Q: Are there any life safety requirements concerning courtyards? We have an outdoor courtyard, surrounded on all sides by our building, with one door entering and exiting the area. As of now, the door remains locked with “Not An Exit” sign posted on it. Our management team would like to open the area to our visitors and came to me for LS concerns. From my perspective, we would need to look at Life Safety issues involving entering the area and look at adding an ‘Exit’ sign, inside the courtyard above the door that goes back into the hospital. Is there anything else that could pose a concern?

A: Beside the ‘Exit’ sign over the door from the courtyard, the courtyard would have to have constant illumination and the door from the courtyard to the indoors must be unlocked all the time.  The walking surface in the courtyard must be level with no abrupt changes in elevation greater than ¼ inch. Also, the “Not An Exit” sign is incorrect; the sign must read “NO EXIT” with the word “NO” 2 inches tall and the word “EXIT” 1 inch tall.

Mechanical Room Exit Signs

Q: Is there a code that states every mechanical room needs an ‘Exit’ sign? I am being pressed to do so and I understand if the exit is obvious you don’t need a sign.

A: No… there is not. But section of the 2012 LSC says access to exits shall be marked by approved signs in all cases where the exit or the way to reach the exit is not readily apparent to the occupants. So, one way this is interpreted, if you’re standing inside the mechanical room and the entrance door to the mechanical room (which also is an exit access) is not readily apparent, then you will need ‘Exit’ signs.

This is actually a very simple test that a surveyor can do while touring your facility… If the surveyor cannot see the entrance door when he/she stands anywhere in the mechanical room, then that is a clear indication the room needs to have the way to reach the exit marked. But if you can always see the entrance door, then one can say the way to reach the exit is readily apparent.

It is recommended that you use the internally illuminated ‘Exit’ signs connected to EM power, rather than trying to get by with externally illuminated signs.

Battery Powered ‘Exit’ Signs

Q: Do ‘Exit’ signs with battery backup require the same testing as emergency lighting in the path of egress as indicted in section of the 2012 Life Safety Code?

A: Well… yes, but not exactly. Section of the 2012 Life Safety Code requires all ‘Exit’ signs to be visually inspected for operation of the illumination sources at intervals not to exceed 30 days. That is a visual inspection and is not a 30-second test or an annual 90-minute test that you’re alluding to.

But section says ‘Exit’ signs connected to, or provided with, a battery-operated emergency illumination source must be tested and maintained in accordance with 7.9.3, which is the section that requires a 30-second monthly test and a 90-minute annual test of the battery system. So, you’re correct in that battery powered ‘Exit’ signs need to be tested monthly and annually just like battery powered emergency lights, but you just had the wrong code reference.

Photoluminescent ‘Exit’ Signs

Q: Can illuminated ‘Exit’ signs be replaced with photoluminescent ‘Exit’ signs? If so, does this eliminate the requirement for monthly inspections of ‘Exit’ signs?

A: Photoluminescent ‘Exit’ signs are permitted, provided they meet the requirements of of the 2012 Life Safety Code, which requires constant illumination from an external source while the building is occupied. Since the hospital is occupied 24-hours per day, then this means the source of illumination must be constant.

The source of illumination must be connected to emergency power for healthcare occupancies. You really don’t gain anything by using photoluminescent ‘Exit’ signs over traditional internally illuminated ‘Exit’ signs because section requires all ‘Exit’ signs to be inspected monthly to ensure they still have a source of illumination.

I do not recommend using photoluminescent ‘Exit’ signs because they are greatly misunderstood and are typically installed in areas that are not compliant.

Exit Signage

Q: This question was recently brought to my attention: “Why do rooms, offices, and work areas do not have “Exit” signs over the doors leaving the rooms?” I could not find an answer for that. But I did notice that rooms within a room do not have “Exit” signs as well. The “Exit” signs throughout our hospital are all in the corridors that lead patrons to the public way.  But if you are in a room, or within another room, are “Exit” signs required?

A: Not necessarily. Look at section in the 2012 LSC, which says: “Access to exits shall be marked by approved, readily visible, signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.” (Emphasis mine).

If the path of egress is readily apparent to all occupants of a room or area, then the case can be made that “Exit” signs are not required to mark the access to the exit. An office does not require an “Exit” sign because the occupant obviously knows the way out of the room. It is “readily apparent” to the occupant. However, “Exit” signs would be required in a cafeteria dining rooms or an auditorium because it is likely there will be people, such as visitors or patients, who do not necessarily know the way out, so the exit is not ‘readily apparent’ to them.

The danger with not marking a means of egress comes with the assumption that every employee knows the way out, and the way to reach the exit is readily apparent. Departments that are visited by people not familiar with the way out need to be marked with “Exit” signs, regardless whether those people are employees or visitors.

Exit Signs in Suites

Q: We have just remodeled a suite and are planning on moving the chemo infusion department into it. There are 5 bays but total occupancy would never be more than 50. Are we required to have exit signs over both exits? Upon exiting the suite into the exit corridors there is less than 50 feet to exit to the outside of building.

A: Yes… You would need ‘Exit’ signs over the doors to the corridor. The reason is, section of the 2012 Life Safety Code requires access to exits be marked with ‘Exit’ signs, unless they are readily apparent. In your situation, the doors to the corridors would not be readily apparent to the patients and visitors, although they may be to the employees who worked there.

Illumination of the Means of Egress

Q: My question is in regards to illumination of the means of egress, specifically, illumination provided outside the building to a public way. I was told by a consultant that the only means of egress requiring illumination are the “designated” egress paths. We were cited for no illumination for the exit path to the public way, and it was not marked by Exit signs. Is emergency lighting required for illumination outside the building?

A: I agree that only the portions that are designated as the path of egress on the exit discharge are required to be illuminated. The exit discharge becomes a ‘designated path of egress’ when the exit from the building discharges onto the walkway outside the building. I have seen many paths outside the building that are confusing and unsure which path to follow to the public way. In those situations, outdoor ‘Exit’ signs need to mark the path of egress, even though it is outside.  Section of the 2000 edition of the LSC clearly states that the exit discharge only includes ‘designated’ stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. If you were cited for not having illumination on an outside sidewalk that lead to a dumpster or other such area that does not serve as a means of egress, then I would say that was an incorrect finding and should be appealed. However, if the finding was for lack of illumination for an outside walkway that does serve as a means of egress from an exit of the building, then that would seem to be a correct finding.

Your question: “Is emergency lighting required for illumination outside the building?” depends on what type of building it is. If the building is healthcare occupancy or ambulatory care occupancy, then yes, emergency lighting is required. According to section (and for ambulatory care) of the 2000 edition of the LSC, emergency lighting must be provided according to section 7.9. Section 7.9.1 says the exit discharge is included in this emergency lighting requirement. You are permitted to utilize battery back-up lighting (as long as it meets the requirements), or generator power for the emergency lighting. Most hospitals use generator power for their emergency lighting since they already have the generator. Battery back-up emergency lights take much more maintenance in monthly and annual testing.

If the building is a business occupancy, then section states emergency lighting is only required in a building that has two or more stories above the level of exit discharge; in a building that is subject to an occupant load of 100 or more persons, above or below the level of exit discharge; or in a building that is subject to 1000 or more total occupants.

Exit Sign Monthly Inspections

Access Control Locks WEb 2Why is it that hospital facility managers are often surprised when surveyors ask to see the documentation that their exit signs were inspected on a monthly basis? Probably because no one has ever asked to see that documentation before. If that is the case, then the facility manager appears to be preparing for a triennial survey based on the results of the previous survey, which is a dangerous strategy to follow.

Section 7.10.9 of the 2000 Life Safety Code requires exit signs to be inspected monthly to ensure that the sign is in fact illuminated. This inspection can be done when the exit sign is illuminated by normal power or emergency power, but is not required to be checked under both sources of power. The inspection is to ensure the sign is illuminated, and the lamps inside the sign are not burned out, or the circuit is not de-energized.

Some facility managers try to argue this requirement away by saying their exit signs are LED and therefore the lamps never burn out. Well, LED lamps do burn out, but it just takes forever to do it. Unfortunately, the 2000 LSC does not have an exception to NOT inspect exit signs for illumination if they are equipped with LED lamps.

Perhaps facility managers are surprised when surveyors ask to see the exit sign inspection documents because The Joint Commission does not have a specific standard or EP that addresses the issue. That does not mean a Joint Commission surveyor cannot ask to see that documentation, though. But Joint Commission is not the only authority that hospitals have to be concerned with. How about CMS; or their state health departments; or the local fire inspector; or their insurance company? Surveyors for those entities could very well ask to see that documentation.

If you are not already inspecting your exit signs on a monthly basis for illumination, then I suggest you get started. Develop a monthly PM work order that has your maintenance staff or security staff looking at each exit sign, and recording whether or not it passed or failed its inspection.

Emergency Power Needed for Exit Signs?

Q: We have a physicians’ office building in an existing business occupancy, which has two remotely located exits.  Exits paths are clearly marked with lit exit signs and the egress corridors have battery backup emergency lighting. However, the exit signs have only normal power (no battery backup). Is this practice non-compliant, and should we replace the exit signs with battery backup units?

A: It depends on the height of the building, and the number of occupants. You state that your physician’s office is an existing business occupancy, so the provisions of chapter 39 of the LSC apply. Section 39.2.10 discusses the Marking of a Means of Egress, which refers us to section 7.10. So, section 7.10.4 discusses the power source for the illumination of the sign, which says if emergency egress lighting is required by the occupancy chapter, then the ‘Exit’ signs need to also be powered by emergency sources as well. Back we go to chapter 39 and look for emergency lighting requirements, which we find in section 39.2.9. Emergency egress lighting is only required in business occupancies, where any one of the following exists:

  • The building is 2 or more stories in height above the level of exit discharge
  • The occupancy is subject to 100 or more occupants above or below the level of exit discharge
  • The occupancy is subject to 1,000 or more total occupants
  • All underground and windowless buildings (see section 3.3.197 for definitions of these types of structures)

So, if your physician’s office qualifies for any of the above bullet points, then the ‘Exit’ signs are required to have an emergency power source. The ‘Exit’ signs are permitted to be illuminated by either internal or external light source, as long as it is reliable and the signs remain legible in the normal and emergency lighting mode. As always, remember to check with your local authorities to see if they have more restrictive requirements.