Staff Sleeping Room

Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that these staff sleeping rooms are required to have single-station smoke alarms since they are considered a different occupancy (Lodging & Rooming House) and must meet section of the 2012 LSC. But can I use the hospital smoke detector system in lieu of installing a battery-operated smoke alarm in these rooms?

A: Yes… According to section of the 2012 LSC, smoke detectors connected to the building’s NFPA 72-2010 approved fire alarm system are permitted instead of installing the battery-operated smoke alarms. However, section does say these system smoke detectors must be arranged to function in the same manner as single-station or multiple-station smoke alarms. The typical building system smoke detectors are detectors only and do not provide any occupant notification.

But the single-station smoke alarms provide both functions: Detection and occupant notification. Therefore, on a technical standpoint, the basic fire alarm system smoke detectors are not enough and some sort of occupant notification system must be provided. Now, having said that, I do know that some accreditation organizations are simply accepting a smoke detector in the on-call sleeping room without the inclusion of an occupant notification device. But, I am aware that some state agencies surveying on behalf of CMS do enforce the letter of the code and will cite you if you do not have an occupant notification device in the room.

Physician On-Call Sleep Rooms

Q: Are non-patient sleeping rooms (i.e. physician sleep rooms) that are located in a hospital occupancy considered part of that hospital occupancy classification?

A: Well…. There is no occupancy classification called ‘hospital occupancy’. Probably what you are referring to is healthcare occupancy, which is where inpatients are located. So, to answer your question… it depends. Non-patient sleeping rooms are usually physician on-call rooms and they are often located in close proximity to where their inpatients are located. They must comply with Lodging or Rooming House occupancy classification, and usually they are not separated from the healthcare occupancy, so it would be considered a mixed occupancy situation. That means the physician on-call sleeping rooms must meet the most restrictive requirements between Lodging or Rooming House occupancy, and Healthcare occupancy.

If the physician on-call sleeping rooms are part of the healthcare occupancy, they still must meet requirements from Lodging or Rooming House occupancy, which means the room must have smoke detectors.

Staff Sleep Rooms

Q: In regards to audio/visual strobes in staff sleeping rooms, is it required for them to hear the fire alarm system?

A: According to section of the 2012 Life Safety Code, single-station smoke alarms are required to be installed in sleeping rooms for lodging or rooming house occupancies. A staff sleeping room in a hospital would have to qualify for the requirements of a lodging or rooming house occupancy, so a single station smoke alarm is required.

A single station smoke alarm has a built-in occupant notification device. But section of the 2012 Life Safety Code says fire alarm system smoke detectors that comply with NFPA 72 and are arranged to function in the same manner as a single-station smoke alarm shall be permitted in lieu of smoke alarms. Even if you install a fire alarm system smoke detector in the staff sleeping room, section would imply that some sort of occupant notification device is still required to awaken the staff member sleeping in that room.

But section 18.4.4 of the NFPA 72-2010, allows for the Private Mode installation for fire alarm system occupant notification devices, and hospitals typically are designed to this requirement. Section requires the occupant notification device to have an audible sound level 10 dB above the average ambient sound level to be compliant, and in many cases, an occupant notification device located in the corridor outside of the staff sleeping room can achieve this requirement.

If you measure the dB level inside the staff sleeping room of the corridor-mounted fire alarm system occupant notification device, and it is 10 dB above the average ambient sound level in the staff sleeping room, then you should be good. But have those sound readings available to show the surveyor, as they will want to see some proof of compliance.

Staff On-Call Sleeping Rooms

Q: Does the Life Safety Code require hospital staff sleeping rooms have smoke detection inside the room and door closers installed? We have an on-call sleeping room for physicians in our Labor & Delivery unit and a consultant said we need smoke detectors and a closer on the door.

A: The answer is yes, the Life Safety Code (2000 edition), does require it. Section says where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards must comply with the most restrictive life safety requirements of the occupancies involved. This means where there is a dominate occupancy (such as healthcare occupancy in the Labor & Delivery unit) that also has a small portion of a different occupancy (such as the staff on-call sleeping room which is actually hotels and dormitories occupancy) and these two occupancies are not separated by a 2-hour fire rated barrier, then this means the two occupancies are mixed, and the most restrictive requirements of both occupancies apply. As you indicated, hotel and dormitory occupancy does require single station smoke alarm and a closure on corridor doors to sleeping room (see sections and However, there is an exception to section which says where incidental to another occupancy, buildings used as follows shall be permitted to be considered part of the predominant occupancy and subject to the provisions of the Code that apply to the predominant occupancy:

  1. a) Mercantile, business, industrial, or storage use;
  2. b) Nonresidential use with an occupant load fewer than that established by Section 6.1 for the occupancy threshold.

This exception is allowing small incidental use of one occupancy to not have to comply with the requirements of that particular occupancy, and instead may comply with the requirements of the predominant occupancy, which in your case would be healthcare occupancy. There is only one catch, though. The phrase ‘incidental’ is ambiguous and is not defined. Therefore, the authority having jurisdiction (AHJ) gets to answer the question: What does incidental mean? I do not know what state and city you are located in, so I do not know who your AHJs are, but it’s a sure bet you have 5 or 6 AHJs who enforce the Life Safety Code, and it is likely that not all of them would make this interpretation the same way:

  • Joint Commission (or one of the other accreditation organizations)
  • CMS
  • State fire marshal
  • State public health
  • Local fire inspector
  • Insurance company

Since you have so many AHJs who have the right to interpret the phrase ‘incidental’, my advice is to take a very conservative approach and do not consider the exception, and go with installing a single station smoke alarm and a closure on the door to the corridor for the sleep room. By the way, most of the AHJs accept the fact that a smoke detector connected to the building fire alarm system in a hospital is equivalent to a single station smoke alarm, so you may be okay by just installing a smoke detector, rather than a single station smoke alarm. That’s your call.

On-Call Sleeping Rooms

Q: We have a physician on-call sleeping room inside our labor and delivery unit. A surveyor told us that we need audible smoke alarms in each on-call sleeping room. We have smoke detectors, but rely on staff waking up any sleeping physicians in the event of a fire alarm. Isn’t that good enough?

A: Well, the surveyor is correct, although most AHJs usually allow smoke detectors connected to the building fire alarm system as being sufficient. Non-patient sleeping rooms in the healthcare occupancy do require single-station smoke alarms, such as the battery powered type found in residential homes. They are not required to be inter-connected with other smoke alarms or the building fire alarm system. Your hospital has multiple occupancies inside the facility, such as Healthcare, Ambulatory Care, Business, Mercantile, and Hotels & Dormitory Occupancies. If you have chosen to have mixed occupancies rather than separated occupancies (at least in the case of the on-call sleeping rooms) then you have to comply with the most restrictive requirement of the multiple occupancies. In the case of the on-call sleeping rooms, section of the 2000 LSC does require single-station smoke alarms. I would not install your building fire alarm occupant notification device (horn/strobe unit) as they are not required and are too costly. Just buy simple 9 volt residential style smoke alarms and install them no more than 12 inches below the ceiling. Put these devices on your PM schedule to have the batteries replaced once per year.