Hazardous Rooms of Different Options

Q: There appears to be many different ways a hazardous room is maintained: If it is sprinklered, does it have to be 1-hour rated? If it is existing construction, does it have to be sprinklered? What rules apply if there is a lay-in ceiling? What are the basic requirements for a hazardous room?

A: A hazardous room in a hospital includes a room larger than 50 square feet used for the storage of combustible supplies. How many combustible supplies are needed to make it a hazardous room? Not much, but it is a judgment call by the surveyor. If the room is designated ‘existing conditions’ (created prior to March 11, 2003) then there are two options on how it has to be maintained:

  • If there are no sprinklers in the room, then the walls need to be one-hour fire rated and extend from the floor to the deck above, and the door to the room needs to be ¾-hour fire rated, self-closing and positive latching.
  • If there are sprinklers in the room, then the walls only have to be smoke resistant, and extend from the floor to the ceiling, as long as the ceiling also resists the passage of smoke. The door to the room may be non-rated, but must be self-closing and positive latching.

If the room is designated ‘new conditions’ (created on or after March 11, 2003) then there is only one option for the room: The room must be sprinklered, and the walls must be one-hour fire rated and extend from the floor to the deck above, and the door must be ¾-hour fire rated, self-closing and positive latching. Also, if the supply room was originally constructed to ‘new conditions’, but before March 11, 2003, it cannot be down-graded to ‘existing conditions’, but must be maintained as ‘new conditions’. Any ceiling that has sprinklers or smoke detectors must be maintained to resist the passage of smoke. This is because smoke and heat will migrate above the ceiling if there are cracks, voids or missing tiles, and the detectors and sprinklers may not activate properly.

Kitchens as Hazardous Areas – Revisited

Q: You recently posted a question about whether or not hospital kitchens are hazardous areas. Your response noted that kitchens are not included in the list of 8 specific scenarios listed in 19.3.2.1. While that is true, 19.3.2.6 Cooking Facilities would seem to cover the hazards found in a kitchen (aside from the storage areas associated with a kitchen). 19.3.2.6 requires compliance with 9.2.3 which in turn references NFPA 96. It would seem that if the criteria of NFPA 96 is met, then it would not be necessary to define the kitchen itself as a hazardous area. Storage areas associated with a kitchen (particularly dry stores) would be hazardous areas. Am I overlooking something, or is a kitchen where the cooking facilities comply with NFPA 96 not a hazardous area?

A: We both agree that kitchens are not listed in the specific areas found under 18/19.3.2.1 of the 2000 Life Safety Code. I agree with you that 18/19.3.2.6 of the 2000 LSC requires cooking facilities (kitchens) to be protected in accordance with 9.2.3 of the 2000 LSC, which in turn requires compliance with NFPA 96, 1998 edition. NFPA 96, 1998 edition includes language that requires fire extinguishing systems in the exhaust hoods used in commercial kitchens.

Nowhere in 18/19.3.2.1, 18/19.3.2.6, 9.2.3, or NFPA 96 addresses whether or not kitchens are hazardous areas. It simply is not discussed, so there is no reference to draw on to say that kitchens are (or are not) hazardous areas. So, why do I believe they are hazardous areas? Take a look at section 3.3.13.2 in the 2000 LSC, which defines hazardous areas as: “An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.” (Underline mine). I think we would all agree that cooking appliances are heat-producing appliances.

So, NFPA defines an area with heat producing appliances as a hazardous area, which applies to kitchens since they have heat-producing appliances. Going back to 19.3.2.1 in the 2000 LSC, it says any hazardous area shall be safeguarded, and it continues to describe how the hazardous area must be safeguarded. Section 18.3.2.1 of the 2000 LSC has a similar approach to safeguarding hazardous areas, but it takes into the account that all new or renovated areas must be sprinklered.   

So, from the NFPA definition of a hazardous area alone, it is apparent that kitchens are hazardous areas, and according to 18/19.3.2.1 they have to be safeguarded. To address your question directly; there is no language in the 2000 Life Safety Code that says if kitchens comply with NFPA 96, they are not considered hazardous areas. I recently took this issue to the national authorities having jurisdiction (AHJ) over hospitals and asked them directly if they considered kitchens to be a hazardous area solely based on the NFPA definition of hazardous areas according to the 2000 LSC, and here is what they said:

  • CMS:                          Yes, kitchens are hazardous areas
  • HFAP:                        Yes, kitchens are hazardous areas
  • DNV:                         Yes, kitchens are hazardous areas
  • Joint Commission:      No, kitchens are not hazardous areas

So, most of the national AHJs say kitchens are hazardous areas, but Joint Commission (the accreditor who accredits the most hospitals) says they are not. I remind you that hospitals have to comply with all of the AHJs standards and interpretations, so if a hospital is Joint Commission accredited and receives funds for Medicare & Medicaid services, then they must treat kitchens as hazardous areas because CMS says they are even though Joint Commission says they are not.

Now, the technical committee for NFPA 101 (Life Safety Code) understood this dilemma and decided to make a change. Take a look at section 18/19.3.2.5.5 of the 2012 LSC, which says: “Where cooking facilities are protected in accordance with 9.2.3, the presence of the cooking equipment shall not cause the room or space housing the equipment to be classified as a hazardous area with respect to the requirements of 18/19.3.2.1, and the room or space shall not be permitted to be open to the corridor.” So, when the 2012 edition of the LSC is finally adopted, this whole issue of “is a kitchen a hazardous area?” will finally be resolved and everyone will be on board with the same interpretation. Then, the LSC will agree with your point, that as long as kitchens comply with 9.2.3 and NFPA 96, they will not be have to be classified as hazardous areas.

Thanks for being a reader….

Hazardous Areas

Q: If hazardous areas like a carpentry shop and a paint shop are combined in a separate building distant from hospital building, what can be an appropriate reference to determine the required fire and life safety measures? If this building is a single story and has HVAC ductwork, is it required to provide smoke compartmentation and fire dampers also?

A: It is apparent that the building you described does not house patients, so it could be considered business occupancy or industrial occupancy. It really depends on what else is in the building besides the carpentry shop and paint shop. For example, if this separated building also houses offices or general storage, then I could see it having to comply with business occupancy requirements. In business occupancies, hazardous areas which have a degree of hazard greater than that normal to the general occupancy of the building must be enclosed with 1-hour fire rated barriers, or protected with an automatic sprinkler system. These code references are found in the 2000 edition of the Life Safety Code, sections 39.3.2.1, and 8.4. However, if the separated building is not mixed with offices or general storage, and is only a carpentry shop and a paint shop, then you could classify it as an industrial occupancy. Section 40.3.2 does not require added protection of hazards in industrial occupancies as long as the hazards are not considered ‘high hazards’. A high hazard (another name for this is a ‘severe hazard’) is one in which quantities of flammable, combustible, or hazardous materials are present that are capable of sustaining a fire of sufficient magnitude to breach a 1-hour fire separation. According to NFPA 90A, 1999 edition, fire dampers are only required in fire barriers of 2-hour rating or greater, with the exception of a 1-hour fire rated vertical shaft, or if the HVAC duct is open ended (a return air plenum ceiling) on one side of a 1-hour fire rated barrier. Your question indicated the building is single story so it appears that a vertical shaft is not present. If the option of a 1-hour fire rated barrier is selected for the protection around the carpentry shop and paint shop in a business occupancy, and the HVAC duct is open at the fire barrier, then a fire damper would be required. Please check with your local and state authorities to determine if they have other requirements which may apply.

Multiple Trash Containers

Q: We just completed a renovation of our cafeteria dining area and as part of the project an 8 container trash cabinet was built and installed in a separated area off of the dining floor. It is sprinklered and the containers are all 32 gallons. The cafeteria area is a separate smoke compartment. Is this allowed?”

A: Well, this is an interesting question. The answer is… it depends on the square footage of the trash cabinet and how it is constructed. I would say each individual 32 gallon trash container would have to be physically separated from all the others by a cabinet wall, which would create a small, individual room or area for the container. The reason for this is section 18.7.5.5 of the 2000 edition of the LSC, which only allows up to 32 gallons of trash collection capacity in a given 64 square foot area. This means, if there are no physical separations between trash containers then I could see a surveyor or inspector citing you for having more than 32 gallons capacity in a given 64 square foot area. Since each individual compartment for the trash containers would presumably be less than 50 square feet in size, then you would not have any problems meeting the requirements of 18.3.2.1 for hazardous areas. It is interesting to note that the exception to 18.7.5.5 does allow more than 32 gallons capacity in a 64 square foot area provided the area qualifies as a hazardous area, but it is unlikely that an 8 container trash cabinet could do so. The key element in your question is the comment that the individual trash containers do not exceed 32 gallons each.

Oxygen Cylinders and Clean Linen Carts

Q: Are oxygen cylinder tanks (in holders) allowed to be stored in alcoves in corridors? Also, what about clean linen carts? I am told that our accreditation organization allows this, but I don’t know if CMS does.

A: Oxygen cylinders are permitted to be stored outside of a designated room, provided they are properly secured; they do not infringe upon the required corridor width; and the aggregate total of cubic feet of medical gas in cylinders (all gas, not just oxidizing gas) does not exceed 300 cubic feet per smoke compartment. So, a couple E size cylinders in holders, stored in an alcove sounds acceptable to me.

Under normal conditions, the presence of combustibles, such as paper, cardboard, plastics, and clean linen are not considered to be hazardous until the area in which they are contained exceeds 50 square feet. A clean linen cart in an alcove that does not exceed 50 square feet appears to not meet the requirements of a hazardous area (see 19.3.2.1), and therefore does not have to be contained in a room designated as a hazardous room. However, some accreditation organizations may take a different look at this, and consider the volume of a 6 foot tall, by 4 foot wide, by 2½ foot deep clean linen cart to be sufficient capacity of combustibles to be a significant threat, even though it does not meet the LSC definition of a hazardous area. I know that at least one accreditation organization requires the corridor and alcove to be sprinklered in order to store a clean linen cart there.

Temporary Storage in Patient Rooms

Q: We have a short-term project where we need to find some space to store equipment until they are installed. The equipment is electronic and needs to remain in their cardboard boxes until it is installed. We think we need to store these items for 6 – 8 weeks. Can we use patient rooms that are not in service as temporary storage areas?

A: Your question is more like “Can we violate the Life Safety Code (LSC) for a short period of time?” In some situations you are permitted to violate the LSC. Section 4.6.10.1 of the 2000 edition of the LSC says you are permitted to occupy the building during construction, repair, alterations, or additions where alternative life safety measures (aka Interim Life Safety Measures), which are acceptable to the authority having jurisdiction, are in place. If the equipment that you wish to store in the out-of-service patient rooms qualifies as construction, repair, alterations or additions, then I would say you have a legitimate position, as long as you implement alternative life safety measures. The measures that you implement should be in accordance with your policies.  However, out-of-service patient rooms cannot be used for storage of combustibles (in this situation, the cardboard boxes would be considered combustible) that is not associated with construction, repair, alteration or additions. The reason is most patient rooms are not constructed to meet the requirements for hazardous storage rooms. Make sure you perform the alternative measures and document each inspection.

Closures on Inactive Door Leafs?

Q: A consultant has mentioned that several of our doors to hazardous areas are non-compliant.  The door configuration is such that there is a normal 3’x7’ door paired with a small, inactive leaf about 1’x7’.  The inactive leaf has an automatic flush bolt but is not provided with a self-closer. I realize that hazardous rooms need self-closing positively latching doors under the new construction healthcare occupancy requirements, but I cannot find any discussions on inactive leaves.  My question to you is do you know of any requirements where the configuration I described would be allowed?

A: Section 8.2.3.2 of the 2000 edition of the Life Safety Code requires fire doors to be in compliance NFPA 80 Standard for Fire Doors and Fire Windows, 1999 edition. Section 2-4.4.5 of NFPA 80 discusses the requirements for an inactive leaf in a room which is not occupied by people. The exception to this section of the code specifically states that self-closing devices on the inactive leaf are not required. The caveat in this exception is the phrase “where acceptable to the authority having jurisdiction” and the interpretation is subject to their whim. So, if you ever get an AHJ that does not permit it, then you’re out of luck. But you could proceed with the conditions of the exception until such time an AHJ says you can’t. As far as I know, Joint Commission and CMS are in agreement with this exception.

Document Shredding Containers

Q: During a recent survey, the surveyor noted that we had two 64 gallon capacity containers which we use for document shredding, sitting side-by-side in the laboratory work room. He stated we couldn’t have them in the room because they exceeded 32 gallons capacity. I was under the impression that if it was in a secured area and in a room with positive latching and sprinkled it was OK. How far off am I? What about other areas, such as medical records?

A: Section 19.7.5.5 of the 2000 edition of the LSC says trash containers greater than 32 gallons must be stored in a hazardous room. Most authorities will consider document shredding containers to be equal to trash containers. Also, section 19.3.2.1 says all laboratories that employ flammable liquids in quantities less than what would be considered severe are considered hazardous areas. So, your laboratory is already considered to be a hazardous area, and should be protected accordingly. If it is new construction (plans for construction approved by local authorities on or after March 11, 2003) it would be required to be fully protected with automatic sprinklers and be protected with 1-hour fire rated barriers. If it is existing conditions (plans for construction approved by local authorities before March 11, 2003) then it needs to be protected with automatic sprinklers or with 1-hour fire rated barriers. You are allowed to have as many 64-gallon document shredding containers in the laboratory as you would like, since the laboratory is already classified as a hazardous area. Unless there are other contributing factors, it appears to me that the surveyor is incorrect in this finding. The medical records area would have to qualify as a hazardous room in order to allow the 64 gallon containers in there. [Editor’s note: The 2012 edition of the LSC will exempt approved document shredding containers up to 96 gallons capacity from having to be stored in a hazardous room.]

Are Kitchens Really Hazardous Areas?

If you read my Q&A on kitchens being hazardous areas, which was posted last Sunday (July 8th), then you may have been surprised by my position that kitchens are considered hazardous areas in healthcare occupancies. I know many readers are and they were not in the least bit bashful to tell me so. Some flat out told me I was wrong.

The question that the reader asked was “Is the main kitchen in a hospital considered a hazardous area? I’m referring to the main kitchen where all the food is prepared for the hospital, not the kitchenettes that are located on the units.” This individual went on to say that her hospital kitchen was cited for not being protected as a hazardous area.

My reply was I believe kitchens are hazardous areas based on the NFPA definition of hazardous areas, found in section 3.3.13.2 of the 2000 edition of the LSC: “An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.” The last time I looked, kitchens have heat producing appliances, therefore kitchens are hazardous areas.

But that’s not the full picture. Section 4.4.2.2 of the LSC says: “Where specific requirements contained in chapters 11 through 42 differ from general requirements contained in chapters 1 through 10, the requirements of chapters 11 through 42 shall govern.” The definition of hazardous areas is found in Chapter 3. The provisions for healthcare are found in chapter 18 and 19, and as far as I can see, there is nothing in those chapters that differs with the definition of hazardous areas found in chapter 3. Therefore, there is no conflict (or difference) between these chapters. My point being, I cannot find anything in the healthcare chapters that would override the definition found in chapter 3. Therefore, the definition must stand on it’s own merit, and it applies to kitchens in the hospital.

Those individuals that protested my answer all cited the same reason: The NFPA technical committee on healthcare occupancies never wanted kitchens to be a hazardous area. In fact, I learned from one of them that prior to the 1985 edition of the LSC, kitchens were in fact identified in the occupancy chapters as a hazardous area, along with many of the current areas, such as boiler rooms, paint shops, repair shops, storage rooms (over 50 square feet containing combustibles) and the like. However, the technical committee preparing the 1985 edition decided to remove kitchens from the list of hazardous areas and require them to have fire suppression systems as defined by NFPA 96. But the list of hazardous areas found in the healthcare occupancy chapters was never intended to be all inclusive. It is representational, and furthermore, it stipulates all hazardous areas to comply with section 8.4, which requires 1-hour fire rated barriers, or sprinklers. Nothing in the healthcare occupancy chapters said kitchens were exempt from being considered hazardous areas. The technical committee may have meant that, but the LSC doesn’t say that.

If you were to call the NFPA liaison to the healthcare occupancy chapters for the LSC, and asked them if they considered kitchens to be hazardous areas, I’m sure they would say no. The NFPA has dealt with this issue and they firmly believe that kitchens are not hazardous areas. In fact, the technical committee went so far in the new 2012 edition to specifically say that kitchens that comply with NFPA 96 are NOT to be considered hazardous areas. But that language is not in the 2000 edition, which is the edition that most hospitals must comply with. Also, here’s one important fact that many of the objectors seemed to conveniently overlook: The NFPA only writes the LSC, they do not enforce the LSC. Basically (and I don’t mean to be rude when I say this), it doesn’t matter what the NFPA says, it only matters what the NFPA writes, and the 2000 edition of the LSC says areas with heat producing appliances are hazardous areas.

Authorities having jurisdiction (AHJ) worth their salt must enforce what is written in the LSC, not what people (including me) says the LSC means. Even the opinions from life safety experts at NFPA are not what the AHJs should base their interpretation on, but only what the written code says. Otherwise, the code keeps getting interpreted differently depending on who you talk with. I did a poll of my contacts from the four major AHJs who enforce the LSC in hospitals and here is what I found out:

The Centers for Medicare & Medicaid Services (CMS) considers kitchens in hospitals to be hazardous areas. This interpretation is considered unofficial, as CMS rarely issues official interpretations, and when they do it takes months or years for them to issue one.

 

The Joint Commission does NOT consider kitchens as hazardous areas in hospitals. This is an official statement from their public relations department. It really does not surprise me that TJC feels this way as they have been known to “pick and choose” certain requirements of the NFPA codes to follow and not follow.

The American Osteopathic Association / Healthcare Facilities Accreditation Program (HFAP) officially considers kitchens in hospitals to be hazardous areas.

Det Norkse Veritas (DNV) officially considers kitchens in hospitals to be hazardous areas.

So, 3 of the top 4 AHJs who survey hospitals consider kitchens to be hazardous areas in hospitals. The 3 accreditors (TJC, HFAP and DNV) receives their authority to accredit hospitals from CMS and if one of them has a differing opinion (such as TJC) than CMS, that’s a conflict. Don’t look for this to become a big issue, however. Since the 2012 edition has already resolved this, and since CMS is seriously looking to adopt the 2012 edition, this conflict goes away once the finally do.

 

 

Kitchens as Hazardous Areas

Q: Is the main kitchen in a hospital considered a hazardous area? I’m referring to the main kitchen where all the food is prepared for the hospital, not the kitchenettes that are located on the units.

A: Section 19.3.2.1 in the 2000 edition of the Life Safety Code (LSC) discusses the protection requirements for hazardous areas. That section lists 8 specific scenarios that shall be included as hazardous areas, but hazardous areas are not limited to just this list. It is interesting to note that kitchens are not on the list. But that is not the end of the issue, as the same section says hazardous areas must be safeguarded in accordance with section 8.4.1 of the same code. So, section 8.4.1 requires any area having a degree of hazard that is greater than that which is normal to the general occupancy of the building must be protected with 1-hour fire rated barriers (which would include ¾ hour fire rated self-closing and positive latching doors), or be protected with automatic sprinklers. According to section 3.3.13.2, the definition of ‘hazardous area’ is: “An area of a structure or building that poses a degree of hazard greater than that normal to the general occupancy of the building or structure, such as areas used for the storage or use of combustibles or flammables; toxic, noxious, or corrosive materials; or heat-producing appliances.” So, the whole basic concept of cooking food involves heat-producing appliances, and in many hospitals, gas-fired (gas which is considered flammable) appliances are used. Therefore, I would answer your question as a definite ‘Yes’, the main foodservice kitchen in a hospital is considered a hazardous area. If your kitchen is considered an existing condition (designed prior to March 11, 2003, with no major renovations) then it qualifies for the 1-hour fire rated barriers if it is not protected with sprinklers, or just smoke resistant barriers with doors that self-close if protected with automatic sprinklers. For new construction, the kitchen would need 1-hour fire barriers and be protected with automatic sprinklers.