Business Occupancy Soiled Utility Room

Q: Do business occupancy buildings with soiled utility rooms have to be one-hour fire-rated or just sprinkled if the building falls under a hospital license and will be inspected by State and CMS surveys?

A: It depends…. Is the soiled utility room used for general storage? In business occupancies, soiled utility rooms are not considered outright to be a hazardous area like they are in healthcare occupancies. However, many soiled utility rooms are also general storage rooms, and section 38/ of the 2012 Life Safety Code specifically says general storage rooms are considered hazardous areas and must be maintained in accordance with section 8.7. Section says the room needs to be either 1-hour fire rated or protected with sprinklers.

Whether or not the business occupancy falls under the hospital license is not a factor, regardless who inspects the building. The LSC is clear: If used for general storage, then the room is either sprinklered or 1-hour fire rated. If the room is not used for general storage, then there is no requirement. This is based on its occupancy; not its license.

Soiled Utility Room

Q: Is it a requirement that all units have a soiled utility room?

A: It is not a Life Safety Code requirement or a NFPA requirement that all units must have a soiled utility room, but is a guideline found in the Facilities Guideline Institute (FGI), 2014 manual. And, it could very well be a state licensure requirement, depending on where you reside.

Hand Washing Sinks in Soiled Utility Rooms

Q: Is it required that all soiled utility rooms have a dedicated sink for handwashing only?

A: The NFPA Life Safety Code and related standards do not address this issue, but according to the 2010 FGI guidelines, a hand-washing sink is not required in a soiled utility room. Section 2.1- specifically omits the requirement of a hand-washing sink for soiled utility room. Now, clean supply rooms would be required to have a hand-washing sink (according to section 2.1-, but not a soiled utility room.

However, the FGI guidelines are not regulations or standards; they are considered guidelines to be used in lieu of any regulation or standard. Therefore, you need to check with your state and local authorities to determine if they have any regulations concerning hand-washing sinks in soiled utility rooms.

Soiled Utility Rooms

Q: What is the protocol to maintain a soiled utility room on a patient floor? What guidelines have to be met?

A: As far as what guidelines have to be met, most states and accreditation organizations want you to follow the FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities, 2014 edition, unless there are more restrictive requirements from your state authorities. From a design standpoint, the FGI guidelines require the following:

  • Must be separate from and have no direct connection with clean workrooms or clean supply rooms;
  • Hand-washing station;
  • Flushing-rim clinical service sink with a bedpan washer (omission of the flushing-rim clinical service sick is permitted if the room is only to be used for holding soiled material);
  • Work counter;
  • Space for separate covered containers.

As far as general life safety requirements by accreditation organizations, soiled utility rooms in a healthcare occupancy must be treated as a hazardous room, regardless of the size. This is a requirement of the Life Safety Code (see 18/ of the 2012 LSC) which means if it is considered existing conditions (created before January 1, 1988, the date the 1985 LSC was adopted ) then the soiled utility room must be protected with 1-hour fire resistive rated barriers that extend from the floor to the deck above; or if it is protected with sprinklers, then it can be protected with smoke resistive rated barriers that extend to the ceiling, provided the ceiling also resists the passage of smoke. However, if it was constructed or renovated since January 1, 1988, then it must be protected with sprinklers and it must be protected with 1-hour fire resistive rated barriers.

There are other infection control issues that you must follow, such as clean supplies are not permitted to be stored in the soiled utility room, but you should check with your infection control practitioner for that.

Soiled Utility Room Door Signage

Q: Are you aware of any door signage requirements for soiled utility rooms and/or trash rooms?

A: There is no Life Safety Code requirement for signs on a soiled utility room door or a trash collection room door, unless the door could somehow be confused with an exit door. Then a ‘NO EXIT’ sign will have to be posted on the door, with the word ‘NO’ 2 inches tall, and the word ‘EXIT’ 1 inch tall, and the word ‘NO’ has to be on top of the word ‘EXIT’. If the doors to the soiled utility room or the trash collection room are fire-rated doors, then the sign must be no larger than 5% of the overall surface area of the door, and can only be attached to the door with adhesives. Nails and screws are not permitted to attach a sign to a fire rated door. Perhaps you may be thinking of a state regulation whereby every door must have a number or name assigned to it. I have seen this regulation in many states. However, I am not aware of any CMS, Joint Commission, HFAP or DNV requirement for signs on these doors.

Locked Doors for Utility Rooms?

Q: Where is the reference in the Life Safety Code that requires the doors to housekeeping or soiled utility rooms to be locked? I have a Risk Management director that tells me the code requires these doors to be locked.

A: There is no Life Safety Code requirement to lock housekeeping or soiled utility room doors. There is no Joint Commission, CMS or any other national authority that requires housekeeping or soiled utility room doors to be locked. Where hospitals get into trouble with CMS and the accreditation organizations on this issue is the failure to assess the risk to safety for patients and staff, when these doors are left unlocked. Each of the national authorities has a standard that requires hospitals to either identify safety and security risks in the environment, or their standard requires the hospital to maintain a safe environment for their patients.  An unlocked utility room that contains a risk to the patients would certainly be suspicious to a surveyor that the environment may not be safe for the patients. A housekeeping room may contain cleaning supplies that could be considered dangerous to unauthorized individuals (such as children). If the door to the housekeeping room was left unlocked, then people could gain access to the hazardous items and hurt themselves or others. Likewise for soiled utility rooms, which by definition would have soiled linens which may be bio-hazardous. This does not mean all soiled utility rooms or housekeeping rooms need to be locked. They just have to be assessed for the safety or security risks associated with the contents of the rooms. In my encounters, most of the soiled utility rooms that I see in hospitals are unlocked. Only soiled utility rooms where children are prevalent are the ones that are typically locked. Now, on the other hand, most (if not all) housekeeping janitor’s closets that I see are locked, partly due to the hazardous cleaning chemicals stored in them, but also because Housekeeping doesn’t want their other supplies stolen. But, to be sure, there is no direct requirement in the LSC or in the accreditation organization standards to keep these doors locked.

New Soiled Linen Room

Q: We plan to take an existing small closet and make it into a new soiled linen room. It measures approximately 35 square feet and I plan to construct this room with 1-hour rated walls from floor to deck and a 45 minute self-closing, positive-latching door and fire rated frame. Are there any other design concerns that I should be aware of?

A: Yes, there are. Along with the 1-hour construction, you will need to install automatic sprinklers in this room. The change from the existing closet to a new soiled linen room constitutes a change in use and an alteration, and according to section 4.6.7 of the Life Safety Code (LSC), you are required to comply with new construction requirements.. All new construction is required to be protected with automatic sprinklers, according to section There is no LSC requirement for a smoke detector, unless you are under an approved equivalency from an authority that requires smoke detectors in all habitable areas. Authorities Having Jurisdiction (AHJ) frequently refer to the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities (2001 edition) as a guide for ventilation. Table 7.2 specifies a minimum of ten (10) air changes per hour, with all air exhausted directly to the outdoors, and the room under a slight negative.  Please check with your local and state authorities to determine if they have any other specific requirements.

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 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.