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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 …
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 …
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 …
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 …
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, …
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 …
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 …
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, …
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 …
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, …
Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are …
Q: We have a long-term care facility and want to know if we can place soiled linen containers in dining rooms and activity rooms? A: From a Life Safety Code …
Q: Do entrance doors to x-ray rooms and CT scanner rooms have to be controlled by door closers? A: According to the Life Safety Code, they only need closers if …
Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape …
Q: In a business occupancy and an ambulatory occupancy do we need to test our generator on load each month or can we do a load bank test once per …
Q: There is an existing clinic which is classified as business occupancy that leases space within a rehabilitation and nursing center. Does this need to be separated by a 2 …
Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party …
Q: Our hospital bulk stores alcohol based hand-rub (ABHR) sanitizer containers of 1000 ML (33.8 fl. oz.) per container & 750 ML (25 fl. oz.) per container in its housekeeping …
Q: In follow up to your articles on locks on doors, we are a mental health facility and have mag-locks operated by swipe cards / fobs. The same doors also …
Q: I have several hospitals that have been cited by surveyors for having carpet in the stairwells. Can you tell me if there is any code requirement that states that …
Q: We have a water-flow switch on the line that rises through a nursing wing stairwell and feeds the hose cabinets. There are no longer any hoses in the cabinets …
Q: Can I install security cameras in stairwells A: You can…. But be prepared to remove them. Many Accreditation Organizations (AOs) and most states who survey on behalf of CMS …
Q: What if anything can be stored in a room called trash chute collection room? We have housekeeping wanting to store boxes of new waste receptacles in there. I think …
Q: We are planning to install double egress doors within the corridor for the purpose of separating the clean OR area from the dirty side. The doors and frame that …
Q: I am being told by a building engineer that low voltage cable cannot be attached (i.e. wire-tied) to existing conduits in the hospital. In ten-plus years in this business …
Q: I have been told several different ways that our facility didn't have an eye wash station in our janitor’s closet. So, I was told to purchase the single-use portable …
Q: I am a consultant and I have a hospital that was cited for co-mingling full and not-full ‘E’ size oxygen cylinders on a rack located on the loading dock …
Q: We have a potential elopement risk at the nursing home where I work. A patient gets into the stairwell and down to the first floor and exits the building …
Q: We are looking to construct a surgery center which will be classified as Healthcare Occupancy on the third floor of an existing five story building which is classified as …
Q: Is there a specific time-limit required by the accreditation organizations for decontamination purposes, from activation of a drill to being able to put victims through a decontamination tent? A: …
Q: Is there a Life Safety Code requirement for cabinet doors to be locked underneath sinks in patient rooms, in a hospital? A: No… There is no Life Safety Code …
Q: I currently serve as plant operations director at a nursing home in east Tennessee. State surveys questioned the locking arrangement on bathroom doors used both by the public and …
Q: I recently heard that a hospital was cited for leaving a construction cart unattended in the hall and the surveyor inventoried the entire cart and cited the hospital for …
Q: Our hospital has round door knobs to latch cross corridor smoke doors. I am thinking this is not okay. Does the Life Safety Code address this? A: Other than …
Q: Are doors in fire rated barriers also required to be listed and installed as a smoke barrier? A: No… Fire rated barriers are not necessarily smoke barriers. They are …
Q: I have a question concerning an ambulatory surgery center that is now converted over to a business office only. We are not doing any patient care in this facility …
Q: We are being told by our local AHJ that a stairwell in a 2 story building has to be 2-hour fire resistance rated so that it meets the requirements …
Q: If a building changes ownership, do waivers stay active with their 1-year window or do the new owners have to resubmit if the building is cited the same deficiency? …
Q: Is it okay to store latex paint in a mechanical/air handler room? The mechanical room is located in the hospital and is in a 2 hour fire rated wall …
Q: Our Respiratory Therapist has brought this question to me and I wanted your input. We have the new ‘E’ size oxygen cylinders that are called Oxytote. They are the …
Q: Other than the annual fire door inspection that is required in the 2012 Life Safety Code, are there other inspections required? Fire doors that are included are also single …
Q: Do hospitals and nursing homes need to have a Laundry Policy? If so, what should the policy cover and what specific information should the policy contain? A: From a …
Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any …
Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments …
Q: Our hospital has several "out buildings" or offsite Doctor's offices. Are we required to do fire drills at these offices? Three of our buildings have fire alarm systems that …
Q: Is it legal for a deadbolt lock to have a thumb turn on the inside where the user needs to "push and turn" to open rather than just turn …
Q: We have an isolation room next to a nurse station in the Emergency room. The corridor door to the Anteroom has a door closer on it. My question: does …
A 'Conversation' Regarding Environmental Services Closets Q #1: Are housekeeping closets considered clean or dirty rooms and what type of supplies can you store in them? EVS is being advised by …
Q: We have a surveyor that says if we have portable storage racks against the perimeter walls and have items stored closer than 18 inches of the ceiling but the …
Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and beds and other equipment (usually broken chairs) are …
Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the …
Q: Are gas-fired ventless fire places permitted in nursing homes? A: I would say they are not permitted, but it has a lot to do whether or not the gas …
Q: There is so much discussion on the proper use of power strips that it can cause confusion amongst even the seasoned facility managers. There is absolutely no guarantee that …
Q: Where in the ambulatory health care occupancy chapter of the Life Safety Code does it permit to have a means of egress from an ASC or a suite within …
Q: A hospital is building a small addition that will serve as a corridor to a mobile OR unit. ICC construction type of addition is I-B. The mobile OR will …
Q: Can testing and inspections of features of life safety be completed in-house or does a third party need to complete them? I would like to know which areas need …
Q: What are the requirement for operating room fire drills per Joint Commission, CMS, and AORN? Are operating room fire drills required to evacuate patients? A: I cannot speak to …
Q: Are there any problems with maintaining an emergency exit for a hospital OR area that travels through an adjacent construction project? Also, can these doors be taped or sealed …
Q: With regards to the 2012 edition of the Life Safety Code and the requirement to perform annual inspections of smoke/fire doors, would it be safe to assume that annual …
Q: Does section 19.3.2.1 of the 2012 Life Safety Code allow hazardous rooms to not be constructed with one-hour fire rated barriers if it is fully fire sprinklered? If healthcare …
Q: What is the storage height requirement in buildings that are not sprinkled? In other words, how high can we stack items on shelves in storage areas in a non-sprinkled …
Q: Are there any storage requirements for full small calibration gas cylinders? The tanks are secure in that they are in holders; however, they are stored under a shelf in …
Q: Is there a minimum height requirement for a fully sprinklered corridor? A: Yes… you will find the minimum headroom height requirement in section 7.1.5.1 of the 2012 LSC. Means …
Q: I'd like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter 7.2.1.15 States "Where required by Chapters 11 through 43, the following door …
Q: Is there a fire rating requirement for a temporary construction barrier that will separate a construction area from a patient care area which will be an occupied space throughout …
Q: I understand that with the adoption of the new 2012 Life Safety Code there is a change in corridor projections from 6 inches to 4 inches. Would this new …
Q: Is it allowed to use door wedges to keep the exam doors locked? If an intruder enters our hospital, there was some talk about using the door wedges to …
Q: Do doctor’s sleep rooms have to be separated from other areas on a patient floor by a 2 or 1 hour fire-rated barrier? A: No… There is no requirement …
Q: There’s a lot of confusion surrounding this topic; primarily when and where elevator lobbies are required. The consensus of the architects and fire protection engineers I’ve talked to is …
Q: We have a suite inside of a smoke compartment. We are trying to find out if the dividing wall needs to be the same as the 1-hour smoke barrier …
Q: Electric fire pumps needed to be run once a week. Then that was changed to once a month. Now the new NFPA 25 has the pump being run once …
Q: Our hospital is wondering if it is a requirement to have fire extinguishers in our linen/trash chute room? If so where can I find the code reference? A: No… …
Q: During a recent webinar, the presenter said waivers and equivalencies are only valid until the next triennial survey. Does that really mean if CMS approved a waiver or an …
Q: Are you aware of any regulation that would disallow the use of Ozone machines in hospitals? Are ozone machines allowed in hospitals? We had thought about using ozone machines …
Q: With the elimination of the CMS Waivers, I was trying to clarify what now applies for mechanical room combustibles storage (i.e. mechanical areas with only stairway and elevator access …
Q: What (if any) is the regulation on the governance of holiday lights in a healthcare occupancy? A: Section 19.7.5.6 of the 2012 LSC only address combustible decorations, and does …
Q: Can you tell me where I could find the code reference for how often batteries serving fire alarm panels (booster panels, control panels, etc.) need to be replaced based …
Q: Are smoke barrier doors and frames required to have a fire rating label? A: No. This seems to be a difficult issue for many people (including surveyors) to grasp …
Q: Recently we had an actual fire that set off our fire alarm. Our operators did not silence the audible horns, which are very loud, before announcing the code and …
Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 7.2.1.15.2 of the 2012 Life Safety Code says smoke door assemblies have to be …
Q: I am struggling with the Life Safety Code and need some clarification. I have an offsite clinic that is classified as a business occupancy with a basement measuring approximately …
Q: What is the Life Safety Code ruling on cameras and speakers in stairwells? Joint Commission was in and cited us on having cameras in the stairwells. We were told …
Q: Our operating rooms were constructed with deadbolt locks on each surgical room. I'm told they did this to keep someone from entering the room during a case. Since this …
Q: I have a question that is still a little fuzzy regarding fire drills. My hospital is partners with a separate clinic. Several of the clinics throughout the community have …
Q: Somewhere I read that at least 50% of fire drills had to be unannounced. I don't find that requirement in NFPA Life Safety Code so it may have been …
Q: I have a behavioral health unit where the lab technicians have placed a chair in the corridor to draw blood samples from the patients. This chair is left in …
Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient …
Q: We have an assisted living and basic care units at our facility. We have 48 total units: 24 on the east side and 24 on the west side. On …
Q: Is it required that all soiled utility rooms have a dedicated sink for handwashing only? A: The NFPA Life Safety Code and related standards do not address this issue, …
Q: I reside in California. Do I need a special license or certificate to perform monthly and quarterly sprinkler systems tests and/or inspections? Primarily, I am interested in main drain …
Q: How many spare sprinkler heads are we required to keep on hand in our hospital? Some people have told us we need 6 of each kind of head we …
Q: As always I enjoy reading your articles and appreciate your opinions. My question this time focuses on special relocatable power taps and is centered around the AIV PowerMate special …
Q: In an OB (obstetrics) supply room, can beverages such as apple juice, water or an ice machine be stored in the room with central supply items? A: The Life …
Q: While I realize that the UL label is accepted by most all AHJs, what about the ETL label from Intertek? Recently I had a fan purchased by a member …
Q: Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections? A: Yes they do …
Q: If a fire door is in a wall that is not a fire-rated wall, will the wall need to be brought to be a fire-rated wall? A: No… not …
Q: During our mock inspection this week at our hospital, they are asking for temp and humidity checks in the surgery hallways. We do monitor the surgery rooms and center …
Q: For business occupancies, does the requirement that alcohol based hand sanitizers cannot be installed above a carpeted floor apply? The business occupancy does not have an automatic fire suppression …
Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection? A: NFPA 80-2010, section 5.2.3.1 says fire doors must be tested by …
Q: Our organization is accredited by Joint Commission. I know for inspection purposes we need to have the current year plus that past three years of documentation for LS and …
Q: Does a diesel generator that is located in a business occupancy require the same testing frequencies as the one at our hospital requires? A: It depends if the generator …
Q: During our last survey the life safety code specialist discovered that 2 of our stairwells were deficient as far as the fire-rating. The contractor did a lousy job as …
Q: What code states that quarterly communication between our fire panel and our local fire department must be completed? A: What used to be called the off-site monitoring transmission equipment …
Q: What is the maximum you can have between the bottom of door and the thresholds for a fire-rated door assembly? I have some stairwell doors with 1 inch to …
Q: I am looking for clarification on the storage of alcohol based hand rub (ABHR) solution. I know the standard indicates that no more than 10 gallons of ABHR can …
Q: I work in a psychiatric hospital. One of the therapies used here involves our clients doing their own personal laundry, so we have multiple laundry rooms off the units …
Q: Do the accreditation organizations require a fire extinguisher inside the MRI room, or can it be located in the MRI control room? A: The accreditation organizations would follow what …
Q: It has been our practice to not allow door hold open wedges on any door within the hospital. As far as code requirements go is it rated doors only, …
Q: Is there a specific code reference in regards to storage of boxes on the floor? I am trying to locate any specific code language for preventing the use of …
Q: Our fire plan says if there were ever a fire in our hospital, we would evacuate our patients horizontally to the other side of the smoke barrier. It then …
Q: I have a procedure room in our Cath Lab that Administration wants to convert to a storage room. The building is fully sprinkled and as I look at NFPA …
Q: I have a nursing home that is over 20 years old that has carpet on the corridor walls below the handrails. I am been told that this carpet must …
Q: We have a corridor that connects an existing elevator lobby on the 2nd floor of a three story hospital to a new addition. The corridor is used for the …
Q: We are planning to update a pair of fire-rated automatic corridor doors which happened to be located in our Emergency Room and in a 2-hour rated wall. The work …
Q: A surgery suite (5 ORs), PACU (8 bays), and ASU (17 rooms), newly built on the 3rd floor of a business occupancy building. A 2 hour box was constructed …
Q: Our firm has designed several Psychiatric Units lately and there is a question regarding the seclusion room construction. There is a concern as to whether or not the Seclusion …
Q: The computer server is located in the mechanical room. IT wants the room locked for HIPAA compliance. Is it permissible to lock a mechanical room? Doesn't locking compromise access …
Q: In regards to the new annual fire rated door assembly inspection, are we to inspect every door that has a fire rating or the doors that are located in …
Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but …
Q: What is the protocol to maintain a soiled utility room on a patient floor? What guidelines have to be met? A: As far as what guidelines have to be …
Q: We are being told that section 7.2.2.5.4.3 of the 2012 Life Safety Code requires us to install paint on the nose tread on stairs in existing egress stairways as …
Q: Our facility recently installed water-mist fire extinguishers in all of our operating rooms, which is the sole fire suppressant. Is this acceptable? A: It could be okay to have …
Q: Is it permissible to completely cover a fire rated door in a hospital with a polyvinyl picture/mural? Also, is it permissible to cover a fire rated wall, from floor …
Q: This question was recently brought to my attention: “Why do rooms, offices, and work areas do not have “Exit” signs over the doors leaving the rooms?” I could not …
Q: Must combustible decorations have a flame-retardant coating and sticker affixed (or documentation provided) as long as the total area does not exceed the 30% wall surface threshold for fully-sprinklered …
Q: Can you give me some direction in the Life Safety Code on where alcohol-based hand rub (ABHR) dispensers are not allowed in business occupancy corridors? A: Take a look …
Q: In regards to emergency generator backup lights, I seek clarity how long does the battery have to last? I'm assuming that the battery should be able to be tested …
Q: The egress lighting in our facility is connected to our generator through the life safety circuit and the light fixtures have no batteries. The task lighting in our operating …
Q: In regards to the new CMS requirements regarding corridor projections, will alcohol based hand-rub (ABHR) dispensers have to comply? Currently, our ABHR dispensers exceed the 4-inch limit for items …
Q: We have an existing overhead rolling fire door acting as a curtain-window between a phlebotomy area and the egress corridor that is no longer needed (like to those found …
Q: How long does Joint Commission require records to be kept on inspections like fire alarm systems, fire drills, sprinklers, fire dampers, and PM records for beds and refrigerators, etc? …
Q: I just had a survey and received a finding for dust on some of the sprinkler heads. I understand that foreign material is not permitted, but minute amounts of …
Q: Is there a specific date for construction that is a cut-off point between chapter 18 and chapter 19, or does chapter 19 always applies once the new construction is …
Q: Are firefighter emergency call phones still required in new construction? We have an existing hospital and management is wanting to add a whole new patient tower and the construction …
Q: My questions are in relation to access control into electrical closets and life safety equipment closets. We have several electrical closets "locked down" by our IT department because they …
Q: Does section 7.2.1.5.10.2 of the 2012 edition of the LSC, which prohibits more than one releasing actions to operate the door apply to office doors within a healthcare occupancy? …
Q: Do we have to conduct a monthly flow test on fire pumps in healthcare? A: No… NFPA 25-2011, section 8.3.1.2 requires monthly test of the electric-driven fire pump at …
Q: I listened in on your webinar when you introduced all of us to the changes with the new 2012 Life Safety Code. In regards to the section involving fire sprinklers …
Q: We are in the process of designing a new building for our ASC. I have been asked to mark the building plans with where I want the red outlets …
Q: In regards to oxygen cylinder storage on the nursing units, is there a code or standard that restricts the distance between a storage rack of 6 E size cylinders …
Q: In regards to multi-sensor devices, such as rate of rise/fixed temp combo heat detectors; if the rate of rise portion of the device is testable, but the fixed temp …
Q: I read where the annual fire pump test requires a 30-minute churn test but does not differentiate between a diesel or electric pump (as in the weekly test). NFPA …
Q: I have been asked about the requirements for the use of the lower bottom rod hardware in cross-corridor egress doors which provide positive latching and building separation. For aesthetic …
Q: We have just remodeled a suite and are planning on moving the chemo infusion department into it. There are 5 bays but total occupancy would never be more than …
Q: We are in the process of putting manual pull station covers on most if not all of our stations. Some of the stations are dual action. Will putting a …
Q: In regards to oxygen cylinder storage, if the quantity of gas in storage is between 300 and 3000 cubic feet in a smoke compartment and the full cylinders are …
Q: We have some sprinkler piping that runs the length of the hall with multiple wires wrapped around the pipe. There is no way of removing the wiring from the …
Q: I have an existing 3 story building in an urban environment with an exterior stair which discharges into an enclosed rear yard. The access to a public way is …
Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the …
Q: We are doing a fire extinguisher annual maintenance on a Hospital and find that there is a high volume of ABC dry powder units through the site and very …
Q: Are recovery rooms and observation units considered sleeping suites or non-sleeping suites? What is the definition of what constitutes a sleeping suite? A: Recovery rooms, surgical suites and pre-op …
Q: What is the standard in hospitals regarding use of toasters or popcorn machines up in nursing units where patient care areas are located? Is there an issue or concern …
Q: We have an underground tunnel that feeds and branches out three ways into three different hospitals. We are defining the tunnel as a business occupancy. There is a 2-hour …
Q: Is positive latching required for any fire rated door in any occupancy classification? If so, are there any exceptions? What about double egress corridor doors; are they required to …
Q: Is Class 'A' wiring required in new construction for new fire alarm systems? A: Per NFPA 72-2010, chapter 23.4.3.1, unless a class of wiring is determined by a local …
Q: Does a corridor door that serves an office have to swing into the office? The office is on a patient floor and the door does not serve as any …
Q: Are locks permitted on patient room doors? Where can I locate the NFPA requirements for adding new hardware to patient room doors? A: Section 19.2.2.2.2 of the 2012 Life …
Q: I have a life safety consultant doing our annual inspection, and he keeps saying that I need to have individual smoke detectors for my corridor fire rated doors. The …
Q: In regards to penetrations through fire separations: Our latest survey from Joint Commission identified that "Hot Patches" (a piece of 5/8 sheet rock placed over a hole and the …
Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, …
Q: We have a connecting bridge between two of our buildings. On one side of the bridge is healthcare occupancy and on the other side is business occupancy. There is …
Q: Is emergency lighting required for mechanical rooms? A: The answer depends on whether the mechanical room has a designated aisle, the occupancy classification of the building, and whether it …
Q: We are required to conduct a fire drill every quarter. If I did one on March 22, when is the earliest and the latest dates that I can do the next …
Q: Per NFPA 101 2012 edition: are plastic barriers (w/zippers) no longer acceptable around construction areas though the facility is fully sprinkled? A: No… I wouldn’t say that. But the …
Q: I would like to know the 2012 Life Safety Code requirements for an audio testing room in a high rise hospital building. The floor, wall and ceilings are covered …
Q: Does a roof top air handler require sprinkler heads if it is unoccupied? We have large walk-in style air handlers on the roof of our hospital and they are …
Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any …
Q: We have a large wall 15 ft. x 12 ft. in our public cafeteria in the hospital that gets decorated with a different theme every quarter. This was started …
Q: Is there an NFPA code requirement for labeling fire / smoke rated walls above ceiling and if so what is it? A: No… there is not a NFPA code …
Q: The 2012 Life Safety Code allows for 96 gallon containers outside a hazardous area for clean waste. Unfortunately, our vendor that handles recycling does not have a 96 gallon …
Q: Are fire extinguishers required to be placed in mechanical rooms in our hospital? I've searched NFPA 10 and the Life Safety Code and haven't found anything concrete. The mechanical …
Q: I have a question about putting pictures up in stairwells. Someone in our administration department at our hospital wants to put pictures up in a stairwell. We have already …
Q: I am pushing to get all corrugated cardboard out of all areas of the hospital - not allowing materials management to send any items out of their department in …
Q: I recently had a state validation inspection and wanted to get some clarification on a few their findings: “K 353: The facility failed to provide complete visual observation checklist …
Q: What does the NFPA codes and standards require for clearances around electrical panels, fire alarm pull stations, and med gas panels? A: The National Electrical Code (NFPA 70, 2011) …
Q: Does a door that accesses a construction site within a hospital need to have an automatic closer installed on the access door? What if the door is constructed within …
Q: I am wondering where I can find the Joint Commission/CMS requirements regarding Environment of Care rounds? We have always practiced twice a year for clinical areas, once a year …
Q: We have “clinic” type areas within suites. Some of these doors that lead to the main corridor for egress, have regular “turn handle” type handles. Not panic hardware. What …
Q: What supplies qualify as having to be stored in a “sterile storage” room? The 2014 FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities requires these rooms …
Q: Our life safety drawings list the basement level at the Hospital as healthcare. There are no patient services in the basement and only support services. I would like to …
Q: If there are oxygen tanks stored on a unit that does not exceed the 12 tank threshold, does the door to the storage area where the tanks are stored …
Q: A Hospital System that I do work for is in the process of constructing a Medical Office Building off-campus (over 250 yards from the Hospital). The building will house …
Q: What are the ventilation requirements for the scope room in endoscopy? This is the room where the clean instrumentation is kept. A: It all depends if you’re talking about …
Q: I understand it would be best to not place something affixed to the walls of the exit stairwell that protrudes in to the path of egress, which in turn, …
Q: I work in a 420 bed Hospital and during a recent survey we got cited for our yearly inspection dates on our fire extinguishers, which I understand. But on …
Q: I have a 3 story hospital and I would like to have a mixed occupancy classifications for different floors. The basement floor is for support - no patients are …
Q: Where are eyewash stations required in a hospital/ambulatory care facility? A: They are required in areas where corrosive or caustic materials (i.e. chemicals) are used, stored or handled and …
Q: Should Emergency Departments be classified as healthcare, ambulatory healthcare, or business occupancies? A: According to the 2012 Life Safety Code, a typical Emergency Department (ED) may be classified as healthcare …
Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher …
Q: Is there a code that says anything about adding a vent through a door that is in the corridor of our hospital? A: Well… you might be able to …
Q: During a recent survey, we were cited for not having monthly inspections on our extinguishers during the month of the annual inspection. We have never run into this before …
Q: Is there a specific distance that fire alarm audible/visible notification appliances are required to be mounted from other similar devices? We have multiple strobe devices in some rooms, but …
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 …
Q: Can a chair lift device be installed in an exit stairwell? What are the regulations? A: The Life Safety Code and the local building codes set minimum widths of …
Q: If I want to classify my building as a healthcare occupancy, even though I have a business or ambulatory healthcare occupancy in it, I know I need to meet …
Q: I'm working with a hospital on their temperature and humidity monitoring in their Central Supply area, and was wondering what specific parameters they should follow in the two different …
Q: I recently attended a conference where the speaker in the Life Safety session talked about the fire rating of the doors. She spoke of having the fire information labels …
Q: What standard in the Life Safety Code prohibits storage under sinks? A: There is no direct standard in the Life Safety Code or any of the standards the LSC …
Q: Are Won-Door control panel batteries required to be tested annually with other fire alarm system batteries? A: I don’t believe so. The batteries in the fire alarm control panels …
Q: Are bins holding patient records waiting to be shredded required to have a FM fire rating in a hospital? A: Yes. Section 19.7.5.7.2 of the 2012 edition of the …
Q: I am a consultant and I am surveying a system where the bottom strike rod and the floor receiver have been removed. I think this "field" modification may void …
Q: If a door is a fire-rated door is it required to be maintained as a rated door in compliance with NFPA 80, regardless if its location doesn't require a …
Q: We have a building adjacent to our main hospital (separated by a two hour fire wall) that is a mixed occupancy. There are three stairwells that serve this building, …
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 …
Q: We have audible notification devices for the fire alarm system installed in our physician sleep rooms. We have a physician requesting the one in his area be removed. Are …
Q: My mother suffers from a syndrome which causes her feet to turn white and feel extremely icy. She is not allowed to use an electric blanket which allows her …
Q: Could you clarify whether bronchoscopy procedures should be performed in a negative pressure room or positive pressure? It's seems as though many folks are doing them bedside and using …
Q: In the 2012 edition of the Life Safety Code, section 19.3.2.6 (9) states dispensers of ABHR are permitted to be installed directly over carpeted floors in fully sprinkled smoke …
Q: Can fiber optic and low voltage cables be attached or strapped to conduit? Also, what certification is needed for individuals who perform the annual line isolation monitor (LIM) tests …
A reader has an objection to one of the answers I provided in yesterday's blog concerning Power Strips... Brad: In the Sept. 2, 2016 article on Power Strips the following …
A client of mine sent me the following questions regarding power strips. The answers were taken from the CMS S&C memo 14-46 regarding the use of power strips in accordance …
Q: Can you provide some clarification? The NFPA 101 2012 edition was adopted July 5th is that correct? Joint Commission and CMS will not be reviewing using this current edition …
Q: Hello Brad, I hear the SOC as of 8/4/2016 will no longer be used. If time is needed to do a repair for a life safety item we need …
Q: I could’ve sworn I read somewhere that a monthly fire extinguisher inspection shall be done within 30 days AND that there is to be a 10 day grace period… …
Q: A state surveyor cited us for not doing a monthly fire pump automatic transfer switch (ATS) test. We are doing a weekly churn test and an annual fire pump …
Q: In the past our hospital has used different brands of fire caulk on the same fire wall assembly. The fire caulk is two different brands and different colors and …
Q: Are surgery rooms considered to be patient sleeping rooms or non-sleeping rooms? In reference to allowable suite sizes, what is the maximum area of the suite? A: Surgery rooms …
Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to …
Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised …
Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that …
Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors …
Q: There appears to be many different ways a hazardous room is maintained: If it is sprinklered, does it have to be 1-hour rated? If it is existing construction, does …
Q: Why does the escutcheon plate on a sprinkler need to be required when the ceiling is not rated and the corridor walls extend to the deck? If a basement …
Q: We have an old dark room that was converted into an air handler room. What’s the requirement for a door to this room? A: It all depends where this …
Q: The Joint Commission standard for weekly testing of the fire pump only requires us to record the test date of the inspection. We were cited for not recording the …
Q: Can a sterile supply corridor that feeds the back of Surgical OR's have a corridor of less than 8' if the patient access is from the front of the …
Q: Does NFPA 72-1999 edition specifically state that annual fire system inspection documentation include an itemized inventory of each system device as passed or fail? Does a report stating that …
Q: My question is in regards to illumination of the means of egress, specifically, illumination provided outside the building to a public way. I was told by a consultant that …
Q: Our pneumatic tube vendor is telling our Engineering folks that they have to install dampers inside the system everywhere that a pneumatic tube run penetrates a fire wall or …
Q: Is it better to have an eye wash station that doesn't comply with ANSI standards or to remove eyewash stations from ambulatory clinics setting which may contradict Joint Commission …
Q: I know it is inappropriate to place a flushing hopper sink in a trauma room between the hand washing sink and clean storage cabinets but I can't find the …
Q: Is it mandatory that we perform a “Standpipe Hydrostatic and Flow Test” every 5 years? We do not have a dry system. Our system is full of water and …
Q: Recently I attended a meeting with our State Fire Marshall Department. One item which became a HOT topic of discussion was the monthly Specific gravity testing of the battery …
Q: During the winter season how much time would a surveyor give us to remove all snow from the exit discharge leads out of the hospital? Since it could be …
Q: I am doing a renovation project in our hospital and the area of renovation is 50% of the total building area. Part of the renovation scope is a fire …
Q: Are fire dampers required in 1-hour fire rated walls if the facility is fully sprinkled? Also, we have a couple of inaccessible dampers and I was wondering if I …
Q: Where in the Life Safety Code does it require clearance in front of a fire alarm control panel? I have a situation in our hospital where we want to …
Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not …
Q: Do you need a fire smoke damper at floor level in an open duct shaft? Or where the duct comes out through the shaft wall? A: Section 19.7.5.1 of …
Q: Our facility uses full shower curtains mounted to tracks in the ceiling for all behavioral health units. These curtains and tracks are ‘break-away’ type for suicide prevention. Our administration …
Q: While conducting fire drills in the hospital, one of the questions on our drill evaluation sheet is, "Did the security doors in the fire zone release properly?" We have …
Q: The Centers for Medicare & Medicaid Services (CMS) standard §482.41(c)(4) states in their Interpretative Guidelines that hospitals must comply with the Facilities Guidelines Institute (FGI) for ventilation in anesthetizing …
Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual …
Q: Do table top exercises count as a fire drill? We are updating our old policies and traditionally it has been allowed to have tabletops count as a fire drill, …
Q: Are existing healthcare occupancies required to have smoke detectors if they are fully sprinklered? A: Smoke detectors are required in certain areas of healthcare occupancies, but they are not dependent …
Q: Joint Commission standard LS.01.02.01, EP 11 requires the hospital to perform an additional fire drill during periods of Life Safety Code deficiencies that cannot be immediately corrected or during …
Q: Are portable heaters permitted in long term care facilities in offices and other locations? A: Portable space-heating devices are prohibited in healthcare care occupancies (such as hospitals, nursing homes, …
Q: Got any tips for a novice on how to navigate through the Life Safety Code? I’m interested in specifics on sprinkler placement for water curtains. A: NFPA 13 (1999 …
Q: We are getting ready to complete our fire drill schedule and need clarification. When conducting fire drills how many remote fire zone/smoke areas are required to be observed and …
Q: What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals? I see where we are supposed to test and know what …
Q: Should the official Life Safety drawings for an existing space within a hospital show the rating on a fire barrier as it was originally built or as it is …
Q: We recently had a survey which resulted in multiple Life Safety findings. We want to clarify away some of these findings, and were told we can only clarify the …
Q: I am looking for a code reference which specifies the installation height for stairwell signage. It appears that NFPA 101 indicates 5 feet above the stairwell landing but does …
Q: Brad, how does the date need to be recorded on the fire extinguisher tags for the monthly inspection? Does the year need to be included on the inspection tag …
Q: We recently heard of a facility receiving an “immediate jeopardy” because their beds and stretchers had not had annual preventative maintenance. This is part of our Equipment Management plan and …
Q: I read an article you wrote on alcohol based hand rub (ABHR) dispensers for FacilityCare. We have had a question come up about changes in the regulations concerning the locations …
Q: Are fake smoke detectors permitted to be installed in a hospital according to NFPA codes and standards? I discovered that our Security department installed a manufactured security camera that …
Q: My loved one is in a nursing home and needs additional heat in the winter time, what do I do? The building seems to be at a comfortable temperature, …
Q: Can you give me the NFPA Life Safety Code (2000 edition) reference showing 8 foot required width in egress corridors in an existing healthcare occupancy? A: There is no …
Q: I have 3 Post Indicator Valves (PIV) and 1 Wall Post Indicator Valve (WPIV). I'm not finding anything in NFPA in regards to the testing frequency. My PIVs and …
Q: Do air handler mechanical rooms located at the top of a hospital, and are healthcare occupancies, require sprinkler systems? A: Yes… if the rest of the hospital is required …
Q: Can you clarify for me if the elevator equipment room is required to be sprinklered and have a shunt trip installed in our nursing home. A: Yes, elevator equipment …
Q: How do I determine if our outpatient facility is an ambulatory healthcare occupancy? A: Based on what the 2000 Life Safety Code says, an ambulatory healthcare occupancy is a …
Q: Does an eye wash station need to be mounted over a designated “clean sink” or can it be in any sink? Some of our Labs only have one sink, …
Q: We were recently cited by a surveyor for not conducting annual fire drills at our offsite blood draw locations. I have reviewed the Life Safety Code for business occupancies …
Q: We have an offsite physician’s clinic with a fire alarm system that is tied into our main hospital campus control center and is monitored 24/7. Are we required to …
Q: I am new to this position and I am working on updating my management plan on fire safety. Currently it states "The fire department's Fire Prevention Bureau will conduct …
Q: I have a question regarding fire extinguishers. We have our extinguishers located in cabinets that are flush with the wall. Is it required to have signage above the extinguisher? …
Q: We are looking at the difference between a "wired" and "wireless" nurse call system in our healthcare facility addition. Our current health center has a "wired" call system however …
Q: Are we required to have an eyewash station inside a kitchen? A: Maybe yes and maybe no…. It all depends on whether or not there are caustic or corrosive …
Q: I have an existing medical gas storage room in an outpatient surgery center that was constructed with 1-hour barriers and ¾ hour fire rated door. A surveyor cited me …
Q: Are evacuation route drawings required to be posted at nurse stations or anywhere else per Joint Commission or CMS requirements? A: No. There is no Joint Commission standard or …
Q: Can we store compressed butane gas cylinders used for food-warming and heating in the kitchen or do they require special storage? A: NFPA 30 requires all flammable gases and …
Q: Does the Life Safety Code require hospital staff sleeping rooms have smoke detection inside the room and door closers installed? We have an on-call sleeping room for physicians in …
Q: Can we have a helium tank if secured properly in gift shop? And what are requirements for hand sanitizer locations- location to switches or outlets? A: Provided the tank …
Q: Are you aware of any door signage requirements for soiled utility rooms and/or trash rooms? A: There is no Life Safety Code requirement for signs on a soiled utility …
Q: I am working on an aesthetic corridor remodel for a hospital. Can you please tell me if there are specific requirements as to handrail locations (i.e- one side of the …
Q: We have a construction project that involves removing all of the ceiling tiles in the area. Do we have to relocate the sprinklers heads to within 12" from the …
Q: Are hand-made temporary directional signs permitted to be taped to fire doors? We had a surveyor tell us that nothing can be taped to a fire door. A: Yes, …
Q: Is there any specific regulation that addresses storing items under stairwells and if so does it differentiate between public stairs and stairs which are utilized to access areas not …
Q: A local fire inspector approved our outdoor storage shed for full oxygen cylinders. Now a surveyor says it is not compliant because the shed is made of wood, and …
Q: A consultant told me that emergency generator rooms are required to be maintained at least 40 degrees F. Do I need to maintain that temperature if I have block …
Q: Are stairway evacuation chairs required in all high rises, or business occupancies in general? A: According to the Life Safety Code, there is no requirement to provide stairway evacuation …
Q: I have never been able to understand what a fully ducted heating system is and when a damper is not required. Can you explain this matter to me? A: …
Q: What is the permitted force to open a fire door? What kind of means can be used to test this onsite? A: The answer to your question is found …
Q: Do medical records in an off-site, business occupancy building have to be fire protected? This was not cited during our survey, but I heard from another hospital that this …
Q: I am having trouble with locating in the 2000 edition of the Life Safety Code where single station battery powered smoke alarms are being addressed for maintenance. I know …
Q: As the cold weather starts to creep up on us I'm continuously asked by staff if they can have a personnel heater in their office space (not patient care …
Q: Are there any requirements regarding outer hospital windows to have curtains or blinds? Some seem to think that they are required in case of severe weather as curtains are …
Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business? A: The Life …
Q: We have a separate building on our campus that includes our behavioral health unit, along with related offices and meeting rooms for the support staff. The behavioral health unit …
Q: Are electric blankets permitted to be used by patients in long term care facilities? I cannot find any references to electric blankets in any NFPA codes or standard. A: …
Q: Which edition of NFPA 110 are we expected to follow? I read that we’re expected to comply with the 1999 edition, the 2005 edition and now the 2010 edition …
Q: We own and operate a hotel on our hospital campus and are revamping our fire plan. Are we required to have all the hotel guests evacuate their rooms upon …
Q: Can an Ambulatory Surgical Center (ASC) have a waiting room that is shared with another physician’s practice that is not associated with the ASC, but is located in the …
I have received quite a few questions concerning combustible decorations this season and thought I would run this special Q&A today... Q: My administration is decorating our hospital lobby and has …
Q: With regards to installing a hook on a fire rated door, would an adhesive backed hook be considered a modification to the door? A: As far as I can …
Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital? A: The monthly inspection and annual …
Q: We completed our hospital sprinkler installation in 1994, and most of the sprinklers that were installed were quick response sprinklers. Now I hear at an ASHE conference that we …
Q: Are we supposed to have smoke detectors in the corridors of our hospital? I see the Statement of Conditions ask if we have smoke detectors in our corridors, which …
Q: We have an attached building that houses an ambulatory surgical center and the building is classified as a business occupancy. We want to convert it from business occupancy to …
Q: Our administration wants us to discontinue applying bar-code labels on each extinguisher in our facility, and begin applying the labels on the cabinets and walls where the extinguishers are …
Q: We have an Ambulatory Surgical Center (ASC) located in a one story nonsprinklered building, and is separated from a physician’s office. The exit access from the ASC leads into …
Q: Are portable fans permitted in patient care areas? At times, a patient may become too warm and the normal HVAC system does not provide adequate cooling. A: The use …
Q: How are we supposed to deal with patient owned equipment that is brought into the hospital, such as laptop computers, hairdryers, and electric razors? Are we required to maintain …
Q: How does CMS and the accreditation organizations look at preventive maintenance of household electrical items, such as lamps and coffee makers used by staff in the hospital? Do I …
Q: I was always under the impression that no storage was allowed in mechanical rooms within hospitals. Now I work at a hospital that allows ladders and supplies to be …
Q: We have been asked to install a lock on a door in the path of egress through an office. For security reasons they would like to lock the doors …
Q: Can cardboard boxes be stored in an electrical room that is over 50 square feet, fully sprinklered, and has only dry transformers under 112 1/2 kVA? A: Yes, only …
Q: Since the Life Safety Code addresses ambulatory surgery centers in chapters 20-21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage …
Q: Do we have to have a special placard on our fire extinguishers in our kitchen, alerting people to activate the cooking hood fire suppression system first, before using the …
Q: Are there any NFPA regulations which require doors serving as exits from suites must swing in the direction of egress? I have identified smoke barrier double doors in corridors …
Q: Concerning latching hardware for a surgical suite, I could not locate any exceptions in the Life Safety Code to the positive latching requirements concerning operating room doors. From an …
Q: Is there a NFPA standard for emergency lighting placement in an anesthetizing location? A specific requirement where on the wall or ceiling it must be mounted? Do the self-check …
Q: Our new clinic integration program has made us look closely at the clinic's life safety process. The clinic is classified as a business occupancy. Is the assessment for life …
Q: During a recent survey, the life safety surveyor wrote a finding that my refrigerator and freezer walk-in coolers are not in compliance with the building having full sprinkler coverage …
Q: Where are main drain tests required to be done? This is a large medical facility with nine story towers. Several fire mains feed the various campus buildings. Is the …
Q: Our hospital has an offsite building for our cardiac rehab, physical therapy, and pulmonary rehab programs. It also houses our business office and some physician offices. The building is …
Q: I cannot find a code reference that prohibits storage in the generator enclosure. Is there a specific reference for this in the 2000 edition of the Life Safety Code? …
Q: If hazardous areas like a carpentry shop and a paint shop are combined in a separate building distant from hospital building, what can be an appropriate reference to determine …
Q: We are going to prepare an action card for fire safety as part of our major emergency response plan. What information regarding fire safety would you suggest we include …
Q: Are there any requirements to firestop penetrations in Information Technology (IT) closets and electrical rooms in business occupancies? A: Only if the barriers surrounding the IT closets are designated …
Q: Are there any special storage requirements for flammable liquids and flammable aerosol cans in the work area? A: Yes, flammable liquids in all forms and capacities must be stored …
Q: Are Interim Life Safety Measures (ILSMs) required in Business Occupancies due to construction or life safety code deficiencies? Do we have to conduct a fire watch in Business Occupancies? …
Q: I read the June, 2012 article in HLSC about power strips in healthcare facilities and we have been hesitant to use power strips in patient care areas because the …
Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We …
Q: If renovation requires replacement of fire doors in multiple areas of the hospital, and must be completed in a short period of time, what would be appropriate interim life …
Q: Our facility is a freestanding ambulatory surgical center and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story …
Q: During a recent survey, the surveyor said a card reader on the stairwell door cannot be located on an adjacent wall or door frame, but it must be an …
Q: We are a freestanding ambulatory surgical center (ASC) and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story …
Q: Where is the reference in the Life Safety Code that requires the doors to housekeeping or soiled utility rooms to be locked? I have a Risk Management director that …
Q: How many spare sprinkler heads are we supposed to have in stock at our facility? We had an inspection recently, and the fire marshal said we did not have …
Q: Is the Life Safety Surveyor a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and various areas of survey?” …
Q: We have decorative wood panels in our cafeteria ceiling which do not provide a seal to limit the passage of smoke. In fact, there are wide gaps between the …
Q: Are we required to install fire alarm occupant notification devices and manual pull stations in construction areas? I couldn’t find anything in NFPA 72 or the Life Safety Code …
Q: The health care facility where I work needs additional privacy on the nursing floor from the rest of the building. I would like to know if we could mount …
Q: Can evacuation chairs be installed in stairwells? A: The answer is… maybe yes and maybe no. Sorry, that’s not a direct answer, so please allow me to explain. Section …
Q: What are the testing frequencies for fire alarm panel batteries and where do you find this requirement? A: The testing frequencies for batteries for fire alarm control panels (including …
Q: We have a situation in our Lab where they would like to purchase another incubator that requires additional CO2 gas. The problem is that we do not have a …
Q: Do emergency power generators have to be located in a room by themselves? We have a generator that is located in a mechanical room which is shared with an …
Q: I have a reception area that has a sprinkler head in the middle of a 2'x2' ceiling tile and less than twelve inches from this sprinkler head the interior …
Q: We are designing a retrofit for a dental office in an existing business occupancy building without a fire sprinkler system. The space we are remodeling was formerly a doctor's …
Q: When will we know if CMS will adopt the 2012 version of the NFPA LSC book? A: You will not have to worry about that… Nearly everyone will be …
Q: Is there a right way and a wrong way for fire doors to swing? During evacuations, one is encouraged to stay to the right in hallways and stairways. Thus …
Q: Do different occupancies have to be separated by fire-rated barriers both horizontally as well as vertically? We are considering installing a dialysis unit on the second floor of a …
Q: During a recent survey we were almost cited because one of the fire extinguisher signs was on the front of the fire extinguisher cabinet and the rest were above …
Q: We are renovating one of our patient sleeping suites in an existing area. Would it be permissible to stage construction materials (some of which will be combustible) in one …
Q: We just completed a renovation of our cafeteria dining area and as part of the project an 8 container trash cabinet was built and installed in a separated area …
Q: We have an electrical room that is not protected with sprinklers and the old-timers here say the building department would not permit sprinklers in this room when the hospital …
Q: I came across a bunch of wheelchairs folded up in an equipment storage room. Each had an oxygen cylinder attached. Are these cylinders included in the tally for aggregate …
Q: Are oxygen cylinder tanks (in holders) allowed to be stored in alcoves in corridors? Also, what about clean linen carts? I am told that our accreditation organization allows this, …
Q: We have a physician on-call sleeping room inside our labor and delivery unit. A surveyor told us that we need audible smoke alarms in each on-call sleeping room. We …
Q: Two different state authorities are telling me conflicting information concerning the maximum temperature for domestic hot water. The first one is telling me the hot water cannot exceed 100°F …
Q: We are in the process of installing a door in a 2 hour fire barrier with an automatic door operator and positive latching. The door operator will be activated …
Q: What is the required inspection frequency on sprinkler systems for a building classified as business occupancy? Is it less than what would be required for the main hospital? A: …
Q: What is the proper method to store and dispose of waste alcohol prep pads? Are they considered hazardous waste? A: The quantities of liquid alcohol in the preps would …
Q: How are ‘wet locations’ defined in the NFPA codes and standards? We are not clear if we have any ‘wet locations’ in our hospital. A: You probably do, based …
Q: We recently found out that our own maintenance staff is not qualified to service our fire alarm system. What other systems or items in the hospital requires our own …
Q: Do existing fire rated doors (in a 2-hour fire rated barrier) have to have a vision panel (window) in the door? A: No, I do not believe that they …
Q: What is the amount of air delivery (in CFM) that an air handler needs to have before it is required to have a smoke damper on the discharge of …
Q: I came across a medical gas shutoff valve that was located behind an access panel in a small storage closet in a surgery department. The closet was packed and …
Q: A surveyor cited us for not having positive latching doors to our entrance of the ICU suite. We have magnetic-locks on those doors and pointed out that they serve …
Q: What is the spacing requirement for fire alarm occupant notification devices? A: The spacing requirements are not listed in a specific distance, but they are listed by their decibel …
Q: We recently had a survey where we were cited for not having a paved sidewalk from the exit door of a stairwell, to the parking lot. The surveyor said …
Q: Where is the main drain test supposed to be conducted? Is it supposed to be at the sprinkler riser or low point drain? A: According to NFPA 25 Inspection, …
Q: Are we required to have portable fire extinguishers in our parking garages? A: No. The placement of portable fire extinguishers is dependent on the requirements for that particular occupancy …
Q: We had a question as to whether or not we are required to have posted emergency evacuation route signage posted throughout the hospital and clinical buildings. Given the fact …
Q: Are fire rated walls the same thing as fire rated barrier? And are smoke compartment barriers actually fire rated walls? A: As it has been explained to me, a …
Q: We are in the process of renovating an existing two story office building where a dialysis unit will be located on the lower level. According to our state requirements, …
Q: We have wall mounted recessed cabinets in our corridors next to the patient room doors that have access doors on both the corridor side and the patient room side …
Q: Are gas-fired ventless fire places permitted in nursing homes? A: I would say they are not permitted, but it has a lot to do whether or not the gas …
Q: Do we have to conduct a fire drill in every department and unit at least once per shift per quarter throughout our hospital? Some staff is telling me that …
Q: We discovered our offsite free standing Dialysis center is in a building that is classified as Business Occupancy, but we were recently told by a consultant that the building …
Q: Our project team has to do a domestic water shutdown for about 12 hours and unfortunately the water they want to shut down serves water-cooled refrigeration units in the …
Q: The 2008 edition of NFPA 25 allows vane-style waterflow switches to be tested semi-annually, but during a recent survey, the surveyor cited us for not testing them on a …
Q: Is it allowed to combine the 3-year 4-hour generator load test along with the annual 2-hour load test? Our generator test company plans on running the generator at 50% …
Q: What is the distance needed to prevent obstructing medical gas shut-off valves? Is it just not having anything directly in front of the valve itself - or does it have …
Q: My sprinkler testing contractor is questioning the requirement that fire pumps are to be flow-tested annually at 150% load on emergency power. It's the emergency power requirement in question …
Q: Are smoke compartment barriers considered to be fire rated barriers? The architect that we have doing our drawings wants to call the smoke compartment barrier walls “1-hour smoke/fire barrier”, …
Q: We just had an outside company update our SOC (Statement of Conditions) and even though we haven't changed anything in 20 years he noted what he considered to be a …
Q: Our corporate office has informed us that we need to remove all artificial plants from the hospital if they do not have a fire rating label attached to the …
Q: We have a short-term project where we need to find some space to store equipment until they are installed. The equipment is electronic and needs to remain in their …
Q: Can an FSES equivalency be written for an oversized ER suite? Our ER was constructed in 2005 and the designer made it 13,450 square feet, which is more than …
Q: What are your thoughts on the flammability of disinfectant hand wipes? One of our VPs raised the question, noting that the wipes burn pretty well. Are these wipes a …
Q: We have many offsite locations that are not hospitals but are clinics for diagnostic imaging, testing and physician’s offices. What, if any Life Safety Code standards apply in these …
Q: Are “fire pump running” and “fire pump power loss” switches which are connected to the hospital fire alarm system considered to be supervisory signal devices? I say they aren’t …
Q: Are existing corridor doors required to be positive latching? Section 19.3.6.3.2 of the 2000 edition of the Life Safety Code does not require corridor doors to be positive latching, …
Q: Are signs permitted on fire rated doors? We posted a sign on a fire rated stairwell door that instructed our staff to temporarily not use the door, and a …
Q: Several of our department have stretchers with onboard E-size oxygen cylinders. Can these be considered "in use" and not count against the smoke compartment's 300 cubic feet limit? Also, …
Q: A consultant has mentioned that several of our doors to hazardous areas are non-compliant. The door configuration is such that there is a normal 3’x7’ door paired with a …
Q: In a Psychiatric hospital emergency room, are patient holding rooms allowed to have dead bolts on the corridor side with no thumb latch on the inside of the room? …
Q: We have an ambulatory healthcare occupancy which has clean supply and soiled linen rooms. Since these rooms are considered storage with combustibles, the Life Safety Code (LSC) views them …
Q: We have a large computer center that has a halon system in the room. They know in a sprinkled area that they must keep items 18" below the sprinkler but is that …
Q: During a recent survey, we were cited for not maintaining at least 36 inches of clear width in our suites for exiting purposes. I thought one of the advantages …
Q: During a recent survey, the surveyor noted that we had two 64 gallon capacity containers which we use for document shredding, sitting side-by-side in the laboratory work room. He …
Q: We recently had an inspection and we were cited for not having a smoke detector in the on-call sleeping room for physicians which is located on our Labor & …
[This week's Q&A came from the 49th Annual Conference and Exhibition of the American Society for Healthcare Engineering (ASHE), held in San Antonio, TX, last July, and how it applies …
[This week's Q&A came from the 49th Annual Conference and Exhibition of the American Society for Healthcare Engineering (ASHE), held in San Antonio, TX, last July, and how it applies to …
Q: During a recent survey, the inspector cited us for not exercising our circuit breakers downstream of our generator. Does the LSC require annual exercising of all circuit breakers between …
Q: We have a new facility which has recently opened, and it is a physician’s office/business occupancy. There is a medical record storage room which contains combustible files which we …
Q: Our Risk Management Department has conducted an assessment of our waiting areas in our hospital. They are stating that staff should be able to see all patrons who are …
Q: Do linen chute doors have to be locked? Our risk manager says they are required to be locked, but I don’t see anything in the LSC that says that …
Q: Can we install shelving along the walls within a patient sleeping suite? This shelving would not be limited to a supply room, but would be permanently affixed to the …
Q: Do corridor doors have to have door closers on them? I know they have to latch, but an architect said all corridor doors have to have closures on them …
Q: Are we allowed to install a hook on the inside of a patient room corridor door? Our nurses would like a hook installed on our wood patient room doors …
[NOTE: The following Q&A is from my good friend Lori Greene, Manager of Codes and Resources for Ingersoll Rand Security Technologies, Needham, MA. Check out her blog at www.idighardware.com ] Q: …
Q: Are battery powered emergency lights required in business occupancies? We have a small clinic that does not have battery powered emergency lights (or battery powered “Exit’ signs for that …
Q: We have equipment rooms on the top floor of our hospital that contain mechanical equipment, but no boilers or generators. Are these equipment rooms required to be protected with …
Q: In a recent posting a question was raised about storage in a mechanical room. What about storage in an electrical room? Is it permitted? A: In some cases storage …
Q: Our medical supply room contains combustibles, and is larger than 100 square feet. It does not have a door and the room opens onto the corridor, behind our nurse …
Q: I have a storage question for you that relates to storing beds and other hospital equipment in our mechanical rooms. Is this allowed or would I be cited for …
Q: Is the hospital responsible for the fire extinguishers supplied by the contractors while they are performing work in our hospital? We had a surveyor cite us for not performing …
Q: Is the main kitchen in a hospital considered a hazardous area? I’m referring to the main kitchen where all the food is prepared for the hospital, not the kitchenettes …
Q: Our entire hospital is protected with automatic sprinklers. Do the contents and furnishings in our patient rooms need to meet a flame spread standard? A: The answer to this …
Q: Is it prohibited to store items in a mechanical equipment room? We have different opinions at our hospital as to what is allowed and what is not allowed. Do …
Q: How would you define unannounced when it comes to fire drills? There doesn’t appear to be anything in the standard that explains what this means. What do you say? …
Q: I have a compressor that delivers medical air for our patients and want to know what the requirements are for the alarm system for the air dryers. Where do …
Q: Is it a requirement to keep access to the medical gas alarm panel clear in a similar manner that access to medical gas shutoff valves must remain clear? These …
Q: I had a state inspector tell me that communication wires and cable in our hospital are not permitted to be tied to conduit containing electrical wires. Is this true? …
Q: I have a supply room on a medical surgical floor and the door opens into the corridor. The corridor and the room are protected with automatic sprinklers. Because it …
Q: What is the actual spacing requirement for alcohol based hand-rub (ABHR) dispensers from electrical sources such as light switches in the hospital? I have heard it must be 4 …
Q: We are about to install a new shelving system into a room that is protected with automatic sprinklers. I know we are supposed to maintain 18 inches clearance underneath …
Q: How do you calculate the Common Path of Travel and/or Total Travel Distance for a multi tenant suite when the space planning for the individual rooms has not been …
Q: We recently failed a licensing inspection because the gap at the bottom of the door exceeded 1/8". The inspector stated "no gap between surfaces greater than one-eighth of an inch is …
Q: We recently did a survey on our fire rated doors and found many of the frames on the doors had issues with the labels. Some of the door labels …
Q: We are putting in fire recall on our elevators. Now the elevator people are telling us that due to the age of some of our elevators they can only …
Q: We have a contractual Dialysis Unit on the 2nd Floor of our Medical Office Building which consists mainly of one large open room. Very often in the treatment area …
Q: At our hospital, we have differing opinions concerning the proper method to restrain compressed gas cylinders. Would you please provide us the code reference regarding the correct method to …
Q: We have an outpatient clinic which is a business occupancy and provides ancillary services like physical therapy and radiology, and there are no fire alarm pull stations in the …
Q: We recently replaced our old fire pump with a brand new unit that is up to date with the current requirements of NFPA 20 Standard for the Installation of …
Q: Is there any formal requirement to have a “contract” with a fire extinguisher company for extinguisher maintenance? I have a copy of their credentials but recently was I lead …
Q: In regards to stairwell signage, when you have restrictive access back into the building from a stairwell in accordance with section 7.2.1.5.2 of the NFPA 101 Life Safety Code, …
Q: Are dead-bolt locks permitted on patient room doors, to keep unauthorized people from entering the rooms? We have dead-bolt locks on the patient room doors in our behavioral health …
Q: Can a door that opens onto the corridor have a magnet hold-open device that is not connected to the building fire alarm system, and does not release when the …
Q: We have these big recycling containers mounted on wheels all over the hospital, which must have a capacity of 50 gallons each, at least. Does this container need to be …
Q: I have a supply room on a medical surgical floor and the door opens into the corridor. The corridor and the room are protected with automatic sprinklers. Because it …
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 …
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 …
Q: Does the kitchen in a nursing home have to be considered as a hazardous room? I don’t see where the LSC defines the kitchen as a hazardous room, but …
Q: Are we required to have solid bottom shelves in all areas where we have items stored, including on carts? Does this requirement extend to all stored items? A: It …
Q: Are we required to conduct fire drills on every unit and in every department once per quarter per shift in our hospital? Are we required to make sure everyone …
Q: I’ve read that installing sprinklers in our existing hospital, even when they are not required such as a renovation project, provides us with exceptions to the LSC. If we …
Q: During a recent survey, we were cited by the surveyor for a 6 inch round duct that did not have a smoke damper installed where it penetrated a smoke …
Q: Our projects team currently disables our fire alarm control panel each morning during periods of construction and restores the panel each evening. They do this to prevent unwanted fire …
Q: Do employee locker rooms automatically have to be considered a hazardous area? If they are protected with sprinklers, does this change the situation? A: No, employee locker rooms are …
Q: During a recent survey, the surveyor told us that we could not have Alcohol Based Hand Rub (ABHR) dispensers over carpeting in areas of the hospital that do not …
Q: What is the requirement for bulletin boards in exit corridors? I heard from another hospital that bulletin boards greater than 4 square feet must be protected with glass. Is …
Q: Are waste container required to be fire retardant in hospitals? What about long term care facilities? A: No, they are not. At one time, the Life Safety Code® (LSC) …
Hazard Classification Hazard Type Minimum Fire Extinguisher Rating Travel Distance Class A Low 2-A 75 ft Class A Moderate 2-A 75 ft Class A High 4-A 75 ft Class B …
Q: What is the requirement for water flow testing fire pumps under emergency power? I have heard some hospitals are being cited for not doing this, but a surveyor once …
Q: The AHJs who inspect my hospital require that I conduct a three-year, four-hour load test, which we do simultaneously with our annual load bank test. One AHJ says this …
Q: Can you direct me to the standard that states we must have a CO2 fire extinguisher in the operating rooms of our surgery department? Our operations chief insists a …
Q: We are looking at purchasing a medical practice with a business occupancy rated office, which is not sprinkled. They are using a room on the second floor as a …
Q: Do you know of any guidelines for the amount of time you have to conduct a fire watch during an Interim Life Safety Measures (ILSM) operation? Does it have …
Q: Is there a minimum reaction time for an air handler to respond to a duct detector activation? We had a consultant say that we had to record documentation that …
Q: Brad- Are alcohol based hand-rub (ABHR) dispensers permitted in corridor of business occupancies? A: The LSC is very silent about alcohol based hand rub (ABHR) dispensers in a business …
Q: Can you please direct me to where it says we have to have locks on our linen and waste chutes? What is the requirement and where does it come …
Q: We have all seen the signs “In case of fire, do not use elevators.” This to me suggests when the fire alarm sounds no one is to use the …
Q: I was recently informed by a contractor the magnetic locks that we use to lock our ER department doors are not allowed to be connected to our emergency generator …
Q: As we work through deficiencies that were found by a consultant, there is one question we need to have clarified regarding doors. The reference to the deficiency is LSC …
Q: We have an existing 24-inch diameter chute throughout our building that is designed for housekeepers to shake out the dry dust mops into the chute. A ventilation fan takes …
Q: Can you tell me if there is a requirement for the operating rooms to have a CO2 fire extinguisher inside the rooms themselves? Our hospital received a citation by …
Q: We have a stairwell in our hospital that extends from the 8th floor to the 1st floor, where there is a door that discharges the occupants to the outdoors …
Q: I was recently informed by an architect that an electrical equipment room does not need to be sprinkled if it has a two-hour fire resistant separation. Have you heard …
Q: We have a penthouse mechanical room on top of our hospital that has a vertical shaft used for pipes, conduits and HVAC ductwork which is open to the mechanical …
Q: We have portable little butane one burner stoves that dietary likes to use to cook one pan of something in the server area, but they also use it to …
Q: We have exposed sprinkler heads in our hospital, and the design rings around the sprinkler heads occasionally fall off and disappear. One of our sprinkler contractors said those rings …
Q: Is there a Life Safety Code regulation stating the need for 100% outside air for the lab HVAC system or where could I find the requirements that regulate this …
Q: How close can a sprinkler head be located to a wall mounted cabinet? I have some cabinets that were added after the sprinkler heads were installed, and the heads …
Q: NFPA 13 (1999 edition) section 5-3.1.5.2 states whenever standard response sprinklers are changed to quick response type, then all of the sprinklers have to be changed in the that …
Q: I read with interest the article Understanding the Importance of Construction Types in the February, 2011 issue of HLSC. The article said a 2-hour fire resistance horizontal barrier is …
Q: Are fire alarm notification appliances required to have annual sound level measurement testing? We had a consultant tell us that we are supposed to conduct the sound level testing …
Q: Can the entire patient sleeping suite of rooms, such as an ICU, be considered a hazardous room? This would allow us to store supplies in the common area of …
Q: During a recent mock survey it was mentioned that cardboard boxes are not allowed in clean storage rooms because they are combustible. Many of the supplies that we have …
Q: What are the limitations to bulletin boards that have paper tacked to them, in exit corridors in a hospital? Do they have to be behind glass doors? A: No, …
Q: We have a new 12 story patient tower that is built next to our original 4 story hospital. On the 4th floor there is a bridge that spans across the …
Q: We are considering the use of storage devices that hook over the top of the patient room corridor doors that will store supplies that we use for contact precautions …
Q: Is there a rule about how far apart hand sanitizers should be? One of my directors wants to put one just inside a patient room and outside in the …
Q: In 1970, our smoke compartment barriers were originally constructed to 1-hour fire ratings, but I see that the Life Safety Code allows existing smoke compartment barriers to be only …
Q: I read an article were an interruption gate is required in a stairwell to prevent people from traveling past the floor where they should exit. Is this a requirement …
Q: Are electrical equipment rooms required to be fire rated? We have a dry-type transformer in an utility room on one of our nursing units and wanted to know if …
Q: Do all electrical rooms have to have automatic sprinklers installed in them? Our electrician tells us there are exceptions to installing sprinklers in an electrical room even when the …
Q: We have open concrete beam floor construction in our hospital, and the depth of the beams are14 inches below the deck, and they are spaced 70 inches center-to-center. The …
Q: Are hard-surface sidewalks, such as concrete, required between the exit door and the public way in order to qualify as an exit discharge? I was told that we need …
Q: In a business occupancy (physician medical office) can waste receptacles that are used for exam room waste paper be made of plastic, or do they have to be fire …
Q: Are we required to replace the batteries that start our emergency generators every two years? Our generator service contractor told us that the code requires us to replace the …
Q: What, if any, are the limits on bulletin boards in a means of egress corridor? I have managers who want to place large quantities of paper on their bulletin …
Q: We have a contractor who wants to use a propane gas-fired portable heater to warm an unoccupied space that is currently under renovation in the hospital. The central heating …
Q: What are the limitations to installing a 112 kVA dry-type transformer in a soiled utility room? Our local building inspector wants a shield around the transformer separating it from …
Q: Do we need to test our elevator recall system once a month? I don’t see where this is required in the Life Safety Code (LSC). We test our elevator …
Q: Our hospital is fully protected with automatic sprinklers. Our cubicle curtains have an open mesh at the top to prevent water discharged from a sprinkler head from being obstructed …
Q: Our gas storage room has little mini-helium tanks which are full and under pressure. Are these tanks required to be restrained in the same way that the larger ‘E’ …
Q: During a recent survey, an inspector cited us for not having the escutcheon (trim) plates around all of our sprinkler heads. I always thought these plates were for decorative …
Q: What ILSM's apply to occupancies other than healthcare? For example, if a fire alarm/sprinkler system is out of service for more than 4 hours in a 24 hour period in …
Q: What is actually required in order to perform a Fire Watch when the fire alarm system is inoperative? How often should a Fire Watch be performed? A: The Life …
Q: We are aware of the NFPA 99 requirements to separate the transfilling operation of liquid oxygen from our patient care areas with a 1-hour fire rated room with noncombustible …
Q: Like many older hospitals, we have areas with a mix of quick response sprinkler heads and standard response sprinkler heads. Are we required to go back and make them …
Q: Our project team insists on using non-combustible plastic sheeting for temporary barriers between construction areas and occupied areas of our hospital. Is this acceptable according to the Life Safety …
Q: We recently had a consultant advise us to always activate our fire alarm system whenever we conduct a fire drill. We don’t always do that because we perform so …
Q: During a recent inspection, the surveyor cited our hospital for having dead-bolt locks on our patient room doors. None of the doors were locked at the time of the …
Q: Is it acceptable for a 20 minute fire door to be used for a hazardous room in a new construction of a hospital? I'm looking at the Life Safety …
Q: We are completing a project that includes a new generator for our hospital. The installing contractor will conduct a 2-hour load test as part of his commissioning. My question …
Q: What is the LSC stance on card swipe systems to access doors? We were told by a city inspector that we could not install access control locks because we …
Q: Is it allowable to use clean compressed medical air to blow off equipment in central sterile? Currently, we use compressed air from our medical air distribution system to dry …
Q: Is an elevator equipment room required to be sprinklered in a hospital? A consultant recently told us that NFPA 13 requires us to install sprinklers inside our elevator equipment …
Q: We have multiple paths of egress from an area used by our Bio-Med staff, and for security reasons we lock the doors to and from this area. This is …
Q: Is every nursing unit in our hospital required to have one fire drill per shift per quarter? Our Director of Quality says we are required to do so, but …
Q: We want to relocate a smoke compartment barrier to the entrance of our OR Surgery, in order to make the OR Surgery a suite of room. Do you see …
Q: In my hospital, I have an exit stairwell that does not discharge to the outside of the building, but rather it terminates in a corridor inside the building. Is …
Q: We plan to take an existing small closet and make it into a new soiled linen room. It measures approximately 35 square feet and I plan to construct this …
Q: We have our Code Blue medical emergency system tied into the hospital’s fire alarm system and the control panel is located next to the telephone operators. They will then …
Q: I am aware that medical gas manifold systems have to meet the regulations of NFPA 99-1999 (NFPA 99-2005 for Joint Commission and CMS compliance), and there are specific requirements …
Q: We have a physicians' office building in an existing business occupancy, which has two remotely located exits. Exits paths are clearly marked with lit exit signs and the egress …
Q: Are toasters, toaster ovens, microwave ovens and coffee makers prohibited in a staff lounge? We have nursing units that want these appliances in their staff lounge but we want …
Q: Have you ever heard of patient files on shelves needing to be covered with a sheet of plastic to protect it from the sprinkler system? My VP of Accreditation …
Q: Is there a maximum distance that a fire extinguisher needs to be located from a helipad? Where would I find the fire extinguisher requirements for a helipad? A: NFPA …
Q: I know that Joint Commission permits alcohol based hand-rub (ABHR) dispensers in the corridors of hospitals, but I do not see where it is permitted according to the Life …
Q: Is joint compound acceptable to use to seal penetrations through a fire rated barrier made with gypsum wall board? We used the joint compound to seal around conduits and …
Q: Are you really in favor of re-classifying patient rooms for floor storage? I thought that was dicey business. Aren't there a lot of things that need to be done …
Q: I have an unattached building that houses a cardiac rehab/wellness center with office space. We are converting 4900 sq ft into a day care. It is separated from the …
Q. Is there a Life Safety Code requirement to post “No Smoking” signs on patient room doors where oxygen is being administered? Our Respiratory Care department insists on posting No …
Q: Does the Life Safety Code specify if we have to lock up our sterile scalpels in the same way that our syringes are locked? I have looked everywhere on …
Q: What is the requirement in time that a fire alarm needs to be transmitted to the fire department? Our fire alarm communication automatic dialer takes nearly 3 minutes to …
Q: During a recent inspection, our fire marshal said the 5-year standpipe water-flow test is required to have at least 500 gallons per minute (GPM) at the roof. We are …