ASC Soiled Utility Room

Q: How does one handle a “Soiled Utility” room in an Ambulatory Healthcare Occupancy? If it is a small storage room without large volumes of flammable liquids, but perhaps containing soiled linens, are there any special fire protection features that need to be included?

A: Soiled utility rooms in ASCs are treated differently than they are in hospitals and healthcare occupancies. Where chapters 18 and 19 specifically identify soiled utility rooms as hazardous areas for healthcare occupancies, chapters 20 and 21 do not for ambulatory healthcare occupancies.

But chapters 20 and 21 refer to chapters 38 and 39 for “Protection from Hazards” and it does identify ‘storage rooms’ as a hazardous area and must comply with section 8.7. Section 8.7.1.1 requires the hazardous room (i.e. soiled utility room in ASC) to be protected in one of the following two ways:

  1. Enclosing the room with 1-hour fire rated barriers, that would include a ¾ hour fire rated door assembly that is self-closing and positive latching, or:
  2. Protect the room with sprinklers.

That’s what you need to do.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.