Q: Are hospital gift shops required to be treated as hazardous areas? We had a survey recently and the inspector said the entrance door to our gift shop needed to have positive latching hardware.
A: This is one of those “it depends” answers. Section 184.108.40.206 of the 2000 Life Safety Code clearly states that gift shops are required to be treated as hazardous areas if they contain combustible items in quantities considered hazardous. Most hospital gift shops do contain items that are considered combustible, such as greeting cards, stuffed animals, clothing, and other items. The question is: Are they in sufficient quantities to be considered hazardous? This is a question that only an Authority Having Jurisdiction (AHJ) can answer. If an accreditation surveyor were to consider the combustible items in sufficient quantities to be a hazard, then the gift shop must be treated as a hazardous area. However, please be aware that there are more than one AHJ, and in most cases, an opinion of one AHJ does not have much bearing on the opinion of another AHJ. Therefore, I suggest that you be very conservative on this issue, and if your gift shop has any combustible items, then treat it as a hazardous room and all corridor doors must be positive latching. This would require either automatic sprinkler protection with smoke-resistant self-closing positive latching doors, or 1-hour fire rated walls with ¾-hour fire rated self-closing positive latching doors, or both if new. When a gift shop does not have combustible items on display or in storage, and does not exceed 500 square feet, and is fully protected by sprinklers, then it does not have to be treated as a hazardous area, meaning it could be open to the corridor.
Q: Another hospital in our area recently had a survey and they were cited for communication wires that were strapped to the sprinkler pipe above the ceiling. I have not heard of this as being a problem. We have the same situation in our hospital. Do we have to remove these cables from the sprinkler piping and hangers?
A: According to 6-1.1.5 of NFPA 13 Standard for the Installation of Sprinkler Systems (1999 edition) sprinkler piping and hangers cannot be used to support non-sprinkler system components. The reason for this requirement is the hangers and supports are only designed to sustain the weight of the water-filled pipe, plus a safety factor. No allowance has been made for any additional non-sprinkler system components. While one may believe that communication wire or cable does not add a significant weight load, at what point does the addition of the weight of these non-sprinkler system components exceed the capacity of the hangers? I too have read where some Authorities Having Jurisdiction (AHJ) have cited hospitals for wires and cables attached to sprinkler hangers. Since the Life Safety Code requires you to comply with NFPA 13, then this seems to be a legitimate finding. I suggest you examine all of your sprinkler piping and remove all non-sprinkler system components.
Q: We have in our fire policy that someone is to be posted at the elevator during a fire alarm to make sure no one uses the elevator. I believe this is only necessary if the elevator is located in the smoke compartment that is identified for the origin of the fire. Even then, the smoke detector outside the elevator should keep the doors from opening on that floor. What’s your take on this?
A. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of the responding fire department are required to comply with NFPA 101-2000 Life Safety Code (LSC) section 220.127.116.11. This in turn requires the elevator to comply with Elevator Recall as described in ANSI A17.3 Safety Code for Existing Elevators and Escalators. I say all that to explain that your elevators should comply with recall, which will seize control of the elevator car and deliver it to a pre-designated floor whenever the lobby smoke detector or machine room detector is activated on any floor for that elevator shaft. That elevator car will not be available for use by your staff until it is reset. If your elevators have this recall properly installed, then I agree with your statement that the elevator shaft doors should not open on the floor where there is a presence of smoke.
Annex section A.9.4.1 of the LSC explains that elevators can be used as an accessible means of egress; however they just cannot serve as the required means of egress. Therefore, it is permissible by the LSC to allow use of elevators that are not directly involved in the fire situation. Quite honestly, if you have to evacuate bed-ridden patients vertically from a floor that is involved with a fire, you will want to utilize the elevators that are not involved with the fire rather than the stairs. A person who is designated to go to each patient floor elevator lobby and attempt to hold the elevator for the possibility of evacuation is certainly a viable plan. But, it may not be necessary to do so, as the elevator could be called, and some elevators even have “Emergency” call buttons to over-ride other calls.
It certainly is your call whether or not to continue with this policy to have someone posted at the elevator during an alarm. If the elevator is involved with the fire on that or any other floor, then it will be out-of-service (Phase I Recall). If the elevator is not involved with the fire, then it is perfectly fine to use the elevator. If it were me: I would vote to discontinue this policy, as you will be evaluated as to how well you comply with your own policies. I suggest you take it to your Safety Committee and let them discuss and vote on it.
Q: Do soiled utility room doors have to be locked all the time? I was informed by our VP Quality Assurance that all of the soiled utility room doors must be locked, but I do not see any requirement for this in the Life Safety Code.
A. Soiled utility rooms are defined as hazardous rooms, according to section 18.104.22.168. There are many requirements for hazardous rooms, such as 1-hour fire rated walls (or sprinkler protection) and a door that has a closure on it. But there is no requirement in the LSC that says you must lock any soiled utility room door, or any door to a hazardous area. However, that is not the end of the discussion for this issue. Your AHJ may very well expect you to lock any room that is considered hazardous, unless you have conducted an assessment for risks to safety. An example of a soiled utility room that should be locked is when it contains hazardous items accessible to unauthorized individuals. This could occur near a pediatric department, or in a location that is not constantly supervised by staff. Each hazardous room, including soiled utility rooms, should be assessed on a case by case basis to determine whether or not they should be locked. Remember: All risk assessments should be reviewed and approved by your safety committee.
Q: Is there a specific fire code requirement for an equipment room containing electronic video conference equipment? I have been told there are specific requirements for electrical and mechanical rooms, but I do not find anything specific for video equipment.
A: Electrical rooms have specific requirements that are found in NFPA 70-1999 National Electric Code such as access to the rooms must be locked or have other approved means, such as constant supervision (110.31) and there are minimum clearance standards around electrical equipment as described in table 110.34(A), and transformer rooms are not allowed to have any combustible items stored in them (450.23[(A]).
Mechanical rooms that do not contain any fuel-fired heating equipment by definition are not considered to be hazardous rooms (see NFPA 101-2000 Life Safety Code section 22.214.171.124) and therefore are not required to be sprinklered or have fire rated walls and doors. Many Authorities Having Jurisdiction (AHJ) do not permit general storage (including video equipment) in mechanical rooms, since the room is intended to support the purpose of the room. However, many AHJ will allow you to store one change of air filters in the mechanical rooms without the room being designated as a hazardous room.
Your question asks are there specific fire codes for an equipment room where items are stored for a video conference center. The answer is no, there are no specific codes for that room, but there is the general requirement for hazardous rooms (section 126.96.36.199 of the LSC). If the room is greater than 50 square feet and contains combustible items (in quantities deemed hazardous by the AHJ), then it has to be protected with sprinklers or 1-hour construction.
However, if the room was not originally a storage room (meaning if it was formerly an office, patient room, or used for any other purpose other than storage) and you are now converting it to a storage room, and if it is greater than 100 square feet, then you must meet new construction requirements (section 188.8.131.52) and install both sprinklers and 1-hour fire rated walls, and ¾ hour fire rated self-closing and positive latching door.
Q: Are smoke detectors required to be installed in the corridors of hospitals? I attended a seminar recently and the instructor said we did not need them in the corridors. We have them in corridors and patient sleeping rooms in our hospital and I thought the Code required them.
A. Generally speaking, the Life Safety Code (LSC) does not require smoke detectors to be installed in corridors or patient sleeping rooms of hospitals. (You need to be sure what your state and local codes require for smoke detection, as those building codes may have a different requirement than the LSC.) Actually, for hospitals, smoke detectors are only required in strategic locations to satisfy specific needs of fire safety features, and to compensate for other deficiencies where an equivalency is being sought.
The LSC does require smoke detectors within 5 feet of a fire rated or smoke compartment door that is held open by a mechanical device (184.108.40.206.6), in elevator lobbies and machine rooms where Phase I elevator recall has been installed (220.127.116.11), and in areas permitted to be open to the corridor that do not have direct supervision (18.104.22.168). In certain applications of 22.214.171.124, the corridor may need smoke detectors installed. The NFPA 72 National Fire Alarm Code does require a smoke detector above the fire alarm control panel in order to protect the panel in the event of a fire.
Equivalencies, such as the Traditional Equivalencies and the NFPA 101A Guide on Alternative Approaches to Life Safety Fire Safety Evaluation System (FSES), frequently rely upon smoke detectors to be installed throughout a smoke compartment to compensate for a deficiency to a life safety feature. When an equivalency is accepted by an Authority Having Jurisdiction (AHJ), the compensating changes (such as the installation of smoke detectors) must remain until the equivalency is no longer valid.
Limited care facilities (which are not hospitals) do have a requirement for smoke detectors in corridors (126.96.36.199.1) and new nursing homes are required to have smoke detectors installed in corridors (188.8.131.52.2) and patient sleeping rooms with certain combustible items, but these requirements do not apply to hospitals. The logic behind this LSC decision is a fire will be discovered quickly in hospitals where the staffing level is much higher. Remember: The requirements of the LSC are minimum requirements, and it is perfectly acceptable to exceed these minimum requirements.
Q. Do hazardous areas in business occupancies require a self-closing door if the room is protected with automatic sprinklers? We had a surveyor cite us for not having a closure on the door to a storage room that is considered to be hazardous.
A. Existing business occupancies are required to follow chapter 39 of the Life Safety Code which says hazardous areas, such as storage rooms must follow section 8.4. Section 184.108.40.206 offers three options to protect hazardous areas, which are:
- Create 1-hour barrier around the room (which would include a fire rated door, which would have to positively latch and have a closure), or
- Protect the area with sprinklers, or
- Do both if hazard is severe.
You are only required to comply with one of the above, not all. If your storage room is protected with automatic sprinklers, as you imply, then there is no requirement for a barrier or a door. If there is no requirement for a door, then there is no requirement for a closure on the door.
However, section 220.127.116.11 requires new construction to provide smoke partitions when the hazardous area is protected by automatic sprinklers. Smoke partitions are required to have self-closing doors (8.2.4). If your storage room qualifies under new occupancy (or new construction in an existing occupancy) then the surveyor is correct: You need a closure on that door.
Q. We have delayed egress locks in our hospital and during a recent inspection a fire marshal said we had to test the locks on an annual basis. Is this true? If so, what are we supposed to be testing?
A. Although the Life Safety Code occupancy chapters for healthcare (chapters 18 and 19) permits delayed egress locks in hospitals, section 18.104.22.168.1 explains how they need to be installed. One of the aspects of operation for the delayed egress locks is the requirement to be interfaced with the building fire alarm system or the automatic sprinkler system. The doors are required to unlock upon water-flow, or activation of a heat detector or no more than two smoke detectors. (Please note: This does not necessarily include the activation of a manual pull station.) While the LSC does not reference a specific requirement for testing the delayed egress locks, NFPA 72-1999 National Fire Alarm Code does have a written requirement for testing interface equipment. Table 7-2.2, paragraph 19 says interface equipment connections shall be tested by operating or simulating the equipment being supervised. Signals that are required to be transmitted must be verified at the control panel. Delayed egress locks are not necessarily supervised, but they do have an interface device (control relay) that unlocks the doors on a signal from the fire alarm control panel. NFPA 72 recommends the testing frequency of interface equipment to be conducted annually.
One could draw the conclusion that your delayed egress locks should be tested annually, to ensure that the power controlling the locks actually drops out upon water-flow, or activation of a heat detector, or no more than two smoke detectors.
Q. Should a free standing medical office (business occupancy) be required to evacuate everyone when an alarm is pulled? In this situation the building is a single story and has a sprinkler system.
A. Yes, generally speaking, occupants in free standing medical offices should evacuate the building whenever the fire alarm is activated, unless there are extenuating circumstances, such as testing of the fire alarm system has been announced. There are multiple references that support this requirement.
One of the goals of the NFPA 101-2000 Life Safety Code (LSC) is to provide for a reasonably safe movement of people in the event of an emergency, as identified in section 4.1.2. That supports the concept of keeping the occupants safe from fire and maintaining a safe egress from the building. Since the building you described is a business occupancy, chapter 39 of the LSC applies. Section 39.7.1 discusses the requirements for fire drills which applies to buildings with occupants of 500 or more, or 100 occupants above or below the level of ext discharge. Even if your building may not meet this occupant load requirement, you may have other fire drill requirements from another Authority Having Jurisdiction (AHJ), such as Joint Commission or your local fire marshal.
Section 39.7.1 refers to section 4.7 which discusses in detail about evacuation and relocation. The whole purpose of conducting fire drills is to prepare and train your staff for the proper response when an actual fire occurs. Therefore, the occupants in your free-standing medical office will need to evacuate from the building whenever the fire alarm activates under non-testing conditions.
It is better to get the people out safely and then determine what caused the alarm. It should be noted here, that you are not required to evacuate patients during a fire drill. During a drill, staff needs to demonstrate that they know and understand the procedures and pathway to evacuate the building and where the relocation rallying point is at once they get outdoors. They can use simulated patients or other staff members playing the role of patients to demonstrate this knowledge during drills.
This concept of evacuating the building in the event of fire does not apply to all occupancies, however. Most notably: healthcare occupancies (hospitals, nursing homes) and detention or correctional occupancies (prisons) have language that requires staff to be trained in the relocation of occupants to areas of refuge or smoke compartments.
Q: The Joint Commission’s standard on Interim Life Safety Measures (ILSM) requires the hospital to implement ILSM for deficiencies to the Life Safety Code (LSC) when the deficiency cannot be immediately corrected. Please define the time-frame that they mean with the word “immediately”. Can the implementation of an ILSM wait until the Safety Committee approves it?
A: The implementation of an ILSM cannot wait for a committee’s review and approval. The intent of the word “immediate” suggests that the ILSM must be implemented as soon as it is determined the deficiency cannot be resolved the moment it is discovered. This means to me that you need to implement an ILSM the same day a deficiency is discovered.
Each hospital is required to have a written Interim Life Safety Measure policy that applies to situations when LSC deficiencies cannot be immediately resolved due to equipment failure, maintenance, or construction. Your policy should proactively identify the process in which you meet the 11 different prescriptive requirements found in the standard. By following your own policy, your staff should be able to determine which measure to implement based on the deficiency that was discovered. This implementation phase may be approved by someone in authority at your facility, but it should not be held up for approval by a committee. However, it is encouraged that all ILSMs be presented to your Safety Committee as evidence of your organization managing the life safety deficiency. This will foster general discussion which should be reflected in your committee’s minutes.
Be very conservative with the implementation of ILSMs. Failure to implement appropriate ILSMs can lead to an adverse decision at your next survey.
Q: We have a mechanical room in our hospital whose entrance door opens into the top of an exit stairwell. I was informed by a consultant that this arrangement is not permitted and we must create a vestibule so the mechanical room does not open directly onto the stairwell. Is this true? If so, is this our only option?
A: The requirement for the arrangement that you described is found in the Exits section of chapter 7 of the 2000 Life Safety Code. This chapter applies to both new occupancies and existing occupancies. Section 22.214.171.124.1(d) requires openings to exit enclosures (stairwells) to be limited to normally occupied spaces. A mechanical room is not considered by many authorities having jurisdiction (AHJ) to be normally occupied. Therefore, by this definition alone, your consultant is correct and your arrangement does not appear to meet the requirements of the Code.
However, you do have other options to building the vestibule. Later editions of the Life Safety Code address this exact issue and actually permit an opening into an exit enclosure from an unoccupied mechanical room space, provided it meets the following criteria:
- The space does not contain any fuel-fired equipment
- The space does not contain storage of combustible equipment
- The building is protected throughout by an approved automatic sprinkler system
If your mechanical space meets these conditions, it is my recommendation your organization submit an equivalency to the AHJ that has regulatory control over your facility. You should cite the change in chapter 7 of the 2006 edition of the Life Safety Code as your facility meeting an equivalent level of safety. This is an acceptable alternative to meeting this requirement, rather than constructing a vestibule which could be costly.
Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets controlled by card-swipe badge readers and with wall-mounted push buttons. They are on emergency power and eight-hour battery back-up. They are also approved by our local and state fire marshals. Is the inspector correct, or do I have a case for an appeal?
A: The concept of a Suite-Of-Rooms requires the barriers of the suite to be protected in the same manner as any other room bordering on an exit access corridor. Therefore, entrance doors to the suite must meet the requirements of corridor doors. In your question, you did not specify if your organization is considered a new healthcare occupancy or an existing healthcare occupancy. This is an important issue, as there are different requirements for each. If your facility’s construction documents were approved by the local authorities after March 1, 2003, then it is considered a new healthcare occupancy.
In new healthcare occupancy, section 126.96.36.199.2 of the 2000 edition of the Life Safety Code specifically requires positive latching hardware for corridor doors. The definition of positive latching is a spring-loaded throw on the edge of the door to engage in the strike plate of the door frame. Magnetic locks do not qualify as positive latching hardware. Therefore, you may not use magnetic locks in new healthcare occupancies for suites (corridor doors).
However, for existing healthcare occupancies, section 188.8.131.52.2 of the same Code specifically allows a device capable of keeping the door fully closed with a minimum force of 5 foot-lbs. Some authorities having jurisdiction (AHJ) approve of magnetic locks for this purpose as long as power to the locks is NOT interrupted during a fire alarm signal. Doors in the path of egress are not permitted to be locked except where the clinical need of the patient requires it. Not all AHJs agree on what types of patients qualify for this exception. When locks are permitted on egress doors, they must meet the requirements found in 184.108.40.206.4. The entrance door to a suite-of-rooms is permitted to be locked, as the path of egress is not allowed into and through a suite.
Magnetic locks in lieu of positive latching on corridor doors is not recommended as there are many complications and challenges in compliance, and not all of the AHJs agree on this application. It appears that a successful appeal on this issue would be difficult.
Q: Why are corridors within the business offices of our hospital permitted to be 44” rather than the 8’ that the rest of the hospital has to maintain? Our hospital is considered 100% existing healthcare occupancy, with no mixed or separated occupancies.
A: Section 220.127.116.11 of NFPA 101-2000 Life Safety Code refers to exit access corridor width in existing healthcare occupancies. Existing corridors wider than 4 ft. can’t be reduced to less than 8 ft. under 4.6.7. However, exception number 1 to 18.104.22.168 states that aisles, corridors and ramps in adjunct areas not intended for the housing, treatment or use of inpatients is permitted to be 44 inches in width. The definition of adjunct is something that is associated to another in a subordinate way. Therefore, aisles and corridors in a business office area which is not intended for the housing, treatment or use by inpatients is adjunct to the main exit access corridors found in the rest of the hospital, and permitted to be 44 inches wide.
Also, if the business office qualifies as a suite-of-rooms, exception number 2 of 22.214.171.124 allows an exemption to the corridor width requirement for suites-of-rooms that qualify under 19.2.5. Therefore, there are no requirements for corridor widths inside a suite, because by definition, there are no corridors.
For those hospitals that are mixed occupancies, you should follow that appropriate chapter in the Life Safety Code for corridor widths. The only exception to this is if the exit access corridor in the other occupancy also serves as an exit from a healthcare occupancy. Then you would need to meet the requirements of corridor width from the most restrictive chapter, which is usually the healthcare occupancy chapter.
Q: In the February issue of Healthcare Life Safety Compliance, I found your article on Interior Finish Requirements to be helpful, but it did raise a question for me. In most areas where carpet is installed, a 6″ banded carpet cove base is used in lieu of a rubber top set. Is this 6″ banded carpet base required to have a Class I or a Class A or B rating? The product is used in an existing healthcare occupancy, in sprinklered and non-sprinklered areas. Thank you.
A: The answer is Class A. Cove base by definition is applied to a vertical surface and is considered part of the wall. NFPA 101-2000 Life Safety Code, section 19.3.3 (for existing healthcare occupancies) discusses the many options for interior wall and ceiling finish, and states interior finishes must be in accordance with section 10.2. Normal interior finish on walls and ceilings are permitted to be Class A or Class B, and in some cases Class C. However, carpet is considered a textile, and the Code has specific requirements for textile wall coverings found in section 10.2.4.
The use of textiles as wall coverings is limited to Class A provided they are used in areas protected by automatic sprinklers. It is not permitted to be used in areas that are not protected with automatic sprinklers. Newly installed textiles as wall coverings must meet the requirements of NFPA 265-1998 Standard Methods of Fire Tests for Evaluating Room Fire Growth Contribution of Textile Wall Coverings. Please check with the manufacturer of the carpet for documentation of compliance with this standard.
126.96.36.199 allows existing wall and ceiling finishes to be Class A and Class B, and in rooms with sprinklers, Class C. However, this is only limited to those materials identified in 10.2.3 which does not include textile finishes. Therefore, you are limited to Class A textiles in areas protected by automatic sprinklers. Your question indicates that this product is used in non-sprinklered areas of the facility. It appears that you will have to remove the textile cove base in those areas.
Q: We currently have a Building Maintenance Program (BMP) that surveyors said was a good program during recent surveys. However, I’ve learned that the Joint Commission no longer offers scoring advantages for a BMP, and since this program requires quite a bit of time and resources, my VP wants us to discontinue it. Are there any advantages to continuing a BMP even though the surveyors no longer will offer scoring breaks?
A: The Overview of the Life Safety Chapter to the Joint Commission 2009 Hospital Accreditation Standards manual explains the changes to the BMP. You are correct when you say they no longer offer scoring advantages for a successful BMP. However, that is not a good reason to discontinue a BMP. There are many advantages with a BMP that should not be overlooked:· A successful BMP routinely conducts inspections of critical life safety features of the facility. This is a large part of a Life Safety Assessment, which you are still required to do. · Deficiencies found during a BMP should be immediately resolved, or if they are unable to be resolved immediately, then they can be managed through the Statement of Conditions Plan for Improvement (PFI) list. This allows management of a deficiency that may not otherwise be discovered until a survey.· A BMP provides education and staff knowledge of the building’s life safety features to those individuals who perform the inspections. This translates into pride and ownership by those individuals and will pay off in years to come.· A successful BMP provides confidence for the facility manager (and the VP) that the building is in compliance with the Life Safety Code, and is ready for an inspection. My advice: If you currently have a BMP, continue it. If you do not currently have a BMP, start one.