O2 Cylinder Storage

Q: Can full oxygen cylinders be stored in a hospital soiled utility room?

A: Yes… however, anything stored in a soiled utility room is considered soiled. That would require staff to clean the O2 cylinder before using it on a patient, and the likely hood of that happening every time is not very good.

Most surveyors will have a problem with full O2 cylinders stored in a soiled utility room because of that issue and would expect the hospital to have a policy or at least a written procedure on the proper cleaning of each cylinder before use.

It is best to not store full O2 cylinders in a soiled utility room. Now, empty O2 cylinders stored in a soiled utility room should not be a problem because they would not be used on patients.

Mechanical Room Exit Signs

Q: Is there a code that states every mechanical room needs an ‘Exit’ sign? I am being pressed to do so and I understand if the exit is obvious you don’t need a sign.

A: No… there is not. But section of the 2012 LSC says access to exits shall be marked by approved signs in all cases where the exit or the way to reach the exit is not readily apparent to the occupants. So, one way this is interpreted, if you’re standing inside the mechanical room and the entrance door to the mechanical room (which also is an exit access) is not readily apparent, then you will need ‘Exit’ signs.

This is actually a very simple test that a surveyor can do while touring your facility… If the surveyor cannot see the entrance door when he/she stands anywhere in the mechanical room, then that is a clear indication the room needs to have the way to reach the exit marked. But if you can always see the entrance door, then one can say the way to reach the exit is readily apparent.

It is recommended that you use the internally illuminated ‘Exit’ signs connected to EM power, rather than trying to get by with externally illuminated signs.

Penetrations in Corridor Walls

Q: Our life safety drawings identify the corridors in our hospital as being smoke partitions. My question is do wall penetrations above the dropped ceiling need to be sealed with a fire caulk like products used in 1 and 2 hour walls?

A: According to the Life Safety Code, a hospital corridor wall is required to be meet two-different standards, based on whether or not the smoke compartment where the corridor is located is fully protected with sprinklers. If protected with sprinklers, then the corridor wall is permitted to be smoke resistant (not-fire-rated) and extend from the floor to the deck, or from the floor to the ceiling if the ceiling also resists the passage of smoke. Be aware, however, that where NFPA recognizes that a suspended grid and tile ceiling does resist the passage of smoke, the IBC does not.

The other corridor wall requirement is where the smoke compartment is not fully protected with sprinklers, then the corridor wall must be 30-minute fire-rated and extend from the floor to the deck above. There is no exception to terminate at the ceiling if the ceiling resists the passage of smoke. NFPA describes a 30-minute fire-rated wall as steel studs with one layer of gypsum board on one side.

Since you state your corridor walls are smoke partitions, then the question is, do they have to extend all the way to the deck or do they qualify to terminate at the ceiling provided the ceiling also resists the passage of smoke? Since these are smoke partitions and not fire-rated barriers, you would be permitted to use non-rated, non-combustible caulk to seal any penetration, in lieu of using fire-rated materials.

Transfilling Oxygen Cylinders

Q: What are the requirements for a small storage room becoming a transfer station for filling oxygen cylinders? What code would there be? What type of ventilation do we need if any? Are there any fire ratings required if any?

A: If you’re referring to transfilling liquid oxygen, then you need to comply with NFPA 99-2012, sections and Specifically, the following is required:

  • A designated area separated from any portion of the facility where patients are housed, examined, or treated by a fire barriers of 1-hour
  • The area is mechanically ventilated, sprinklered and has ceramic or concrete floor
  • The area is posted with signs indicating transfilling is occurring and that smoking in the immediate area is not permitted
  • The individual transfilling the containers has been properly trained
  • The guidelines of CGA pamphlet P-2.6 are met

If you’re referring to transferring gaseous oxygen from one cylinder to another then you must follow CGA pamphlet P-2.5. Transfilling of any gases from one cylinder to another in patient care rooms of health care facilities is prohibited. See sections and of NFPA 99-2012.

Temporary Construction Barriers

Q: Regarding the 2012 Life Safety Code referencing the 2009 edition of NFPA 241 Standard for Safeguarding Construction, Alteration and Demolition Operations which does not allow “tarps” for construction barriers, what is their definition of a tarp? Will using fire resistant sheet poly be allowed or is that now defined as a tarp?

A: The definition of a tarp has yet to be explained. Since the NFPA 241 does not adequately explain it, it will be up to CMS and the accreditation organizations (AOs) to decide if flame retardant plastic sheets are acceptable or not. I suspect some AOs will be lenient and allow the flame retardant plastic, and I suspect some AOs will not, and consider flame retardant plastic sheet to not be acceptable. Until CMS provides a definitive answer, I suspect there will be different interpretations.

Section 8.6.2 of the 2009 edition of NFPA 241 has changed how the temporary construction barriers must be built. Now, a 1-hour fire rated barrier must be constructed to separate a construction area from an occupied area, if the construction area is not equipped with a properly installed active sprinkler system. This means steel studs and 5/8 gypsum board on both sides must be constructed from the floor to the deck above, and include a 3/4 hour fire rated doors assembly that is equipped with a closer and positive latching hardware. And the seams on the gypsum boards will have to be properly taped and mudded with joint compound.

However, if the construction area is protected with a properly installed active sprinkler system, then the temporary construction barrier is permitted to be non-rated. But it quickly says “tarps” are not permitted in the Annex section. That’s where the issue becomes cloudy. It seems without tarps, the only way you can achieve a non-rated construction would be by using steel studs and 1 layer of gypsum board.

The Annex section is not considered part of the enforceable standard, but information is inserted there as a guide to authorities having jurisdiction to help them understand what the technical committee was thinking when the standard was written.

But in conversations with un-named experts who are in a position to know, it appears that the major accreditation organization will not allow flame retardant plastic sheeting for temporary non-rated construction barriers.

I suggest you contact your AO directly and ask them what they will accept, before you are surprised during a survey.

Fully Sprinklered Buildings

Q: Our facility is a four story facility, and is a combination of different structures built in different years. All of the different structures are protected with sprinklers except for our power plant. Our power plant is 24 hours manned and has Fire Alarm System devices installed or equipped. Do we need to ask for a waiver as per the new NFPA 101 2012 edition that is to be implemented this year?

A: Existing healthcare occupancy buildings are not required to be fully protected with sprinklers. There is no requirement with the new 2012 LSC to install sprinklers in existing buildings (unless the building is a high-rise) so there is no need to ask for waivers.

Now, it is very desirable for healthcare occupancy buildings to be fully sprinklered because if they are, it allows you to do many terrific things. Take a look at the following 2012 Life Safety Code references, which describes the many advantages of having a fully sprinklered building:

  • – Delayed egress locks are allowed only if the entire building is protected with sprinklers or smoke detectors
  • – Capacity factors for egress components improve if entire building is sprinklered
  • 7.7.2 – No more than 50% of required exits may discharge through the level of exit discharge if area is sprinklered
  • – A hazardous area may not have to have 1-hour fire rated walls if protected with sprinklers (Note: This does not supersede section 18/
  • – Class C interior finishes are permitted in locations where Class B is permitted, and Class B interior finishes are permitted in locations where Class A is permitted, provided the area is protected with sprinklers. (Note: This does not supersede section 18/
  • – Class II interior floor finish is permitted in locations where Class I is permitted providing the area is protected with sprinklers.
  • 10.3.3 – Upholstered furniture must meet the requirements in accordance with NFPA 260 and NFPA 261, unless the furniture is located in rooms protected by sprinklers.
  • 10.3.4 – Mattresses must meet the requirements in accordance with Part 1632 of the CFR 16, and NFPA 267, unless the mattresses are located in a room that is protected with sprinklers.
  • – Lesser levels of Construction Types are permitted if the entire building is protected with automatic sprinklers.
  • Travel distances between any point in a room and the exit increases by 50 feet if the entire building is protected with automatic sprinklers
  • Hazardous areas are not required to be 1-hour fire rated if the walls are smoke resistant and area is protected with automatic sprinklers
  • – No interior floor finish requirements apply in smoke compartment protected with automatic sprinklers
  • – Areas open to the corridor are afforded exceptions if the smoke compartment is protected with automatic sprinklers
  • – Corridor walls are not required to be ½ hour fire rated provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Corridor doors do not have to be 1 ¾ inch thick, solid-bonded wood core or of construction that resists fire for not less than 20 minutes provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Smoke dampers are not required in fully ducted penetrations of smoke barriers provided both smoke compartments served by the barrier is protected with automatic sprinklers.

By the way, CMS will not consider a waiver request until such time the Life Safety Code deficiency has been cited in a report. So, don’t plan on submitting a waiver request until after you have been cited.

Storage in an Ambulatory HCO Mechanical Room

Q: I’m trying to find out particular rules regarding storage and what is allowed to be done in a penthouse. We have a new-construction Ambulatory Care occupancy. The question is not what we can’t use it for; but what we can use it for.  It is currently fully sprinkled, but not separated from the rest of the ASC with fire resistive construction. It is built and considered “unoccupied” space. So, can I put up a work bench? Can I store filters and other maintenance supplies? It has tons of room and is wide open in parts.  The rest of the building has no space at all designated for facilities maintenance; no workshop, no equipment and tool room, nothing at all.

A: NFPA codes and standards prohibit storage in a mechanical room based on specific issues, such as an unoccupied mechanical room that opens onto an exit enclosure (stairwell), or when there is fuel-fired equipment in the mechanical room. But in a general sense, there is no NFPA code or standard that specifically prohibits storage in a mechanical room as long as the room itself meets the requirements for storage. Also, access to the mechanical equipment in the room must be maintained free and clear since that is the original purpose of the room.

Section 20.3.2 in the 2012 LSC references hazardous rooms. Basically, it says any room used for storage has to meet the requirements of section 8.7 for hazardous rooms. Section 8.7 says the room has to be either protected with sprinklers (which you say it is), or enclose the room with 1-hour fire rated barriers (which you say it is not). It appears to me that you would be compliant with the 2012 Life Safety Code, but I suggest you contact your state and local authorities to determine if they have other codes and regulations that would be more restrictive.

ABHR Dispensers

Q: Could you clarify the placement of alcohol based hand dispensers in corridors and waiting rooms.  I was just looking for clarification.

A: For healthcare occupancies (i.e. hospitals, nursing homes, long-term care, free-standing ERs) follow section of the 2012 Life Safety Code for alcohol based hand-rub (ABHR) dispensers, which basically says:

  • You cannot mount them in corridors less than 6 feet wide
  • Maximum dispenser capacity is 1.2 L for rooms and corridors and 2.0 L for suites
  • Maximum dispenser capacity for aerosol containers is 18 oz.
  • Dispensers must be separated from each other by 48 inches
  • Not more than 10-gallon aggregate total of ABHR solution or 1135 oz. of aerosol solution shall be in use outside of a storage cabinet per smoke compartment, except for the next bullet point
  • One dispenser per room shall not be included in the aggregate quantities mentioned above
  • Storage of quantities greater than 5 gallons in a single smoke compartment must meet the requirements of NFPA 30 (1-hour FRR room, or fire-resistant cabinet)
  • Dispensers must be mounted at least 1 inch away (as measured side-to-side) from ignition sources, and cannot be mounted above ignition sources
  • Dispensers mounted over carpeted floors are permitted only in sprinklered smoke compartments
  • Maximum 95% alcohol by content
  • The dispenser must be designed, constructed and operated in such a way that ensures accidental or malicious activation of the dispensing device is minimized

For ambulatory health care occupancies (ASCs, outpatient physical therapy) you follow section which is essentially the same as For business occupancies (physician’s offices, administration facilities) there is nothing in the occupancy chapter that permits ABHR dispensers in corridors, but other than corridors, you would follow the same as above.

Card-Swipe Reader on Access-Control Locks

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 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.

Two Releasing Devices for Doors

Q: I heard in a webinar that under the 2012 edition of the Life Safety Code, I can you have two releasing devices on doors. Is this true?

A: Yes, it is true, but only in very limited situations is it permitted. A new section ( of the 2012 Life Safety Code allows two releasing operations to be permitted for existing hardware on a door serving an occupant load not exceeding three persons, provided the releasing mechanisms do not require simultaneous operations. This only applies to existing conditions, and does not allow you to install deadbolt locks on doors that only serve three people. Existing means the second releasing device (i.e. deadbolt lock) was on the door prior to July 5, 2016.