Outpatient Centers and Clinics

Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business?

A: The Life Safety Code defines different occupancies by the level of care and/or activities that take place in them. A hospital may have many different occupancy classifications, or it may have only one… it’s the organization’s decision. Here is a run-down on the most common occupancy classifications found in healthcare today, and their requirements:

Healthcare Occupancy

An occupancy used for purposes of medical care or other treatment where four or more persons are incapable of self-preservation; and provides sleeping accommodations for those patients.

Ambulatory Care Occupancy

An occupancy used for purposes of medical care or other treatment on an outpatient basis, where four or more persons are incapable of self-preservation, and does not provide sleeping accommodations.

Business Occupancy

An occupancy used for the transaction of business other than mercantile.

So, to answer your question, an outpatient center and clinic could very well be ambulatory care occupancy or it may be business occupancy; it all depends on what level of care and treatment is provided. It is permissible to have more than one occupancy in the same building, provide appropriate fire rated barriers separates the occupancies. A 2-hour fire rated barrier is required to separate a healthcare occupancy from any other occupancy, and a 1-hour fire rated barrier is required to separate different occupancies that are not healthcare.

There are distinct requirements for each occupancy, but the requirements are less for ambulatory care compared to healthcare, and they are even less for business as compared to ambulatory care. So there is an advantage to the organization if the clinic was classified entirely as business occupancy. However, you may not have 4 or more persons incapable of self-preservation in a business occupancy, so make sure you are in synch with that.

Also, CMS considers all ambulatory surgical centers (ASC) to be ambulatory care occupancies regardless of the number of patients incapable of self-preservation, and they also consider end stage renal disease (ESRD) dialysis centers to be ambulatory care occupancies if they are located on a floor other than the level of exit discharge, or if they are contiguous to a high-hazard occupancy. Be aware that in their proposed rule to adopt the 2012 Life Safety Code, CMS has indicated that they intend to classify facilities that have 1 or more patients incapable of self-preservation as an ambulatory care occupancy. Whether they will adopt that as a final rule is unclear, but you should be aware of the possibility.


Portable Fire Extinguishers

Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital?

A: The monthly inspection and annual maintenance requirements for the portable fire extinguisher is the same for all occupancies, and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:

  • Make sure extinguisher is in its designated place
  • Make sure the access to the extinguisher is not obstructed
  • Make sure the operating instructions on the nameplate is legible and facing outward
  • Make sure the safety seals and tamper indicators are not broken or missing
  • ‘Heft’ the extinguisher to determine fullness (pick it up and hold it)
  • Examine the extinguisher for obvious damage, corrosion, leakage or clogged nozzle
  • Make sure the pressure gauge (if so equipped) is in the normal operating range
  • For wheeled units, check the condition of the tires, wheels, carriage, hose, and nozzle
  • Make sure the HMIS label is in place

This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable) and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. An annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection is required. A 12 year hydro-test of the extinguisher is also required.

Upgrading from Business to Healthcare Occupancy

Q: We have an attached building that houses an ambulatory surgical center and the building is classified as a business occupancy. We want to convert it from business occupancy to healthcare occupancy so we can have overnight patient care sleeping accommodations. What should we be concerned about?

A: It is classified as business occupancy and you have an ambulatory surgical center in the building? That doesn’t seem right, but I’m glad you’re going to fix that problem. Construction type is one of the many issues that must be dealt with in converting a building from business occupancy to healthcare occupancy, but there are other issues to consider as well. The first thing that needs to be understood is, changing from business to healthcare means the building has to meet new construction requirements found in chapter 18 of the 2000 Life Safety Code, not in chapter 19 which is for existing construction. Therefore, here is a quick summary of the things to investigate to ensure you are in compliance with chapter 18, mainly because these items may not be required in business occupancy. (NOTE: This is not an all inclusive list):

  • Construction Type requirements (as already noted)
  • Occupant load factors are different for healthcare
  • Means of egress components are more restrictive for healthcare, such as fire escape stairs are not permitted
  • Means of egress doors have different locking arrangements that actually favor healthcare
  • Stair width for existing is 44 inches while the business occupancy building may have been constructed to lessor standards
  • Horizontal exits, while not required, if used in the renovated business occupancy cannot have any penetrations (duct, conduit, etc.)
  • Corridor width MUST be 8 feet wherever inpatients are housed or treated, but may be 44 inches wide where inpatients would never be (such as a basement support services or administration).
  • The minimum clear width of the doors in a means of egress is 41.5 inches, which is far wider than what you would find in a business occupancy
  • Healthcare allows the use of suites, both for sleeping arrangements and non-sleeping arrangements which is a great benefit to the hospital
  • Dead-end corridors are only permitted to be 30 feet in healthcare while they are permitted to be 50 feet in business
  • Travel distances to an exit is less in a healthcare occupancy as compared to a business occupancy
  • Emergency lighting is required in healthcare
  • Protection from hazards is more restrictive with healthcare
  • Medical gases must be in compliance with NFPA 99 (1999 edition) which means a Level 1 piped system would have to be installed for a surgery
  • Interior finish requirements are more restrictive, but this is not usually a problem
  • A fire alarm system is required, with more devices and appliances than what a business occupancy would require
  • The entire building would have to be sprinklered with quick response sprinklers
  • Corridors in healthcare are required to be separated from all other spaces, while there is no requirement for corridors in business
  • There are multiple examples where spaces may be open to the corridor in healthcare that the hospital may take advantage of
  • Corridor walls have construction requirements
  • Corridor doors have certain requirements
  • Healthcare requires each floor to be subdivided into at least two smoke compartments and there are specific construction requirements for the compartment barriers and doors
  • Utilities must comply with section 9.1, which includes gas, electrical and emergency power
  • Healthcare facilities must have Level 1 emergency power as described and prescribed in NFPA 99. This requires significant changes to life safety branch and critical equipment branch, which business occupancies would not have to comply with.
  • The healthcare facility must have evacuation plans and relocation plans and fire drills once per quarter per shift
  • Combustible decorations are not permitted in healthcare
  • Portable heating devices are not permitted in patient care areas

That’s just a quick list of things but I’m sure there are more items in greater detail that you would need to comply with as well. As you can see, this is a large undertaking to convert a building that was never intended to be healthcare occupancy into a hospital. Most organizations choose to build a brand new building when they realize the cost in converting an existing building.

Clinic: Business Occupancy

Q: Our new clinic integration program has made us look closely at the clinic’s life safety process. The clinic is classified as a business occupancy. Is the assessment for life safety compliance different than an acute care hospital?

 A: While the clinic is classified as a business occupancy, the approach to a life safety assessment would be similar as conducting a life safety assessment for a healthcare occupancy (hospital), but you do not assess the clinic to the same set of standards as you would the hospital. Healthcare occupancies must comply with the core chapters of the 2000 Life Safety Code (LSC), which are chapters 1-4, and 6 – 11, and they have to comply with the occupancy chapters 18 and 19. Business occupancies likewise have to comply with chapters 1 – 4, and 6 – 11, but they have a different set of occupancy chapters to comply with; chapters 38 & 39. Chapter 38 is for new construction and chapter 39 is for existing construction. A facility is considered new construction if its construction plans and documents were approved by the local authorities after March 11, 2003. A facility is considered existing construction if its construction plans and documents were approved by the local authorities on or before March 11, 2003. Also, any renovation conducted in existing construction buildings on or after March 11, 2003 must comply with new construction requirements.

Why the date of March 11, 2003? Because that is the date that the Centers for Medicare & Medicaid Services (CMS) adopted the 2000 edition of the LSC. Assuming your clinics qualify for existing construction occupancy, you must assess the building for compliance with chapter 39. You will find that the life safety requirements are far less restrictive for business occupancies as compared to healthcare occupancies. Examples where there will be significant differences (and leniencies) in compliance, are:

  • Construction Type                     (39.1.6)
  • Overhead Rolling Fire Doors     (
  • Means of Egress Arrangement   (39.2.5)
  • Emergency Lighting                  (39.2.9)
  • Hazardous areas                                    (39.3.2)
  • Fire alarm systems                     (39.3.4)
  • Sprinkler systems                       (39.3.5)
  • Corridor walls                           (39.3.6)
  • Smoke compartments                (39.3.7)
  • Fire Drills                                  (39.7.1)
  • Fire Extinguisher Training          (39.7.2)

While fire damper testing in healthcare occupancies enjoys a 6-year cycle, that is not the case in business occupancies, which requires a 4-year testing interval. You will have to research each issue individually to determine your level of compliance.

Oxygen Storage in Business Occupancies

Q: Our hospital has an offsite building for our cardiac rehab, physical therapy, and pulmonary rehab programs. It also houses our business office and some physician offices. The building is classified as a Business Occupancy. What are the requirements for storing oxygen cylinders in a non-rated storage room?

A: A business occupancy that provides services for cardiac rehab, physical therapy, and pulmonary rehab programs is considered to be a health care facility. Assuming you are either Joint Commission accredited, or receive federal reimbursement monies for Medicare or Medicaid services, you are required to comply with NFPA 99 (1999 edition) Health Care Facilities standard. According to section 1-2, NFPA 99 (1999 edition) applies to all health care facilities, and section 2-1 defines a health care facility where medical care is provided. Chapter 13 in NFPA 99 is the chapter for “other” health care facilities which are not hospitals, nursing homes and limited care facilities. Section 13-3.8 requires all gas equipment to conform to chapter 8. Section 8-3.1.11 lists the storage requirements for nonflammable gases greater than 3,000 cubic feet and quantities less than 3,000 cubic feet which are similar (but not the same) as those requirements for hospitals. For storage of quantities of nonflammable gas greater than 3,000 cubic feet, the requirements are the same as those for hospitals, which are found in section 4- of NFPA 99. However, for quantities less than 3,000 cubic feet, there is a difference in storing nonflammable gas in quantities of 300 cubic feet or less. Hospitals have the advantage of having a special dispensation granted by The Centers for Medicare & Medicaid Services (CMS), in the form of S&C Letter 07-10, published January 12, 2007. In this letter, CMS allows hospitals (but not medical offices or clinics) the advantage of following the 2005 edition of NFPA 99, which permits quantities up to 300 cubic feet of nonflammable gas to not be stored in any special rooms or areas. This exception for ‘up to 300 cubic feet’ is not found in the 1999 edition of NFPA 99. Therefore, your business occupancy must store all nonflammable gas cylinders in quantities from 0 to 3,000 cubic feet in accordance with section 8-, which requires a specially designated room which has a door capable of being locked, and all oxidizing gases in this room must be separated from combustibles by 20 feet (or 5 feet if the room is protected with automatic sprinklers), or the oxidizing gases are to be stored in a flammable cabinet with a fire rating of at least 30 minutes.

Interim Life Safety Measures

Q: Are Interim Life Safety Measures (ILSMs) required in Business Occupancies due to construction or life safety code deficiencies? Do we have to conduct a fire watch in Business Occupancies?

A: Yes, interim life safety measures are required for any impairment to a life safety deficiency, regardless of the occupancy type. This is based on two specific requirements. 1) Section of the 2000 edition of the Life Safety Code describes alternative life safety measures (which are the same thing as ILSM) as a general requirement for all occupancies. It is not specific for just healthcare occupancies. 2) Also, if you are Joint Commission accredited, the overview to their Life Safety (LS) chapter says section LS.01.02.01 on ILSMs is applicable to all occupancies.

Sprinklers in a Dental Medical Gas Room

Q: We are designing a retrofit for a dental office in an existing business occupancy building without a fire sprinkler system. The space we are remodeling was formerly a doctor’s office. We are adding a medical gas system with oxygen and nitrous oxide delivered from an “exterior” medical gas room. It is required to have a “sprinkler”. What kind of system can be added to meet the requirement for a “sprinkler”?

A: In regards to the dentist office you are referring to, is it a conclusion that your local, state or accreditation authorities require compliance with the NFPA 101 Life Safety Code? And if so, which edition would that be? If the dentist office is to be accredited by Joint Commission and will receive reimbursements from Centers for Medicare & Medicaid Services (CMS), then the answer is yes, compliance with the LSC is required and the edition would be the 2000 edition. If not, then other codes or standards may apply, based on local or state authorities. In regards to your comment that the exterior gas room requires a sprinkler, what code or standard reference are you referring to? Is this a local or state requirement? I do not see a NFPA 101 Life Safety Code (2000 edition) or a NFPA 99 Health Care Facilities (1999 edition) requirement for the storage room or a medial gas manifold room to be sprinklered, for business occupancy (or for healthcare occupancy for that matter). There are certainly requirements for this room, that are found under NFPA 99 (1999 edition), section 4-3.1.1, but sprinkler protection is not one of them. To answer your question, many AHJs permit isolated rooms to be sprinklered using domestic water, provided the supply is adequate and no more than 7 heads are piped from the domestic system. Water-flow switches and control valves connected to the fire alarm system are required. But since sprinklers are not required based on NFPA codes and standards, you would have to negotiate the use of domestic water from the authority requiring sprinklers.

Conversion from Business Occupancy to Ambulatory Care Occupancy

Q:  We discovered our offsite free standing Dialysis center is in a building that is classified as Business Occupancy, but we were recently told by a consultant that the building has to be classified as Ambulatory Care Occupancy. Is this true? If so, what differences between the two occupancies should we be aware of?

A: It really depends if you are under the authority of CMS or not. If the dialysis center receives Medicare & Medicaid reimbursements, then you must follow CMS’s requirements. In a memo to their state survey agencies (S&C Letter 09-24) dated February 11, 2009, the dialysis unit must be classified as either existing ambulatory care occupancy, or new ambulatory care occupancy. In this memo CMS defines a new occupancy as a dialysis facility that receives their approval for construction on or after February 9, 2009, and they define an existing occupancy which receives approval for construction or renovation prior to February 9, 2009. However, if you are not under the authority of CMS, then the occupancy type is determined by the number of patients in the unit that are incapable of self-preservation. If there are 4 or more patients incapable of self-preservation at any given time, then the unit would have to be considered ambulatory care occupancy. But many authorities having jurisdiction (AHJ) have made the interpretation that all patients on dialysis is incapable of self-preservation, therefore, if you have 4 or more patients in the Dialysis center, then ambulatory care occupancy requirements apply. To be sure, you need to determine how your AHJ interprets the capability of the average dialysis patient to be able to disconnect themself from the machine, arise, and walk out of the unit under their own power, without assistance from anyone. There are differences between ambulatory care and business occupancies. Here is a short-list of ambulatory care occupancy requirements that differ from business occupancy:

  • Construction type: sprinklers required if Type II (000) Type III (000) and Type V (000)
  • Corridor width (44 inches)
  • Two approved exits from the unit
  • Travel distance to the exit cannot exceed 150 feet (200 feet if sprinklered)
  • Minimum door opening is 32 inches
  • A manual fire alarm system
  • Smoke compartment barriers unless the unit is less than 5,000 square feet and protected with smoke detectors, or unless the unit is less than 10,000 square feet and the area is protected with automatic sprinklers
  • A 2-hour fire rated barrier separating the dialysis unit from a healthcare occupancy, or a 1-hour fire rated barrier separating it from any other occupancy

Offsite Locations

Q: We have many offsite locations that are not hospitals but are clinics for diagnostic imaging, testing and physician’s offices. What, if any Life Safety Code standards apply in these locations?

A: The Life Safety Code is a document that needs to be adopted by some authority in order for it to become an enforceable standard. Normally, for free standing offsite clinics and physician’s offices, they are regulated by state and/or local authorities. For construction, the local building code would apply, and for fire safety, either the Life Safety Code or the International Fire Code would apply, depending on which document is used by the local fire inspector. For ambulatory surgical centers, dialysis centers, and other facilities where there may be more than 3 patients incapable of self-preservation, there could be multiple authorities having jurisdiction, such as the Centers for Medicare & Medicaid Services (CMS), Joint Commission, and your state oversight agency on public health. CMS and Joint Commission do enforce the Life Safety Code at these types of facilities, but your state agency may enforce the International Fire Code. If you are unsure of which code or standard that complies, I suggest you contact your local and state authorities and ask them. In regards to the Life Safety Code, there are applicable standards to follow depending on the occupancy classification.

Fire Drills in Offsite Patient Care Locations

Here is a scenario: A hospital has multiple ‘quick draw’ blood stations scattered across the community in which they are located. These blood draw stations are situated in other occupancies, and strategically located in shopping malls and other high-traffic areas for the convenience of their patients. Hospital staff occupy and manage these blood draw stations, although the actual area is approximately 250 square feet, or the size of an average patient room in a hospital.

The hospital failed to conduct fire drills in these blood draw stations because they did not feel they qualified since they were so small in size. A Joint Commission surveyor discovered the fact that fire drills were not conducted and wrote them up for failure to do fire drills in an offsite business occupancy environment.

I think the finding is valid as the TJC standard EC.02.03.03, EP 2 is very clear: “The hospital conducts fire drills every 12 months from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated.”  The situation described sounds like a business occupancy to me, and the act of drawing blood from a patient is certainly ‘treatment’. So, they got hit from two different angles.

I would agree with the surveyor that a fire drill should have been conducted annually at the draw stations, regardless of their size. It’s one disadvantage for the hospital having their own staff and quick draw station, rather than sub-contracting it out. They also have to do annual emergency response drills at these locations as well, which really doesn’t amount to much at all. In addition, all of the 6 EOC management plans have to apply to these quick draw stations and, the SOC Basic Building Information (BBI) has to list these locations as well. The cost to ‘manage’ the Environment of Care at these offsite locations is extensive, and probably wasn’t considered when they wanted to open them up.  The organization has to manage these locations in a similar way they would manage a clinic.

A fire drill is not an easy proposition at these types of small locations, situated within another building. The Life Safety Code requires the activation of the building’s fire alarm system whenever a fire alarm is conducted. This would have to be coordinated with the building owner.