Strange Observations – Ceiling Penetrations

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

This picture was taken in an electrical room. Where the conduits extend upwards and penetrate the suspended ceiling, the gaps around the conduits are too large.

Most surveyors will use the NFPA 80 maximum 1/8-inch gap rule fire door clearance to frames as a standard for the maximum gap around conduit penetrations, where the ceiling is required to act as a membrane for smoke detectors or sprinkler heads.

In situations like this, the easiest and best solution is to remove the suspended ceiling from the electrical room, and relocate the lights in the ceiling to the deck above.

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.

Contiguous Facilities Used by Inpatients

Q: We have a building that is next to our hospital that is an imaging center, that is not a healthcare occupancy. Are we allowed to take patients from the hospital into the imaging center for diagnosis purposes?

A: Section of the 2012 Life Safety Code says ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation. This section is new to the 2012 Life Safety Code and was not found in previous editions. The Handbook for the 2012 Life Safety Code says this requirement is intended to permit one, two, or three ambulatory inpatients to visit doctor’s offices simultaneously in an adjacent business occupancy, for example, without requiring classification of the business occupancy as a health care facility.

But, there are caveats to this section that need to be reviewed.

  1. Section says the facility needs to be contiguous to the healthcare occupancy. This means it has to be physically connected to the healthcare occupancy. Does your imaging center meet that requirement?  I do not believe a portable trailer would qualify as being contiguous, if that is what you have. I also do not believe it would be acceptable if there is a different occupancy classification between the healthcare occupancy and your imaging center. Make sure the imaging center is actually physically connected to the healthcare occupancy.
  2. Only ambulatory inpatients may be taken from the healthcare occupancy into the contiguous facility for diagnosis or treatment services. This would mean patients need to be able to get up and walk out of the building under their own power without the assistance from others, and they can take action for self-preservation without the assistance from others. This does not mean they have to walk under their own power, but only that they are able to do so.

My recommendation to you is to use section to your advantage. If your imaging center qualifies under and the inpatients going there are fully ambulatory and capable of self-preservation, and you have no more than 3 inpatients in the contiguous facility at a time, then you would qualify under Use it until you are told by an AHJ that you cannot use it. So far, I have not seen anything from CMS or the accreditation organizations that would prevent you from using this section of the LSC to your advantage.

Corridor Doors Have to Be Fire-Rated?

Q: We have an engineer who is telling us that the 2012 Life Safety Code requires our corridor doors to be fire-rated. He is referencing Table which says exit-access corridor walls that are either 1-hour rated or ½-hour rated require a 20-minute fire-rate door. He says the healthcare occupancy chapter sections and support this as well. Is this true?

A: Well… it appears your engineer is reading the Life Safety Code wrong. When you want to learn what the Life Safety Code requires pertaining to any subject, you start with the occupancy chapter first, not the core chapters (chapters 1 – 11). Section of the 2012 LSC says corridor walls in healthcare occupancies are ½-hour fire-rated and extend from the floor to the deck above. However, in smoke compartments that are protected throughout with approved sprinklers, the corridor walls are permitted to be non-fire-rated, but only resist the passage of smoke and extend from the floor to the ceiling provided the ceiling also resists the passage of smoke.

And according to section, doors in corridor walls in healthcare occupancies are only required to resist the passage of smoke, be 1¾-inches thick, solid bonded, wood core, or made of materials that resists fire for a minimum of 20 minutes. This does not mean the door has to be 20-minute rated… just constructed to resist fire for a minimum of 20-minutes.

According to section, whenever there is a conflict between the occupancy chapters and the core chapters, the information in the occupancy chapter governs. The information your engineer saw in Table is general information and applies to all occupancies. However, the existing healthcare occupancy chapter differs with information in Table, which means the information in the occupancy chapter governs.

I don’t see what you are referring to regarding It does not say doors have to be 20-minute rated. It says doors do not have to be 1¾-inches thick, solid bonded, wood core, and resists fire for 20-minutes for certain areas such as toilets rooms, bathrooms, and shower rooms. It is giving you a break for being an existing healthcare occupancy. In some very old hospitals, they installed doors that were not 1¾-inches thick, and this section is permitting them to remain.

And section is stating what I’ve already mentioned: Corridor walls in smoke compartments that are fully protected with sprinklers are permitted to be non-fire-rated smoke resistant partitions that extend from the floor to the ceiling, provided the ceiling also resists the passage of smoke.

Strange Observations – Combustible Materials in Structural Support

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

So… I’m above a ceiling in a pre-assessment testing area and I see in the corner what appears to be a wood 2×4.

According to NFPA 220, construction types I and II cannot have combustible material in the structural components. (This hospital was a Type II (222).

This wood 2×4 is supporting an interior wall and the suspended ceiling.

You have to keep an eye on contractors while they are renovating your departments… they will do things like this that will eventually get you in trouble.

Alcohol Disinfectant Wipes

Q: What is your opinion on alcohol based disinfectant wipes and their inclusion in the aggregate amount of flammable liquids in a smoke compartment?  We are considering a product that contains 55% isopropyl alcohol and would be 857ml.  There is one opinion posted online that includes these products in the NFPA 30 standard compliance.

A: I would agree with the concept that any alcohol product would contribute to the aggregate total of ABHR liquids or aerosols to not exceed 10 gallons in dispensers per smoke compartment. Therefore, if you had one 857 ml dispenser of alcohol-based disinfectant wipes, then you would be limited to 36 one-liter ABHR dispensers per smoke compartment so you would not exceed 10 gallons of product in dispensers per smoke compartment. This would be consistent with section (5) of the 2012 LSC.

Locks on Bathroom Doors

Q: In a multi-tenant office building, can restrooms in the common areas have controlled card access and mag locks tied into the fire system on the entry/exit doors?

A: Well, as long as the locks are installed in accordance with section of the 2012 Life Safety Code, I believe it would be okay from an NFPA viewpoint. But you need to ask your state and local authorities to see if they have other restrictions that would prevent this from happening.

Boot Camp Group Photo

Here is a group photo of those individuals who attended the Keyes Life Safety Boot Camp this past week in Jackson, TN. Everyone seemed to have enjoyed themselves and based on the evaluation sheet comments, I would say it was a success.

Thank you to Compliance One staff Ali Rogers and Joe Humphries for coordinating the event, and a very special THANK YOU to the West Tennessee Healthcare, Jackson-Madison County General Hospital for hosting the event.

There will be additional Keyes Life Safety Boot Camps later this year so keep your eye on this website for announcements when those details become finalized.

Delayed Egress Locks

Q: Our hospital is not fully sprinklered and is not fully smoke detected, but we want to install an infant security locking system in our Mother/Baby unit. I discussed this with our vendor who wants to sell us the infant security locking system, and he says we qualify for delayed egress locks because being 100% fully sprinklered is not the only criterion for compliance. He says we comply because we demonstrate the existence of an approved, supervised automatic fire detection system by having an automatic fire detection system in our hospital, so that should allow the installation of the infant security locking system. The vendor also said as long as the local AHJ approves the installation, that’s all we need, because the local AHJ has the final word. What do you say?

A: NFPA 101 Life Safety Code, 2012, section is rather clear: Among other requirements, in order to have delayed egress locks, you need one of the following:

  • The building needs to be fully protected throughout by an automatic sprinkler system, or;
  • The building needs to be fully protected throughout by an automatic fire detection system.

Being fully protected throughout with automatic sprinklers is obvious – you need full sprinkler coverage everywhere in the building. But it appears the term ‘being fully protected throughout by an automatic fire detection system’ is not so obvious. If you are not fully protected with sprinklers, then section requires a smoke detector in all occupiable areas. This is explained in section of the 2012 LSC. This means a smoke detector must be inside every room, every sleeping room, every procedure room, every corridor, every office, every conference room, every utility room, every lounge, every classroom, every work-room, every mechanical room, etc. In my 40-years of doing this work, I’ve yet to see a hospital qualify for this in regards to installing smoke detectors in all occupiable areas. If you believe your hospital meets the requirements for being fully protected with smoke detectors, then I would like to schedule a visit and take a look, because I’ve never seen that before.

Please understand the way your vendor described it “demonstrate the existence of an approved, supervised automatic fire detection system”, does not meet the description of being fully protected throughout by an automatic fire detection system. All hospitals have an approved, supervised automatic fire detection system, because the LSC requires that. But no hospital (so far that I have seen) has a smoke detector in all occupiable areas. It’s not required and it is too costly to install. Sprinklers are far cheaper.

Your vendor is correct, though: Sprinklers are not the sole criterion for the installation of delayed egress locks. But, it is one of two criteria, and so far, no hospital is choosing to go with the other choice (smoke detectors). Even if you could afford to install smoke detectors in every occupiable areas, the hospital would likely not be able to afford the maintenance (testing & inspection) and all of the false alarms that go with it.

By the way… the phrase “the local AHJ has the final word” is not accurate. I appreciate the respect that the vendor is trying to say, but all AHJs have the final word, not just the local AHJ. The typical hospital has many (between 5 and 8) AHJs that they have to comply with regarding the Life Safety Code:

  • CMS (Federal)
  • Accreditation organization
  • State licensing agency
  • State agency in charge of hospital construction
  • State fire marshal
  • Local fire authority
  • Local building code authority
  • Insurance company

All AHJs are equal. No one AHJ can override the decision of another AHJ. Any AHJ can decide to interpret the LSC in the way they deem necessary and if it disagrees with another AHJ, then so be it. The hospital must comply with the most restrictive interpretation. So, saying the local AHJ has the final word is not accurate; all AHJs have the final word. For example: If the local AHJ said it is okay to install delayed egress locks for infant security (because nobody wants to see infants stolen), even though the building is not fully sprinklered and not fully smoke detected, that’s not okay with other AHJS like CMS, your accreditation agency and your state agency on hospital construction. So, the hospital cannot do that, because they have to follow the most restrictive interpretation.

I see other hospitals that are not fully sprinklered or fully smoke detected use infant security systems but they do not install the door locking hardware. So, it operates like a warning system. If the hospital does not want to invest in being fully protected with sprinklers (or smoke detectors), then that is their only option. It is an incentive to become fully protected with sprinklers.

Clean Linen Stored in a Corridor

Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and carts of clean linen are being stored on one side of the breezeway for more than 30 minutes, would this be allowed as long as the width is maintained at 8ft or greater?

A: Let’s re-think this situation… You have a breezeway, and you want to store clean linen in this breezeway? Do you see anything wrong with this picture…?

Talk with your Infection Control people. It does not make sense to me to store clean linen in a breezeway. Clean linen must be stored in a clean environment, such as a designated storage room for clean linen. A breezeway is not a clean environment and is not a suitable place to store clean linen.

But… if you’re asking about storing items in the corridor and if it is okay with the Life Safety Code, the answer is…. It depends.

You may store non-combustible items in the corridor as long as the required width of the corridor remains clear. You indicate the required width of the corridor is 8-feet… is that because inpatients would be using this corridor?

However, you cannot store combustible items in the corridor even if they do not obstruct the required width of the corridor. Clean linen is combustible, so therefore, to answer your question: No, you cannot store clean linen in the corridor.