A client of mine contacted me last week and wanted to know if they could temporarily store combustibles in a patient room that is currently under renovation. Apparently the suite where the patient room is located is undergoing a facelift, involving wall coverings and floor coverings, and the patients have been relocated.
I don’t know if my answer was what they wanted to hear, but I informed them whenever combustibles are stored in a room greater than 50 square feet, the room must comply with section 188.8.131.52 of the 2000 edition of the LSC. The reason we need to follow chapter 18 instead of chapter 19 is by placing combustibles in storage in a patient room, we are now changing the use of the room, and a change in use requires compliance with chapter 18.
Section 184.108.40.206 requires all new construction to be sprinklered and Table 220.127.116.11 requires rooms that are over 50 square feet but no more than 100 square feet to have a self-closing door. For combustibles stored in a room exceeding 100 square feet the room must be sprinklered (per 18.104.22.168), have 1-hour fire rated barriers, and have a 3/4 hour fire rated self-closing, positive latching door.
What if the patient room is over 100 square feet and is not constructed to 1-hour fire rated standards, do you have to spend thousands of dollars to modify the room for temporary storage? I say no, you don’t. That’s what section 22.214.171.124 on Alternative Life Safety Measures (or Interim Life Safety Measures as some AHJs call them) is for. Conduct a risk assessment of the combustibles temporarily stored in the patient room and compare the results with your policy on ALSM (or ILSM). Implement whatever compensating measures are needed according to your policy, and document the assessment.
Make sure you do what your policy says you will do, and document all actions, and you should be OK.
Today, I was reviewing a Fire Safety Evaluation System (FSES) equivalency request on behalf of AOA/HFAP, and the requester wanted an equivalency for an interior discharging exit stairwell, because it did not discharge into an exit passageway, but discharged into a common corridor.
I sent the requester an email asking if the stairwell qualified for the three (3) conditions on Section 7.7.2 of the 2000 edition of the LSC where no more than 50% of the exit stairwells may discharge on the level of exit discharge and not have to comply with exit passageway requirements.
Their reply said no, it did not, because the stairwell discharge was positioned in such a way that the occupants would not be able to see the exit when they discharged from the stairwell.
Well, that’s not what is required by the standard. Provision #1 of 7.7.2, reads:
“Such discharge shall lead to a free and unobstructed way to the exterior of the building, and such way is readily visible and identifiable from the point of discharge from the exit (stair)”
The provision says “…such way is readily visible…” it does not say the exterior (or exit) of the building is visible., but the ‘way’ to the exit is visible. This actually is a common mistake, and one that I remember making when I still worked in a hospital. It wasn’t until I was preparing an equivalency request myself and I sent it to a good friend of mine for review before I sent it to Joint Commission, and he informed me that I didn’t need to ask for an equivalency because the stairwell discharge (the one in the picture, above) qualified for the provisions under 7.7.2.
So, what did I do in regards to the equivalency request today? I denied it, of course. I informed them that the interpretation that AOA/HFAP has is there is no Life Safety Code deficiency, and therefore, there is no need for an equivalency.
Q: Regarding a recent question on access-control locks, you said the egress side of the door is required to have motion sensors and a wall-mounted “Push to Exit” button. Does it make any sense to have a card-swipe reader on the egress side of an access controlled door? Wouldn’t the motion sensor on the egress side be over-riding the card swipe reader? (Or is that the point you are trying to make?).
A: You are exactly correct… That is the point. A card swipe reader on the egress side of a magnetic-locked door is totally unnecessary, since a motion sensor and a “Push to Exit” button are required in accordance with 126.96.36.199.2 of the 2012 LSC. If you do not have the motion sensor and “Push to Exit” button then you are non-compliant. It does not make any sense to have a card-swipe reader on the egress side of a properly installed access-control lock. The card-swipe reader is indeed, pointless.
Q: Our hospital has an outpatient clinic attached via a hallway and connected to the hospital directly. When I am in the out-patient clinic you cannot hear the fire alarms going off in the hospital. Do the systems need to communicate? They are currently on 2 different systems.
A: No… the two systems are not required to communicate with each other unless the expectation is for staff at one location is to respond to fire alarms in the other location. However, it may be practical for the alarm to communicate in each other’s building, in some fashion. There may be key individuals (i.e. engineering staff, management staff, and executives) who may be in one location and if the alarm is activated in the other location, they should know about it. But this can also be accomplished using two-way radios or pagers.