Occupational Therapy Kitchens

Q: Do occupational therapy kitchens need to meet NFPA 96 standards? This unit will be a new build and will fall under business occupancy requirements, but the Life Safety Code for new business occupancies refers me back to 9.2.3, which refers me to NFPA 96.

A: Is the cooking equipment really ‘commercial cooking equipment’? For an occupational therapy kitchen, you would be using residential cooking equipment, would you not? Also, is the cooking equipment that is used for occupational therapy ever turned on…? Do they ever actually cook or bake anything on the stove?

If it were a healthcare occupancy, the answer is a no-brainer, since section specifically says residential cooking equipment that is used for food warming or limited cooking does not have to meet the requirements of 9.2.3. While that section may have been written for food warming equipment in staff lounges, one could apply it towards occupational therapy kitchens as well.

But you may have a good case with sections 38/ (3), which says something similar and exempts cooking equipment used only for food warming from having to meet section 9.2.3. There are a few other points that would prevent you from having to meet NFPA 96 requirements. According to NFPA 96-2011, section 1.1, it says the following regarding residential equipment:

  • 1.1.2 This standard shall apply to residential cooking equipment used for commercial cooking operations.

(You’re not using this residential cooking equipment for commercial cooking operations, so therefore, NFPA 96 does not apply).

 1.1.4* This standard shall not apply to facilities where all of the following are met:

(1) Only residential equipment is being used.

(2) Fire extinguishers are located in all kitchen areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

(3) The facility is not an assembly occupancy.

(4) The authority having jurisdiction has approved the installation.

(Make sure you comply with the above four items and you do not have to comply with NFPA 96.)

So, I think you have enough to go on to convince an AHJ that a NFPA 96 exhaust hood is not required for occupational therapy residential cooking equipment in business occupancies.

Tamper-Proof Screws in Psychiatric Unit

Q: Do all of the screw heads in a psych ward need to be tamper proof?

A: There is no specific code or standard that addresses screw heads in a psych unit, but CMS and the accreditation organizations have a standard that requires you to provide a safe environment for your patients and staff. Therefore, having a screw head in a psych unit that is not the tamper-proof style would likely be a citation by a surveyor because the environment is not considered safe by their point-of-view.

Staff Sleep Room

Q: Within our X-ray department we have a room (7 1/2 ft. by10 ft.) that was our dark room for film reading years ago. We would like to make this a sleep room for staff that get called in. It has a sprinkler head; if we install a sounder base detector can we make this a sleep room and be compliant?

A: Sleeping with the old X-ray developing chemicals….? What a lovely thought.

Yes, I think you can convert this room to a staff sleep room. Your thought of putting in a smoke detector with an occupant notification device is good, but let’s look at the other items that may be needed.

First you need to confirm which occupancy chapter you need to comply with. Staff sleeping rooms is not covered under the Healthcare occupancy chapters, so you would consider “Lodging or Rooming Houses” occupancy or “Hotels or Dormitories” occupancy chapter. Reviewing the definitions of each, “Hotels or Dormitories” occupancy chapter is for 16 or more people, and “Lodging or Rooming Houses” occupancy chapter is for no more than 16 people. So, I would say that you need to follow “Lodging or Rooming Houses” occupancy chapter, and specifically, chapter 26 for new construction.

Section of the 2012 Life Safety Code requires single-station smoke alarms must be installed in every sleeping room. So, according to this requirement, you would need to install a single-station smoke alarm, that has an annunciating device as you suggested. Some AHJs allow hospitals to install a building smoke detector in lieu of a single-station smoke alarm, but be aware not all AHJs see it that way.

Section requires the sleeping room to be separated from the corridor by smoke partitions. So that means there cannot be any louvers in the door or walls.

Section requires the door to the sleeping room to be self-closing (i.e. door closer) if the building is not fully protected with automatic sprinklers.

Section requires the sleeping room to be protected with sprinklers, as you mentioned.

According to section, the door to the sleeping room cannot be locked against the means of egress. But section covers that in depth and only allows certain exceptions to door locks. Keep in mind that section does not allow the installation of deadbolt locks that are separate from the latch-set hardware.

As always, have this plan reviewed and approved by an architect and then obtain necessary approvals from your state and local authorities.

That should do it….

Cords on Nurse Call Stations

Q: We have a behavioral health unit and want to know if pull-cords are required on the nurse-call system in the patient bathroom? Is there an alternative to cords so this type patient can’t hang themselves?

A: The NFPA codes and standards do not address this issue, but the FGI Guidelines do. CMS and the accreditation organizations expect you to follow the FGI Guidelines for new construction, unless there are other more restrictive requirements for other authorities, such as state health departments or local building codes.

Section 2.5- of the 2010 FGI Guideline says a nurse call system is not required in psychiatric nursing units, so you do not have to provide cords on the call-buttons. Also, section 2.5- says call cords or strings in excess of 6 inches are not permitted. Now, the latter section is for geriatric, Alzheimer’s, or dementia units, but the concept can carry-over to your behavioral health unit.

Pharmacy Door Locks

Q: Is it a common practice to keep pharmacy access controlled doors so they will not unlock on a fire alarm activation? Texas Pharmacy board requirements to secure medications is the reasoning behind this setup, which I feel is wrong. Narcotics are secured within the pharmacy area in a narcotics room, so the requirement for securing narcotics and meds is compliant, but I believe the main pharmacy door should release in the event of a fire alarm activation. Our fire alarm system is designed to activate as general alarm so all electrically locked doors other than the pharmacy release. Is there a standard or exception that will allow this type of set-up? The doors can be manually released from the inside, but my concern is the obstacle created by the access control when an emergent response is required.

A: You may be confusing the old NFPA 72 requirement that all doors in the required means of egress equipped with electrical locks have to unlock on a fire alarm signal. At one time, NFPA 72 did require that, but the Life Safety Code always over-rides referenced standards when there is a conflict. In actuality, the Life Safety Code governs in a situation like this. Besides, the technical committee for NFPA 72-2010 made a change to this requirement. In section 21.9.2 of NFPA 72-2010, it says electrically locked doors in a required means of egress must unlock as prescribed by other codes, laws, and standards. This is different than what previous editions of NFPA 72 said, and now NFPA 72-2010 is clear that it differs to other codes, laws, and standards (i.e. the Life Safety Code) regarding the need to unlock a electrically locked door in the means of egress during a fire alarm. There are only five (5) exceptions to of the 2012 Life Safety Code, which says doors in the path of egress must not be locked:

  1. Delayed egress locks ( which requires the door to unlock on a fire alarm signal
  2. Access-control locks ( which requires the door to unlock on a fire alarm signal
  3. Elevator lobby locks ( which requires the door to unlock on a fire alarm signal
  4. Clinical needs locks ( which does NOT require the door to unlock on a fire alarm signal
  5. Specialized protective measure locks ( which does require the door to unlock on a fire alarm signal.

But pharmacies would not qualify for clinical needs locks (used on psychiatric units), elevator lobby locks, or specialized protective measure locks (used on OB/nursery units, ICUs and ERs). That leaves delayed egress locks or access-control locks which must unlock the door on a fire alarm signal. So, your assessment is correct in that the pharmacy door in the required means of egress cannot remain electrically locked during a fire alarm signal. If you examine the Texas Pharmacy board requirements carefully, it probably says the pharmacy must be secured against unauthorized entry… not egress.

What many people forget: The Life Safety Code governs when it comes to the means of egress and over-rides other standards and codes. Getting out of the building in the event of a fire is paramount supersedes other laws, codes or standards. Why don’t you change the locks on the pharmacy doors and eliminate the electrical locks and install standard passage locks (not deadbolt locks) that do not require more than one action to operate the door? This way, the door would not be locked in the path of egress (getting out of the pharmacy) but would remain locked against unauthorized entry during a fire alarm. This is what I see other hospital pharmacies do.

Medical Equipment Contractor

 Q: When I came into this new position the medical equipment program was run by a third party managing our own Bio-med technicians. We changed the 3rd party contractor and we still have a problem as far as the PM’s not being done by the new contractor (huge back log). We think with good reason that the hospital is at risk.   We put pressure on the contractor by mentioning our concerns regarding an upcoming accreditation survey, or the state public health department survey, and CMS (which could happen at any time), not to mention the safety of our patients. The contractor’s answer is we should not be concerned since the accreditation organization and CMS will accept the fact that we are “in transition” and that it is commonly accepted to experience a backlog in this type of situation. We asked them to provide documentation to support their position, but we have not heard anything yet. What are your thoughts?

A: I think that is faulty logic. There is nothing in the accreditation standards or the CMS CoPs that allows non-compliance based on a change in contractors. Either you are or you are not compliant. Most surveyors will not care why you’re not compliant.

It is likely that the contractor who told you this was provided misleading information. Perhaps they were part of a survey where the surveyor was benevolent said something like that. If so, then that is an individual surveyor’s preference and is not the policy of the accreditor or the CMS. The chances are you will have a surveyor in your upcoming survey who may be sympathetic, but still cite you if you’re not compliant.

Get cracking on that contractor… You’re the boss, not them.  If they fail to perform, withhold payment and find a new contractor, or better yet, use this situation as a validation to your leadership that you need to manage this important process in-house, and no longer have outside contractors manage your Bio-med services.

Sleep Labs

Q: Are sleep labs considered healthcare occupancies or business occupancies? I have a fire marshal who says it has to be a healthcare occupancy.

 A: These types of things are interpretations. There is not a firm paragraph in the Life Safety Code that says “Sleep labs are business occupancies”. But, if you (or the AHJ) examines the different definitions of occupancies in the Life Safety Code, then one draws the conclusion that it is a business occupancy. For example:

Healthcare occupancy consideration:

“A healthcare occupancy is used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants control.” ( of the 2012 LSC)

“The healthcare facilities regulated by this chapter shall be those that provide sleeping accommodations for their occupants and are occupied by persons who are mostly incapable of self-preservation because of age, because of physical or mental disability, or because of security measures not under the occupants control.” (

So, let’s examine how a sleep Lab meets this criteria:

  • A patient in a sleep lab is not an inpatient of the facility;
  • A patient in a sleep lab is not being provided medical care, or other treatment. The sleep lab is monitoring the patient… not providing care.
  • A patient in a sleep lab is fully capable of self-preservation.
  • The sleep lab does provide sleeping accommodations, but that alone does not make it a healthcare occupancy because the patients are not inpatients, are not receiving care or treatment, and are not incapable of self-preservation. If just providing sleeping accommodations makes the sleep lab a healthcare occupancy, then all residential, hotels, dormitories and apartment facilities would have to be designated a healthcare occupancy.

Therefore… the conclusion is a sleep lab is not a healthcare occupancy. Now, a sleep lab may be located in a hospital that is a healthcare occupancy and that would be a mixed occupancy situation. But if the sleep lab is located offsite from the hospital, it does not have to be considered a healthcare occupancy.

 Ambulatory healthcare occupancy consideration:

  • “An occupancy used to provide services or treatment simultaneously to four or more patients (one or more patients per CMS) that provides, on an outpatient basis, one or more of the following:
  • Treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.” (

While a patient in a sleep lab is an outpatient, that person is not receiving services or treatment that renders them incapable of self-preservation.

  • The sleep lab patient is not under anesthesia.
  • The sleep lab patient does not have an illness or injury that prevents them to take self-preservation action under emergency conditions without the assistance of others.
  • The sleep lab patient is not receiving emergency or urgent care.


Therefore, the conclusion is a sleep lab is not an ambulatory healthcare occupancy. To further this discussion… a sleep lab is not a hotel or dormitory, and is not a residential board & care occupancy. So, the conclusion is, a sleep lab is a business occupancy… not unlike your typical physician-office exam room. A patient in a sleep lab is being examined… not treated. That is how the Life Safety Code is interpreted. The challenge many facility managers have is convincing state or local AHJs that a sleep lab is a business occupancy. Once they see ‘sleeping accommodations’ and ‘healthcare’ they automatically want to lump it in with healthcare occupancy. If you have this situation, then you need to educate those AHJs so they understand that sleep labs are business occupancies.

Locked Exit Doors From Psychiatric Unit

Q: I am a consultant and I have a 30% sprinklered high rise hospital with locked psychiatric units. The state authority made them unlock the stairwell doors under the 2000 LSC. The stairwell doors were locked with a key. With the 2012 LSC, can those doors have delayed egress installed for security of patients or does the entire building need to be sprinklered?  The smoke compartments into the stairs in question are sprinklered.

A: No… they cannot install delayed egress locks on any door in the building because section of the 2012 LSC requires the entire building to be either fully protected with sprinklers or smoke detectors. I’ve yet to find a hospital that is fully protected with smoke detectors, so it is a safe bet it is not. Since the building is not fully protected with sprinklers, then they cannot install delayed egress locks (, elevator lobby locks (, or specialized protective measure locks ( Their only recourse is to install clinical needs locks ( or access-control locks (, but access-control locks do not lock the door in the path of egress).


Did the state agency explain why they could not lock the stairwell exit doors via clinical needs locks ( Perhaps the hospital did not comply with all of the requirements found in, or perhaps it was a personal preference of the state inspector…

Staff Sleeping Rooms

Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that these staff sleeping rooms are required to have single-station smoke alarms since they are considered a different occupancy (Lodging & Rooming House) and must meet section of the 2012 LSC. But can I use the hospital smoke detector system in lieu of installing a battery operated smoke alarm in these rooms?

A: Yes… Section does allow the use of the smoke detectors connected to the building’s NFPA 72-2010 approved fire alarm system, instead of installing the battery-operated smoke alarms.

However, section does say these system smoke detectors must be arranged to function in the same manner as single-station or multiple-station smoke alarms. The typical building system smoke detectors are detectors only and do not provide any occupant notification. But the single-station smoke alarms provide both functions: Detection and occupant notification. Therefore, on a technical standpoint, the basic fire alarm system smoke detectors are not enough and some sort of occupant notification system must be provided.

Now, having said that, I do know that some accreditation organizations are simply accepting a smoke detector in the on-call sleeping room without the inclusion of an occupant notification device. But, I am aware that some state agencies surveying on behalf of CMS do enforce the letter of the code and will cite you if you do not have an occupant notification device in the room.

Fire Drills in Sleep Labs

Q: For an EEG sleep testing unit with an overnight stay in a business occupancy, are fire drills required quarterly or annually ?

A: Annually. The frequency of fire drills is determined on the occupancy designation of the facility, and chapter 38/39.7.1 of the 2000 Life Safety Code says fire drills are required to be conducted ‘periodically’. If you are Joint Commission accredited, they will expect annual fire drills, as would most any other authorities having jurisdiction. What may have you concerned is the term ‘sleeping rooms’ for the Sleep Lab. These are not sleeping accommodation rooms, so Hotel and Dormitory occupancy is not the correct designation for occupancy, as they would require quarterly fire drills. The Sleep Lab ‘sleeping rooms’ are actually exam rooms, which are monitored closely by staff all the time the patient is sleeping. The Sleep Lab is considered an out-patient service, and since there are no sleeping accommodation rooms, it can be designated as business occupancy, which allows for annual fire drills. Now, if you want to upgrade the occupancy designation to Hotels and Dormitories, then feel free to do so. But there will be more than just additional fire drills to contend with, and I would not recommend it.