Corridor Transaction Window

Q: Do transaction windows in a smoke resistive non-rated corridor wall in a healthcare occupancy need be self-closing?

A: It depends on what space the window is open to. Section of the 2012 LSC says corridors (in healthcare occupancies) must be separated from all other areas by partitions (either smoke resistant or ½-hour fire-rated, depending on the sprinkler protection), unless it complies with one of the following exceptions to be open to the corridor:

Spaces unlimited in size, provided:

  • The smoke compartment is fully protected with quick-response sprinklers;
  • The space is not used for patient sleeping rooms, treatment rooms, or hazardous areas;
  • The corridor is protected with smoke detectors, or the smoke compartment is protected with QR sprinklers;
  • The space is protected with smoke detectors, or the space is arranged to allow direct supervision by staff;
  • The space does not obstruct access to required exits.

Spaces unlimited in size, provided:

  • The space is not used for patient sleeping rooms, treatment rooms, or hazardous areas;
  • The space and the corridor are protected with smoke detectors;
  • The space is protected with sprinklers, or the furnishings and furniture, in combination with all other combustibles within the area, are of such minimal quantity and arrangement that a fully developed fire is unlikely to occur;
  • The space does not obstruct access to required exits.

The presumption here is the space is not a waiting area, a nurse station, a Gift shop, a limited-care facility, a kitchen, or a group meeting room, so those exceptions do not apply. So, you say it is a transaction window… Let’s assume it is a sliding window to an accounting area where patients can make payments. If the accounting area meets exceptions #1 or #2, then a sliding window that does not resist the passage of smoke or positively latch is permitted. However, you will need to identify on the Life Safety drawings that the corridor wall no longer exists where the sliding window is located but is now located around the back of the accounting area. That means the walls in the back of the accounting area now becomes the corridor walls, and they must meet the requirements for corridor walls ( and any openings must meet the requirements for corridor doors ( might just be easier to make the sliding window smoke resistant and positive latching.

Door Locking Arrangements

Q: I have read your response to secondary locks on fire egress doors. ( – Two releasing operations shall be permitted for existing hardware on a door leaf serving an area having an occupant load not exceeding three, provided that releasing does not require simultaneous operations.) My question is: Are there any other references or code standards regarding secondary locks on fire/egress doors?

A: Section “Special Locking Arrangements” would apply to all doors, including fire-rated door assemblies. This section includes:

  • Delayed egress locks (
  • Access-control locks (
  • Elevator Lobby Locks (

Then, for healthcare occupancies, there are additional locking arrangements that would be permitted on fire-rated door assemblies, such as:

  • Clinical needs locks ( Permitted only for the use of securing psychiatric patients, dementia patients, Alzheimer patients, etc.
  • Specialized protective measure locks ( Permitted for locking nursery units, mother/baby units, ICUs, ERs, etc.

While all doors may not be fire-rated, all doors are egress doors and the above listed special locks would be permitted on all doors, provided you qualify for them.

Fire Watch

Q: Your recent answer regarding fire watches left me confused and requesting the clarification that follows. Your answer seems to imply that a fire watch is required anytime the sprinkler system is impaired within the construction space. The last sentence notes that the fire watch does not affect the rated barrier (because just having a fire watch does not eliminate the need for the 1-hour barrier where sprinklers are impaired). However, it seems to me that the original question posed is whether the 1-hour barrier eliminates the need for the fire watch. My understanding previously is that if the construction space is separated by a 1-hour barrier then a fire watch is not required. Is my understanding incorrect? Does the use of a 2-hour rated barrier change any of these requirements?

A: Sorry. No, your understanding is not correct. The need to conduct a fire watch is based on whether or not the required fire alarm system is impaired (see section of the 2012 LSC) or the required sprinkler system is impaired (see section 15.5.2 (4) of NFPA 25-2011). It has nothing to do with the level of fire-rating on the temporary construction barriers. Increasing the temporary construction barrier to a 2-hour rating does not change the need to conduct a fire watch.

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.

Brad… Are You Nuts…?!

Q: I have a Medical Office Building with multiple exam rooms, and it is constructed with 5-foot wide corridors. This building followed design reviews including Life Safety expertise from the local AHJ. In many cases, an alcohol-based hand-rub (ABHR) sanitizer dispenser is located just outside the exam rooms in the egress corridor. Why are you saying these dispensers are not permitted especially when section says they are? Are you nuts…?

A: Well, I may be a bit crazy, but I’m pretty sure ABHR dispensers are not permitted in medical office building corridors.

Section is applicable for healthcare occupancies, such as hospitals, nursing homes, long-term care facilities, etc. And section is applicable for ambulatory health care occupancies such as Ambulatory Surgical Centers. But these sections are only applicable to their respective occupancies, and the typical Medical Office Building is not any of these… they are business occupancies. And unfortunately for you, there is nothing similar in business occupancy chapters 38 and 39 for ABHR dispensers.

It really all starts with section which says no storage or handling of flammable liquids shall be permitted in any location where such storage would jeopardize egress from the structure. The ABHR gel or foam product in these dispensers have a high enough alcohol content to cause it to be classified as a Class 1-B flammable liquid, according to NFPA 30. So, according to, flammable liquids (i.e. ABHR dispensers) cannot be used in a corridor of a facility. But sections and permit ABHR product and dispensers in corridors of healthcare occupancies and ambulatory health care occupancies… so what’s up with this conflict?

According to section whenever the occupancy chapter differs with the core chapters, then the occupancy chapter governs. So, on the issue of ABHR dispensers, they are permitted in the corridors of healthcare occupancies and ambulatory health care occupancies because those chapters have specific language that over-rides the core chapter.

But not so for business occupancies. Chapters 38 & 39 are silent regarding ABHR dispensers. Therefore, you cannot have ABHR dispensers in the corridors of business occupancies because they are a flammable liquid.

Even if the Medical Office Building was re-classified as ambulatory health care occupancy (I don’t recommend it), you still could not place the ABHR dispensers in the corridors because the corridors are not 6-feet wide.

I don’t see that this issue will likely be cited by surveyors, for a couple of reasons: 1) Not all surveyors know and understand this issue very well. They know ABHR dispensers are permitted in hospitals and figure the requirements for hospitals are more restrictive than business occupancies, and would allow them in a medical office building; 2) Typically, the surveyors who survey medical buildings (i.e. business occupancies) are nurse surveyors or physician surveyors…. not Life Safety surveyors, so they would not be as familiar with the LSC on this issue.

Penetrations in a Smoke Compartment Barrier

Q: In an EXISTING hospital, when the corridor walls are ALSO a smoke compartment barrier, can the penetrations above the ceiling be sealed with a non-rated sealant or are they required to be treated the same way as a 1-hour rated wall?  Please advise.

A: All smoke compartment barriers need to have penetrations sealed with proper fire-rated materials designed for use on fire-rated walls. The reason for this is, while the smoke barrier is not a fire-rated barrier because the doors in the smoke barrier are non-fire-rated, the actual wall that makes up the smoke barrier is a fire-rated wall (1-hour for new construction and 30-minutes for existing construction… see and in the 2012 LSC). Since the actual wall of the smoke barrier is required to be fire-rated, all penetrations in that wall need to be sealed using approved fire-rated materials.

Even though section of the 2012 LSC implies that non-rated materials are permitted to seal penetrations in smoke barriers, the occupancy chapters for Healthcare Occupancies over-rides that and requires fire-rated materials for sealing penetrations in a smoke barrier, since they require fire-rated barriers for smoke barriers.

You may be thinking about smoke resistant partitions (such as corridor walls or walls separating an existing hazardous area protected with sprinklers), that are not required to be fire-rated. Those walls may have penetrations sealed with non-fire-rated materials.

Dutch Doors

Q: I have been asked by a clinic manager at one of our primary care clinics to install a door knob on a split Dutch type door that goes into a lab area. They are requesting that the lock set be a double cylinder type where one would have to use a key to enter from the hallway as well as use a key to exit from inside of the room. I have never heard of this before (that doesn’t necessarily mean anything). I have concerns regarding egress safety, should I do this?

A: I advise you to not do this. From what you describe, it sounds to me that there would be multiple violations with this arrangement. First, having a second latch set on the Dutch door would require two actions to operate the door, which is not permitted according to section of the 2012 LSC.

Second, it sounds like a key would be required to egress the door which is not permitted according to section I’m glad you asked, but it sounds like trouble to me if you agree to install this equipment.

Suites in AHCO

Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion?

A: Well… that surveyor is mistaken. Suites are definitely permitted in ambulatory health care occupancies (AHCO). Sections 20/ of the 2012 LSC specifically permit suites and says any site larger than 2500 square feet must have at least two exit access doors remotely located from each other.

The term ‘remotely located’ is defined by section which says the two exits must be located at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the suite, measured in a straight line between the nearest edges of the exits. In a fully sprinklered building, section says it is 1/3 the length of the maximum overall diagonal dimension of the suite.

There are no size limitations on suites in AHCO. And they are not prohibited in business occupancies either, even though there is no advantage to having them in business occupancies. I suggest you ask the surveyor (if he/she is still with you) to show you where in the LSC it prohibits suites in AHCO. I also suggest you ask your state and local authorities if they have any restrictions that would prohibit suites in AHCO.

New vs. Existing Construction

Q: How do we classify existing versus new construction? Do we look at the date of adoption of the current Life Safety Code as the cutoff? Anything constructed before that date is considered existing construction? The 2000 LSC required areas of major rehabilitation to be classified as new construction. The 2012 LSC appears to just require those areas be fully sprinklered. On our Life Safety plans all areas of the hospital were constructed prior to the adoption of the 2012 Code. Can the entire hospital now be considered existing and can we remove all notes on the plans referring to new construction?

A: According to the CMS Final Rule on adopting the 2012 Life Safety Code which was released in May, 2016, they identified July 5, 2016 as the threshold date to differentiate between new construction and existing conditions. However, the 2012 Life Safety Code says in section that whenever a feature of life safety is required for compliance, it must be maintained as such for the life of the building. Section continues to say that features of life safety shall not be removed or reduced where such features are required for new construction.

What this means, is you cannot down-grade a feature of life safety that was installed under new construction requirements, to meet existing condition requirements now that it is no longer considered new construction. It is true that something built prior to July 5, 2016 is now considered existing conditions, but you still are not permitted to down-grade the feature to meet existing condition requirements.

A Two-Hour Separation Between Hospitals

Q: I have a client that is building a new Women’s and Children’s Hospital. The women’s component will be licensed to one organization, and the children’s component will be licensed to another. Both organizations intend to operate separately and self-sufficient but would like the new building to look like one comprehensive hospital building. Is a two-hour occupancy separation required between the two, separately licensed hospitals in the same building?

A: As long as the occupancy designation is the same for both units, then no… a 2-hour fire-rated occupancy separation is not required according to the Life Safety Code. But check with your state and local authorities to see if they have more restrictive requirements.