Door Closing Time

Q: Is there a maximum time required for doors to automatically close? This question came up in a recent department meeting and we cannot find any code reference that specifies how quickly a door must close.

A: It depends if the door is a swinging type or sliding type. The LSC and NFPA 80 Fire Doors and Fire Windows (1999) does not specify the amount of time that a closure must close a swinging door, whether it be for a fire rated door or a non-fire rated door. However, section 4-4.1.1 and 4-4.1.2 of NFPA 80 requires horizontal sliding doors to have a delay of no more than 10 seconds in the initiation of the closing, and the average speed of the closing must be between 6 and 24 inches per second. I suggest you ask your local AHJ if they have a requirement other than NFPA that addresses this issue.

Smoke Detectors Used for Door Release

Q: In our hospital, we have smoke compartment doors in the corridor that are held open with magnetic hold-open devices. When the fire alarm system is activated, the magnetic devices release and the doors automatically close. Are we required to have smoke detectors located within 5 feet of these doors, even though the smoke compartments on either side of the doors are fully protected with smoke detectors?

A: The Life Safety Code (2000 edition) requires your fire alarm system to be in compliance with section 9.6 which further requires compliance with NFPA 72-1999 National Fire Alarm Code. Section 2-10.6 of the National Fie Alarm Code states that smoke detectors that are part of an open area protection system that is covering the room, corridor or enclosed space on each side of the smoke door and that are located and spaced according to NFPA 72-1999, section 2-3.4, shall be permitted to accomplish smoke door release service. Therefore, if your smoke detectors actually meet the spacing requirements found in 2-3.4 on both sides of the smoke door, then you do not need to have a smoke detector mounted within 5 feet of the door to release the door in the event of an alarm.

Time Clock in an Exit Stairwell

Q: Is it permitted to have a time clock in an exit stairwell of a hospital? My VP of Operations wants to install time recording stations in stairwells where employees will have to record their time. Our hospital is over 30 years old and is fully sprinklered.

A: Section 19.2.1 of the Life Safety Code (LSC) 2000 edition refers to Chapter 7 for means of egress requirements. Section 7.1.3.2.1(e) prohibits penetrations and opening into an exit enclosure (stairwell) unless it serves the stairwell. The addition of new time clocks would not meet the definition of “serving the stairwell”.  If electrical cable, wires or conduit is needed to operate the time clock, then this section alones prohibits you from installing it in the stairwell.

If the time clock is a wire-less device then section 7.2.2.5.3 states that no open space within the stair enclosure may be used for any purpose that has the potential to interfere with egress. The annex section of the LSC explains an example of interference with egress is storage. Here is one way to look at this: If a person is inside the stairwell and standing in front of the time clock attempting to “punch” in or out, and it interferes with another person trying to exit, then that interferes with egress, and the time clock would not be permitted. This is basically a judgment call as to whether or not the time clock is interfering with egress, but the Authority Having Jurisdiction (AHJ) is ultimately the one who makes this decision. I suggest that you take a conservative approach on this issue. Discuss it with your local AHJ and your safety committee for their opinions.

Gift Shops

Q: Are hospital gift shops required to be treated as hazardous areas? We had a survey recently and the inspector said the entrance door to our gift shop needed to have positive latching hardware.

A: This is one of those “it depends” answers. Section 19.3.2.5 of the 2000 Life Safety Code clearly states that gift shops are required to be treated as hazardous areas if they contain combustible items in quantities considered hazardous. Most hospital gift shops do contain items that are considered combustible, such as greeting cards, stuffed animals, clothing, and other items. The question is: Are they in sufficient quantities to be considered hazardous? This is a question that only an Authority Having Jurisdiction (AHJ) can answer. If an accreditation surveyor were to consider the combustible items in sufficient quantities to be a hazard, then the gift shop must be treated as a hazardous area. However, please be aware that there are more than one AHJ, and in most cases, an opinion of one AHJ does not have much bearing on the opinion of another AHJ. Therefore, I suggest that you be very conservative on this issue, and if your gift shop has any combustible items, then treat it as a hazardous room and all corridor doors must be positive latching. This would require either automatic sprinkler protection with smoke-resistant self-closing positive latching doors, or 1-hour fire rated walls with ¾-hour fire rated self-closing positive latching doors, or both if new. When a gift shop does not have combustible items on display or in storage, and does not exceed 500 square feet, and is fully protected by sprinklers, then it does not have to be treated as a hazardous area, meaning it could be open to the corridor.

Locked Doors on Soiled Utility Rooms

Q: Do soiled utility room doors have to be locked all the time? I was informed by our VP Quality Assurance that all of the soiled utility room doors must be locked, but I do not see any requirement for this in the Life Safety Code.

A. Soiled utility rooms are defined as hazardous rooms, according to section 19.3.2.1. There are many requirements for hazardous rooms, such as 1-hour fire rated walls (or sprinkler protection) and a door that has a closure on it. But there is no requirement in the LSC that says you must lock any soiled utility room door, or any door to a hazardous area. However, that is not the end of the discussion for this issue. Your AHJ may very well expect you to lock any room that is considered hazardous, unless you have conducted an assessment for risks to safety. An example of a soiled utility room that should be locked is when it contains hazardous items accessible to unauthorized individuals. This could occur near a pediatric department, or in a location that is not constantly supervised by staff. Each hazardous room, including soiled utility rooms, should be assessed on a case by case basis to determine whether or not they should be locked. Remember: All risk assessments should be reviewed and approved by your safety committee.

Video Equipment Storage

Q: Is there a specific fire code requirement for an equipment room containing electronic video conference equipment? I have been told there are specific requirements for electrical and mechanical rooms, but I do not find anything specific for video equipment.

A: Electrical rooms have specific requirements that are found in NFPA 70-1999 National Electric Code such as access to the rooms must be locked or have other approved means, such as constant supervision (110.31) and there are minimum clearance standards around electrical equipment as described in table 110.34(A), and transformer rooms are not allowed to have any combustible items stored in them (450.23[(A]).

Mechanical rooms that do not contain any fuel-fired heating equipment by definition are not considered to be hazardous rooms (see NFPA 101-2000 Life Safety Code section 19.3.2.1) and therefore are not required to be sprinklered or have fire rated walls and doors. Many Authorities Having Jurisdiction (AHJ) do not permit general storage (including video equipment) in mechanical rooms, since the room is intended to support the purpose of the room. However, many AHJ will allow you to store one change of air filters in the mechanical rooms without the room being designated as a hazardous room.

Your question asks are there specific fire codes for an equipment room where items are stored for a video conference center. The answer is no, there are no specific codes for that room, but there is the general requirement for hazardous rooms (section 19.3.2.1 of the LSC). If the room is greater than 50 square feet and contains combustible items (in quantities deemed hazardous by the AHJ), then it has to be protected with sprinklers or 1-hour construction.

However, if the room was not originally a storage room (meaning if it was formerly an office, patient room, or used for any other purpose other than storage) and you are now converting it to a storage room, and if it is greater than 100 square feet, then you must meet new construction requirements (section 18.3.2.1) and install both sprinklers and 1-hour fire rated walls, and ¾ hour fire rated self-closing and positive latching door.

Hazardous Areas in Business Occupancies

Q. Do hazardous areas in business occupancies require a self-closing door if the room is protected with automatic sprinklers? We had a surveyor cite us for not having a closure on the door to a storage room that is considered to be hazardous.

A.  Existing business occupancies are required to follow chapter 39 of the Life Safety Code which says hazardous areas, such as storage rooms must follow section 8.4. Section 8.4.1.1 offers three options to protect hazardous areas, which are:

  1. Create 1-hour      barrier around the room (which would include a fire rated door, which      would have to positively latch and have a closure), or
  2. Protect the area      with sprinklers, or
  3. Do both if      hazard is severe.

You are only required to comply with one of the above, not all. If your storage room is protected with automatic sprinklers, as you imply, then there is no requirement for a barrier or a door. If there is no requirement for a door, then there is no requirement for a closure on the door.

However, section 8.4.1.2 requires new construction to provide smoke partitions when the hazardous area is protected by automatic sprinklers. Smoke partitions are required to have self-closing doors (8.2.4). If your storage room qualifies under new occupancy (or new construction in an existing occupancy) then the surveyor is correct: You need a closure on that door.

Testing of Delayed Egress Locks

Q.  We have delayed egress locks in our hospital and during a recent inspection a fire marshal said we had to test the locks on an annual basis. Is this true? If so, what are we supposed to be testing?

A.  Although the Life Safety Code occupancy chapters for healthcare (chapters 18 and 19) permits delayed egress locks in hospitals, section 7.2.1.6.1 explains how they need to be installed. One of the aspects of operation for the delayed egress locks is the requirement to be interfaced with the building fire alarm system or the automatic sprinkler system. The doors are required to unlock upon water-flow, or activation of a heat detector or no more than two smoke detectors. (Please note: This does not necessarily include the activation of a manual pull station.) While the LSC does not reference a specific requirement for testing the delayed egress locks, NFPA 72-1999 National Fire Alarm Code does have a written requirement for testing interface equipment. Table 7-2.2, paragraph 19 says interface equipment connections shall be tested by operating or simulating the equipment being supervised. Signals that are required to be transmitted must be verified at the control panel. Delayed egress locks are not necessarily supervised, but they do have an interface device (control relay) that unlocks the doors on a signal from the fire alarm control panel. NFPA 72 recommends the testing frequency of interface equipment to be conducted annually.

One could draw the conclusion that your delayed egress locks should be tested annually, to ensure that the power controlling the locks actually drops out upon water-flow, or activation of a heat detector, or no more than two smoke detectors.

Interim Life Safety Measure Implementation

Q: The Joint Commission’s standard on Interim Life Safety Measures (ILSM) requires the hospital to implement ILSM for deficiencies to the Life Safety Code (LSC) when the deficiency cannot be immediately corrected. Please define the time-frame that they mean with the word “immediately”. Can the implementation of an ILSM wait until the Safety Committee approves it?

A: The implementation of an ILSM cannot wait for a committee’s review and approval. The intent of the word “immediate” suggests that the ILSM must be implemented as soon as it is determined the deficiency cannot be resolved the moment it is discovered. This means to me that you need to implement an ILSM the same day a deficiency is discovered.

Each hospital is required to have a written Interim Life Safety Measure policy that applies to situations when LSC deficiencies cannot be immediately resolved due to equipment failure, maintenance, or construction. Your policy should proactively identify the process in which you meet the 11 different prescriptive requirements found in the standard. By following your own policy, your staff should be able to determine which measure to implement based on the deficiency that was discovered. This implementation phase may be approved by someone in authority at your facility, but it should not be held up for approval by a committee. However, it is encouraged that all ILSMs be presented to your Safety Committee as evidence of your organization managing the life safety deficiency. This will foster general discussion which should be reflected in your committee’s minutes.

Be very conservative with the implementation of ILSMs. Failure to implement appropriate ILSMs can lead to an adverse decision at your next survey.

Magnetic Latches on Suites

Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching.  The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?

A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.

In new healthcare occupancy, section 18.3.6.3.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).

However, for existing healthcare occupancies, section 19.3.6.3.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception.  When locks are permitted on egress doors, they must meet the requirements found in 19.2.2.2.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.

Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.