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 6.1.14.4.1) 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 7.1.3.2.1(9)(c)]:

  • 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 7.1.3.2.1.

Table 6.1.14.4.1 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.