Separation Between Hospital and Parking Structure

Q: We have a three-story parking structure attached to a hospital. The top floor of the parking structure is not covered and is open to the atmosphere. Is the exterior wall of the hospital adjacent to the top floor of the parking structure required to be fire-rated? Our original drawings show the wall as not rated.

A: Yes… I would say so. According to section of the 2012 LSC, a parking garage would be considered a Storage Occupancy, and since this is contiguous to the hospital (which is a healthcare occupancy) section (2) would require that you need a 2-hour fire-rated barrier separating the healthcare occupancy from the storage occupancy.

Technically speaking, the entire parking garage is open to the atmosphere, so the only difference between the top deck of the parking garage and the lower decks is there is no roof on the top deck. The top deck is still a storage occupancy just like the lower decks. The LSC does not allow any exceptions to not provide a 2-hour fire rated barrier between the healthcare occupancy and any other occupancy just because it does not have a roof.

Hole in the Wall

Q: I have a surgery suite that had a hole punched into the wall by the door knob. Is there anything in LSC that states ” if a hole is made in a surgery wall the drywall needs to be replaced from stud to stud”, not just repair the hole?

A: No… The LSC does not concern itself with the way the walls are repaired. When it comes to walls, the LSC only concerns itself with identifying which walls must be smoke resistant, fire-rated, or smoke rated. The UL listings for the walls will determine how the wall is constructed, and repairs to the wall must follow the same UL listing.

Now, if the wall with the door knob hole is only required to be smoke resistant, then you can seal the hole with any type of patch that makes the wall resistant to the passage of smoke. But if the wall is fire-rated, or is required to be a 1-hour rated smoke barrier, then you must excise the hole from stud to stud, insert a new piece of gypsum board, and screw, tape and apply joint compound in accordance with the UL listing for that wall.

I’m sure your Infection Control practitioner would have a lot to say about a hole in a wall in surgery.

Plumbing Chase vs. Shaft

Q: What are the code requirements for penetrations in plumbing chases? During the water fountain project we found openings in the floor in the back of the plumbing chases from the original construction in 1949. Pluming lines pass through these openings. Is it required that these penetrations be fire stopped.

A: It depends…Were you looking at chases or shafts? A ‘pipe chase’ is where pipes run vertically from one story to another story, internally to the building, and the deck between the two stories is sealed over and meets the requirements for fire-rated construction for the horizontal barrier (i.e. floor). The vertical pipes penetrating the horizontal deck are sealed with proper fire-stopping materials. If the pipe chase has any vertical walls to protect the pipes, they are not required to be fire-rated and any pipe penetrations though these non-rated chase walls are not required to be fire-stopped.

A ‘mechanical shaft’ may look similar to a chase, but the horizontal deck between the stories is open and there is no attempt to seal the opening between the two stories. This means the vertical shaft walls must be fire-rated and any penetrations through these fire-rated shaft walls must be properly fire-stopped. Also, any HVAC duct penetration through a vertical shaft wall must have a fire damper at the shaft wall opening, regardless of the fire-resistance construction of the shaft walls.

So, you say you found openings in the floor, and since you could see them, that implies there were no vertical fire-rated walls concealing the shaft. So, it sounds like you have a serious breach of the horizontal barrier (i.e. floor) that needs to be repaired back to the original intention of the building. If these are small holes, then proper fire-stopping materials would likely be acceptable. If these are large holes, you may have to reconstruct the floor in that area as fire-stopping materials are only valid for a certain size opening.

Fire-Rated Doors in Fire-Rated Barriers?

Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read in NFPA 101 that they do not….

A: Where do you read that…? I would like to know what you’re reading to be able to provide you with a better answer.

Generally speaking, where you have a fire-rated barrier, you usually need to have fire-rated doors in openings in the fire-rated barriers. But there are some exceptions:

  • Fire-rated barriers that separate an atrium from the rest of the facility are not required to have fire-rated doors.
  • Corridor walls in existing healthcare occupancies located in a smoke compartment that is not fully sprinklered, are required to be 30-minute fire-rated and the corridor doors are permitted to be non-fire-rated, but must limit the passage of smoke.
  • Some building codes that require fire-rated corridor walls do not require fire-rated doors in the openings. But this is not a LSC issue.
  • Smoke barriers that separate smoke compartments are required to be rated (1-hour for new construction) but doors in smoke barriers are not required to be fire-rated.


Strange Observations – Exit Enclosure

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

This is not corridor, but rather an exit enclosure to a stairwell. There was a construction project in progress and to achieve a negative air pressure in the project area, the contractor cut a hole (twice) in the 2-hour fire-rated barrier for the exit enclosure to run the temporary flex duct to the exhaust fan.

Section (10) of the 2012 LSC does not allow penetrations into and through an exit enclosure for this purpose, even on a temporary basis.

If you’re asking what the hospital should have done if this was their only option to create negative air for the project, I would say they could have set-up a HEPA filter negative air machine inside the project area, and discharge the air from the HEPA blower to an adjacent corridor. Not the best solution, but one that is far better than making penetrations into the exit enclosure.

There is also the issue of headroom which must be at least 7-foot 6-inches, according to section

Strange Observations – Picture Hanging Device

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

Apparently, sidewall sprinkler heads can also be used to hang pictures…. NOT.

[That was sarcasm…]

I admit I did not take this picture, but it was contributed to this effort by Tim Niemer… Thanks Tim.

Strange Observations – Gypsum Patches

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

Holes in rated walls that are too large to be sealed with fire-rated materials, cannot be ‘fixed’ with a gypsum board patch, as shown in the picture.

However, there is a UL system W-L-0014 that does permit installing gypsum patches over holes in rated walls, but it requires an equal-sized patch on the opposite side of the wall, along with other requirements, such as 3-inch long screws with fender washers. The W-L-0014 system is part of the Hilti Firestop System library of listed products.

Fire Rated Barriers vs. Smoke Barriers

Q: Are doors in fire rated barriers also required to be listed and installed as a smoke barrier?

A: No… Fire rated barriers are not necessarily smoke barriers. They are two distinctly different barriers with different purposes. Now, if an organization wanted to combine the two purposes into one barrier, then that is acceptable as long as you meet the most restrictive requirements of each type of barrier. A fire-rated barrier requires fire-rated opening protectives (i.e. doors, windows). Fire rated door assemblies are required to have fire-rated doors and frames, self-closing devices, and positive latching. A fire rated barrier that is rated at 2-hours or greater must have fire dampers in any HVAC ductwork that penetrates that barrier.

A new construction smoke barrier is required to have walls constructed to 1-hour rating, but the doors and frames in the smoke barrier are not required to fire-rated. The doors are only required to be 1¾ inch thick, solid bonded, wood-core doors, or be of construction that resists fire for 20 minutes. Please understand that this does not mean the door has to be 20 minute rated; only be of construction that resists fire for 20 minutes. The door has to be self-closing but is not required to be positive latching. HVAC ductwork penetrating a smoke barrier must have smoke dampers, unless both sides of the smoke compartment barrier are protected with sprinklers. However, please understand this is an NFPA exception and the IBC does not recognize that, so your state or local authorities may not allow a smoke barrier without smoke dampers in the HVAC ductwork.

So, technically, a combination fire-rated barrier and a smoke barrier could be the same wall, but the requirements for both barriers need to be included.

Hot Patches on Fire Barriers

Q: In regards to penetrations through fire separations: Our latest survey from Joint Commission identified that “Hot Patches” (a piece of 5/8 sheet rock placed over a hole and the fire caulked around sheet rock) are not an effective way to seal a penetration. We just built a 90,000 square foot addition where builders used “hot patches”. Our district Deputy Fire Marshal states this is an acceptable method (not in writing). Your thoughts?

A: My thoughts…? I think the Deputy Fire Marshal is incorrect. He may accept them on behalf of the Fire Marshal office, but a ‘patch’ over a hole in a fire-rated barrier is not consistent with the UL listing of the way the fire-rated barrier was required to be built. The Joint Commission surveyor is correct. To maintain the UL listing of the fire-rated barrier, you would have to remove the section of gypsum board that has the hole from stud-to-stud, and cut in a new solid piece of gypsum board (without the hole of course) and secure it with the proper amount of screws, tape and joint compound as called for in the UL listing.

Just another example where one AHJ approves something, does not mean it is acceptable for another. The Joint Commission is not under any obligation to accept what the fire marshal says, and vice-versa… It is within the rights of the Deputy Fire Marshall to accept a ‘patch’ over a hole, but that is only for his review and approval. No other AHJ has to accept the fire marshal’s opinion and in this case, I believe the Joint Commission surveyor was correct in his observation.

Fire Barriers in Ambulatory Healthcare Occupancies -Part 2

 Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to install a fire barrier after the unit is constructed and if there are any other options. Your comments would be appreciated.

A: Well…. From a code standpoint, you may be obligated to have two different barriers:

  1. A 1-hour fire rated barrier to separate the ambulatory healthcare occupancy from other units that are not ambulatory healthcare occupancies (i.e. physician’s offices that would be classified as business occupancies). See sections and of the 2000 Life Safety Code.
  2. A 1-hour rated smoke compartment barrier to subdivide your ambulatory healthcare occupancy into two compartments. Exceptions to this requirement apply if your unit is less than 5,000 square feet and the unit is fully protected with smoke detectors, or if the unit is less than 10,000 square feet if the unit is fully protected with automatic sprinklers. See section of the 2000 Life Safety code.

If you receive Medicare & Medicaid reimbursement funds then you are obligated to comply with these codes. However, CMS does allow you to apply for a waiver if compliance with the Life Safety Code is a hardship for the organization. You cannot apply for a waiver until you are first cited for a Life Safety Code deficiency by an accreditation organization or a state agency surveying on behalf of CMS. But there are no guarantees that CMS would grant approval of a waiver request for this deficiency. Even if they did, the waiver is only valid for 3 years then you have to be cited again and then you have to submit a waiver request again. At best, it is a temporary process… not a permanent solution. My suggestion is to make plans to resolve the deficiency as soon as possible and if you get cited in the meantime, you can always submit a waiver request as part of your Plan of Correction.