Q: I have a Medical Office Building with multiple exam rooms, and it is constructed with 5-foot wide corridors. This building followed design reviews including Life Safety expertise from the local AHJ. In many cases, an alcohol-based hand-rub (ABHR) sanitizer dispenser is located just outside the exam rooms in the egress corridor. Why are you saying these dispensers are not permitted especially when section 126.96.36.199 says they are? Are you nuts…?
A: Well, I may be a bit crazy, but I’m pretty sure ABHR dispensers are not permitted in medical office building corridors.
Section 188.8.131.52 is applicable for healthcare occupancies, such as hospitals, nursing homes, long-term care facilities, etc. And section 184.108.40.206 is applicable for ambulatory health care occupancies such as Ambulatory Surgical Centers. But these sections are only applicable to their respective occupancies, and the typical Medical Office Building is not any of these… they are business occupancies. And unfortunately for you, there is nothing similar in business occupancy chapters 38 and 39 for ABHR dispensers.
It really all starts with section 220.127.116.11 which says no storage or handling of flammable liquids shall be permitted in any location where such storage would jeopardize egress from the structure. The ABHR gel or foam product in these dispensers have a high enough alcohol content to cause it to be classified as a Class 1-B flammable liquid, according to NFPA 30. So, according to 18.104.22.168, flammable liquids (i.e. ABHR dispensers) cannot be used in a corridor of a facility. But sections 22.214.171.124 and 126.96.36.199 permit ABHR product and dispensers in corridors of healthcare occupancies and ambulatory health care occupancies… so what’s up with this conflict?
According to section 188.8.131.52 whenever the occupancy chapter differs with the core chapters, then the occupancy chapter governs. So, on the issue of ABHR dispensers, they are permitted in the corridors of healthcare occupancies and ambulatory health care occupancies because those chapters have specific language that over-rides the core chapter.
But not so for business occupancies. Chapters 38 & 39 are silent regarding ABHR dispensers. Therefore, you cannot have ABHR dispensers in the corridors of business occupancies because they are a flammable liquid.
Even if the Medical Office Building was re-classified as ambulatory health care occupancy (I don’t recommend it), you still could not place the ABHR dispensers in the corridors because the corridors are not 6-feet wide.
I don’t see that this issue will likely be cited by surveyors, for a couple of reasons: 1) Not all surveyors know and understand this issue very well. They know ABHR dispensers are permitted in hospitals and figure the requirements for hospitals are more restrictive than business occupancies, and would allow them in a medical office building; 2) Typically, the surveyors who survey medical buildings (i.e. business occupancies) are nurse surveyors or physician surveyors…. not Life Safety surveyors, so they would not be as familiar with the LSC on this issue.
Q: We have a medical office building attached to the hospital using a 2-hour fire-rated separation. Two questions: 1) Our 8th floor is under renovations for a new auditorium and is not always occupied in that area. They have suppression, but also the whole ceiling grid is now open with the tiles removed. Does this require a fire watch? Am I correct in saying either they have to turn the sprinkler system upright to 12-inches from the decking or conduct a fire watch? 2) Our lobby is under renovation and the majority is ceiling tiles but also in the middle it opens up to the 2nd floor. They put up a flame retardant plastic sheeting barrier on the sides but not the ceiling which extends to the 2nd floor. This is also not under negative pressure as there are patients walking throughout. Is this a problem?
A: Yes… you’ve got a problem. When you remove the ceiling tiles from an acoustical grid and tile ceiling, the sprinklers are now impaired. You must conduct a continuous fire watch which requires a qualified trained individual to patrol the impaired area constantly and that person cannot do any other work, and must stay in the area until the impairment is resolved or he is relieved by another individual.
The sprinklers must be within 12-inches of the deck to no longer be considered impaired, and the sprinkler heads must be the correct orientation (upright vs. pendant). Since the construction area is not protected with sprinklers, the temporary separation barrier must be 1-hour fire rated with all openings ¾-hour fire rated doors that self-close and latch. The 1-hour barrier used is typically steel studs with 5/8-inch gypsum board on each side that is taped, mudded and the screw heads covered.
Q: In an EXISTING hospital, when the corridor walls are ALSO a smoke compartment barrier, can the penetrations above the ceiling be sealed with a non-rated sealant or are they required to be treated the same way as a 1-hour rated wall? Please advise.
A: All smoke compartment barriers need to have penetrations sealed with proper fire-rated materials designed for use on fire-rated walls. The reason for this is, while the smoke barrier is not a fire-rated barrier because the doors in the smoke barrier are non-fire-rated, the actual wall that makes up the smoke barrier is a fire-rated wall (1-hour for new construction and 30-minutes for existing construction… see 184.108.40.206 and 220.127.116.11 in the 2012 LSC). Since the actual wall of the smoke barrier is required to be fire-rated, all penetrations in that wall need to be sealed using approved fire-rated materials.
Even though section 18.104.22.168 of the 2012 LSC implies that non-rated materials are permitted to seal penetrations in smoke barriers, the occupancy chapters for Healthcare Occupancies over-rides that and requires fire-rated materials for sealing penetrations in a smoke barrier, since they require fire-rated barriers for smoke barriers.
You may be thinking about smoke resistant partitions (such as corridor walls or walls separating an existing hazardous area protected with sprinklers), that are not required to be fire-rated. Those walls may have penetrations sealed with non-fire-rated materials.
Q: I have been asked by a clinic manager at one of our primary care clinics to install a door knob on a split Dutch type door that goes into a lab area. They are requesting that the lock set be a double cylinder type where one would have to use a key to enter from the hallway as well as use a key to exit from inside of the room. I have never heard of this before (that doesn’t necessarily mean anything). I have concerns regarding egress safety, should I do this?
A: I advise you to not do this. From what you describe, it sounds to me that there would be multiple violations with this arrangement. First, having a second latch set on the Dutch door would require two actions to operate the door, which is not permitted according to section 22.214.171.124.10.2 of the 2012 LSC.
Second, it sounds like a key would be required to egress the door which is not permitted according to section 126.96.36.199.4. I’m glad you asked, but it sounds like trouble to me if you agree to install this equipment.
Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion?
A: Well… that surveyor is mistaken. Suites are definitely permitted in ambulatory health care occupancies (AHCO). Sections 20/188.8.131.52 of the 2012 LSC specifically permit suites and says any site larger than 2500 square feet must have at least two exit access doors remotely located from each other.
The term ‘remotely located’ is defined by section 184.108.40.206.2 which says the two exits must be located at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the suite, measured in a straight line between the nearest edges of the exits. In a fully sprinklered building, section 220.127.116.11.3 says it is 1/3 the length of the maximum overall diagonal dimension of the suite.
There are no size limitations on suites in AHCO. And they are not prohibited in business occupancies either, even though there is no advantage to having them in business occupancies. I suggest you ask the surveyor (if he/she is still with you) to show you where in the LSC it prohibits suites in AHCO. I also suggest you ask your state and local authorities if they have any restrictions that would prohibit suites in AHCO.
Q: In our hospital the nurses found the architectural room numbers too confusing and wanted all patient care rooms to be in numerical order, so about 15 years ago they inserted paper numbers under the placards (for example one room will be C159 with an insert of 110). What are the codes for room numbers and labeling? Where can I find references?
A: The Life Safety Code does not provide much direction on room numbering. But NFPA 99-2012 section 18.104.22.168.1 does say medical gas shutoff valves must be identified (i.e. labeled) with the room that they serve. So, make sure the room numbers on the door match up with the room numbers on the labels for the medical gas shutoff valves.
If you are saying each room has two different numbering systems marked on the door, then that is certainly confusing to an outsider and would likely lead to a finding by a surveyor.
Other than that, I suggest you check with your state or local AHJs to determine if they have any requirements concerning this issue.
UPDATE: After this posting was published, I received the following reply from a reader:
In addition to the Medical Gas references, just a quick friendly comment to supplement the post regarding Patient Room Numbering, at least in the State of Florida: NFPA 99-2012 section 22.214.171.124 and 126.96.36.199 Nurse Call Systems; and FGI Guidelines 2.1-8.3.7 Call Systems, all address the issue of communication of patient staff calls for assistance and information, medical device alarms, and patient safety and security alarms. The code requires annunciation of each call in several locations including the nursing station of the associated nursing unit. If the staff must learn alternative room numbers that are not annunciated over the system, this will most definitely generate a survey deficiency that will need to be corrected immediately. It is best practice for both the design professionals preparing the original plans, the life safety officer and/or consultant surveying the facility, and the AHJ reviewing plans and/or conducting regular surveys to require that the physical wayfinding room/bed location numbers posted agree with the Nurse Call System annunciation.
While I agree with the reader’s comment, it is important to understand that any finding by a surveyor would be based on an interpretation of NFPA 99-2012, section 188.8.131.52, as there is no specific standard that requires the nurse call annunciation to agree with the actual room numbers. Authorities are permitted to make this interpretation based on section 184.108.40.206 of the 2012 Life Safety Code.
Q: How do we classify existing versus new construction? Do we look at the date of adoption of the current Life Safety Code as the cutoff? Anything constructed before that date is considered existing construction? The 2000 LSC required areas of major rehabilitation to be classified as new construction. The 2012 LSC appears to just require those areas be fully sprinklered. On our Life Safety plans all areas of the hospital were constructed prior to the adoption of the 2012 Code. Can the entire hospital now be considered existing and can we remove all notes on the plans referring to new construction?
A: According to the CMS Final Rule on adopting the 2012 Life Safety Code which was released in May, 2016, they identified July 5, 2016 as the threshold date to differentiate between new construction and existing conditions. However, the 2012 Life Safety Code says in section 220.127.116.11 that whenever a feature of life safety is required for compliance, it must be maintained as such for the life of the building. Section 18.104.22.168 continues to say that features of life safety shall not be removed or reduced where such features are required for new construction.
What this means, is you cannot down-grade a feature of life safety that was installed under new construction requirements, to meet existing condition requirements now that it is no longer considered new construction. It is true that something built prior to July 5, 2016 is now considered existing conditions, but you still are not permitted to down-grade the feature to meet existing condition requirements.
Q: I have a client that is building a new Women’s and Children’s Hospital. The women’s component will be licensed to one organization, and the children’s component will be licensed to another. Both organizations intend to operate separately and self-sufficient but would like the new building to look like one comprehensive hospital building. Is a two-hour occupancy separation required between the two, separately licensed hospitals in the same building?
A: As long as the occupancy designation is the same for both units, then no… a 2-hour fire-rated occupancy separation is not required according to the Life Safety Code. But check with your state and local authorities to see if they have more restrictive requirements.
Q: We previously built personal protective equipment (PPE) cabinets that are permanently mounted to the wall. These cabinets protrude in to the hallway 5-inches. The previous NFPA guidelines allowed 6-inch projections so we were within the limits. Now, the new NFPA 2012 decreased that projection allowance to 4-inches. Since these are isolation cabinets, are they allowed to stay in the hallway?
A: Well… you’re not quite correct…
The 2012 LSC actually does permit 6-inch projections into corridors. See section 22.214.171.124 (2). What has changed is the CMS Final Rule to adopt the 2012 Life Safety Code and the 2012 NFPA 99 Health care Facilities Code, where CMS said they will enforce the ADA requirements of a maximum corridor projection of 4-inches.
And this does apply to existing conditions where the removal of barriers to accessibility are readily achievable. So, since CMS adopted the 2012 LSC on July 5, 2016, this 4-inch maximum corridor projection rule does apply to new and existing conditions. And no, the cabinets are not allowed to stay in the corridor just because they are isolation supply cabinets.
You do have a few options:
- Look into converting the area where your PPE cabinets are installed to be a suite-of-rooms, which eliminates the corridors and the 4-inch rule goes away;
- Consider not doing anything and when (or if) you get cited, apply for a waiver based on ‘financial hardship’;
- Remove the cabinets.
Q: The Joint Commission standard for annual door testing states “The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested”. The Joint Commission also references NFPA 105 (smoke doors). Would this include all smoke barrier doors?
A: It appears you have an older copy of the Joint Commission standards. In January, 2019, the standard in which you refer has been changed to specifically identify the need to inspect and test fire door assemblies. Their note to this standard says nonrated doors including smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.
It is the position of CMS and all accreditation organizations that non-rated doors in smoke barriers (barriers that separate smoke compartments) do not have to be inspected on an annual basis.
Here is why: Even though section 126.96.36.199.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested, that conflicts with the occupancy chapter for healthcare. Section 188.8.131.52 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 184.108.40.206 says doors in smoke barriers shall comply with section 8.5.4. Section 220.127.116.11 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 18.104.22.168 (which requires testing).
Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies. Now… you may have an AHJ that believes differently. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but ultimately they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC.
Q: Do generators for healthcare need to be load-bank tested annually if they meet the 30% nameplate load requirement during each monthly test?
A: No. Load bank testing is only required when any monthly load test fails to achieve 30% of the nameplate rating of the generator. Then, an annual load bank test is required of 50% load for 30 minutes and 75% load for 60 minutes. A 3-year 4-hour test is required, and the load is a connected load from the facility and must reach a minimum of 30%. A supplemental load may be used if the connected load cannot reach 30%.
Q: The hospital where I work is leased, and the landlord is not a healthcare architect and pushes back on everything. My need is to have the life safety plan drawings updated to reflect proper boundaries and identification of the smoke compartments, hazardous areas, door assembly ratings, suites with sleeping or non and size, etc, etc.. Is there a standard or code which prescribes “requirements” or at least the expectation for what types of info should be on the LS plan?
A: Yes…. Every accreditation organization has some sort of standard or requirement that sets expectations regarding Life Safety drawings. Ironically, neither NFPA or CMS has any standard that requires Life Safety drawings yet the state agencies surveying on behalf of CMS will expect that you have an accurate set of Life Safety drawings.
Life Safety drawings are considered operational documents (not unlike a management plan or a policy) and I could see where a landlord is not responsible for providing operational documents for you at no charge. I suggest you contract with your own favorite architect to create these LS drawings, because a reluctant landlord will do you a lousy job at best.
Joint Commission’s standard identifies their minimum requirements for Life Safety drawings:
- Identify areas of the building that are sprinklered
- Identify locations of hazardous areas
- Identify locations of all fire-rated barriers
- Identify locations of all smoke-barriers
- Identify the locations of all suites and identify the size of each suite in square footage
- Identify the location of smoke compartments
- Identify the locations of all chutes and shafts
- Identify locations under approved waivers or equivalencies
Q: Is it required to dropped power to your electric driven fire pump while it is running to ensure it starts back up and continues to run on emergency power?
A: If you are referring to the annual fire pump flow test, the answer is yes. Section 22.214.171.124 of NFPA 25-2011 requires a simulated power failure while the pump is operating at peak capacity (150% of nameplate capacity) and confirm that the fire pump continues to operate at peak capacity under EM power. This means a second set of pitot readings are necessary while the pump is operating on EM power at peak capacity. Check with your contractor who conducts this test. Surprisingly, many contractors who perform the annual fire pump test fail to include this procedure.
Q: Our facility is a nursing home. I have been asked a question if a resident can have a clothes iron in their room? I said no and would check on it. What do you think?
A: While there is not a specific code or regulation preventing a nursing home resident to use a clothes iron, it does present a specific hazard since it can get very hot. If you allowed it, a surveyor could likely cite you for an unsafe environment, which does seem logical. But if you allowed the resident to use the clothes iron with supervision by one of your staff, that would seem to be acceptable (at least by me). Whatever you decide to do, you should have a policy and/or risk assessment on it.
Q: In a physician’s clinic that is claimed to be fully protected with sprinklers, the building elevator control room is not sprinklered. Must I install or can I leave it that way?
A: A Business Occupancy building that is fully protected with sprinklers provides you with the ability to meet certain options in the LSC that allows you to take advantage of certain features, such as:
- Delayed egress locks would be permitted
- Less restrictions on egress capacity factors
- Exits permitted to discharge through the interior of the building
- Less restrictions on hazardous areas
- Less restrictions on interior finishes
- Increased travel distances
According to NFPA 13-2010, the standard for sprinkler installation, there are very few exceptions to not installing sprinklers, and allow the building to still be considered fully sprinklered:
- 2-hour fire-rated barriers around an electrical room
- Clean agent suppression system installations
However, the 2012 Life Safety Code does have an exception specific to elevator machine rooms. Section 126.96.36.199 says sprinklers shall not be installed in elevator machine rooms serving occupant evacuation elevators, and such prohibition shall not cause an otherwise fully sprinklered building to be classified as non-sprinklered. This is one situation where the Life Safety Code trumps NFPA 13 on the installation of sprinklers.
The 2012 Life Safety Code Handbook continues to provide insight on this prohibition:
The presence of sprinklers in the elevator machine room would necessitate the installation of a shunt trip for automatically disconnecting the main line power for compliance with ASME A17.1 Safety Code for Elevators and Escalators, as it is unsafe to operate elevators while sprinkler water is being discharged in the elevator machine room. The presence of a shunt trip conflicts with the needs of an occupant evacuation elevator, as it disconnects the power without ensuring that the elevator is first returned to a safe floor so as to prevent trapping occupants.
So, no… you should not install sprinklers in the elevator machine rooms.