Closet Doors

Q: Are closet doors located inside a corridor considered corridor doors and do they have to meet life and safety codes referring to corridor doors?

A: It depends…. What does your Life Safety drawings say?

Section of the 2012 LSC requires doors in the corridor to be positive latching. If the closet door is in the corridor wall then it must be positive latching. However, there may be a possibility that the corridor wall could run behind the closet, provided the back of the closet wall meets the requirements of for construction of corridor walls.

But your Life Safety drawings need to specifically identify that the corridor wall runs behind the closet. If they do not, then the surveyor has no choice but to hold your closet doors compliant to for positive latching corridor doors.

Life Safety Drawings

Q: Should the official Life Safety drawings for an existing space within a hospital show the rating on a fire barrier as it was originally built or as it is required to be rated according to the Life Safety Code? We have a soiled utility room that was required to be sprinklered and constructed with smoke resistant partitions according to the code in effect at the time it was constructed, but it was constructed to 1-hour fire resistance rated walls and a 45 minutes rated door. What should the Life Safety drawings reflect for the fire rating of the soiled utility room walls?

A: This may be a tricky question to answer. To be sure, Life Safety drawings are not construction drawings, so the actual type of construction for the barrier is not what is needed. The concept of Life Safety drawings is to indicate what fire-rating the Life Safety Code requires the barriers to be. This is not the same as saying the Life Safety drawings should reflect what fire rating the walls were constructed to. A case in point is in the lower level of a hospital, it is quite common for designers to specify cement block walls for the corridors since there is so much support services traffic in these areas. The walls where carts and pallets commonly travel will stand up to a lot more abuse than steel stud and gypsum board walls. But cement block walls often have a fire-rating of 2-hours or more, but that is not why cement block walls were chosen. The Life Safety Code may only require non-rated smoke resistant walls in the corridor, so that is what the Life Safety drawings should say; not the actual fire rating of 2-hour (or more). A surveyor will hold you accountable to what your Life Safety drawings say; so it is best to only identify what the Life Safety Code requires for the walls and barriers, rather than what they were actually constructed to. In the case of your soiled utility room that qualifies as existing conditions, I suggest the Life Safety drawings should reflect what is required for existing conditions.

Evacuation Route Maps

Q: We had a question as to whether or not we are required to have posted emergency evacuation route signage posted throughout the hospital and clinical buildings. Given the fact we have extensive exit lights in place throughout all buildings is there a Joint Commission requirement that the evacuation route be posted within the buildings?

A: No, there is no Life Safety Code, Joint Commission or CMS requirement to have emergency evacuation route maps posted in the hospital. As far as I can tell, there never has been a Joint Commission requirement of this, but at one time, the interpretation handed down to state CMS inspectors did require hospitals to post emergency evacuation route maps. It was determined that this was an incorrect interpretation on the CMS form 2876S (also called K-Tags) about 10 years ago, and CMS removed the emergency evacuation route map requirement from the K-Tags document. It is possible that the misinterpretation may have started with section of the Life Safety Code (2000 edition) which requires hospitals to have written plans for evacuation from the building. No matter how the mistake was made, it is comforting to know the officials did the correction and now evacuation route maps are not mandatory, however they can be very helpful when they are accurate. Please check with your local and state authorities to see if they have any requirements to post evacuation routes.