Elopement Risk

Q: We have a potential elopement risk at the nursing home where I work. A patient gets into the stairwell and down to the first floor and exits the building. We have an alarm system that alerts us when any door is activated. My question is: Can we install interrupter gates on the second floor leading down to the first to deter elopement risk?

A: I’m not sure what you believe to be an interrupter gate … but they won’t do you any good in restricting egress. By definition, an interrupter gate cannot restrict egress. If you are fully sprinklered, you can install delayed egress locks that will slow down egress for 15 seconds, allowing staff to respond to the local alarm and prevent someone from leaving. For normal egress you can provide authorized people ID badges that can be swiped or read on a card reader bypassing the delayed egress locks. You may even consider specialized protective measure locks as described in section of the 2012 LSC. They may cost you more, but they are effective for your concern.

Stairwell Fire Rating

Q:  We are being told by our local AHJ that a stairwell in a 2 story building has to be 2-hour fire resistance rated so that it meets the requirements of occupancy separation since one floor is healthcare and one floor is business. Do you agree?
A: Well…. That is a matter of interpretation, and I can understand the logic with the requirement to be 2-hour fire rated. Another way of looking at it is if a stairwell was only one hour fire rated, it would take a fire starting on the 1st floor (business occupancy) one hour to penetrate the stairwell barrier, and then it would take one more hour to penetrate the 2nd floor (healthcare occupancy) which is a total of 2 hours. Personally, I would not buy into that line of thought, and if I were an AHJ, I would not allow a 1-hour fire rated stairwell to separate a business occupancy from a healthcare occupancy. I would require it to be 2-hour rated. But, that’s me. Remember… Every AHJ has the right to interpret the Life Safety Code as they see fit.

Existing Mechanical Equipment Spaces Opening onto Exit Enclosures

Q: With the elimination of the CMS Waivers, I was trying to clarify what now applies for mechanical room combustibles storage (i.e. mechanical areas with only stairway and elevator access vs. hallway access and stairway access, or just hallway access). Does it mean no combustible storage without a “buffer room” to a stairway still applies as described in the old waiver? I was confused with NFPA 101-2012, Separation of Occupancies in Healthcare (Table which appears to show 2-hour separation for all Storage, normal to hazardous. Confused with their footnote: ‡The 1-hour reduction due to the presence of sprinklers in accordance with the single-dagger footnote is not permitted.

A: Let me clear up some of the issues that may be confusing you. First of all, CMS did not eliminate any waivers. Healthcare organizations may still submit waiver requests provided the non-compliance that is being requested to be waived has been cited first during an accreditation survey or state survey on behalf of CMS. Since CMS adopted the 2012 Life Safety Code all of the Categorical Waivers that they issued over the past few years have not been eliminated, but rather they have been completed. The Categorical Waivers (for the most part) allowed healthcare facilities to use certain sections of the 2012 LSC early, before CMS formally adopted the 2012 Life Safety Code. Since CMS did adopt the 2012 LSC on May 4, 2016, with an effective date of July 5, 2016, there is no need for the Categorical Waivers. They were not eliminated or deleted; they just were completed.

Under the 2000 Life Safety Code, openings in exit enclosures (i.e. stairwells) were limited from normally occupied spaces and corridors. This means unoccupied mechanical rooms that had their only access through a stairwell were non-compliant with the 2000 Life Safety Code. The Life Safety Code Technical Committee recognized that was a problem in many hospitals, so they changed the code in the 2012 edition, to allow existing openings into exit enclosures from mechanical equipment spaces to remain, provided the following conditions occur [see section]:

  • The door assemblies between the exit enclosure and the mechanical space are properly rated
  • The space is used for non-fuel-fired equipment
  • The space contains no storage of combustible materials
  • The building is fully protected by automatic sprinklers

So… if you are attempting to use the above section for mechanical rooms that open onto a stairwell, then you are not permitted to have any combustibles stored in the mechanical space. This means no boxes of filters; no cardboard boxes containing repair parts; no storage of anything that could burn. And the entire building has to be protected with sprinklers. However, if you do have a vestibule separating the mechanical space from the stairwell, then you do not have to comply with the above requirements since you are compliant with section

Table that you referenced is a table to identify the separation between differing occupancies… not a separation involving storage rooms within the same occupancy. There are many different occupancies that a healthcare facility may have: Healthcare occupancy, business occupancy, and even a storage occupancy are just a few. Anytime there are different occupancies that are contiguous and one of the occupancies is a healthcare occupancy, then the barrier separating the two occupancies must be 2-hour fire rated. This table has nothing to do with the separation required around a storage room inside a healthcare occupancy.

Security Cameras in Stairwells

Q: What is the Life Safety Code ruling on cameras and speakers in stairwells? Joint Commission was in and cited us on having cameras in the stairwells. We were told by the surveyor that they don’t pertain to the stairwells.

A: The Life Safety Code does not specifically address cameras in the stairwells, but section of the 2012 LSC does limit what penetrations are permitted into an exit enclosure. Conduit is permitted as long as the conduit serves the stairway. This seems to be an interpretation issue, and apparently, the surveyor decided the use of cameras does not fit the description in To me, a camera focused on people using the stairway seems to fit the description of “serving the stairway”, but it really doesn’t matter what I think.

If you can prove the camera installation qualifies as ‘existing’ conditions, then it should be accepted by the accreditor. The definition of ‘exiting’ conditions is any design, construction, or governmental approval that was in existence prior to July 5, 2016 (the date the 2012 LSC was adopted). However, since the 2000 LSC also prohibited new penetrations in stairwells for cameras, it is likely that a surveyor will hold you accountable to what the 2000 LSC required when you were supposed to comply with that edition, and that edition was adopted March 11, 2003. So, if the camera was installed in the stairwell since March 11, 2003, I can see that the surveyor would have a legitimate finding.

Evacuation Chairs in Stairwells

Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but the surveyor did not care that state fire marshal gave his blessing 8 years ago to have chairs at tops of stairwell and during the previous two Joint Commission surveys the chairs were not an issue. Your thoughts on this would be greatly appreciated.

A: First of all, it doesn’t matter what a state or local inspector or fire marshal says. Joint Commission and/or CMS does not have to comply with what a state or local authority says on an issue, and often does not care. All authorities having jurisdiction (AHJ) are equal, but separate. To have the permission or interpretation of one authority does not provide you with any leverage or influence with any other authority. Often times the authorities simply do not care what the other authorities say.

The Life Safety Code is not entirely clear on the subject of evacuation chairs mounted in stairwells. At one point (section of the 2012 Life Safety Code) the code says no space in the exit enclosure may be used for any purpose that has the potential to interfere with egress. One may conclude that if the evacuation chairs are mounted off to the side of the top landing where there is no possibility of egress interference, then you can mount an evacuation chair there. But the code does not specifically say that and it would have to be an interpretation by the authority to allow it.

But section also says an exit enclosure cannot be used for any purpose that has the potential to interfere with its use as an exit. According to the Annex section, the intent of this standard is the exit enclosure should be sterile with respect for fire safety hazards. The authorities can interpret this any way they want since the code is not clear.

Apparently, the Joint Commission (through the surveyor) is saying they will not allow it, and it is well within their right to say so. I have been in conferences where representatives from the Joint Commission engineering department say they do not allow stairwell evacuation chairs to be stored inside the stairwell.

Stairwell Tread Marking

Q: We are being told that section of the 2012 Life Safety Code requires us to install paint on the nose tread on stairs in existing egress stairways as a requirement. I read it as if you want to install a paint stripe, here is what you need to do. Who is correct?

A: Section in the 2012 LSC is very clear: Where new contrasting marking is applied to stairs, there are four (4) criterions to follow. It does not say all stairs must have contrasting markings applied to the stairs. This section only applies if you decide to apply contrasting markings to the stairs. Also, section says exit stair path markings are only required if the occupancy chapter requires them. Healthcare occupancy does not require them.

Pictures Hanging in Stairwells

Q: I have a question about putting pictures up in stairwells. Someone in our administration department at our hospital wants to put pictures up in a stairwell. We have already received a citation for having a camera in a stairwell so I am almost certain we would get one for this also. I want to quote this section: A from the NFPA 101 Life Safety Code as I cannot find any other section on it but want to make sure there is nothing I missed since it is an executive asking to do this and I want to make sure I have every angle covered.

A: You’re correct…. AHJs can be very tough on anything placed in a stairwell that does not serve the function of the stairwell. Under previous editions of the Life Safety Code, a camera would not be permitted because it was not considered to serve the stairwell. But in the Annex section A. of the 2012 Life Safety Code, penetrations for electrical wiring for security cameras would be permitted as long as the AHJ approves. You would have to ask all of your AHJs for approval. Pictures would not serve the function of the stairwell and likely would be cited by AHJs. Section of the 2012 Life Safety Code says the exit enclosure (i.e. stairwell) cannot be used for any other purpose that has the potential to interfere with the use of the exit enclosure. A picture hanging on the wall could interfere with individuals exiting the facility. The intent is to prohibit any equipment (i.e. pictures) not necessary for safety. The Life Safety Code intends for the exit enclosure to essentially be “sterile” with respect to safety hazards.

Evacuation Chairs Stored in Stairwells

Q: I understand it would be best to not place something affixed to the walls of the exit stairwell that protrudes in to the path of egress, which in turn, may interfere with egress. But we have two sets of stairwells, that in the middle of each floor, is a landing which has about a 7’ alcove going away from the path of egress on the landing, and the path of egress does not use this alcove.

So my question is, can we store evacuation chairs in these alcoves? I can understand affixing these items in the path of egress within the stairwell, can interfere with egress, but these alcoves are clearly out of the way and not in the path of egress.

A: To answer your question, let’s first take a look at section of the 2012 Life Safety Code (LSC), which says there shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

What this section appears to say is you may store your evacuation chairs in the alcove of your stairwell since the alcove is not part of the egress, and the stored evacuation chairs would not interfere with egress. But there are surveyors and AHJs that take a much more severe look at this issue, based on section of the 2012 LSC, which says an exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

Some AHJs take a very strong stand against anything being stored in the stairwells, but the Annex section of explains this requirement a bit further, and says the provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be ‘sterile’ with respect to fire safety hazards.

The above reference is in the Annex section of the LSC which means it is not part of the enforceable section of the code, but it is an explanatory section to help authorities understand the intent of the technical committee who wrote the code. Most AHJs follow what the Annex section says, although they do not have to. The Annex section for does prohibit storage in the stairwell that is “not necessary for safety”, but one could make the point that evacuation chairs are necessary for safety and therefore are permitted to be stored in the stairwell, as long as they do not interfere with egress.

The bottom line is it is apparent to me that the Life Safety Code does permit the storage of evacuation chairs in an exit stairwell, as long as the chairs are stored in such a way as to not interfere with egress. However, not all AHJs actually agree with this and some do cite hospitals if they have anything stored in the stairwells. If you want to pursue this and store the evacuation chairs in the alcove of your stairwells, I suggest you document these sections of the Life Safety Code and show them to any surveyor who questions the practice. It may prevent you from having a citation, or it may not.

Stairwell Chair Lift

Q: Can a chair lift device be installed in an exit stairwell? What are the regulations?

A: The Life Safety Code and the local building codes set minimum widths of the required exit stairwells, pertaining to the required doors to the exit stairwells, and they set a minimum number of exit stairwells the hospital must have. These are all calculated by the architect who designed the facility to accommodate people exiting the building during an emergency. To install a chair-lift device in a stairwell would violate these conditions and would cause the building to be non-compliant with the Life Safety Code.

The following sections of the 2012 Life Safety Code set the requirements for minimum widths of required egress components:

  •   36 inches clear width for existing stairs
  •  36 inches clear width for new stairs serving less than 50 occupants
  •  44 inches clear width for new stairs serving 50 to less than 2000 occupants
  •  56 inches clear width for new stairs serving 2000 or more occupants
  •           The minimum clear width of doors in existing healthcare occupancies is 32 inches
  •           The minimum clear width of doors in existing healthcare occupancies is 28 inches where evacuation by bed, gurney or wheelchair is required

These are minimum width requirements, and actual widths would have to increase based on the number of occupants calculated to use these components.

Section of the 2012 LSC says nothing may be installed in exit enclosures that could interfere with egress. I suspect a chair-lift would interfere with egress.

If you have a stairwell that is not an exit stairwell, then the possibility may be that a chair-lift could be installed as long as minimum aisle widths (36 inches) are met. Check with your design professional and your state and local AHJs to determine if that is possible.

I’m also told that the ADA requirements do not allow chair lifts in exit stairwells, and check with your state department of hospital licensing to see if they have any additional restrictions.

Strange Observations – Part 1

Cage in StairwellI thought you might be interested in seeing some of the strange things I have observed as a consultant for healthcare organizations. This is a picture of a cage that a hospital built inside the stairwell. It was their attempt to create a locked door to prevent access to the roof.

It was successful in keeping unauthorized people from having access to the roof but it is not compliant with section of the 2000 LSC which says you cannot lock doors in the path of egress. Also, section says you cannot have anything in the stairwell that could interfere with exiting.

A cage with a locked door would certainly interfere with exiting.