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 (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 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 supports this concept.

But please understand, section 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 But the business occupancy chapters 38 and 39 do not have this language to over-ride, 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 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 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.

ABHR Dispensers in Business Occupancies

Q: In the 2012 edition of the Life Safety Code, section (9) states dispensers of alcohol based hand rub (ABHR) solution are permitted to be installed directly over carpeted floors in fully sprinkled smoke compartments. My question is: Does this go with business occupancies as well?

A: I would say surveyors would likely ‘borrow’ from chapter 19 and apply certain requirements regarding ABHR dispensers in business occupancies. But there is a huge difference between healthcare occupancies and business occupancies for ABHR dispensers. Section is a healthcare occupancy chapter, and anything written in chapter 19 applies to just existing healthcare occupancies. The Life Safety Code requirements for a business occupancy are found in chapter 38 for new construction business occupancies and chapter 39 for existing business occupancies.

It is interesting to note that chapters 38 & 39 do not have the similar language found in chapters 18 & 19 for healthcare occupancies that permit ABHR dispensers in corridors (i.e. 18/ Therefore, section 38/ is the applicable standard and must be followed, which says hazardous areas must comply with section 8.7. Section says no storage or handling of flammable liquids or gases shall be permitted in any location where such storage would jeopardize egress from the structure. Where chapters 18 & 19 for healthcare occupancies have exceptions that actually permit ABHR dispensers in corridors, chapters 38 & 39 do not for business occupancies. In fact, chapters 38 & 39 actually requires compliance with section which prohibits the handling of flammable liquids (and ABHR solution is considered a flammable liquid) in an egress.

That is why ABHR dispensers are not permitted in business occupancy corridors. Since the business occupancy chapters do not address ABHR dispensers, other than saying flammable liquids cannot be stored or handled in the egress, surveyors would likely follow the chapter 19 requirements on ABHR dispensers for other regulatory requirements in business occupancies. They could easily enforce the width separation and the requirement to keep the dispenser away from ignition sources and other requirements. Since chapters 38 & 39 are silent on the issue of ABHR dispensers, the surveyors could ‘borrow’ from chapter 19 and enforce that, as long as it does not conflict with section

Exiting from Hospital into Medical Building

Q: A main circulation corridor in a Hospital (Institutional Use I-2, 8′ wide) passes thru the 2-Hr Use Group separation of adjacent medical offices (Business Use B) and re-enters the Institutional zone (2-Hr wall) for egress to a fire egress stair. Building has automatic sprinkler system. Are egress corridor movements between Institutional and Business Use permitted? Must all sections of that corridor sequence maintain a consistent width of 8′ clear?

A: [Boy… I wish you architects would use NFPA nomenclature instead of IBC…]. If I understand your question correctly, my reply would be yes… you can exit from the hospital into a business occupancy, but there are extenuating circumstances. Section of the 2012 LSC says when an exit access (i.e. corridor) from an occupancy traverses another occupancy, the multiple occupancy must be treated as a mixed occupancy. For you, that means the most restrictive occupancy requirements apply, which in your case would be healthcare occupancy.

So, this means everything required for healthcare occupancy must be met in the business occupancy building, such as:

  • Construction type
  • Fire alarm system
  • Sprinklers
  • Fire-dampers/smoke dampers
  • Corridor width
  • Corridor doors
  • Fire safety plans
  • Door latching and locking requirements
  • Etc.

However, if you can call the 2-hour fire barrier separating the healthcare occupancy from the business occupancy, a horizontal exit, then you would not have to meet the requirements of healthcare occupancy, in the business occupancy building.

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.

Fire Alarm Activation for Fire Drills in Business Occupancies

Q: I’m responsible for doing annual fire drills in our blood draw stations located throughout several communities. Some are in physician’s offices and some are in office buildings. I can find nothing in NFPA 101, 2012: 4.7 or in 38 or 39 New or Existing Business Occupancy. Can you help with the code requiring alarm activation?

A: Well… according to NFPA Life Safety Code, there are no requirements to activate the fire alarm system during a drill for business occupancies. Where the confusion comes into play, most accreditation organizations requires sub-stations of hospital departments to follow the hospital requirements regarding operations. The healthcare occupancy chapter requires activation of the fire alarm system for fire drills, and some surveyors likely require the same for any offsite department that is an extension of the hospital to comply. If they are requiring the fire alarm system to be activated during a fire drill for a blood draw station located in a business occupancy, that would be a mistake by my opinion. This is an easy mistake for a surveyor to make, as all other aspects of the blood draw station must comply with the hospital’s policies and procedures if it is an extension of the hospital department. So, I can see how a surveyor could expect the fire alarm system to be activated for a fire drill in an offsite blood draw station.

Business Occupancy Fire Drills

Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party during a routine fire drill? We have documented staff participation with each drill. The building fire alarm system including communication with the third party is also completed during the year per standard. The clinic (business occupancy) may be located in a building with many other types of businesses.

A: I don’t think so. If you look at the healthcare occupancy chapter section 18/ (2012 LSC), it says fire drills shall include the transmission of the fire alarm signal. However, there is no comparative section in chapters 38 & 39 for business occupancy. Since the business occupancy chapter does not specifically require the activation of the building fire alarm system for a fire drill, then I would say it is not a Life Safety Code requirement. It would be best practice, but not a requirement.

Sections 38/39.7.2 (2012 LSC) says fire drills in business occupancies (where required) must comply with section 4.7. Section 4.7 discusses many requirements regarding fire drills but activating the fire alarm system is not one of them. Please review your accreditation standards to determine if they require activation of the fire alarm system during a fire drill in a business occupancy.

Business Occupancy Emergency Lighting

Q: I have a question concerning an ambulatory surgery center that is now converted over to a business office only. We are not doing any patient care in this facility. We currently have a generator that supports the egress lighting and exit signs. What are our requirements for testing and maintaining this generator for a business occupancy?

A: Since you say the building is now classified as a business occupancy, we need to look at Chapter 38 in the 2012 LSC for direction. Section says emergency lighting must be provided in accordance with section 7.9 where one of the following conditions exist:

  • The building is three or more stories in height
  • The occupancy is subject to 50 or more occupants above or below the level of exit discharge
  • The occupancy is subject to 300 or more total occupants

If you do not meet one (or more) of the above conditions, then emergency lighting is not required, and therefore testing and maintenance of the generator is not required. However, if you do meet one (or more) of the above conditions, then you must comply with section 7.9 for emergency lighting. Section says new emergency power systems for emergency lighting must be provided by emergency generators in accordance with NFPA 110, and you must continue to maintain weekly inspections, monthly load tests, and 3-year load tests.

Offsite Fire Drills

Q: Our hospital has several “out buildings” or offsite Doctor’s offices. Are we required to do fire drills at these offices? Three of our buildings have fire alarm systems that are tested semi-annually. But we weren’t sure if we were supposed to conducting fire drills at these doctor’s offices or how often they need to be done to be in compliance?

A: Generally, yes… fire drills are required once per shift per year at offsite business occupancies, but it has much to do with your accreditor, or any other authority who enforces the Life Safety Code. Physician’s offices are typically classified as business occupancies and section 39.7.2 of the 2012 LSC says fire drills are only required in business occupancies where the building is occupied by more than 500 persons, or if there is more than 100 persons above or below the street level. So, from a LSC stand point there may be an exception to not conduct fire drills if your physician’s offices are under the 500/100 person threshold.

However, you still have to consider what your accreditation organization requires. For instance, Joint Commission standard EC.02.03.03, EP 2 requires annual fire drills in all business occupancies. Other accreditation organizations, state agencies and local municipalities may have the same requirement. So, it is likely that you do have to conduct annual fire drills.