Testing Delayed Egress Hardware

NOTE:  My good friend Lori Greene from Ingersoll Rand Security Technologies had this comment posted on her website /blog:  www.idighardware.com  last August 15th, addressing the testing requirements for delayed egress locks. I know some of you readers are already subscribers of Lori’s blog and probably have already read this comment. But I thought this was such a well-researched answer by Lori, that those individuals who are not yet regular readers of ‘I Dig Hardware’ might benefit from her knowledge. It is a very relevant subject to the healthcare setting, so with Lori’s permission, I am repeating her answer to the question: “What are the testing requirements for delayed egress locks?”   Brad Keyes

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Testing Delayed Egress Hardware- What are the Requirements?

( by Lori Greene)

The 2009 International Building Code (IBC) doesn’t include testing guidelines in section 1008.1.9.7 Delayed Egress Locks, but that makes sense because the IBC is used during construction and not for ongoing maintenance.  I checked the 2009 International Fire Code, and the section for delayed egress locks is exactly the same as the one in the IBC.  But since a delayed egress lock requires immediate release upon fire alarm, I thought I might find something in Chapter 9 of the IFC – Fire Protection Systems.  In the section on Testing, Inspection, and Maintenance (907.9), I found this statement:  “Testing. Testing shall be performed in accordance with the schedules in NFPA 72 or more frequently where required by the fire code official.”

NFPA 72 is the National Fire Alarm and Signaling Code.  There were some changes in the 2010 edition relative to this question, so I used that edition in my research.  According to NFPA 72-2010, “door unlocking” falls into the category of “emergency control functions”:  “Emergency control functions (i.e., fan control, smoke damper operation, elevator recall, elevator power shutdown, door holder release, shutter release, door unlocking, etc.) shall be tested by operating or simulating alarm signals. Testing frequency for emergency control functions shall be the same as the frequency required for the initiating device that activates the emergency control function.”  (Table 14.4.2.2).

Here’s some related information from Annex A – Explanatory Material:

Table 14.4.2.2, Item 23. Initiating devices configured to operate an emergency control function are required to be tested per the test methods listed in Table 14.4.2.2, Item 14 and the test frequencies listed in Table 14.4.5, Item 15. Whenever an emergency control function is observed to not operate properly during a test of an emergency control function initiating device, the problem should be reported to the building owner or designated representative. The failure of the emergency control function should be reported as a possible failure of the fire safety feature and not necessarily of the fire alarm system.

Here’s what NFPA 72-2010 says in the inspection/testing section about emergency control functions:

14.2.6 Interface Equipment and Emergency Control Functions.

14.2.6.1* Testing personnel shall be qualified and experienced in the arrangement and operation of interface equipment and emergency control functions.

14.2.6.2 Testing shall be accomplished in accordance with Table 14.4.2.2.

And finally, Table 14.4.5 says that emergency control functions must be tested annually, as well as upon acceptance/reacceptance.  So a delayed egress lock must be tested when it is installed, repaired, or replaced, and then annually after that.  Since NFPA 72 deals with fire alarm systems, the testing requirement is probably more related to whether the fire alarm unlocks the doors, but I think it makes sense to test the 15-second release at least annually too.  I don’t know of a specific requirement for testing that part of the delayed egress lock, other than the NFPA 101 – Life Safety Code requirement for certain egress doors to be inspected annually, depending on the occupancy type.  Local jurisdictions may require more frequent testing / inspection, and facilities may choose to increase the required frequency of testing and establish a specific process to ensure the safety of building occupants

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

From a healthcare facility point of view, I think Lori nailed the issue straight on top of the head. I agree 100% with what she said and would not have anything to add to your code search.

My experience tells me that currently, few Joint Commission surveyors or CMS inspectors actually request to see documentation on testing delayed egress locks, although it is clear the 1999 edition of NFPA 72 requires testing all interface devices connected to the fire alarm control panel. In order for a delayed egress to operate correctly, it must have an interface device between the delayed egress locks and the fire alarm control panel.

I believe surveyor and inspector awareness will improve when the CMS finally adopts the 2012 edition of the LSC, as the 2010 NFPA 72 explains the testing of emergency control functions much better.

Thank you Lori, for a well thought-out answer.      Brad Keyes

 

Application of Delayed Egress Locks and Access Control Locks

I was recently asked to explain the difference between delayed egress (DE) locks and access controll (ACE) locks, and what are their applications.

The main difference between DE and ACE locks is, DE locks provide a measure of security in the path of egress, where ACE locks do not. The DE lock provides for a 15 second delay before the door will unlock, once the releasing device (crash bar) is activated. Although the Life Safety Code does say 30 seconds is permitted if the authority having jurisdiction allows it, don’t count on this. Even if your local and state authorities permit it, Joint Commission and CMS will not. Since Joint Commission and CMS are authorities having jurisdiction, then you would need their approval as well.

ACE locks automatically unlock in the path of egress when someone approaches the door,  and also by the actuation of the manual release button which is mounted within 5 feet of the door.

So, where would a hospital use a DE lock and where would they use an ACE lock, and why?

Delayed egress locks would be used where the security needs of the patients requires a certain level of delay in an unauthorized individual trying to flee the unit, such as a nursery, pediatrics, labor and delivery or mother-baby units. The 15 second delay can alert staff on the unit that someone is trying to leave the unit who should not be doing so.

Delayed egress locks would be used in a department that has highly sensitive materials, such as medical records, or accounts receivables, or even a large storage room with valuables where the attendant cannot monitor all of the exits. The 15 second delay can alert staff in the area that someone is trying to leave the unit (or room) who should not be doing so.

Delayed egress locks can be used in patient care areas where the patients are somewhat ambulatory but do not qualify for ‘clinical needs’ locks. (Clinical needs locks are permitted in psychiatric and Alzheimer’s units.) Areas such as emergency rooms, radiology, physical therapy, and even some acute care nursing units may use DE locks to discourage those patients who are able to get up and walk around on their own, from unauthorized leaving against medical advice (AMA).

NOTE: In order to qualify to use DE locks, the entire facility needs to be protected with automatic sprinklers, OR be protected with smoke detectors.

Access control locks are typically used where access into a unit or department is desired to be locked. Consider the situation where there is a single leaf entrance door in the corridor to a laboratory which swings into the lab when opened. Access into the lab is desired to be controlled so ACE locks are installed in conjunction with a card swipe reader. The function of the ACE lock would have the magnetic lock preventing unauthorized individuals from entering the lab, but authorized individuals could swipe their ID card on the reader, which would deactivate the mag-lock and the door would unlock and they could enter. Individuals who wanted to exit the lab would approach the door and the motion sensor would sense their presence and automatically deactivate the mag-lock and the door would unlock and they could egress the lab.

Access control locks are frequently misapplied and misused throughout the healthcare industry. Often times portions of ACE locks are installed on cross-corridor doors attempting to limit access into a certain area, and the organization fails to install the motion sensor and the ‘Push to Exit’ button on the wall. All they have is a card swipe reader to release the mag-lock. This is not permitted if the locks are installed on a door in the path of egress. Take a look at the ‘Exit’ signs. If the ‘Exit’ signs direct you through a door, then it is not permitted to be locked without the delayed egress locks or the access control locks.

These comments are based on sections 7.2.1.6.1 and 7.2.1.6.2 of the 2000 edition of the Life Safety Code. Please refer to these sections for further details on installation and operation requirements. Also, consult with your lcoal and state authorities for other requirements concerning DE and ACE locks.

Locked Doors to Utility Rooms?

Utility rooms, whether they are clean utility rooms, or soiled utility rooms, are not required to be locked according to any NFPA standard, Joint Commission standard or CMS Condition or standard. However, if there is a perceived risk to safety because a utility room door is left unlocked and the hospital has failed to assess that risk, then the surveyor or inspector has every right to cite the organization for ‘interior spaces which are unsafe to occupants of the building’. This would be scored under EC.02.06.01, EP 1 for Joint Commission, or under §482.41 for CMS. The big problem with §482.41 for CMS is this is a ‘Condition’ rather than a standard that would be considered out of compliance and that alone would trigger a full-fledged CMS validation survey, which is very undesirable.  So this is something you definitely do not want to happen at a hospital.

So, the way a risk assessment is conducted to determine if a perceived risk is OK as is, or if something further needs to be done to compensate for that risk, is very simple. Take a sheet of paper, draw a vertical line down the middle, and list all the ‘Pros’ of the risk on the left side and all the ‘Cons’ of the risk on the right side. Whichever side has the most items or the most severe items listed, wins. If the ‘Pro’ side wins, then you don’t have to lock the door, but if the ‘Con’ side wins, then the doors should be locked.

Here’s an easy example: For a pediatric unit, where it is not uncommon to see children patients walking up and down the corridor (even though they are supervised) a clean or soiled utility room door which is not locked poses a HUGE risk to safety for the children, and the utility room doors should be locked. However, utility room doors on a geriatric unit does not pose the same risk as there are far fewer children roaming the hallways, so the doors could remain unlocked.

The risk assessment has to be documented, and I always advise my clients to have many stakeholders involved in the risk assessment process, including:

  • Safety officer
  • Security manager
  • Facility manager
  • Infection Control manager
  • Nurse manager
  • Chief Nurse Executive
  • Risk manager
  • Etc.

Then, once the risk assessment is complete, I advise them to have it reviewed and approved by the Safety Committee, and get it in the minutes. Then, if ever challenged by a surveyor or inspector who thinks the doors should be locked, you can tell them:

  • There is no code or standard that requires the doors to be locked
  • An assessment to determine the level of risk to the patients was conducted by an interdisciplinary team of professionals who decided that the doors are not required to be locked (or are required to be locked, depending on the outcome of the risk assessment)
  • This risk assessment decision was affirmed by the organization’s Safety Committee and here are the minutes to indicate that

The risk assessment process is a great tool to use when decisive action is not clear, or when the codes and standards do not seem to address an issue very well. You can never go wrong with a risk assessment especially if many different professionals (who have the best interests for the safety of the patient at heart) agree on the conclusion.

One last thing… Risk assessments are not ‘forever’. They should be renewed once a year to see if any of the conditions have changed.

Door Locks for Safety Needs

As we discussed in the previous posting, the healthcare chapters of the Life Safety Code allows for three (3) special locking arrangements:

  1. Clincal needs
  2. Delayed egress
  3. Access control

The phrase ‘Clinical needs’ was always poorly defined (or not defined at all) in the 2000 edition of the LSC, and was left to the authority having jurisdiction (AHJ) to decide for themselves what doors in a hospital qualify for locking arrangement as allowed by ‘clinical needs’. Many AHJs were liberal and allowed ‘clinical needs’ locks not only for psychiatric or Alzheimer’s patients, but also for infant security as well. However, there are some state AHJs who represent CMS that did not permit the use of ‘clinical needs’ locks for infant security. That alone caused quite a bit of problems for hospital facility managers.

Well, the 2012 edition includes explanatory information (which is not in the 2000 edition) in the annex section that identifies psychiatric, Alzheimer’s and dementia patients as examples where ‘clinical needs’ locks would be allowed. It specifically did not include infant security protection. However, section 19.2.2.2.5.2 of the 2012 edition says:

“Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:

  • Staff can readily unlock doors at all times
  • A total (complete) smoke detection system is provided throughout the locked space or locked doors can be remotely unlocked at an approved, constantly attended lcoation within the locked space
  • The building is protected throughout by an approved, supervised automatic sprinkler system
  • The locaks are electrical locks that fail safely so as to release upon loss of power to the device
  • The locks release by independent activation of a smoke detection system or waterflow in the automatic sprinkler system”

The Annex section of 19.2.2.2.5.2 does state pediatric units, maternity units and emergency departments as examples that qualify foir ‘safety needs’ locks. Now, the Annex section is not part of the enforcable code, but it does offer guidance and direction for AHJs to follow on their over-all interpretation of the the LSC. This new section in the 2012 edition should solve the debate if a nursery or pediatric unit can be locked.

Changes With Electrically Locked Doors

Electrically locked doors. The 2000 edition of the LSC does not discuss them, directly. However, it does talk about the three types of locks that are permitted in hospitals: 1). Clinical needs; 2). Delayed egress, and 3). Access control.

Access control locks are the most misunderstood locks in hospitals today, and I would say nearly all the hospitals that I visit, have some sort of deficiency with access control locks. Let’s review quickly what is required for access control locks: A motion sensor on the egress side; A wall-mounted ‘Push to Exit’ button within 5 feet of the door; When the ‘Push to Exit’ button is depressed, it interrupts power to the lock for a minimum of 30 seconds; A loss of power to the control system renders the lock disabled; And activation of the building’s fire alarm or sprinkler system automatically unlocks the door. Nearly all of the access control locks that I have seen in my career utilize magnetic door locks, or mag-locks for short. These access control locks end up being a problem for facility managers because they get installed by well-intentioned, but poorly informed individuals who do not consult with the person who is knowledgeable on the Life Safety Code.

Now, when the 2012 edition of the LSC is adopted, there will be a new version of door locks, that will solve a lot of these problems. The three locks permitted in hospitals (clinical needs, delayed egress, and access control) will remain, but Chapter 7 will now permit doors that are ‘electrically locked’ to be considered the same as any other normal lock on the door. Section 7.2.1.5.6 says:

“Door assemblies in  the means of egress shall be permitted to be electrically locked if equipped with approved, listed hardware, provided that all of the following conditions are met:

  • The hardware for the occupant release of the lock is affixed to the door leaf
  • The operation has an obvious method of operation that is readily operated in the direction of egress
  • The hardware is capable of being operated with one hand in the direction of egress
  • Operation of the hardware interrupts the power supply directly to the electric lock and unlocks the door assembly in the direction of egress
  • Loss of power to the listed releasing hardware automatically unlocks the door assembly in the direction of egress
  • Hardware for new installation is listed in accordance with ANSI/UL 294.”

Now it is important to note that this section is under the heading of 7.2.1.5 “Locks, Latches and Alarm Devices” (2012 edition) and is not under the the heading 7.2.1.5.6 “Special Locking Arrangements”. That implies this new ‘electrically locked door’ section is not considered a special locking arrangement, but places it squarely on the same level as regular door locks. This is significant, as the healthcare chapter (18 and 19) specifically permits this new ‘electrically locked door’ under section 18/19.2.2.2.1, which says “Doors complying with 7.2.1 shall be permitted.” Well, that alone permits 7.2.1.5 and does not require it to qualify as a ‘Special Locking Arrangement’ in 7.2.1.5.6, which includes the access control requirements.

So, the mag-lock in the picture below is the typical ‘electrically controlled lock’ used in hospitals, and when the 2012 edition is finally adopted, this lock will be allowed (in accordance with the provisions of 7.2.1.5.6) in lieu of access control locks. However, be careful with the application and selection of equipment. The electronic ‘touch-sensitive’ crash bar in the picture above, probably would not be permitted, as a person wearing a glove would not be able to make the completion of the electrical circuit that bare skin requires. Also, those applications where a card-swipe reader or a proximity reader is used in conjunction with a mag-lock will not qualify for the 7.2.1.5.6 ‘electrically controlled locks’, as those locks require the use of a special tool. Section 19.2.2.2.4 (2012 edition) still does not allow the use of a special key or tool to operate the lock.

 

Patient Room Door Locks

Q: Are dead-bolt locks permitted on patient room doors, to keep unauthorized people from entering the rooms? We have dead-bolt locks on the patient room doors in our behavioral health unit which can be unlocked from the corridor side with the use of a key, and the dead-bolt can be unlocked from inside the room with a thumb turn device. These locks are separate from the door latch and are mounted about 60 inches above the floor.

A: While dead-bolt locks on patient room doors that require two actions to operate the door are not permitted in most applications, dead-bolt locks for clinical needs as you described would be allowed by some authorities having jurisdiction (AHJ). Section 19.2.2.2.2 in the 2000 edition of the LSC does allow locks on patient room doors provided they are operable by staff from the corridor side and the lock does not restrict egress from the room. So far that does describe your arrangement, but we need to take a look at section 7.2.1.5.4 that describes the latch or other fastening device (i.e. the dead-bolt lock) is required to be located not less than 34 inches and not more than 48 inches above the floor, and the door must be operable with not more than one releasing operation. In your situation the dead-bolt lock that is separate from the door latch mechanism does not meet this requirement because the lock is mounted more than 48 inches above the floor.

However, the National Fire Protection Association (NFPA) Healthcare Interpretations Task Force (HITF) made an interpretation in June, 2008 that allows dead-bolt locks that require two actions to operate the door where clinical needs locks are used, which included behavioral health units. The problem with this interpretation is they did not address the dead-bolt lock that is mounted more than 48 inches above the floor, as referenced in 7.2.1.5.4. Joint Commission is on record as saying they will abide by whatever the HITF decides, but CMS does not have the same endorsement. They have said they will abide with the decisions of HITF when it is consistent with their own interpretations. In addition, there is no representation of state AHJs from the department of public health (or other similar agency) on the HITF, so each state AHJ has their own interpretation on this issue that may be different than the HITF. My advice, in order to be in compliance with door locking requirements, you will have to consider using the combination door latch / dead-bolt mechanism typically found in hotel rooms, that meets all of the requirements found in 7.2.1.5.4.

Magnetic Latches on Suites

Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?

A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.

In new healthcare occupancy, section 18.3.6.3.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).

However, for existing healthcare occupancies, section 19.3.6.3.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception. When locks are permitted on egress doors, they must meet the requirements found in 19.2.2.2.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.

Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.

Emergency power for magnetic door locks

Q: I was recently informed by a contractor the magnetic locks that we use to lock our ER department doors are not allowed to be connected to our emergency generator power. I cannot find this exclusion to connect to emergency power in the LSC. Are you aware of this requirement?

A: What you are referring to are either delayed egress locks or access control locks, which are allowed to be used on a door in the path of egress with some limitations. LSC section 7.2.1.6.1 for delayed egress locks and section 7.2.1.6.2 for access-control locks have multiple requirements for their use, but one requirement that is shared by both sections states the doors must unlock upon loss of power controlling the locking mechanisms. Nowhere does it say that emergency power cannot be used. However, that is not the end of the story. The LSC requires hospitals to be compliant with NFPA 72 National Fire Alarm Code, (1999 edition) and section 3-9.7.3 of NFPA 72 says all exits connected with a locking device shall unlock upon loss of the primary power to the fire alarm system, and the secondary power supply shall not be used to maintain these doors in the locked condition. The Annex portion of 3-9.7.3 explains that the LSC refers to batteries in the fire alarm control panel as the secondary power supply, but the Annex portion is not part of the enforceable code, just an explanatory section. Since the LSC is silent as to whether the locks can or cannot be connected to emergency power, it is up to the authorities having jurisdiction (AHJ) to make this interpretation. It appears to me that The Joint Commission does not have a problem with delayed egress or access control locks being connected to emergency power, but I know of some state AHJs that do not allow this. I suggest you contact your state and local AHJs for their interpretations.

Locked Patient Room Doors

Q: During a recent inspection, the surveyor cited our hospital for having dead-bolt locks on our patient room doors. None of the doors were locked at the time of the inspection, but the surveyor said the doors could be locked. Our state inspectors were OK with the locks on the patient room doors as-is, but is this a LSC violation and do we have to remove the locks?

A: Section 19.2.2.2.2 (18.2.2.2.2 for new construction) of the LSC says locks are not permitted on patient room doors. However, there are two exceptions to this requirement: 1) A key-locking device is permitted as long as it restricts access from the corridor to the patient room and is operable from the corridor side, and cannot restrict egress from the room, 2) Patient room doors may be locked where the clinical needs of the patient requires specialized security measures. You did not state whether or not the dead-bolt locks could be unlocked from the room side without the use of a key, tool, or special knowledge (see 7.2.1.5.1). If they can be unlocked from the room side without the use of a key, tool or special knowledge, then I believe they would be permitted, according to exception number 1. However, if the locks are not capable of being unlocked without the use of a key, tool or special knowledge, then that would be a code violation, and the surveyor was correct. Exception number 2 allows locks on patient room doors where the clinical needs of the patients require specialized security measures, such as a psychiatric unit. In those situations, the lock does not need to be un-lockable from the inside of the room, provided the patient is under constant observation and the staff is carrying a key (or other such device) at all times to unlock the door. So, your question as to whether or not the locks need to be removed is dependent upon the clinical needs of the patients for specialized security measures, and whether or not the locks can be unlocked from the inside of the room without the use of a key, tool, or special knowledge.

Access Control Locks and Sprinklers

Q: What is the LSC stance on card swipe systems to access doors? We were told by a city inspector that we could not install access control locks because we are not fully sprinkled in the original section of our old building. In addition, if we finish installing sprinklers in this area, we were told we would need to issue keys as a backup to the access-control locks. Kind of defeats the purpose, doesn’t it?

A: It all depends on where the locks will be installed. If they will be in the path of egress, then you may have a problem. Exception number 2 under section 19.2.2.2.4 refers us to section 7.2.1.6.2 for access control locks. Access controlled locks are widely misunderstood and therefore greatly abused in hospitals. There are specific requirements of the access control locks that you must adhere to: 1) A motion sensor on the egress side to automatically unlock the door; 2) A manual release switch must be mounted 40 – 48 inches above the floor, and within 5 feet of the door. When depressed, the switch must interrupt the power to the lock for a minimum of 30 seconds. 3) Activation of the fire alarm system or sprinkler system (if provided) must unlock the doors. It doesn’t say, however, that sprinklers must be provided. If your card swipe readers are on the egress side of the locked door, and you do not comply with all of the above requirements, then you are not in compliance with the LSC. Having card swipe readers on the side of the door that is not in the path of egress is permitted. I do not see any code reference that requires you to have backup keys for access control locks. Ask the city inspector to provide you with a code reference for the interpretation. Perhaps it is a local or state requirement.