Entries by BKeyes

Smoke Detectors in Hospitals

Q: Are smoke detectors required to be installed in the corridors of hospitals? I attended a seminar recently and the instructor said we did not need them in the corridors. We have them in corridors and patient sleeping rooms in our hospital and I thought the Code required them. A. Generally speaking, the Life Safety more »

Hazardous Areas in Business Occupancies

Q. Do hazardous areas in business occupancies require a self-closing door if the room is protected with automatic sprinklers? We had a surveyor cite us for not having a closure on the door to a storage room that is considered to be hazardous. A.  Existing business occupancies are required to follow chapter 39 of the more »

Testing of Delayed Egress Locks

Q.  We have delayed egress locks in our hospital and during a recent inspection a fire marshal said we had to test the locks on an annual basis. Is this true? If so, what are we supposed to be testing? A.  Although the Life Safety Code occupancy chapters for healthcare (chapters 18 and 19) permits more »

Evacuation During a Fire Alarm

Q. Should a free standing medical office (business occupancy) be required to evacuate everyone when an alarm is pulled?  In this situation the building is a single story and has a sprinkler system. A. Yes, generally speaking, occupants in free standing medical offices should evacuate the building whenever the fire alarm is activated, unless there more »

Interim Life Safety Measure Implementation

Q: The Joint Commission’s standard on Interim Life Safety Measures (ILSM) requires the hospital to implement ILSM for deficiencies to the Life Safety Code (LSC) when the deficiency cannot be immediately corrected. Please define the time-frame that they mean with the word “immediately”. Can the implementation of an ILSM wait until the Safety Committee approves more »

Mechanical Rooms & Exit Enclosures

Q: We have a mechanical room in our hospital whose entrance door opens into the top of an exit stairwell. I was informed by a consultant that this arrangement is not permitted and we must create a vestibule so the mechanical room does not open directly onto the stairwell. Is this true? If so, is more »

Magnetic Latches on Suites

Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching.  The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our more »

Corridor Width in Office Areas

Q: Why are corridors within the business offices of our hospital permitted to be 44” rather than the 8’ that the rest of the hospital has to maintain? Our hospital is considered 100% existing healthcare occupancy, with no mixed or separated occupancies. A: Section 19.2.3.3 of NFPA 101-2000 Life Safety Code refers to exit access more »

Carpet Used as Cove Base

Q: In the February issue of Healthcare Life Safety Compliance, I found your article on Interior Finish Requirements to be helpful, but it did raise a question for me.  In most areas where carpet is installed, a 6″ banded carpet cove base is used in lieu of a rubber top set.  Is this 6″ banded more »

Building Maintenance Program

Q: We currently have a Building Maintenance Program (BMP) that surveyors said was a good program during recent surveys. However, I’ve learned that the Joint Commission no longer offers scoring advantages for a BMP, and since this program requires quite a bit of time and resources, my VP wants us to discontinue it. Are there more »