ILSM in Business Occupancies

Q: Is there a code requirement for implementing an Interim Life Safety Measure (ILSM) for occupancies other than healthcare (i.e. business occupancies) if a life safety code deficiency has been identified?

A: Yes… ILSM (also known as Alternative Life Safety Measures) is found in chapter 4 of the 2012 Life Safety Code, specifically section 4.6.10.1 of the 2012 LSC. This describes the need to implement ALSMs when features of Life Safety are impaired. This chapter is part of the ‘core’ chapters and applies to all occupancy chapters, so that means it applies to business occupancies as well.

Most accreditation organizations should be enforcing this in offsite locations, such as business occupancies. Some surveyors fail to ask for this, but it is an enforceable requirement.

Large Trash Containers

Q: I have a question about the limits on the size of trash containers in healthcare facilities, including ambulatory healthcare facilities. Consider larger collection bins, that are housed in one-hour rated soiled utility rooms, and are then moved close to the loading dock area, an area which is separated from the rest of the facility with 2-hour occupancy separations and is indicated “Business” occupancy although it is the sub-basement of a hospital building. These are staged in a hallway of this business area while awaiting emptying, cleaning and return to the soiled utility rooms. NFPA 101 2012 Chapter 38/39.7.6 would seem to permit this. What do you think?

A: You are correct… As long as the large tubs are located in business occupancies, there is no Life Safety Code requirement that requires them to be stored in a 1-hour hazardous room. That is strictly a healthcare occupancy (see 19.7.5.7.1 of the 2012 LSC) and an ambulatory healthcare occupancy (see 20.7.5.5.1 of the 2012 LSC) requirement.

Brad… Are You Nuts…?!

Q: I have a Medical Office Building with multiple exam rooms, and it is constructed with 5-foot wide corridors. This building followed design reviews including Life Safety expertise from the local AHJ. In many cases, an alcohol-based hand-rub (ABHR) sanitizer dispenser is located just outside the exam rooms in the egress corridor. Why are you saying these dispensers are not permitted especially when section 19.3.2.6 says they are? Are you nuts…?

A: Well, I may be a bit crazy, but I’m pretty sure ABHR dispensers are not permitted in medical office building corridors.

Section 19.3.2.6 is applicable for healthcare occupancies, such as hospitals, nursing homes, long-term care facilities, etc. And section 21.3.2.6 is applicable for ambulatory health care occupancies such as Ambulatory Surgical Centers. But these sections are only applicable to their respective occupancies, and the typical Medical Office Building is not any of these… they are business occupancies. And unfortunately for you, there is nothing similar in business occupancy chapters 38 and 39 for ABHR dispensers.

It really all starts with section 8.7.3.2 which says no storage or handling of flammable liquids shall be permitted in any location where such storage would jeopardize egress from the structure. The ABHR gel or foam product in these dispensers have a high enough alcohol content to cause it to be classified as a Class 1-B flammable liquid, according to NFPA 30. So, according to 8.7.3.2, flammable liquids (i.e. ABHR dispensers) cannot be used in a corridor of a facility. But sections 19.3.2.6 and 21.3.2.6 permit ABHR product and dispensers in corridors of healthcare occupancies and ambulatory health care occupancies… so what’s up with this conflict?

According to section 4.4.2.3 whenever the occupancy chapter differs with the core chapters, then the occupancy chapter governs. So, on the issue of ABHR dispensers, they are permitted in the corridors of healthcare occupancies and ambulatory health care occupancies because those chapters have specific language that over-rides the core chapter.

But not so for business occupancies. Chapters 38 & 39 are silent regarding ABHR dispensers. Therefore, you cannot have ABHR dispensers in the corridors of business occupancies because they are a flammable liquid.

Even if the Medical Office Building was re-classified as ambulatory health care occupancy (I don’t recommend it), you still could not place the ABHR dispensers in the corridors because the corridors are not 6-feet wide.

I don’t see that this issue will likely be cited by surveyors, for a couple of reasons: 1) Not all surveyors know and understand this issue very well. They know ABHR dispensers are permitted in hospitals and figure the requirements for hospitals are more restrictive than business occupancies, and would allow them in a medical office building; 2) Typically, the surveyors who survey medical buildings (i.e. business occupancies) are nurse surveyors or physician surveyors…. not Life Safety surveyors, so they would not be as familiar with the LSC on this issue.

Non-Sprinklered Elevator Control Room

Q: In a physician’s clinic that is claimed to be fully protected with sprinklers, the building elevator control room is not sprinklered. Must I install or can I leave it that way?

A: A Business Occupancy building that is fully protected with sprinklers provides you with the ability to meet certain options in the LSC that allows you to take advantage of certain features, such as:

  • Delayed egress locks would be permitted
  • Less restrictions on egress capacity factors
  • Exits permitted to discharge through the interior of the building
  • Less restrictions on hazardous areas
  • Less restrictions on interior finishes
  • Increased travel distances

According to NFPA 13-2010, the standard for sprinkler installation, there are very few exceptions to not installing sprinklers, and allow the building to still be considered fully sprinklered:

  • 2-hour fire-rated barriers around an electrical room
  • Clean agent suppression system installations

However, the 2012 Life Safety Code does have an exception specific to elevator machine rooms. Section 7.14.4.2 says sprinklers shall not be installed in elevator machine rooms serving occupant evacuation elevators, and such prohibition shall not cause an otherwise fully sprinklered building to be classified as non-sprinklered. This is one situation where the Life Safety Code trumps NFPA 13 on the installation of sprinklers.

The 2012 Life Safety Code Handbook continues to provide insight on this prohibition:

The presence of sprinklers in the elevator machine room would necessitate the installation of a shunt trip for automatically disconnecting the main line power for compliance with ASME A17.1 Safety Code for Elevators and Escalators, as it is unsafe to operate elevators while sprinkler water is being discharged in the elevator machine room. The presence of a shunt trip conflicts with the needs of an occupant evacuation elevator, as it disconnects the power without ensuring that the elevator is first returned to a safe floor so as to prevent trapping occupants.

So, no… you should not install sprinklers in the elevator machine rooms.

Business Occupancy Smoke Detectors

Q: What are the requirements for the use of smoke detectors in a business occupancy physician office that does not have an automatic sprinkler system? The fire marshal is telling me that this is not required, but I cannot find a specific clause in NFPA and want to confirm that statement.

A: The fire marshal is sort-of correct. Smoke detectors are not mandatory in a business occupancy, if the building already has manual pull stations. According to section 39.3.4.2 of the 2012 LSC, only one of the following means to initiate of the fire alarm system is required:

  • Manual pull stations
  • Smoke detectors
  • Sprinkler system water-flow

Of course, you can have more than one type to initiate the fire alarm system, but if you have manual pull stations, then smoke detectors are not required. But, if you don’t have manual pull stations or a sprinkler system, then smoke detectors would be required if the building requires a fire alarm system. Some smaller business occupancies do not require a fire alarm system. Check with your state and local authorities to see if they have other regulations concerning initiating devices.

ABHR Dispensers in Business Occupancy Corridors

Q: Do you know of any other information on alcohol-based hand-rub (ABHR) dispensers not allowed in the egress corridors of business occupancies? I need more information than what you have already posted:

Please be aware that alcohol-based hand-rub (ABHR) dispensers are not permitted in the egress corridors of Business Occupancies. This is found in section 38/39.3.2.1 of the 2012 Life Safety Code which references section 8.7 of the same code. Section 8.7.3.2 states: “No storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure…” Since corridors are used as paths of egress in business occupancies that means ABHR dispensers are not permitted in business occupancy corridors. Now, sections 18/19/20/21.3.2.6 of the 2012 Life Safety Code allows ABHR dispensers in corridors of healthcare occupancies and in ambulatory health care occupancies…. but not business occupancies.

A: Nope… that’s all there is. It is very clear that the Life Safety Code does not permit the storage or handling of flammable liquids in egress areas, based on section 8.7.3.2. However, the Life Safety Code makes specific exceptions for healthcare occupancies (i.e. hospitals, nursing homes, long term care centers, etc.) and ambulatory health care occupancies (ASC, physical therapy units) based on section 18/19. 3.2.6 and 20/21.3.2.6. The problem is, these exceptions do not apply to Business Occupancies and chapters 38/39 do not contain anything that would over-ride 8.7.3.2.

Business Occupancy Soiled Utility Room

Q: Do business occupancy buildings with soiled utility rooms have to be one-hour fire-rated or just sprinkled if the building falls under a hospital license and will be inspected by State and CMS surveys?

A: It depends…. Is the soiled utility room used for general storage? In business occupancies, soiled utility rooms are not considered outright to be a hazardous area like they are in healthcare occupancies. However, many soiled utility rooms are also general storage rooms, and section 38/39.3.2.1 of the 2012 Life Safety Code specifically says general storage rooms are considered hazardous areas and must be maintained in accordance with section 8.7. Section 8.7.1.1 says the room needs to be either 1-hour fire rated or protected with sprinklers.

Whether or not the business occupancy falls under the hospital license is not a factor, regardless who inspects the building. The LSC is clear: If used for general storage, then the room is either sprinklered or 1-hour fire rated. If the room is not used for general storage, then there is no requirement. This is based on its occupancy; not its license.

ABHR Dispensers

Q: In a business occupancy building, can alcohol based hand-rub dispensers be placed over carpeted area with no sprinklers?

A: Maybe yes and maybe no… It all depends on which AHJ is looking at your business occupancy.

Section 19.3.2.6 (8) of the 2012 LSC requires ABHR dispensers that are mounted over carpets, to only be in sprinklered smoke compartments. But this only applies to healthcare occupancies, and section 21.3.2.6 has similar language for ambulatory healthcare occupancies. The problem is, there is nothing written in chapters 38 or 39 regarding the installation of ABHR dispensers in business occupancies.

Since nothing is written in the business occupancy chapters, one may think there are no limitations, and the ABHR dispensers may be placed wherever you want without regard to regulations. Some AHJs may agree, and allow the ABHR dispensers be installed over carpet in an unsprinklered area. But the AHJs with healthcare experience and knowledge probably will not, based on their understanding of chapters 19 and 21. And, this is not an incorrect process, since they know these regulations regarding ABHR dispensers and can apply them to a business occupancy based on safety-related issues. Section 4.6.1.2 supports this concept.

But please understand, section 8.7.3.2 of the 2012 LSC prohibits the handling and storage of flammable liquids where it would jeopardize egress. This means ABHR dispensers are not permitted in egress corridor. Chapter 18/19 and 20/21 specifically permit ABHR dispensers in corridor so that over-rides section 8.7.3.2. But the business occupancy chapters 38 and 39 do not have this language to over-ride 8.7.3.2, so that means ABHR dispensers are not permitted in egress corridor of business occupancies.

My advice is follow the same regulations for ABHR dispensers found in 19.3.2.6 for business occupancies, with the exception that ABHR dispensers are not permitted in egress corridors of business occupancies.

Contiguous Facilities

Q: If an inpatient in a hospital (healthcare occupancy) is taken into a building that is not a healthcare occupancy for say CT or MRI, does this building have to then meet the requirements in the Life Safety Code for a healthcare occupancy?

A: According to section 19.1.3.4.2 of the 2012 LSC, it says ambulatory care facilities, medical clinics, and similar facilities that are contiguous to healthcare occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. This is new for the 2012 LSC and was not found in the 2000 edition, so not everyone may be aware of this.

But the kicker is “inpatients who are capable of self-preservation”. The inpatient really does need to be capable of taking action for their own self-preservation without the assistance of others.

All healthcare occupancy inpatients, even if it is just one inpatient, that are brought into a contiguous facility that is not a healthcare occupancy for diagnostic or treatment purposes must be capable of self-preservation. Otherwise, it is not permitted.

Life Safety Drawings

Q: I just got done with a triennial accreditation survey at one of my facilities and the engineer surveyor requested LSC drawings for all buildings that support patients, not just the in-patient buildings. The support buildings are business occupancy and patients do not sleep in these areas, they only go to these building for program. We are surveyed under Behavioral Health. History has it we have never had to provide LSC drawings for non-inpatient buildings. Have you ever heard of the drawings being requested for all buildings?

A: Oh, sure. This is a common, if not a normal practice. Ask yourself this question: How can you adequately maintain the rated barriers in your offsite business occupancies if you don’t have LS drawings showing their location? How can you demonstrate to the surveyor that your travel distances are within limits? How can you demonstrate to the surveyor that your hazardous areas are properly maintained if you (or he) does not know where they are?

LS drawings are important for all the buildings you maintain… not just the hospital. This finding should not be a deal-breaker with the accreditor… meaning, you may receive a citation (or you may not), but if you do, it will not be a Condition Level Finding. Bully for the LS surveyor for asking to see those LS drawings.