inch, and it is not dependent on whether or not the smoke compartment is sprinklered. Sections 18/ of the 2000 LSC references section 8.3.4 of the same code and the Annex section of says the maximum gap for smoke compartment barrier door clearances is 1/8 inch.

The CMS memo addressed corridor doors that are not fire-rated or located in a smoke compartment barrier. Corridor doors are those doors which separate a room or an area from the corridor. Can a corridor door also be a fire-rated door or a door in a smoke compartment barrier? Yes, certainly; and in those situations the more restrictive requirements must apply.

The bottom line: Doors in smoke compartment barriers must not have gap clearances that exceed 1/8 inch per the 2000 LSC. The CMS S&C memo 07-18 only applies to non-fire-rated corridor doors that are not located in a smoke compartment barrier.

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Aug 15 2013

New Construction Corridor Doors

Category: BlogBKeyes @ 5:00 am

door_thickness[1]I was recently asked what the Life Safety Code required for the thickness and composition of a corridor door in new healthcare occupancy construction. The individual asking me the question was thinking of installing 3/4 inch thick doors on nurse server cabinets which open onto the corridor. I recited from memory: 1.75 inch thick, solid-bonded, wood core doors that limit the passage of smoke and have positive latching hardware. There are some basics in life that cause one to memorize such things and corridor doors is just one of those items in the Life Safety Code for me.

The person asking the question asked me to provide the code reference where it says that. So, I looked it up in Chapter 18 (the chapter for new construction in healthcare occupancies) and …. it’s not there. The code is void of that description for corridor doors in the new construction chapter. Section (of the 2000 edition) of the Life Safety Code essentially says corridors doors have to limit the passage of smoke, and they do not have to comply with NFPA 80 , and the distance between the bottom of the door and the floor cannot exceed 1 inch. Also, section says corridor doors are required to positively latch, and roller latches are not permitted. Nowhere in Chapter 18 can I find that the corridor door had to be constructed to be 1.75 inch thick, solid-bonded and wood core. I even pulled out the handbook for the LSC and it was silent on the subject for new construction. I looked up the same section in the 2012 edition of the LSC to see what it says and it too was very silent as well.

So why was I so quick in quoting corridors doors need to be 1.75 inch thick, solid-bonded wood core? Because that is the requirement for corridor doors in existing construction. Oh… Now it makes sense. One needs to remember that section 4.6.7 says in part, that alterations and new equipment needs to comply with new occupancy chapters, and at the very least must meet the requirements for existing conditions. So, I said they cannot install a new corridor door that does not meet the requirements for an existing corridor door, which is 1.75 inch thick, solid-bonded, wood core.

I was asked where in the code it says that and I referred him to section I then read the Exception #2 to which says corridor doors in smoke compartment fully protected with automatic sprinklers are exempt from this requirement, although they are required to be constructed to resist the passage of smoke…. Oops!…. There’s the hidden truth. Corridor doors in existing occupancies located in smoke compartments that are fully protected with sprinklers are not required to be 1.75 inch thick, yada yada yada.

Corridor doors in new construction are located in smoke compartments that are fully protected with sprinklers, so by the definition of section 4.6.7, a 3/4 inch thick door on a nurse server cabinet that opens onto the corridor would be permitted in new construction, as long as it resists the transfer of smoke and positively latches.

Wow… I learned something new that day. It never ceases to amaze me to learn of the little nuances and intricacies involved in understanding the Life Safety Code. That was a good day for me. I really appreciated that question as it made me learn the truth.

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