Suites in AHCO

Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion?

A: Well… that surveyor is mistaken. Suites are definitely permitted in ambulatory health care occupancies (AHCO). Sections 20/21.2.4.3 of the 2012 LSC specifically permit suites and says any site larger than 2500 square feet must have at least two exit access doors remotely located from each other.

The term ‘remotely located’ is defined by section 7.5.1.3.2 which says the two exits must be located at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the suite, measured in a straight line between the nearest edges of the exits. In a fully sprinklered building, section 7.5.1.3.3 says it is 1/3 the length of the maximum overall diagonal dimension of the suite.

There are no size limitations on suites in AHCO. And they are not prohibited in business occupancies either, even though there is no advantage to having them in business occupancies. I suggest you ask the surveyor (if he/she is still with you) to show you where in the LSC it prohibits suites in AHCO. I also suggest you ask your state and local authorities if they have any restrictions that would prohibit suites in AHCO.

New vs. Existing Construction

Q: How do we classify existing versus new construction? Do we look at the date of adoption of the current Life Safety Code as the cutoff? Anything constructed before that date is considered existing construction? The 2000 LSC required areas of major rehabilitation to be classified as new construction. The 2012 LSC appears to just require those areas be fully sprinklered. On our Life Safety plans all areas of the hospital were constructed prior to the adoption of the 2012 Code. Can the entire hospital now be considered existing and can we remove all notes on the plans referring to new construction?

A: According to the CMS Final Rule on adopting the 2012 Life Safety Code which was released in May, 2016, they identified July 5, 2016 as the threshold date to differentiate between new construction and existing conditions. However, the 2012 Life Safety Code says in section 4.6.12.1 that whenever a feature of life safety is required for compliance, it must be maintained as such for the life of the building. Section 4.6.12.2 continues to say that features of life safety shall not be removed or reduced where such features are required for new construction.

What this means, is you cannot down-grade a feature of life safety that was installed under new construction requirements, to meet existing condition requirements now that it is no longer considered new construction. It is true that something built prior to July 5, 2016 is now considered existing conditions, but you still are not permitted to down-grade the feature to meet existing condition requirements.

Smoke Door Testing?

Q: The Joint Commission standard for annual door testing states “The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested”. The Joint Commission also references NFPA 105 (smoke doors). Would this include all smoke barrier doors?

A: It appears you have an older copy of the Joint Commission standards. In January, 2019, the standard in which you refer has been changed to specifically identify the need to inspect and test fire door assemblies. Their note to this standard says nonrated doors including smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.

It is the position of CMS and all accreditation organizations that non-rated doors in smoke barriers (barriers that separate smoke compartments) do not have to be inspected on an annual basis.

Here is why: Even though section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested, that conflicts with the occupancy chapter for healthcare. Section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing).

Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies. Now… you may have an AHJ that believes differently. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but ultimately they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC.

Life Safety Drawings

Q: The hospital where I work is leased, and the landlord is not a healthcare architect and pushes back on everything. My need is to have the life safety plan drawings updated to reflect proper boundaries and identification of the smoke compartments, hazardous areas, door assembly ratings, suites with sleeping or non and size, etc, etc.. Is there a standard or code which prescribes “requirements” or at least the expectation for what types of info should be on the LS plan?

A: Yes…. Every accreditation organization has some sort of standard or requirement that sets expectations regarding Life Safety drawings. Ironically, neither NFPA or CMS has any standard that requires Life Safety drawings yet the state agencies surveying on behalf of CMS will expect that you have an accurate set of Life Safety drawings.

Life Safety drawings are considered operational documents (not unlike a management plan or a policy) and I could see where a landlord is not responsible for providing operational documents for you at no charge. I suggest you contract with your own favorite architect to create these LS drawings, because a reluctant landlord will do you a lousy job at best.

Joint Commission’s standard identifies their minimum requirements for Life Safety drawings:

  • Identify areas of the building that are sprinklered
  • Identify locations of hazardous areas
  • Identify locations of all fire-rated barriers
  • Identify locations of all smoke-barriers
  • Identify the locations of all suites and identify the size of each suite in square footage
  • Identify the location of smoke compartments
  • Identify the locations of all chutes and shafts
  • Identify locations under approved waivers or equivalencies

NFPA 99 Risk Assessment

Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never had an assessment done in the past but it is my understanding that it became a requirement in 2016. The CMS has established compliance requirements (K Tag) for risk assessment and its completion. Who would be the qualified personnel to perform this procedure and create a formal and documented risk assessment?

A: According to members of the Technical Committee who wrote the new Chapter 4 in NFPA 99-2012, the original intent was the risk assessment only applies to new construction. However, the way chapter 4 is written, it is not clear that the risk assessment is only applicable to new construction.

CMS has instructed the accreditation organizations and the state agencies who survey on the behalf of CMS to require all hospitals to have completed their NFPA 99 risk assessment for new as well as existing construction. Therefore, hospitals must conduct the risk assessment for new and existing conditions. These assessments are not difficult to do and only takes a few minutes.

There is no requirement to make a room-by-room assessment, but the intent is to assess the risk of the entire system if it were to fail and there were no back-up systems. It would stand to reason that most hospital systems would be Category 1 or Category 2. Anyone may conduct the assessment, but would have to have knowledge of the risk assessment process and knowledge of the facility.

Hand Washing Sinks

Q: We have a relatively new Infection Control team.  They are performing rounds and having mock surveys with a nurse-consultant that cites issues from the 2014 FGI in areas that are much older.  The issue comes in when we are required to install new sinks (dirty, clean and a hand washing) in existing spaces.  We are a mixed hospital, some new that has to meet 2014 FGI due to new renovations.  What are your thoughts on the older areas that have not been renovated?  I am working with a design professional to see how he would design a space for the number of sinks and what reference he should use.  If it is simple and best practice to install them, I am all for it but some of the renovations come with a significant space or capital impact.  I am not sure if this is something you can help guide with or not.

A: According to Joint Commission’s standard EC.02.06.05, EP 1, the FGI Guidelines (2014 edition) is only used when planning for new, altered, or renovated spaces. Tell the nurse-consultant surveyor she is mistaken. She cannot apply a new guideline to an existing condition.

Now… if there was a requirement to have hand-washing sinks in the room at the time the room was designed or renovated, then she is correct and the sinks need to be installed. But if she plays that card, then she needs to provide evidence that there was a regulation (state, local, or otherwise) that required the sink at the time the room was designed and constructed.

Risk Assessments

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk level on the impact to patients/staff assuming the item being assessed would not be available or functional? We are performing a risk assessment on facility systems and medical equipment and are wondering what the standard is in the approach.

A: It sounds like you’re referring to the NFPA 99-2012 risk assessment for building system categories. If so, then the assessment is conducted with the assumption of the worst-case scenario, whereby the systems being evaluated fail and back-up systems (i.e. emergency power generators) fail as well. According to section A.4.1 of NFPA 99-2012, the category definitions apply to equipment operations and are not intended to consider intervention by caregivers or others. Also, the Introduction to Chapter 4 in the NFPA 99-2012 Handbook, the authors say:

“Each system must be evaluated for its impact on both the patients and the caregivers if the system should fail. Based on the worst-outcome scenario of a failure’s impact, the system is assigned a category. The chapter on that system the describes the requirements for the selected category.”

Be aware that the chairman of the Technical Committee who wrote this new chapter 4 for NFPA 99-2012 told me the intent was for the risk assessment to be on new equipment only, and existing equipment was exempted. However, chapter 4 of NFPA 99-2012 does not say that, and CMS is requiring all certified hospitals to have this risk assessment conducted on existing equipment as well as new. So, I recommend to my clients to do the assessment (it only takes a few minutes) on all existing and new equipment until such time CMS changes their minds.

Blanket Warmers

Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the same as having a space heater?

A: No… Portable space heaters are regulated by section 19.7.8 of the 2012 LSC. Blanket warmers are not regulated by the LSC.

However, blanket warmers are unofficially regulated by the accreditation organization and by CMS. While there are not specific standards that address blanket warmers, surveyors will expect the hospital to regulate their blanket warmers via their own policies. The hospital is expected to have a policy that sets the maximum temperature that the blankets may be. Usually, the maximum temp is set at 130 degrees F. Anything over that will likely be scrutinized by a surveyor.

Blanket warmers are considered medical equipment and must be included in the medical equipment inventory, and they must be maintained in accordance with the manufacturer’s recommendations.

Clinical Needs Locks

Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required single path of egress? (All options have 4 locked doors in the path.)

A: The 2012 Life Safety Code does not address any restrictions on how many doors in the path of egress may be equipped with Clinical Needs locks. Therefore, if the LSC does not prohibit it, then it is permitted.

However, not all AHJs permit it. For example; I am told that the IBC prohibits more than one Clinical Need lock in the path of egress (or, at least they used to). When I worked at the hospital, I tried to get the state to allow two locked doors in the path of egress from the Psychiatric unit but they would not allow it.

But in my travels, I have seen multiple doors in the path of egress equipped with Clinical Needs locks where permitted in various states around the country. The most common use of multiple Clinical Needs locks create a ‘Sally Port’ or ‘airlock’ that allows one locked door to open but the other locked door must be closed. This is an added security to prevent anyone from eloping.

So, the LSC does not prohibit it, but the IBC and some AHJs do.

Emergency Management

Q: Regarding the new CMS rule on emergency preparedness, are they telling us that we must have full heating and cooling support for the entire hospital during a power outage up to and including adding more generators?

A: No… I don’t believe it is. Section 482.15 (b)(1)(ii)(A) says, “The hospital must develop and implement emergency preparedness policies and procedures … that must address temperatures to protect patient health and safety”. This does not say or mean that you need to add equipment to maintain temperatures (other than what the Life Safety code and NFPA 99 requires). It’s saying you must have a policy and a procedure that must address temperatures to protect the health and safety of patients.

So, your policies must reflect a plan on how you are going to accomplish this. If you lose fuel for the heating appliances, then what is your back-up plan? If you lose normal power and then emergency power, what is your back-up plan? Ultimately, your plan should recognize that you must evacuate the building if you can no longer maintain safe temperatures for your patients and staff.