Fire Alarm Systems in Business Occupancies

Q: We are converting a facility that was used as a physician’s office into our women’s clinic and OB/GYN facility. There were previously 4 exam rooms and we are making it into 6 exam rooms. This unit has no fire alarm, no sprinklers, not even a stand-alone smoke detector. This doesn’t seem right in today’s environment.

A: It appears what you are describing is a business occupancy. Section 38.3.4.1 of the 2012 LSC says this about fire alarm systems in business occupancies: “A fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:

  1. The building is two or more stories in height above the level of exit discharge;
  2. The occupancy is subject to 50 or more occupants above or below the level of exit discharge;
  3. The occupancy is subject to 300 or more total occupants.”

If your facility does not meet any of the above requirements, then you would not be required to have a fire alarm system. Also, section 38.3.5 does not require business occupancies to have sprinklers. But please check with your state and local authorities to see if they have other requirements.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.