Jul 30 2018

Clean Utility Rooms

Category: BlogBKeyes @ 12:00 am

Q: What is the guidance on clean utility rooms and door closers? Under 50 square feet no closer is required, but over 50 square feet a closer is required? Does the clean utility room being located inside a suite make any difference? The normal supplies in there could be considered combustible based on the NFPA definition.

A: You have the 50-square foot limit correct, but it does not matter if the clean utility room is located in a suite or not. It still must meet section 18/ for hazardous areas. If it is a new clean utility room and is over 100 square feet, then it must be 1-hour fire-rated, have a 3/4-hour fire-rated self-closing door, and be protected with sprinklers. If it is a new clean utility room and is over 50 square feet but does not exceed 100 square feet, then the room does not have to be 1-hour fire-rated but must be protected with sprinklers and a self-closing door.

For existing construction, if the clean utility room is larger than 50 square feet then the walls must be either 1-hour fire-rated construction and the door is a 3/4-hour fire-rated self-closing door, or the room is protected with sprinklers and the walls are smoke resistant and the door is smoke resistant and self-closing.

However, the room may meet an exception found in section (2), regarding rehabilitation. A change in use of a space in an existing healthcare occupancy does not have to meet new construction requirements for hazardous areas, provided the space does not exceed 250 square feet and the entire building is protected with sprinklers. But the space does have to meet the requirements for hazardous areas for existing conditions, which is a non-rated smoke resistant self-closing door, and smoke resistant construction for the walls.

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Jan 17 2018

Hazardous Area in Surgery

Category: BlogBKeyes @ 12:00 am

Q: Are clean cores for operating room suites considered hazardous thus required to be separated by a 1-hour fire-rated barriers? I have a client who was informed by their accreditation organization that their existing clean (sterile) core area needed to be upgraded to provide a 1-hour separation. The space is typically occupied and is larger than 100 square feet in a building fully protected by automatic sprinklers.

A: It depends… Is the hospital storing combustible supplies in the core area? If so, then the core area must meet the requirements for hazardous areas. Combustible supplies commonly found in core areas of Surgery are:

  • Paper-wrapped utensils that have been sterilized and waiting for use in surgery
  • Dressing, bandages, sutures, and medical equipment and supplies that are packaged in plastic, cardboard, chip-board, and paper
  • Other supplies that create a hazardous environment

The next issue is, does the hazardous area have to meet new construction requirements to be 1-hour fire rated and be fully sprinklered, or does the hazardous area qualify for the lesser requirements for existing conditions of being protected with 1-hour fire rated construction or smoke resistant construction and being fully sprinkelred? The answer to that question lies in which edition of the Life Safety Code was in effect at the time the core area was constructed or last renovated. If the core area was constructed or last renovated since the 1985 edition of the Life Safety Code was in effect, then yes, the core area is required to be protected with both 1-hour fire-rated construction and be fully sprinklered. (The 1985 edition was adopted by CMS, or the fore-runner of CMS, around January, 1988.) Subsequent editions of the Life Safety Code required new construction hazardous areas to be both 1-hour fire-rated protected and sprinklered. However, if the core area was constructed or last renovated before the 1985 edition of the Life Safety Code was in effect, then the core area is considered existing construction by today’s standards and qualifies for the existing conditions standards of being smoke resistant construction and fully sprinklered.


Jan 10 2018

New vs. Existing Construction

Category: BlogBKeyes @ 12:00 am

Q: Our hospital facility was constructed under the new construction chapter 18 in 2000 Life Safety Code, but is now considered existing conditions under the 2012 Life Safety Code. We have a soiled linen room that is greater than 100 square feet, and is sprinkled, and the door needs to be replaced due to damage. Does the door still need to be a 45-minute fire-rated door assembly, now that the facility is in the existing category of chapter 19?

A: Yes, it does, because sections 4.5.8 and of the 2012 LSC says once a feature of life safety is required by the LSC, you must maintain that for the life of the building unless the new construction requirements change and no longer require it. Also, section says the existing feature of life safety cannot be removed where such feature is a requirement for new construction. So, you need to replace it with a properly rated fire door assembly for new construction. The reason there is an existing healthcare chapter that does not require a ¾ hour fire-rated door on a hazardous room, is it is for the older hospitals that built hazardous rooms when they were not required to be 1-hour fire rated. They are permitted to remain in use without having to meet the new construction requirements. But since your facility was constructed under the 2000 LSC that did require 1-hour fire rated hazardous rooms, you need to maintain that for the life of the building.


Dec 11 2015

Kitchens as Hazardous Areas – Revisited

Category: BlogBKeyes @ 12:00 am

Q: You recently posted a question about whether or not hospital kitchens are hazardous areas. Your response noted that kitchens are not included in the list of 8 specific scenarios listed in While that is true, Cooking Facilities would seem to cover the hazards found in a kitchen (aside from the storage areas associated with a kitchen). requires compliance with 9.2.3 which in turn references NFPA 96. It would seem that if the criteria of NFPA 96 is met, then it would not be necessary to define the kitchen itself as a hazardous area. Storage areas associated with a kitchen (particularly dry stores) would be hazardous areas. Am I overlooking something, or is a kitchen where the cooking facilities comply with NFPA 96 not a hazardous area?

A: We both agree that kitchens are not listed in the specific areas found under 18/ of the 2000 Life Safety Code. I agree with you that 18/ of the 2000 LSC requires cooking facilities (kitchens) to be protected in accordance with 9.2.3 of the 2000 LSC, which in turn requires compliance with NFPA 96, 1998 edition. NFPA 96, 1998 edition includes language that requires fire extinguishing systems in the exhaust hoods used in commercial kitchens.

Nowhere in 18/, 18/, 9.2.3, or NFPA 96 addresses whether or not kitchens are hazardous areas. It simply is not discussed, so there is no reference to draw on to say that kitchens are (or are not) hazardous areas. So, why do I believe they are hazardous areas? Take a look at section in the 2000 LSC, which defines hazardous areas as: “An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.” (Underline mine). I think we would all agree that cooking appliances are heat-producing appliances.

So, NFPA defines an area with heat producing appliances as a hazardous area, which applies to kitchens since they have heat-producing appliances. Going back to in the 2000 LSC, it says any hazardous area shall be safeguarded, and it continues to describe how the hazardous area must be safeguarded. Section of the 2000 LSC has a similar approach to safeguarding hazardous areas, but it takes into the account that all new or renovated areas must be sprinklered.   

So, from the NFPA definition of a hazardous area alone, it is apparent that kitchens are hazardous areas, and according to 18/ they have to be safeguarded. To address your question directly; there is no language in the 2000 Life Safety Code that says if kitchens comply with NFPA 96, they are not considered hazardous areas. I recently took this issue to the national authorities having jurisdiction (AHJ) over hospitals and asked them directly if they considered kitchens to be a hazardous area solely based on the NFPA definition of hazardous areas according to the 2000 LSC, and here is what they said:

  • CMS:                          Yes, kitchens are hazardous areas
  • HFAP:                        Yes, kitchens are hazardous areas
  • DNV:                         Yes, kitchens are hazardous areas
  • Joint Commission:      No, kitchens are not hazardous areas

So, most of the national AHJs say kitchens are hazardous areas, but Joint Commission (the accreditor who accredits the most hospitals) says they are not. I remind you that hospitals have to comply with all of the AHJs standards and interpretations, so if a hospital is Joint Commission accredited and receives funds for Medicare & Medicaid services, then they must treat kitchens as hazardous areas because CMS says they are even though Joint Commission says they are not.

Now, the technical committee for NFPA 101 (Life Safety Code) understood this dilemma and decided to make a change. Take a look at section 18/ of the 2012 LSC, which says: “Where cooking facilities are protected in accordance with 9.2.3, the presence of the cooking equipment shall not cause the room or space housing the equipment to be classified as a hazardous area with respect to the requirements of 18/, and the room or space shall not be permitted to be open to the corridor.” So, when the 2012 edition of the LSC is finally adopted, this whole issue of “is a kitchen a hazardous area?” will finally be resolved and everyone will be on board with the same interpretation. Then, the LSC will agree with your point, that as long as kitchens comply with 9.2.3 and NFPA 96, they will not be have to be classified as hazardous areas.

Thanks for being a reader….

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Jul 12 2012

Are Kitchens Really Hazardous Areas?

Category: BlogBKeyes @ 5:00 am

If you read my Q&A on kitchens being hazardous areas, which was posted last Sunday (July 8th), then you may have been surprised by my position that kitchens are considered hazardous areas in healthcare occupancies. I know many readers are and they were not in the least bit bashful to tell me so. Some flat out told me I was wrong.

The question that the reader asked was “Is the main kitchen in a hospital considered a hazardous area? I’m referring to the main kitchen where all the food is prepared for the hospital, not the kitchenettes that are located on the units.” This individual went on to say that her hospital kitchen was cited for not being protected as a hazardous area.

My reply was I believe kitchens are hazardous areas based on the NFPA definition of hazardous areas, found in section of the 2000 edition of the LSC: “An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.” The last time I looked, kitchens have heat producing appliances, therefore kitchens are hazardous areas.

But that’s not the full picture. Section of the LSC says: “Where specific requirements contained in chapters 11 through 42 differ from general requirements contained in chapters 1 through 10, the requirements of chapters 11 through 42 shall govern.” The definition of hazardous areas is found in Chapter 3. The provisions for healthcare are found in chapter 18 and 19, and as far as I can see, there is nothing in those chapters that differs with the definition of hazardous areas found in chapter 3. Therefore, there is no conflict (or difference) between these chapters. My point being, I cannot find anything in the healthcare chapters that would override the definition found in chapter 3. Therefore, the definition must stand on it’s own merit, and it applies to kitchens in the hospital.

Those individuals that protested my answer all cited the same reason: The NFPA technical committee on healthcare occupancies never wanted kitchens to be a hazardous area. In fact, I learned from one of them that prior to the 1985 edition of the LSC, kitchens were in fact identified in the occupancy chapters as a hazardous area, along with many of the current areas, such as boiler rooms, paint shops, repair shops, storage rooms (over 50 square feet containing combustibles) and the like. However, the technical committee preparing the 1985 edition decided to remove kitchens from the list of hazardous areas and require them to have fire suppression systems as defined by NFPA 96. But the list of hazardous areas found in the healthcare occupancy chapters was never intended to be all inclusive. It is representational, and furthermore, it stipulates all hazardous areas to comply with section 8.4, which requires 1-hour fire rated barriers, or sprinklers. Nothing in the healthcare occupancy chapters said kitchens were exempt from being considered hazardous areas. The technical committee may have meant that, but the LSC doesn’t say that.

If you were to call the NFPA liaison to the healthcare occupancy chapters for the LSC, and asked them if they considered kitchens to be hazardous areas, I’m sure they would say no. The NFPA has dealt with this issue and they firmly believe that kitchens are not hazardous areas. In fact, the technical committee went so far in the new 2012 edition to specifically say that kitchens that comply with NFPA 96 are NOT to be considered hazardous areas. But that language is not in the 2000 edition, which is the edition that most hospitals must comply with. Also, here’s one important fact that many of the objectors seemed to conveniently overlook: The NFPA only writes the LSC, they do not enforce the LSC. Basically (and I don’t mean to be rude when I say this), it doesn’t matter what the NFPA says, it only matters what the NFPA writes, and the 2000 edition of the LSC says areas with heat producing appliances are hazardous areas.

Authorities having jurisdiction (AHJ) worth their salt must enforce what is written in the LSC, not what people (including me) says the LSC means. Even the opinions from life safety experts at NFPA are not what the AHJs should base their interpretation on, but only what the written code says. Otherwise, the code keeps getting interpreted differently depending on who you talk with. I did a poll of my contacts from the four major AHJs who enforce the LSC in hospitals and here is what I found out:

The Centers for Medicare & Medicaid Services (CMS) considers kitchens in hospitals to be hazardous areas. This interpretation is considered unofficial, as CMS rarely issues official interpretations, and when they do it takes months or years for them to issue one.


The Joint Commission does NOT consider kitchens as hazardous areas in hospitals. This is an official statement from their public relations department. It really does not surprise me that TJC feels this way as they have been known to “pick and choose” certain requirements of the NFPA codes to follow and not follow.

The American Osteopathic Association / Healthcare Facilities Accreditation Program (HFAP) officially considers kitchens in hospitals to be hazardous areas.

Det Norkse Veritas (DNV) officially considers kitchens in hospitals to be hazardous areas.

So, 3 of the top 4 AHJs who survey hospitals consider kitchens to be hazardous areas in hospitals. The 3 accreditors (TJC, HFAP and DNV) receives their authority to accredit hospitals from CMS and if one of them has a differing opinion (such as TJC) than CMS, that’s a conflict. Don’t look for this to become a big issue, however. Since the 2012 edition has already resolved this, and since CMS is seriously looking to adopt the 2012 edition, this conflict goes away once the finally do.



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Jan 01 2012

Understanding Hazardous Rooms

Category: BlogBKeyes @ 6:05 pm

The following article was first published in the October, 2011 issue of FacilityCare magazine. 

In my line of work as a consultant, I work with facility managers, safety officers and accreditation professionals in the healthcare industry, and I find there is a wide range of understanding (or should I say misunderstanding?) when it comes to interpreting the Life Safety Code® (LSC). One of the more confusing areas of compliance is the subject of hazardous rooms.

I had a recent conversation with a member of the technical committee on health care occupancies for the LSC and he told me the National Fire Protection Association (NFPA), who writes and publishes the LSC, purposely does not make definitive statements on how the code is to be interpreted on certain subjects, but rather they prefer to leave some interpretation up to the authorities having jurisdiction (AHJ). There is not a better example of this indecisiveness in the LSC as the section that describes hazardous rooms. Section (7) of the 2000 edition of the LSC, is one description of what a hazardous room could be, and it is described as: “Rooms or spaces larger than 50 ft², including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction (AHJ).” So, the key words here are “in quantities deemed hazardous by the AHJ”. I have been asked many times by hospital facility managers, how many combustible supplies are needed to qualify as “hazardous” by an AHJ?

That answer is not an easy one to make, as this is a judgment call, and the only person whose judgment matters is the AHJ. The typical hospital has 5 or 6 different AHJs that will inspect their hospital for compliance with the LSC, or a similar fire safety code. They are:

  • The Joint Commission
  • The Center for Medicaid and Medicare Services (CMS)
  • The state Department of Public Health (or similar jurisdiction)
  • The state Fire Marshal
  • The local Fire Inspector
  • The hospital’s insurance carrier

By the way, there is another AHJ that is often overlooked, and that is the hospital Safety Officer. The definition from the LSC of an AHJ is “The organization, office, or individual responsible for approving equipment, materials, an installation or procedure”. I would condense that definition down to anyone who enforces the LSC, and the hospital Safety Officer is charged with the responsibility to intervene whenever environmental conditions threaten life or health, and is often charged with the responsibility to ensure compliance with the LSC. Therefore, the hospital Safety Officer is definitely an AHJ, but don’t get any ideas of over-riding the decision of another AHJ. No AHJ can over-ride the decision of another AHJ, but can interpret the codes accordingly.

So, the opinion of the AHJ is the one that matters when determining how many combustible supplies are needed to cross the threshold of combustibles which qualifies a room or area as hazardous. Since there are 5 or 6 AHJs who may make that determination, it is prudent to be very conservative in your own assessment in order to be in compliance. What I have observed over the years, is some AHJs are citing a room or area as hazardous if it contains only one shelf full of cardboard boxes, supplies wrapped in paper or plastic, or linens. Just one shelf, not the entire room. When I’m asked to make an assessment on this issue, I have to advise my clients of this strict interpretation and suggest they either remove the combustible supplies or convert the room to meet the requirements of a hazardous room.

There are different requirements on how a room is to be constructed to qualify as a hazardous room, depending on 2 factors: 1). Is the room new construction or existing construction? and 2). If existing construction, has the room been converted from some other use to now be a hazardous room? The basic differences between these two factors are the fire rating of the walls and door, and the room being protected with automatic sprinklers.

Let’s start with new construction. Chapter 18 of the LSC is the chapter to follow for new construction. So, our scenario is you are building a new addition from ground up and you have designated a storage room that will have some combustible supplies. Since chapter 18 requires all new construction to be protected with automatic sprinklers, this designated hazardous room will also be required to be sprinklered. Table allows storage rooms greater than 50 sq. ft., but not exceeding 100 sq. ft. to have walls and doors constructed that resists the passage of smoke, and the doors must self-close and have positive latching hardware. For new construction storage rooms designated as hazardous rooms greater than 100 sq. ft., the walls must be 1-hour fire rated and extend from the floor to the deck above, and have doors that are ¾ hour fire rated, self-closing and positive latching.

But the interpretation for existing construction is a bit trickier. Our scenario now is you remove a patient room from service and want to use it as a storage room for combustible supplies. This qualifies as a change in use of the room, and section 4.6.7 of the LSC states “Any alteration or any installation of new equipment shall meet, as nearly as practicable, the requirements for new construction.” A change of use in a room is an alteration, so new construction requirements, as described above, must apply. If the room is greater than 100 sq. ft. this means the walls must be 1-hour fire rated and the door must be ¾ hour fire rated, self-closing and positive latching, and the room must be protected with automatic sprinklers since it has to meet new construction requirements. This may be an expensive proposition as many patient rooms were not constructed to have 1-hour walls and fire rated doors, not to mention the cost of adding sprinklers if the room is not protected already.

Existing storage rooms that are larger than 50 sq. ft., and contain combustible supplies and were constructed as such when the facility was originally built are provided with an option, as described in section of the LSC. The room is required to be safeguarded with 1-hour fire rated walls, ¾ fire rated self-closing, positive latching doors, or if the room is protected with automatic sprinklers, then the walls are required to be smoke resistant and are permitted to be non-rated and extend from the floor to the ceiling (rather than to the deck above), and the door is permitted to be non-rated, but it has to resist the passage of smoke and it has to have a self-closing device (closure). You will note that storage rooms containing combustible supplies, and are 50 sq. ft. or less are not required to meet this definition of hazardous rooms, This describes the basic closet found in many locations around a hospital.

Now, it is important to note that a storage room that does not contain any combustible supplies does not have to be considered a hazardous room, regardless of its size. So, if you have a storage room that only has non-combustible equipment stored in it, then there is no code requirement to make it a hazardous room. However, the issue with this scenario is many storage rooms that were designated to store only non-combustible equipment (such as wheelchairs, patient lift equipment, medical equipment, etc.) end up also storing supplies that are packaged in combustible wrapping. That changes the equation and now the room could very well be viewed as a room that is required to meet hazardous room qualifications.

So, what about those patient rooms that were removed from service 20 years ago and converted to storage rooms that now contain combustible supplies? Do those rooms have to meet new construction requirements? Well, that answer depends on which AHJ you talk to. Both Joint Commission and CMS have offered up a date and they say anything that has been approved for construction prior to that date is considered existing construction, and anything approved on or after that date is considered new construction. This is a helpful distinction that these two AHJs have made which help hospitals in making this decision. The problem is, they cannot agree on the date, although it is very close. Joint Commission states any plans for new construction, renovations, additions or changes in occupancy approved by the local AHJ after March 1, 2003 is considered new construction. CMS provides the date of March 11, 2003 instead. Similar dates, but not the same. The reason March 11, 2003 was chosen by CMS is that is the date when they adopted the 2000 edition of the LSC for hospitals. When Joint Commission published their standards for 2003, they expected CMS to adopt the 2000 edition of the LSC in March but did not know the exact date, so they made their best guess and they were pretty close.

But the March, 2003, date for new vs. existing construction only applies to Joint Commission and CMS, and not necessarily to the other AHJs. I have more than one state Department of Public Health official tell me that they do not recognize a specific date to determine new construction requirements or existing. They say they go by what was required by the code at the time of the alteration or renovation. So that patient room that was converted 20 years ago to a storage room with combustible supplies would not have to meet new construction requirements according to Joint Commission or CMS, but would have to comply with new construction requirements according to the state’s interpretation, since the LSC at the time did require alterations to meet new construction requirements.

Confusing? It can be, but that’s not all. Section the LSC (2000 edition) defines a hazardous area as “An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.” That definition of a hazardous area is a bit more precise than what section provides, which also specifies what a hazardous area is in a healthcare occupancy. The issue of heat-producing appliances raises the level of the definition to include kitchens. Boiler rooms and fuel-fired heater rooms are hazardous rooms according to, but kitchens are not on that list. Now, who could argue that kitchens do not contain heat-producing appliances? That’s what kitchens do, by definition. By the definition in, kitchens could very well be considered a hazardous area. And what about toasters, toaster ovens, and coffee makers that are frequently found in staff lounges or break rooms in hospitals? Those are heat producing devices, aren’t they? Should those staff lounges and break rooms be classified as hazardous rooms? Well, these are all interesting questions, but the answers must come from the AHJs. It really doesn’t matter what you and I believe, unless you are an AHJ yourself.

My experience is kitchens are commonly considered hazardous rooms by many AHJs. Some Joint Commission surveyors and some CMS inspectors will classify kitchens as hazardous rooms, but it is not a definitive or formal interpretation across the board by all surveyors. As far as break rooms or staff lounges that have coffee makers and toasters, those are frequently overlooked and not considered hazardous rooms, as the quantity of heat produced by these devices is not significant. But throw in a toaster oven, and things start to change. A toaster oven is different in that you can set it for 450º and it will stay at 450º until it burns up or burns something else. Those are frequently not permitted by hospital policy, and if they are permitted, it is usually by conducting a risk assessment to allow them.

Gift shops are also an overlooked commodity by hospitals and the architects who design them. Section of the LSC stipulates that the gift shop must be protected as a hazardous area when they are used for the storage or display of combustibles in quantities considered hazardous. Again, who makes this decision if the quantity of combustibles is hazardous? The AHJ, of course. The problem I find when I visit hospitals is the gift shop is full of combustibles, such as greeting cards, T-shirts, stuff toys, and other gifts packaged in combustible wrapping. What I learn is, during the designing phase the architect was never told what would be on display in the gift shop and makes an assumption there would not be anything combustible. Therefore, the gift shop is designed not to meet hazardous room requirements, which later becomes a problem when the gift shop opens up for business and displays all of the combustible items. I have seen some gift shops in small hospitals that do not display combustibles and therefore do not have to meet the hazardous room designation, but those are few and far between.

So, to summarize, sections 19.3.2 (for existing construction) and 18.3.2 (for new construction) of the LSC spell out definitely what a hazardous room is in a healthcare occupancy. The list includes:

  • Boiler rooms and fuel-fired rooms
  • Bulk laundries larger than 100 square feet
  • Paint shops
  • Repair shops
  • Soiled linen rooms
  • Trash collection rooms
  • Rooms or spaces larger than 50 square feet used to store combustible supplies in quantities deemed hazardous by the AHJ
  • Laboratories containing flammable materials in quantities less than what would be considered a severe hazard (Note: There are additional fire safety requirements for laboratories that contain flammable materials in quantities that would be considered a severe hazard.)
  • Gift shops containing combustibles in quantities deemed hazardous

In addition, the definition of a hazardous area found in section of the LSC includes areas with heat producing appliances, which can be interpreted to include kitchens.

How your hospital protects these rooms and areas is dependent on whether or not the area is considered new construction, or existing construction. I suggest you be very conservative in making any determinations about hazardous areas as some AHJ down the road will be someday make the same conclusion. It would be a prudent move to ask your AHJs what their interpretation of a hazardous area is before you make an incorrect assumption.