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 188.8.131.52 (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 184.108.40.206 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 220.127.116.11 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 18.104.22.168.of 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 22.214.171.124 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 126.96.36.199, 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 188.8.131.52, 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 184.108.40.206 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 220.127.116.11 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.