Happy Birthday…. to me

Well, no, it’s not my birthday, but 10-years ago today I published my first post on this website. In 10 short years, I have made over 1,150 postings, and answered gobs of questions in the process, some of them correctly.

So, in a way, it is the 10th birthday of the Keyes Life Safety website. I’ve enjoyed every minute and I hope we can go another 10-years.

Thanks for being a reader…


Strange Observations – Sprinkler in the Alcove

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

The good news is you have an alcove in the corridor where you can store linen carts. The bad news is a sprinkler head was installed in the alcove preventing you from storing linen carts.

In this photo, the top of the linen cart is too close to the sprinkler deflector. You must maintain at least 18-inches clearance underneath the sprinkler head.

I’m not an expert on sprinkler design, but I suspect they would not need a sprinkler head in the alcove, if another sprinkler head was in close proximity.

Stairwell Signage

Q: With the new 2012 Life Safety Code adoption, my question is around the stairwell signage and Hospitals are confused whether they have to replace all their signs to meet this new code requirement, or if they are grandfathered-in, and not have to comply. From what I interpret from the code, this would be for new stairwells only… is this correct?

A: No… This applies to all new enclosed stairs serving three stories or more, and all existing enclosed stairs serving five stories or more. There is no ‘Grandfathering’ in the Life Safety Code. There are requirements for new construction (Chapter 18) and there are requirements for existing conditions (Chapter 19), but other than that, there is no ‘Grandfathering’.

When new editions of the Life Safety Code are adopted, facilities must comply with new requirements that apply to existing conditions. Just because the building was compliant with the Life Safety Code at the time of original construction, does not permit the building a ‘pass’ on meeting new requirements that apply to existing conditions.


Strange Observations – Wall Mounted Signs

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

The discharge door for a stairwell opened out onto the 1st floor corridor, where egress was just down the corridor. (This is permitted by section 7.7.2 of the 2012 LSC, provided they met all of the other requirements).

As the picture indicates, when the stairwell door is fully opened, it sticks out into the corridor about half the width of the door. This can cause a momentary obstruction to people in the corridor when the door is open.

The facilities department thought it would be a good idea to warn people that the door may be a problem when open and created this sign on a swivel that warns people. To be sure, the sign does swing if anyone came into contact with it, but when it is in its normal position, it projected more than 4-inches into the corridor.

Even though the intentions for the sign were good, it does violate the maximum 4-inch corridor projection rule adopted by CMS, and therefore it was written up.


Q: Is there a limit to the size an alcove can be in a smoke compartment right off of the corridor? I understand equipment can be stored in alcoves but is there a definition of an alcove? I have a one hundred square foot room that was once required to be a remote nurse station, but the area is no longer used as a remote nurse station. There is no door to the room and the opening to the corridor is 6 feet wide. Am I allowed to store wheeled equipment (i.e. wheelchairs, patient lifts and crash carts) not in use in this area?

A: Crash carts are permitted to be left unattended in the required width of the corridor, but your question is valid for the other items. Generally speaking in healthcare occupancies, corridors must be separated from all other areas and rooms. But take a look at section of the 2012 Life Safety Code. There are nine (9) exceptions to the LSC requirement that the corridor must be separated from the rest of the facility.

Depending on certain variables, such as sprinkler coverage, smoke detection, size of the open area, etc., you may be able to qualify for one or more of the exceptions. However, you cannot store any combustibles in this room that is open to the corridor. That means no bed storage (because mattresses are combustible) and no supply carts with combustible supplies can be stored in these rooms.

You will have patrol this area often to ensure it is maintained properly. But to answer your question, I have not seen any limitations on size of alcoves in corridors. And one of the exceptions to says spaces unlimited in size may be open to the corridor if you meet all of the requirements.

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.

Usable Space in an Exit Enclosure

Q: We have an enclosed room in an exit enclosure that is being used as a classroom. I’m using NFPA 101, 2015 LSC, section Usable Space. Is this a code compliant arrangement?

A: It depends…If the enclosed room is separated from the exit enclosure with fire-rated construction equal to the stairwell, and if the enclosed space does not interfere in any way with egress, and the access to the enclosed space is not from the stairwell itself…. Then I would say it is permitted.

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.