Entries by BKeyes

Gift Shops

Q: Are hospital gift shops required to be treated as hazardous areas? We had a survey recently and the inspector said the entrance door to our gift shop needed to have positive latching hardware. A: This is one of those “it depends” answers. Section 19.3.2.5 of the 2000 Life Safety Code clearly states that gift more »

Wires Strapped to Sprinkler Pipe

Q: Another hospital in our area recently had a survey and they were cited for communication wires that were strapped to the sprinkler pipe above the ceiling. I have not heard of this as being a problem. We have the same situation in our hospital. Do we have to remove these cables from the sprinkler more »

Use of Elevators During Fire Alarms

Q: We have in our fire policy that someone is to be posted at the elevator during a fire alarm to make sure no one uses the elevator. I believe this is only necessary if the elevator is located in the smoke compartment that is identified for the origin of the fire. Even then, the more »

Locked Doors on Soiled Utility Rooms

Q: Do soiled utility room doors have to be locked all the time? I was informed by our VP Quality Assurance that all of the soiled utility room doors must be locked, but I do not see any requirement for this in the Life Safety Code. A. Soiled utility rooms are defined as hazardous rooms, more »

Video Equipment Storage

Q: Is there a specific fire code requirement for an equipment room containing electronic video conference equipment? I have been told there are specific requirements for electrical and mechanical rooms, but I do not find anything specific for video equipment. A: Electrical rooms have specific requirements that are found in NFPA 70-1999 National Electric Code more »

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 »