Fire Drills in the Behavioral Health Unit

Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: For fire drills in the main hospital, I am sure it would be best to separate these activities from the Behavioral Health unit. And I am sure we would need to be notified on our panel if an event happened on the unit. Am I on the right track? Is there any code that speaks to this? In addition, what would be your suggestions in regard to stairwell egress in the case of an alarm on the Behavioral Health unit. Delayed egress? Clinical needs locks?

 A: Okay… so there is a lot to cover here. As I understand your question, you will soon be opening a behavioral health unit in an existing acute-care hospital. You say you are partnering with another organization… does this mean the behavioral health unit is a separate entity (i.e. does it have a separate CMS certification number) from the acute-care hospital?

 If the behavioral health unit is a separate entity, then you must conduct separate fire drills (once per shift per quarter) in the behavioral health unit as compared to the rest of the acute-care hospital. If the behavioral health unit is not a separate entity, then you are not required to conduct separate fire drills from the rest of the acute-care hospital. So, you need to verify if the behavioral health unit will be a separate entity from the acute-care hospital.  

The fire alarm control system is a system for the entire building, even if there are separate entities inside the building. If a fire alarm originated on the behavioral health unit, you most definitely need to know about it in the acute-care hospital, and vice-versa.

The behavioral health unit would likely qualify for clinical needs locks as described in 18.2.2.2.5.1 of the 2012 LSC. These locks are not required to automatically unlock on activation of the fire alarm system. You can do that if you want, but there is no requirement to do so. Actually, you really don’t want the locks on the doors in the behavioral health unit to automatically unlock on a fire alarm, because patients will soon figure that out and will loiter around the locked egress doors and jump at the chance to elope whenever a fire alarm actuates. I do not suggest delayed egress locks, but rather clinical needs locks as long as you qualify for them.  

Door Locking Arrangements

Q: I have read your response to secondary locks on fire egress doors. (7.2.1.5.10.6 – Two releasing operations shall be permitted for existing hardware on a door leaf serving an area having an occupant load not exceeding three, provided that releasing does not require simultaneous operations.) My question is: Are there any other references or code standards regarding secondary locks on fire/egress doors?

A: Section 7.2.1.6 “Special Locking Arrangements” would apply to all doors, including fire-rated door assemblies. This section includes:

  • Delayed egress locks (7.2.1.6.1)
  • Access-control locks (7.2.1.6.2)
  • Elevator Lobby Locks (7.2.1.6.3)

Then, for healthcare occupancies, there are additional locking arrangements that would be permitted on fire-rated door assemblies, such as:

  • Clinical needs locks (19.2.2.2.5.1). Permitted only for the use of securing psychiatric patients, dementia patients, Alzheimer patients, etc.
  • Specialized protective measure locks (19.2.2.2.5.2). Permitted for locking nursery units, mother/baby units, ICUs, ERs, etc.

While all doors may not be fire-rated, all doors are egress doors and the above listed special locks would be permitted on all doors, provided you qualify for them.

Dutch Doors

Q: I have been asked by a clinic manager at one of our primary care clinics to install a door knob on a split Dutch type door that goes into a lab area. They are requesting that the lock set be a double cylinder type where one would have to use a key to enter from the hallway as well as use a key to exit from inside of the room. I have never heard of this before (that doesn’t necessarily mean anything). I have concerns regarding egress safety, should I do this?

A: I advise you to not do this. From what you describe, it sounds to me that there would be multiple violations with this arrangement. First, having a second latch set on the Dutch door would require two actions to operate the door, which is not permitted according to section 7.2.1.5.10.2 of the 2012 LSC.

Second, it sounds like a key would be required to egress the door which is not permitted according to section 19.2.2.2.4. I’m glad you asked, but it sounds like trouble to me if you agree to install this equipment.

Deactivating a Magnetic Lock

Q: When deactivating a magnetic lock but leaving it in place, what is the exact/excepted wording used noting that this magnetic lock is no longer in use?

A: What you are saying is not compliant with section 4.6.12.3 of the 2012 LSC which says existing life safety features obvious to the public, if not required by the LSC, shall be either maintained or removed.

If you want that maglock out of service, you must remove it since it is obvious to the public. 

 

Clinical Needs Locks

Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required single path of egress? (All options have 4 locked doors in the path.)

A: The 2012 Life Safety Code does not address any restrictions on how many doors in the path of egress may be equipped with Clinical Needs locks. Therefore, if the LSC does not prohibit it, then it is permitted.

However, not all AHJs permit it. For example; I am told that the IBC prohibits more than one Clinical Need lock in the path of egress (or, at least they used to). When I worked at the hospital, I tried to get the state to allow two locked doors in the path of egress from the Psychiatric unit but they would not allow it.

But in my travels, I have seen multiple doors in the path of egress equipped with Clinical Needs locks where permitted in various states around the country. The most common use of multiple Clinical Needs locks create a ‘Sally Port’ or ‘airlock’ that allows one locked door to open but the other locked door must be closed. This is an added security to prevent anyone from eloping.

So, the LSC does not prohibit it, but the IBC and some AHJs do.

Delayed Egress Locks

Q: Lately, due to many different construction projects within this hospital, contractors install crash bars (aka panic bars) on doors that have locks for security reasons. The doors do lead to alternate evacuation exits/stairs. The crash bars release the locks in 15 seconds and I have been told that signs notifying people of this is required on the doors. Where is the code for this requirement? One location is an entrance directly into an outpatient care service directly off the public elevator lobby. At two newer locations on another floor, employees are to use their ID badge for access but in one location the sensor is not readily seen. In this location employees frequently open the door via the crash bar setting off the alarm requiring someone to go there to reset the alarm. The message contractors are putting on the doors read: PUSH UNTIL ALARM SOUNDS / DOOR CAN BE OPENED IN 15 SECONDS. The message gives people permission as well as instruction of how to enter a secured area. Where is this code requiring the sign and does it specify the message?

A: Yes… The answer to your question is: Section 7.2.1.6.1 of the 2012 Life Safety Code.

What you have on these doors are called “Delayed Egress Locks”, and the sign that reads “PUSH UNTIL ALARM SOUNDS – DOOR CAN BE OPENED IN 15 SECONDS” is a requirement. If you don’t have these signs, you can be cited by an inspector or surveyor.

Also, as an FYI… you are not allowed to use delayed egress locks on doors in the required path of egress unless the facility is fully smoke detected or fully sprinklered. So, check with your staff to determine if your building is fully sprinklered. In all my 40+  years in this business, I have never seen a fully smoke-detected hospital.

Keep in mind, delayed egress locks are not designed to secure an area. They are designed to allow access through the door on a delayed basis. If the door is located in the required path of egress, then you cannot secure the door, unless it meets one of the exceptions provided in section 19.2.2.2.4.

Magnetic Locks

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director?

A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (i.e. relays, control modules) be tested once per year. Since the magnetic locks in access-control and delayed egress locks are connected to the fire alarm system via an interface relay, then the magnetic lock needs to be tested once per year to ensure it disconnects during a fire alarm signal. This test is required to be conducted by someone who is certified in accordance with NFPA 72.

If you are CMS certified or accredited by any of the major accreditation organizations then you would be expected to comply with the manufacturer’s recommendations on preventive maintenance. Most manufacturers of magnetic locks requires periodic maintenance to ensure they are functioning correctly.

Locks on Bathroom Doors

Q: In a multi-tenant office building, can restrooms in the common areas have controlled card access and mag locks tied into the fire system on the entry/exit doors?

A: Well, as long as the locks are installed in accordance with section 7.2.1.6.2 of the 2012 Life Safety Code, I believe it would be okay from an NFPA viewpoint. But you need to ask your state and local authorities to see if they have other restrictions that would prevent this from happening.

Delayed Egress Locks

Q: Our hospital is not fully sprinklered and is not fully smoke detected, but we want to install an infant security locking system in our Mother/Baby unit. I discussed this with our vendor who wants to sell us the infant security locking system, and he says we qualify for delayed egress locks because being 100% fully sprinklered is not the only criterion for compliance. He says we comply because we demonstrate the existence of an approved, supervised automatic fire detection system by having an automatic fire detection system in our hospital, so that should allow the installation of the infant security locking system. The vendor also said as long as the local AHJ approves the installation, that’s all we need, because the local AHJ has the final word. What do you say?

A: NFPA 101 Life Safety Code, 2012, section 7.2.1.6.1 is rather clear: Among other requirements, in order to have delayed egress locks, you need one of the following:

  • The building needs to be fully protected throughout by an automatic sprinkler system, or;
  • The building needs to be fully protected throughout by an automatic fire detection system.

Being fully protected throughout with automatic sprinklers is obvious – you need full sprinkler coverage everywhere in the building. But it appears the term ‘being fully protected throughout by an automatic fire detection system’ is not so obvious. If you are not fully protected with sprinklers, then section 7.2.1.6.1 requires a smoke detector in all occupiable areas. This is explained in section 9.6.2.9 of the 2012 LSC. This means a smoke detector must be inside every room, every sleeping room, every procedure room, every corridor, every office, every conference room, every utility room, every lounge, every classroom, every work-room, every mechanical room, etc. In my 40-years of doing this work, I’ve yet to see a hospital qualify for this in regards to installing smoke detectors in all occupiable areas. If you believe your hospital meets the requirements for being fully protected with smoke detectors, then I would like to schedule a visit and take a look, because I’ve never seen that before.

Please understand the way your vendor described it “demonstrate the existence of an approved, supervised automatic fire detection system”, does not meet the description of being fully protected throughout by an automatic fire detection system. All hospitals have an approved, supervised automatic fire detection system, because the LSC requires that. But no hospital (so far that I have seen) has a smoke detector in all occupiable areas. It’s not required and it is too costly to install. Sprinklers are far cheaper.

Your vendor is correct, though: Sprinklers are not the sole criterion for the installation of delayed egress locks. But, it is one of two criteria, and so far, no hospital is choosing to go with the other choice (smoke detectors). Even if you could afford to install smoke detectors in every occupiable areas, the hospital would likely not be able to afford the maintenance (testing & inspection) and all of the false alarms that go with it.

By the way… the phrase “the local AHJ has the final word” is not accurate. I appreciate the respect that the vendor is trying to say, but all AHJs have the final word, not just the local AHJ. The typical hospital has many (between 5 and 8) AHJs that they have to comply with regarding the Life Safety Code:

  • CMS (Federal)
  • Accreditation organization
  • State licensing agency
  • State agency in charge of hospital construction
  • State fire marshal
  • Local fire authority
  • Local building code authority
  • Insurance company

All AHJs are equal. No one AHJ can override the decision of another AHJ. Any AHJ can decide to interpret the LSC in the way they deem necessary and if it disagrees with another AHJ, then so be it. The hospital must comply with the most restrictive interpretation. So, saying the local AHJ has the final word is not accurate; all AHJs have the final word. For example: If the local AHJ said it is okay to install delayed egress locks for infant security (because nobody wants to see infants stolen), even though the building is not fully sprinklered and not fully smoke detected, that’s not okay with other AHJS like CMS, your accreditation agency and your state agency on hospital construction. So, the hospital cannot do that, because they have to follow the most restrictive interpretation.

I see other hospitals that are not fully sprinklered or fully smoke detected use infant security systems but they do not install the door locking hardware. So, it operates like a warning system. If the hospital does not want to invest in being fully protected with sprinklers (or smoke detectors), then that is their only option. It is an incentive to become fully protected with sprinklers.

Door Lever Hardware

Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not “hook” passing clothing, straps, purses during emergency evacuations? I swear I remember this for healthcare occupancies from somewhere, but can no longer find it in the Life Safety Code.

A: No, the 2012 Life Safety Code does not require a return on door lever handles to prevent hooking clothing during egress. But my good friend Lori Greene (www.idighardware.com) tells me the return is only required by the California Referenced Standards Code, which says: Levers.  The lever of lever-actuated levers or locks shall be curved with a return to within 1/2″ of the face of the door to prevent catching on the clothing of persons during egress. Since this is not a requirement of the NFPA or ICC codes or standards, it would only apply in California.