4-Inch Rule

Q: I just would like to confirm: When you say a 4-inch projection is allowed into the corridor is that for one side of the corridor or is that for a total of both sides cannot exceed 4-inch?

A: I would say that is for each individual side of a corridor. So, each side of the corridor is allowed a 4-inch projection. The reason I say that is the limit on a projection into the corridor is to prevent a sight-impaired person from running into an object while egressing. Since most corridors are wider that the largest human, the 4-inch restriction is based on individual sides of the corridor.

Even though section 19.2.3.4(2) of the 2012 Life Safety Code permits a 6-inch projection into the corridor, CMS explained in their Final Rule to adopt the 2012 Life Safety Code (published May 6, 2016) that they will require all healthcare facilities who receive Medicare/Medicaid reimbursements to comply with the ADA restriction of a 4-inch maximum projection.  The ADA refers to the ANSI standard A117.1-2009, section 307.2 that limits a 4-inch projection from 27-inches above the floor to 80-inches above the floor.

Suite Doors

By Brad Keyes…

Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have different interpretations of 19.2.5.7.1.2.

A: No. Corridor entrance doors to suites must latch. Section 19.3.6.3.5 requires all corridor doors to latch. CMS does not allow the exception for a device that holds the door closed with 5 lbs. of force.

Since a suite is nothing more than a large room with smaller rooms inside, the barrier that separates the suite from the corridor must meet the conditions for corridor walls, which means the door must latch. The provision in 19.2.5.7.1.2 (2) is written to allow existing suites to have smoke resistant walls when fire-rated barriers are required by the corridor walls.

Corridor Projections

By Brad Keyes…

Q: In regards to corridor width, section 19.2.3.4 of the 2012 LSC discusses that a corridor has to be at least 48-inches outside of a sleeping room in clear width. Does that mean that you only need to worry about situations where your corridor projection will reduce the hallway to less than 48 inches? Is clear width from wall to wall, or from projection to wall? When I had asked our Accreditation Organization for guidance on this issue they stated that we did not need to worry about a projection so long as the corridor still maintained 8 feet from the projection to the other wall. I don’t see that that stated anywhere in my copy of the LSC. Is this true?

A: No… it is not true. Let’s put to rest the erroneous comment that you do not need to worry about a corridor projection so long as the corridor still maintained 8 feet from the projection to the other wall. This is absolutely false. A projection into the corridor is not affected by how much distance to the other wall remains. If someone wants to cling to that statement, then ask them to identify where in the Life Safety Code it permits it (they won’t find it).

According to the CMS Final Rule to adopt the 2012 Life Safety Code that was published May 4, 2016, all CMS-certified healthcare providers cannot have a wall-mounted projection of more than 4 inches. This is measured from 27-inches above the floor to 80-inches above the floor according to the ANSI standard A117.1-2009, section 307.2, which is referenced in the ADA standard. But this also allows for wall-mounted items (i.e. clocks, signs, monitors) to extend more than 4-inches into the corridor as long as they are at least 80-inches above the floor.

This is true no matter how wide your corridor currently is, although some exceptions apply for areas open to the corridor like lobbies and waiting areas.

 

Corridor Doors

Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?

A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage. I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency.

Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in either the corridor, or the room. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.

You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.

I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustibles stored in those patient rooms, you have a big problem. The room would have to comply with section 43.7.1.2 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

Horizontal Sliding Doors

Q: Someone just asked me a question and I haven’t thought about this one before.  This AHJ is enforcing the IBC but I’m looking for an NFPA viewpoint and of course I thought of you.  The IBC and the LSC both require corridor doors in a health care facility to latch.  But what if those doors are horizontal sliding doors (manually-operated)?  The IBC allows horizontal sliding doors if the space served by the door has an occupant load of 10 or less.  The doors in question are not in suites.  I don’t see anything that prevents the use of horizontal sliding doors, or anything that says these doors don’t need to latch, but why should they have to latch since they aren’t affected by pressure the same way a swinging door would be?  It seems like latching hardware on horizontal sliding doors would be a pain for hospital staff. Have you ever run into this?

A: Yes… I see this issue a lot in hospitals. Many architects are mistaken when it comes to glass sliding doors. Perhaps they follow IBC and specify non-latching doors, but then they fail to comply with the 2012 Life Safety Code, which gets them (and the hospital) in hot water.

Section 19.2.2.2.10.2 discusses horizontal sliding doors that serve an occupant load of fewer than 10 people have to meet all of the requirements in the sub-headings 1 – 5. Sub-heading 5 says where corridor doors are required to latch, the doors are equipped with a latch or other mechanism that ensures the door will not rebound into a partially open position if forcefully closed.

So, the LSC is clear: Where corridor doors are required to latch, the horizontal sliding doors must also latch.

Yes… there are a lot of requirements in the LSC that are a pain to staff. But patient safety is a job that all have to work for, regardless how inconvenient it may be.

Corridor Transaction Window

Q: Do transaction windows in a smoke resistive non-rated corridor wall in a healthcare occupancy need be self-closing?

A: It depends on what space the window is open to. Section 19.3.6.1 of the 2012 LSC says corridors (in healthcare occupancies) must be separated from all other areas by partitions (either smoke resistant or ½-hour fire-rated, depending on the sprinkler protection), unless it complies with one of the following exceptions to be open to the corridor:

Spaces unlimited in size, provided:

  • The smoke compartment is fully protected with quick-response sprinklers;
  • The space is not used for patient sleeping rooms, treatment rooms, or hazardous areas;
  • The corridor is protected with smoke detectors, or the smoke compartment is protected with QR sprinklers;
  • The space is protected with smoke detectors, or the space is arranged to allow direct supervision by staff;
  • The space does not obstruct access to required exits.

Spaces unlimited in size, provided:

  • The space is not used for patient sleeping rooms, treatment rooms, or hazardous areas;
  • The space and the corridor are protected with smoke detectors;
  • The space is protected with sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimal quantity and arrangement that a fully developed fire is unlikely to occur;
  • The space does not obstruct access to required exits.

The presumption here is the space is not a waiting area, a nurse station, a Gift shop, a limited-care facility, a kitchen, or a group meeting room, so those exceptions do not apply. So, you say it is a transaction window… Let’s assume it is a sliding window to an accounting area where patients can make payments. If the accounting area meets exceptions #1 or #2, then a sliding window that does not resist the passage of smoke or positively latch is permitted. However, you will need to identify on the Life Safety drawings that the corridor wall no longer exists where the sliding window is located but is now located around the back of the accounting area. That means the walls in the back of the accounting area now becomes the corridor walls, and they must meet the requirements for corridor walls (19.2.6.2) and any openings must meet the requirements for corridor doors (19.3.6.3).It might just be easier to make the sliding window smoke resistant and positive latching.

Wall-Mounted Cabinets Project More Than 4-Inches

Q: We previously built personal protective equipment (PPE) cabinets that are permanently mounted to the wall. These cabinets protrude in to the hallway 5-inches. The previous NFPA guidelines allowed 6-inch projections so we were within the limits. Now, the new NFPA 2012 decreased that projection allowance to 4-inches. Since these are isolation cabinets, are they allowed to stay in the hallway?

A: Well… you’re not quite correct…

The 2012 LSC actually does permit 6-inch projections into corridors. See section 19.2.3.4 (2). What has changed is the CMS Final Rule to adopt the 2012 Life Safety Code and the 2012 NFPA 99 Health care Facilities Code, where CMS said they will enforce the ADA requirements of a maximum corridor projection of 4-inches.

And this does apply to existing conditions where the removal of barriers to accessibility are readily achievable. So, since CMS adopted the 2012 LSC on July 5, 2016, this 4-inch maximum corridor projection rule does apply to new and existing conditions. And no, the cabinets are not allowed to stay in the corridor just because they are isolation supply cabinets.

You do have a few options:

  • Look into converting the area where your PPE cabinets are installed to be a suite-of-rooms, which eliminates the corridors and the 4-inch rule goes away;
  • Consider not doing anything and when (or if) you get cited, apply for a waiver based on ‘financial hardship’;
  • Remove the cabinets.

Strange Observations – Sprinkler in the Alcove

Continuing in a series of strange things that I have seen while consulting at hospitals…

The good news is you have an alcove in the corridor where you can store linen carts. The bad news is a sprinkler head was installed in the alcove preventing you from storing linen carts.

In this photo, the top of the linen cart is too close to the sprinkler deflector. You must maintain at least 18-inches clearance underneath the sprinkler head.

I’m not an expert on sprinkler design, but I suspect they would not need a sprinkler head in the alcove, if another sprinkler head was in close proximity.

Strange Observations – Wall Mounted Signs

Continuing in a series of strange things that I have seen while consulting at hospitals…

The discharge door for a stairwell opened out onto the 1st floor corridor, where egress was just down the corridor. (This is permitted by section 7.7.2 of the 2012 LSC, provided they met all of the other requirements).

As the picture indicates, when the stairwell door is fully opened, it sticks out into the corridor about half the width of the door. This can cause a momentary obstruction to people in the corridor when the door is open.

The facilities department thought it would be a good idea to warn people that the door may be a problem when open and created this sign on a swivel that warns people. To be sure, the sign does swing if anyone came into contact with it, but when it is in its normal position, it projected more than 4-inches into the corridor.

Even though the intentions for the sign were good, it does violate the maximum 4-inch corridor projection rule adopted by CMS, and therefore it was written up.

Alcoves

Q: Is there a limit to the size an alcove can be in a smoke compartment right off of the corridor? I understand equipment can be stored in alcoves but is there a definition of an alcove? I have a one hundred square foot room that was once required to be a remote nurse station, but the area is no longer used as a remote nurse station. There is no door to the room and the opening to the corridor is 6 feet wide. Am I allowed to store wheeled equipment (i.e. wheelchairs, patient lifts and crash carts) not in use in this area?

A: Crash carts are permitted to be left unattended in the required width of the corridor, but your question is valid for the other items. Generally speaking in healthcare occupancies, corridors must be separated from all other areas and rooms. But take a look at section 19.6.3.1 of the 2012 Life Safety Code. There are nine (9) exceptions to the LSC requirement that the corridor must be separated from the rest of the facility.

Depending on certain variables, such as sprinkler coverage, smoke detection, size of the open area, etc., you may be able to qualify for one or more of the exceptions. However, you cannot store any combustibles in this room that is open to the corridor. That means no bed storage (because mattresses are combustible) and no supply carts with combustible supplies can be stored in these rooms.

You will have patrol this area often to ensure it is maintained properly. But to answer your question, I have not seen any limitations on size of alcoves in corridors. And one of the exceptions to 19.3.6.1 says spaces unlimited in size may be open to the corridor if you meet all of the requirements.