March 2008 Vol. 10, No.

Healthcare Life
Safety Compliance
The newsletter to assist healthcare facility managers with fire protection and life safety

Surveyors’ focus may bend Consider these three practical benefits of being able to
classify an area in a hospital as something other than a
on occupancy classification healthcare occupancy.

Correctly classifying occupancies using the Life Safe-

ty Code® (LSC) may sound like an esoteric exercise, but ✔ You may be able to save money on needless
there are advantages to doing so. corrective actions.
The Joint Commission (formerly JCAHO) and the For example, ambulatory healthcare occupancies that

Centers for Medicare & Medicaid Services (CMS) both are properly separated from healthcare occupancies don’t

evaluate healthcare facilities based upon how the LSC need to construct
“You don’t have to spend
classifies the sites. corridors that are
your hard-earned dollars
Occupancies are “the foundation of why The Joint at least 8 ft wide if
on repairs that aren’t
Commission and CMS . . . come and visit,” said Joshua a wing undergoes
necessary.”
W. Elvove, PE, CSP, FSFPE, a fire protection engineer renovation. That’s
—Joshua W. Elvove, PE, CSP, FSFPE
in Aurora, CO. because the LSC
sets corridor widths for newly constructed ambulatory sites

A trio of occupancy distinctions to help you at a minimum of 44 inches. “You can save money,” Elvove

Elvove, who is also a former Joint Commission life said. “You don’t have to spend your hard-earned dollars

safety surveyor, spoke during an HCPro audioconference on repairs that aren’t necessary.”

about occupancies in January. (See “Occupancy types

you’ll encounter in the medical industry” on p. 3 for a run- ✔ Joint Commission surveyors may not conduct
down of typical occupancies found in healthcare facilities.) above-the-ceiling inspections of smoke bar-
rier walls in business occupancies.
That’s because the LSC generally sets no provisions for
IN THIS ISSUE
smoke compartments in business occupancies. When look-
p. 4 Occupancy chart
This comparison details the Life Safety Code®’s ing above the ceiling for the integrity of smoke barriers,
requirements among healthcare, ambulatory surveyors often find unsealed penetrations, which can lead
healthcare, and business occupancies.
to a citation. “Don’t have The Joint Commission looking
p. 6 Investigation is under way above your ceiling if you don’t need to,” Elvove said.
A fire that burned an infant in a bassinet at a Minnesota hospital may Note that there are situations in which the LSC re-
turn out to be a one-of-a-kind incident.
quires smoke barriers in business occupancies (e.g., the
p. 9 Cracking the Code
Patient sleeping suite rules offer several benefits, including the use of floor below a healthcare occupancy), he added.
intervening rooms for egress.

p. 10 Questions & Answers ✔ Areas that count as occupancies other than

Does NFPA 72, National Fire Alarm Code, allow for properly trained
hospital employees to perform fire security systems inspections? healthcare may help you avoid two-day life
safety surveys by The Joint Commission.
p. 12 Quick tip
Portable space heaters may be okay in nurses’ stations, says an official As of January 1, the accreditor now schedules two-day
from the NFPA.
> continued on p. 2
Page  Healthcare Life Safety Compliance March 2008

Occupancy < continued from p. 1

life safety tours for buildings that have more than 750,000 a fire protection engineer for Network 3 of the U.S. De-
square feet healthcare occupancy space. partment of Veterans Affairs in West Haven, CT, and
“This is the hook to be thinking about,” Elvove said. If owner of PSL Engineering, LLC, in Shelton, CT.
you can use occupancy classifications to keep your health- With that being the case, it would behoove you to
care areas to less than 750,000 square feet, “it might stave understand what occupancy types you have in your
off an extra day” with a life safety specialist. building and the provisions the LSC sets for each of
them, added Leszczak, who also spoke during HCPro’s
You should anticipate business applications audioconference.
“There’s going to be a lot of business occupancies The chart on pp. 4–5 compares various LSC require-
­within our healthcare facilities,” said Peter Leszczak, ments based on whether an occupancy is healthcare,
ambulatory healthcare, or business. n
Editorial Advisory Board Healthcare Life Safety Compliance

Group Publisher: Bob Croce, bcroce@hcpro.com

Executive Editor: J ulia Fairclough, jfairclough@hcpro.com,
Editor’s note: To purchase a CD of our audioconference,
781/639-1872, Ext. 3109 “Avoid Life Safety Code® Noncompliance: Correctly Classify Occu-
Sr. Managing Editor: S
 cott Wallask, swallask@hcpro.com,
781/639-1872, Ext. 3119 pancies in Healthcare Facilities,” go to www.hcmarketplace.
Contributing Technical Editor: J ames K. Lathrop com/prod-6058.html or call our customer service center at
Vice President
Koffel Associates, Inc. 800/650-6787.
Niantic, CT

James R. Ambrose, PE Peter Leszczak Mixed versus separated occupancies

Principal Network 3 Fire Protection Engineer
Code Consultants, Inc. U.S. Department of Veterans Affairs
St. Louis, MO West Haven, CT Generally, a building can house three types of occu-
Frederick C. Bradley, PE David Mohile
Principal President
pancy configurations:
FCB Engineering Medical Engineering Services, Inc.
Alpharetta, GA Leesburg, VA
1. A building can house a single occupancy and meet
Michael Crowley, PE Daniel J. O’Connor, PE the requirements of that occupancy.
Senior Vice President, Vice President, Engineering
Engineering Manager Schirmer Engineering Corporation 2. A mixed occupancy occurs when two or more occu-
Rolf Jensen & Associates, Inc. Deerfield, IL
Houston, TX pancy types intermingle within an area, and it may be
Thomas Salamone
Joshua W. Elvove, PE, CSP, FSFPE Director of Safety & Security difficult to tell where one type ends and another begins.
Fire Protection Engineer Norwalk Hospital
Aurora, CO Norwalk, CT In such cases, the more stringent requirements of each
A. Richard Fasano Robert Westenberger, CHFM-MCO
Manager, Western Office Construction Project Mgr. occupancy prevail.
Russell Phillips & Associates, LLC Atlantic Health System
Elk Grove, CA Morristown, NJ 3. Separated occupancies are within the same build-
Burton Klein, PE William Wilson, CFPS ing, but divided by an appropriately rated fire barrier.
President Fire Safety Coordinator
Burton Klein Associates William Beaumont Hospitals In these instances, each occupancy observes its own
Newton, MA Royal Oak, MI
provisions. Note that typically, if a required egress
Healthcare Life Safety Compliance (ISSN 1523-7575) is published monthly by HCPro, Inc., 200 Hoods Lane, Marble- from a healthcare occupancy goes through anoth-
head, MA, 01945. Subscription rate is $289 for one year and includes unlimited telephone assistance. Single copy price is $25.
Postmaster: Send address changes to Healthcare Life Safety Compliance, P.O. Box 1168, Marblehead, MA 01945. Copyright
© 2008 HCPro, Inc. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may
er occupancy type, that second occupancy needs to
be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at
978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions meet all healthcare egress requirements in addition
or for technical support with questions about life safety compliance, call 781/639-1872 or fax 781/639-2982. For renewal or sub-
scription information, call customer service at 800/650-6787, fax: 800/639-8511, or e-mail: customerservice@hcpro.com. Occasion- to its own requirements (there are exceptions to this
ally, we make our subscriber list available to selected companies/vendors. If you do not wish to be in­cluded on this mailing
list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of HLSC.
Mention of products and services does not constitute endorsement. Advice given is general and based on National Fire Protec-
provision).
tion Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is ex-
pressed or implied. Information should not be construed as engineering advice specific to your facility and should not be acted
upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information
and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter Source: 2000 Life Safety Code®.
or otherwise. Advisory Board members are not responsible for information and opinions that are not their own.

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© 2008 HCPro, Inc.

March 2008 Healthcare Life Safety Compliance Page 
Occupancy types you’ll encounter in the medical industry
Below are typical occupancies found in healthcare fa-
cilities, along with uses that could correspond to the occu-
pancy types. Some uses may fall among several occupancy
types, depending on the situation. Also, authorities are free
to take their own stance on occupancy classifications:
➤ Healthcare occupancies (Chapters 18 and 19 in
the Life Safety Code ) provide care and treatment of
®
four or more people incapable of rescuing themselves
during a fire due to medical condition or age. These
occupancies also provide 24-hour sleeping accommo-
dations and rely on staff members who are trained to
assist people during an emergency. Examples: hospitals,
limited care facilities, and nursing homes.
➤ Ambulatory healthcare occupancies (Chapters
20 and 21) provide medical care on an outpatient
basis without sleeping accommodations. They may
also provide treatment or anesthesia to four or more
people such that the treatment renders them un-
able to rescue themselves during a fire. Ambulatory
requirements are a hybrid of healthcare and busi-
ness occupancies. Note: If any of these areas serve
four or more litterborne inpatients, then healthcare
occupancy rules apply. Examples: ambulatory surgery
centers, ERs, certain dialysis centers, radiology centers, gas-
trointestinal clinics, and cardiac catheterization labs.
➤ Business occupancies (Chapters 38 and 39) han-
dle business transactions (other than mercantile ac-
tivities). Examples: administrative offices, physician offices,
some outpatient clinics, medical classrooms that house fewer
than 50 people, certain dialysis centers, some laboratories,
and dental offices (as long as they don’t provide anesthesia
to four or more patients).
➤ Residential board and care occupancies (Chap-
ters 32 and 33) provide housing and personal care
services to four or more residents who aren’t related
to the building’s owners. Examples: assisted-living facili-
ties and group homes serving elderly or disabled people.
➤ Lodging and rooming house occupancies (Chap-
ters 26) provide sleeping accommodations for 16 or
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
© 2008 HCPro, Inc.
fewer people, but don’t offer personal care services.
Examples: group homes serving elderly or disabled people,
certain hospices, behavioral health treatment centers, and
assisted-living facilities.
➤ Hotel and dormitory occupancies (Chapters 28
and 29) provide sleeping accommodations for 17 or
more people in rooms under single management. Ex-
amples: behavioral health treatment centers and assisted liv-
ing facilities.
➤ Assembly occupancies (Chapters 12 and 13) act as
gathering places for more than 50 people for the pur-
poses of eating, worship, deliberation, and similar us-
es. Examples: chapels, cafeterias, large conference rooms,
and gymnasiums.
➤ Industrial occupancies (Chapter 40) feature man-
ufacturing, repairing, processing, or mixing services.
Examples: laundries, maintenance shops, mechanical spac-
es, some laboratories, and sterile supply areas.
➤ Storage occupancies (Chapter 42) primarily store
goods, products, merchandise, animals, or vehicles.
Examples: warehouses, parking garages, and cold-storage
facilities. n
Sources
Life Safety Code®; Peter Leszczak, a fire protection engineer for Net-
work 3 of the U.S. Department of Veterans Affairs in West Haven, CT,
and owner of PSL Engineering, LLC, in Shelton, CT; Joshua W. Elvove,
PE, CSP, FSFPE, a fire protection engineer in Aurora, CO; James K.
Lathrop, vice president at Koffel Associates, Inc., in Niantic, CT; and
The Joint Commission.
New Boot Camp dates just announced
Following up on the success of last year’s events,
HCPro has announced the following 2008 dates for the
Life Safety Code® Boot Camp—Hospital Version:
➤ September 8–10 in Burlington, MA (outside of Boston)
➤ October 15–17 in Dallas
➤ November 10–12 in Orlando, FL
Full details are available at www.hcprobootcamps.com
(scroll down the left-hand column).
Page  Healthcare Life Safety Compliance March 2008

Comparing major occupancy classifications in the LSC

This chart compares a sampling of the 2000 Life All of the provisions reflect existing sites as defined in
Safety Code ’s (LSC) requirements among healthcare,
®
the LSC. Provisions for newly constructed sites differ in
ambulatory healthcare, and business occupancies. some areas.

Healthcare Ambulatory Business

Minimum Stringent—various requirements as set Not stringent—various requirements No requirements

construction by Table 19.1.6.2, with added flexibility based on how many stories the build-
for areas protected by sprinklers ing has and whether sprinklers protect
(see 19.1.6) it; also, authorities may approve alter-
nate types of construction (see 21.1.6)

Corridor At least 4 ft (see 19.2.3.3—8 ft must At least 44 inches (see 21.2.3.2) At least 44 inches if the corridor
width be maintained if that width is already serves an occupant load of 50 or
present) more people (see 39.2.3.2)

Number of At least two (see 19.2.4) At least two (see 21.2.4) Generally, at least two, with several
exits from exceptions allowing one exit
(see 39.2.4)
each floor
Travel ➤ No more than 100 ft from the cor- ➤ No more than 100 ft from the No more than 200 ft from any point
distances ridor door of any room to an exit corridor door of any room to an to an exit (300 ft with sprinklers)
(150 ft with sprinklers) exit (150 ft with sprinklers) (see 39.2.6)
➤ No more than 150 ft from any point ➤ No more than 150 ft from any
in a room to an exit (200 ft with point in a room to an exit (200 ft
sprinklers) with sprinklers)
➤ No more than 50 ft from any point ➤ No sleeping rooms allowed in
in a patient sleeping room to the ambulatory
room’s egress door (see 21.2.6)
(see 19.2.6)

Vertical One-hour fire barrier, with some 30-minute fire barrier, with some ex- 30-minute fire barrier, with some ex-
opening exceptions (see 19.3.1.1) ceptions (see 21.3.1 and 39.3.1.1) ceptions (see 39.3.1.1 and 8.2.5.4)
protection
Hazardous One-hour fire barrier or sprinklers in One-hour fire barrier or sprinklers One-hour fire barrier or sprinklers
area most cases (see 19.3.2) in most cases; one-hour fire barrier in most cases; one-hour fire barrier
and sprinklers for severe hazards (see and sprinklers for severe hazards (see
protection
21.3.2 and 39.3.2) 39.3.2 and 8.4)

Sprinklers Not required outright, though many Generally not required; however some Not required
construction types mandate them (see construction types mandate them (see
19.3.5) 21.1.6)

Extinguishers Required throughout the occupancy Required throughout the occupancy Required throughout the
(see 19.3.5.6) (see 21.3.5.2) occupancy (see 39.3.5)

Corridor walls 30-minute fire resistance rating with No requirements No requirements

sprinkler exceptions (see 19.3.6.2)

Subdivision ➤ Smoke compartments required for
of building stories with sleeping rooms for more
than 30 patients
space
➤ Two-hour walls must separate the
facility from ambulatory centers,
medical clinics, and similar sites
(see 19.1.2.2, 19.1.2.3, and 19.3.7)
➤ At least two smoke compart­­ments No requirements
must divide the facility, with
exceptions
➤ One-hour walls must separate
the facility from other occupan-
cies (two-hour walls must separate
healthcare)
(see 21.1.2.1 and 21.3.7)

Source: 2000 Life Safety Code®.

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March 2008 Healthcare Life Safety Compliance Page 

Healthcare Ambulatory Business

Fire drills Quarterly on each shift (see 19.7.1.2) Quarterly on each shift (see 21.7.1.2) Periodic drills required when more
than 500 people occupy the building
or more than 100 people occupy areas
above or below street level (see 39.7.1)

Evacuation Required for staff members (see 19.7.1 Required for staff members No requirements
training and 19.7.2) (see 21.7.1 and 21.7.2)

Smoking Prohibited in areas with flammable liq- Prohibited in areas with flammable liq- No requirements
uids, oxygen, or combustible gases uids, oxygen, or combustible gases
(see 19.7.4) (see 21.7.4)

Egress All permitted except slide escapes, esca- All permitted except slide escapes All permitted except slide escapes
components lators, and fire escape stairs (see 19.2.2) (see 21.2.2 and 39.2.2) (see 39.2.2)

Door width 32 inches (see 19.2.2.2.1 and 7.2.1.2.3) 32 inches (see 21.2.2.1, 39.2.2.2, and 28 inches; 24 inches permitted if not
7.2.1.2.3) serving occupants with mobility im-
pairments (see 39.2.2.2 and exception
1 to 7.2.1.2.3)

Door locking ➤ Access control or delayed egress Access control or delayed egress per- Access control or delayed egress per-
permitted mitted (see 21.2.2.1, 39.2.2, and mitted (see 39.2.2.2 and 7.2.1.6)
➤ Doors may be locked for clinical 7.2.1.6)
reasons
(see 19.2.2.2 and 7.2.1.6)

Dead-end No specific limits (see 19.2.5.10) 50 ft (see 21.2.5 and 39.2.5.2) 50 ft (see 39.2.5.2)
corridors
Common No requirements 75 ft; 100 ft with sprinklers 75 ft; 100 ft with sprinklers
path of travel (see 21.2.5 and 39.2.5.3) (see 39.2.5.3)

Suites ➤ Maximum area of 5,000 square feet Suites more than 2,500 square feet No requirements
or less for patient sleeping suites need at least two exits (see 21.2.4.2)
➤ Maximum area of 10,000 square
feet or less for nonpatient sleeping
suites
➤ Patient sleeping suites more than
1,000 square feet need at least
two exits
➤ Any nonpatient sleeping suites more
than 2,500 square feet need at least
two exits
(see 19.2.5)

Occupant ➤ 120 square feet per person in 100 square feet per person (see 21.1.7, 100 square feet per person (see
load ­patient sleeping areas 39.1.7, and 7.3.1.2) 39.1.7 and 7.3.1.2)
➤ 240 square feet per person in
­patient treatment areas
(see 19.1.7 and 7.3.1.2)

Fire alarm Required (see 19.3.4) Required (see 21.3.4) Required for any of the following:
system ➤ The building is two or more sto-
ries above level of exit discharge
➤ The occupancy has 100 or more
occupants above or ­below level
of exit discharge
➤ The occupancy has 1,000
or more total occupants
(see 39.3.4.1)

Source: 2000 Life Safety Code®.

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© 2008 HCPro, Inc.

Page  Healthcare Life Safety Compliance March 2008
ECRI Institute investigates an infant bassinet fire
Baby suffered burns, but no one yet knows exactly why the incident occurred
A fire that burned an infant in a bassinet at a Min-
nesota hospital may turn out to be a one-of-a-kind
incident.
The infant suffered burns after flames broke out while
the baby received treatment from an oxygen hood. The
fire occurred on January 22 at Mercy Hospital in Coon
Rapids, MN.
The hospital described the fire as a “spontaneous erup-
tion of flames,” according to a statement given to us by
spokesperson David Kanihan.
“This is a unique case,” said Mark Bruley, vice presi-
dent of accident and forensic investigations at ECRI In-
The infant suffered burns
after flames broke out
while the baby received
treatment from an
oxygen hood.
tal has hired to review the bassinet fire. ECRI Institute
is well known within healthcare, and has published nu-
merous resources in the field of fire protection on pre-
venting surgical fires.
The following is the chain of events that occurred dur-
ing the fire, as told by the hospital:
1. The infant was in an open-topped bassinet under
a warmer, and was using an oxygen hood, which
is a transparent cover that surrounds a baby’s
head to provide additional oxygen from a supply
source
2. Something within the oxygen-enriched environ-
ment of the bassinet ignited
3. Nurses who were attending to the baby quickly
extinguished the flames
4. Mercy Hospital transferred the child to Hennepin
County Medical Center in Minneapolis, which of-
fers specialized burn care
No one else suffered injuries from the fire.
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Don’t draw conclusions yet
On the surface, the fire seems similar to the risks en-
countered during surgical fires, but Bruley disagreed
with that notion, at least at this point.
“No, that’s not accurate,” he said when asked about
connecting this blaze to surgical fire risks. “It’s already
been reported from the hospital’s perspective that [offi-
cials there have] never seen anything like this.”
Bruley also has never encountered a fire like this one
in his 31 years in the industry, he said. “Everyone’s look-
ing for an answer, even if the answer is that there’s no
answer,” he added. “We just don’t know [yet].”
stitute in Plymouth Kanihan did not answer further questions from Health­
Meeting, PA. care Life Safety Compliance, including how nurses ex-
ECRI Institute tinguished the flames and what companies manufactured
is a healthcare re- the items involved in the fire.
search company “I’m not able to get into these details while the inves-
that Mercy Hospi- tigation is ongoing,” he said.
Expect a wide review to result
As of early February, the investigation was ongo-
ing, Bruley said. He anticipated his investigation could
take anywhere from three weeks to three months to
complete.
The hospital has invited the Minnesota Department
of Health, the state fire marshal’s office, and the Centers
for Medicare & Medicaid Services to participate in the
investigation.
The hospital has also alerted the U.S. Food and Drug
Administration (FDA), which regulates medical devices
and tracks problems associated with these items.
The FDA’s medical device reporting database lists sev-
eral reports of fire and smoke problems with bassinets,
warmers, and infant oxygen hoods. (See “Federal data-
base tracks past bassinet and warmer fires” on p. 7.)
However, many of the FDA reports are more than 15
years old, and none of them match the early description
of the fire at Mercy Hospital. n
© 2008 HCPro, Inc.
March 2008 Healthcare Life Safety Compliance Page 

U.S. Food and Drug Administration reporting

Federal database tracks past bassinet and warmer fires

The U.S. Food and Drug Administration (FDA) main- Comments: A power module failure may have
tains an extensive database of medical device errors and caused the smoke.
problems, including several fires and smoky situations
that involved bassinets, radiant warmers, and infant ox- April 1990
ygen hoods. Incident: An infant suffered serious burns after a fire
There has been no connection established between the occurred while the baby used an oxygen hood, heater,
list below and a fire that occurred on January 22 that in- and nebulizer.
jured an infant in a bassinet. We provide this list for in- Comments: None listed.
formational purposes only.
June 1989
March 1996 Incident: Something fell from a warmer and burned a
Incident: A warmer’s heating element shorted out, hole through a bassinet’s mattress. There were no injuries.
causing its coating to burn. There were no injuries. Comments: Someone possibly hung an item off the
Comments: An electrical problem caused the short. warmer earlier, which left excess material on the warmer.

April 1993 May 1987

Incident: A spark from the heating element of a ra- Incident: An under-bed heating element started a
diant warmer fell into an empty bassinet, burned a blan- mattress fire. There were no injuries.
ket, and burned a hole through the mattress. Comments: An electrical arc in a temperature sens-
Comments: Improper installation of a heating ele- ing switch was probably the cause of the fire. The warm-
ment likely caused the spark. er was manufactured in 1973. n

November 1991 Editor’s note: You may want to check out for yourself the
Incident: Wires in a bassinet incubator overheated FDA’s medical device reports. Go to www.fda.gov/search/­
and smoked, but there were no injuries. databases.html, scroll down to the Medical Devices heading,
Comments: Poor maintenance of the bassinet, which and click on the MAUDE link. MAUDE stands for the Manu-
was 18 years old, likely led to the overheating. facturer and User Facility Device Experience database. Once you
link through, don’t forget to also explore the “Medical device re-
August 1991 porting search” link at the bottom of the page.
Incident: A clinician reported seeing sparks from an
oxygen regulator installed on an infant radiant warmer. Relocating? Taking a new job?
There were no injuries. If you’re relocating or taking a new
Comments: Hydrocarbon contamination of the oxy- job and would like to continue receiving

gen cylinder’s valve may have caused the sparks. Healthcare Life Safety Compliance, you
are eligible for a free trial subscription.
Contact customer serv­ice with your moving information
February 1991
at 800/650-6787. At the time of your call, please share
Incident: Smoke came from the top of an infant radi-
with us the name of your replacement.
ant warmer. There were no injuries.

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© 2008 HCPro, Inc.

Page  Healthcare Life Safety Compliance March 2008
Joint Commission further explains its life safety chapter
Editor’s note: Below is a series of questions that we e-mailed
to The Joint Commission’s press office on December 18, 2007,
in the hopes of including comments in a prior story about the
proposed life safety standards (see the February Healthcare
Life ­Safety Compliance for full details). The Joint Com-
mission (formerly JCAHO) missed our deadline and sent its re-
plies on January 25. The answers below are quoted directly
from an e-mail from ­Elizabeth Zhani, a spokesperson for the
accreditor.
HCPro: Is it accurate to say that the current scoring
benefits of the building maintenance program do not
exist in the pro-
“The new life safety posed life safety
chapter will clearly standards?
identify which types of Zhani: No.  HCPro: What message is The Joint Commission send-
organizations are subject
to life safety compliance.” HCPro: If the
—Elizabeth Zhani scoring benefits in
fact do still exist
in the proposed standards, where are they mentioned?
Zhani: For 2008, the scoring advantage remains. The
2009 scoring issues have not been published.
HCPro: If the proposed standards are approved as
written, will they essentially replace the current Part
3 in the Statement of Conditions (SOC)? It seems that
many of the proposed EPs are similar to the questions
in Part 3.
Zhani: Yes.
HCPro: The proposed standards seem to be a very
good effort to educate safety officers and facility direc-
tors who are new to life safety. Do you agree with this
statement?
Zhani: The requirements in the life safety chapter
are designed to help organizations protect people from
fire and smoke in buildings where care, treatment, and
services are provided.
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
HCPro: You mentioned in the online overview of the
chapter that The Joint Commission is developing a system
where the “scoring of multiple LS EPs will not, in and of
itself, trigger an adverse decision.” Can you explain what
the scoring system will be for this? What is the concern
that is causing this approach?
Zhani: This is still under discussion.
HCPro: Proposed standard LS.2.50 sets requirements
for fireplaces. Fireplaces don’t appear to be specifically not-
ed in the current hospital fire safety standards or Part 3 of
the SOC. Why did fireplaces get this new emphasis?
Zhani: This is referenced in the NFPA 101-2000 [i.e.,
the Life Safety Code®].
ing, if any, to hospital leaders by pulling life safety into
its own chapter?
Zhani: Creating a separate life safety chapter will re-
move a source of confusion that some organizations
have had with the current management of the environ-
ment of care chapter. The new life safety chapter will
clearly identify which types of organizations are subject
to life safety compliance. 
The life safety chapter applies to the following types of
organizations:
➤ All hospitals, critical access hospitals, and long term
care organizations
➤ Behavioral health care settings that provide 24-hour
care in a building or portion of a building that pro-
vides sleeping accommodations, but that does not
qualify as a one- or two-family dwelling
➤ Freestanding inpatient hospice facilities that are
either owned or leased
➤ Outpatient facilities where four or more patients
at the same time are provided either anesthesia
or outpatient services that would temporarily ren-
der them incapable of saving themselves in an
emergency n
© 2008 HCPro, Inc.
March 2008 Healthcare Life Safety Compliance Page 

Patient sleeping suite rules can benefit facilities,

including the use of intervening rooms for egress
Each month in this column, a staff member at Koffel Associ-
ates, Inc., in Elkridge, MD, clarifies the code references behind
commonly misunderstood healthcare requirements. Fire protec-
tion engineer Diana Hugue, PE, authored this ­installment.
One often overlooked instrument in everyone’s life
safety toolbox is the concept of suites. Suites are created
by rooms that do not have direct access to a corridor.
Unfortunately, the 2000 edition of the Life Safety Code®
(LSC) spreads out suite requirements among various sec-
nursing personnel. The nursing staff must be able to see
all rooms in the sleeping suite.
Exit access varies by suite size
When it comes to size, sleeping suites cannot exceed
5,000 square feet (LSC, 18/19.2.5.6). Note that this pro-
vision changed in the 2006 LSC by allowing suites to go
up to 7,500 square feet.
You can also subdivide all suites with non-fire-rated,
noncombustible, or limited-combustible partitions (LSC,

tions. By comparison, the 2006 LSC consolidates these 18/19.2.5.4).

requirements into easily readable sections. Regardless of Patient sleeping suites of more than 1,000 square feet

edition, the requirements for sleeping suites are the same must have at least two exit access doors that are remote-
ly located from each other (LSC, 18/19.2.5.2). This en-
for new and existing healthcare occupancies.
sures that occupants won’t get trapped in a suite should
There are many benefits to having suites in your facil-
one of the exit access doors become unusable.
ity. For example, when you create a suite, you eliminate
If your facility does not currently use suites, it may be
corridor requirements within the suite space, which al-
worth reevaluating your plans and layouts. n
lows for some leniency with clutter issues. (See “The pros
and cons of suites” at the right for further information.)
This column will specifically discuss suites involving The pros and cons of suites
patient sleeping rooms, using the 2000 LSC as a basis.
Advantages
In the next issue, we will look at nonsleeping suites and
➤ Suites can solve Life Safety Code® problems in existing
their specific requirements. situations or in new design
➤ The circulation space within a suite is not a corridor, thus:
Intervening room provides a unique benefit – Doors do not have to latch
In suites, most of the usual healthcare egress require- – Doors do not have to resist the passage of smoke
ments still apply. But there are some differences. For ex- – The 8-ft width is not applied
ample, every habitable room shall have a door leading – Restrictions on use of a corridor do not apply

directly to an exit access corridor. – Patient treatment can be open within space

However, in the case of a suite, you can have an in-

Common problems
tervening room prior to reaching the exit access corridor
➤ Travel distance within a suite is often excessive
(LSC, 18/19.2.5.1 and its exceptions). The intervening
➤ The required second way out is often not remote
room can’t be a hazardous area (LSC, 18/19.2.5.5). This
➤ Suites often exceed their allowable size
requirement makes sense, as you would not want to put ➤ Suite designs can result in excessive dead-end corridors
occupants in greater danger as they leave the suite. ➤ Suites can improperly restrict egress from other areas
Suites can feature this intervening room as long as the on a floor
arrangement allows for constant, direct supervision by

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© 2008 HCPro, Inc.

Page 10 Healthcare Life Safety Compliance March 2008
Questions
Each month, Jennifer Frecker and James K. ­Lathrop
&Answers
of fire protection consulting firm Koffel Associates, Inc., in
Elkridge, MD, answer your questions about life safety com-
pliance. Our editorial advisory board also reviews the Q&A
column.
Egress arrangements from suites
Recently we divided a nonpatient sleeping area
because we wanted to utilize a suite configuration
and the area was more than 10,000 square feet. We
divided it in half with a smoke barrier, and this barrier
crosses two corridors.
We placed a pair of double egress doors at each
location as part of the smoke barrier. Occupants
will egress through the adjoining suite to an alter-
nate exit. The other egress opens directly onto a
corridor.
My question has to do with these double doors. I
can’t find the requirement, but I remembered seeing
somewhere that the doors had to positively latch,
even though they are in a smoke barrier. I seem to
remember this was because of the suite configu-
ration and the fact that under the 2006 Life ­Safety
Code® (LSC), you can egress through an adjoining
suite. Could you clarify this for me?
For starters, the 2000 LSC—which The Joint Com-
mission (formerly JCAHO) and the Centers for
Medicare & Medicaid Services (CMS) enforce—isn’t
clear on this arrangement. There is no specific discussion
of suites egressing through adjoining suites, and a con-
servative view might conclude that you can’t have this
type of arrangement.
The concept is that suites are separated by a smoke-
resistive wall such as a corridor wall. The ­intent was
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that the positive latching requirements of 18/19.3.6.3.2
apply to this situation.
However, the 2006 LSC is much clearer in stating that
you must provide a latch on a door between suites—see
paragraphs 18/19.2.5.6.2.2(C).
There are options to use the 2006 LSC’s provisions
in light of CMS’ and The Joint Commission’s enforce-
ment of an earlier code edition. The Joint Commission
allows you to use the entire 2006 LSC if you want, as
long as you note it in your Statement of Conditions and
alert surveyors to this fact upon their arrival. You may
also be able to secure a waiver or equivalency by not-
ing the 2006 provisions as clarifications.
Sprinklers rules for suspended ceilings
I am confused as to why my code inspector writes
up every corner that may be chipped in a non-fire-
rated ceiling system. He says that the broken tile lets
hot gases from a potential fire leak above the ceiling,
therefore not letting the space below the ceiling get
hot enough for the sprinklers to go off. I think he is
misinterpreting the code provisions for corridor walls
that terminate at the ceiling. Are sprinklers different
for rooms that do not have ceilings?
The citation of missing or broken ceiling tiles affects
the requirements for smoke-resistive corridors and
sprinkler protection. This issue applies to areas in which
you use drop-in acoustical ceiling tiles. Our answer ad-
dresses only the sprinkler issues because that is what
you asked about.
Listed sprinklers receive testing for a specific con-
figuration (e.g., in an acoustical ceiling tile system).
The test results, on which the listing is based, depend
on the specific configuration, and a deviation from that
© 2008 HCPro, Inc.
March 2008 Healthcare Life Safety Compliance Page 11
­configuration may result in a failure or no listing. This is
why you must install sprinklers per the listing of the type
of sprinkler.
If a ceiling tile is missing or damaged, the hot gases
from the fire would not build up in the same manner
as if the ceiling tile were intact, possibly delaying the
activation of the sprinkler. This problem stems from
the arrangement of the ceiling grid system.
Sprinkler protection must be installed within 12
inches of a ceiling. Usually grid systems are more than
12 inches below the floor or roof above.
In rooms that do not have a suspended ceiling, the
sprinklers must be within 12 inches of the roof or floor
above, permitting the hot gases to build up and acti-
vate the sprinkler. Additionally, upright sprinklers are
generally used in areas that do not have a suspended
ceiling. Again, there are different sprinklers for differ-
ent applications and it all depends on the listing.
Employees inspecting fire protection items
Many years ago our in-house staff members per-
formed the inspection and testing of our fire se-
curity systems (smoke detectors, fire alarm panels,
sprinkler valves, etc.). However, CMS and The Joint
Commission told us that we could not perform these
procedures and needed to have an outside certified
company perform these functions.
Due to a doubling of the cost for these services, we
would like to revisit this issue. In looking at NFPA 72,
National Fire Alarm Code, Chapter 10 appears to allow
staff members who have the proper training and cre-
dentials to perform these functions.
Paragraph 10.2.2.5.1 states that qualified personnel
shall include, but not be limited to, “personnel who are
factory trained and certified for fire alarm system ser-
vice of the specific type and brand of system.”
Does this wording allow for properly trained hospi-
tal employees to perform fire security systems inspec-
tion and testing?
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© 2008 HCPro, Inc.
Although The Joint Commission and CMS recog-
nize the 1999 edition of NFPA 72, we recommend
looking at the 2007 edition as a best practice in this
case because it provides clarification to your question.
In-house staff members can inspect and test the
building fire alarm system as long as they receive fac-
tory training and certification for the specific fire alarm
system type and model being tested (see 10.2.2.5.1.1).
If there are components from various fire alarm
manufacturers in the building, evidence of certification
and training for each type of system is necessary.
The only kink in this assessment is for central sta-
tion service. Central station inspection, testing, and
maintenance activities must be contracted out to a list-
ed central station service.
Note that many jurisdictions have specific qualifi-
cations or license requirements, so the basis for using
contract personnel could have been based upon those
state or local mandates.
As a side note, the NFPA technical committee for
NFPA 72 may add wording to an upcoming edition
that specifically notes it is not the code’s intent to re-
quire employees performing “simple inspections” to re-
ceive factory training or special certification. We’ll see
how NFPA members view the proposal. n
Send us your questions
If you have a question about life safety compliance,
fire codes and standards, or the EC, pass it along to us,
and we’ll include it in one of Healthcare Life Safety
Compliance’s future “Questions & Answers” columns.
Send us your questions in writing by:
➤ Mail to Healthcare Life Safety Compliance, 200
Hoods Lane, P.O. Box 1168, Marblehead, MA 01945
➤ E-mail to swallask@hcpro.com (write “Q&A” in the
subject line)
➤ Fax to 781/639-2982 (to the attention of Health-
care Life Safety Compliance)
Page 12 Healthcare Life Safety Compliance March 2008

Quick tip

Space heaters may be okay in nurses’ stations

“Safety Talk”—our Internet chat group that all of you
can participate in for free as subscribers—had a big go-
around regarding the use of electric space heaters.
The gist of the debate was about whether the Life
Safety Code® (LSC) allows portable space heaters in nurses’
stations.
As a quick refresher, paragraph 19.7.8 in the LSC gen-
erally prohibits space heaters in healthcare occupancies.
However, an exception allows these appliances to remain
in nonsleeping staff and employee areas as long as the
heating element doesn’t exceed 212°F.
Talk group members weigh in
Does a nursing station count as a nonsleeping staff
area? Here’s a sampling of thoughts from “Safety Talk”:
➤ “I don’t think nurse stations or other manned stations
meet the exception—but that’s my interpretation”
➤ “We consider our nurse stations to be nonsleeping
staff/employee areas and thus meet the exception”
Robert Solomon, assistant vice president of building
fire protection and life safety at the NFPA, agrees with
the latter comment.
Space heaters “are okay in areas where we would ex-
pect staff to be present and monitoring them,” Solomon
says. “My opinion is the nurses’ station is an acceptable
location.” (For the record, Solomon’s opinion is not an
official interpretation of the LSC.)
However, the LSC’s intent is to allow space heaters in
areas where employees can supervise their use, he says.
Precautions to use with space heaters
Solomon suggests that facilities consider the following
safeguards when using space heaters in nurses’ stations:
➤ Don’t store combustible material on or near the
appliance
➤ Ensure there is proper ventilation around the heater
“Safety Talk” members offer these other precautions:
➤ Ensure that the nurses’ stations are truly under con-
stant supervision
➤ Verify that the heating element meets the 212°F limit
➤ Have nurses and other staff members sign a user agree-
ment that states they will comply with the hospital’s
rules on space heater use
If you’re interested in participating in “Safety Talk”
but haven’t signed up yet, e-mail Senior Managing Edi-
tor Scott Wallask at swallask@hcpro.com for help in setting
up an account. n

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 Healthcare Life  
Vol. 10 No. 3
March 2008
Safety Compliance
The newsletter to assist healthcare facility managers
with fire protection and life safety Q ui z
Quiz questions March 2008 (Vol. 10, No. 3)

1. (T) (F) H
 ealthcare occupancies have smoke compartment requirements, whereas ambulatory
healthcare and business occupancies do not.

2. (T) (F) A fire that burned an infant in a bassinet has been linked to poor staff member training.

3. (T) (F) D
 oors, other than doors required to be fire-rated, within a patient sleeping suite don’t have
to latch, with the exception of the door that opens onto the corridor.

4. (T) (F) I f the proposed life safety standards are approved as written, they will essentially replace the
current Part 3 in the Statement of Conditions (SOC), according to The Joint Commission.

5. (T) (F) I n a separated occupancy, each occupancy type observes its own provisions from the Life
Safety Code® (LSC).

6. (T) (F) Sprinkler protection must be installed within 12 inches of a ceiling.

7. (T) (F) I n-house staff members can’t inspect and test building fire alarm systems, according to the
2007 edition of NFPA 72, National Fire Alarm Code.

8. (T) (F) I f you observe the proper precautions, you’re probably on safe ground in allowing a portable
space heater at a nurses’ station.

9. (T) (F) E
 ven if a hospital provides 24-hour sleeping accommodations for patients, you may be able
to argue that building is an ambulatory healthcare occupancy.

10. (T) (F) T

 he Joint Commission allows you to use the entire 2006 edition of the LSC if you want, as
long as you note it in your SOC and alert surveyors to this fact upon their arrival.

A supplement to Healthcare Life Safety Compliance



Quiz answers March 2008 (Vol. 10, No. 3)

1. False. W
 hereas business occupancies don’t have smoke compartment requirements, ambulatory
healthcare occupancies do have them.

2. False. A
 s of early February, investigators haven’t determined a cause or reached any conclusions
about the fire.

3. True

4. True

5. True

6. True

7. False. I n-house staff members can inspect and test the building fire alarm system as long as they
receive factory training and certification for the specific fire alarm system type and model
being tested.

8. True

9. False. T
 he LSC notes that ambulatory healthcare occupancies provide medical care on an outpatient
basis without sleeping accommodations.

10. True

Copyright © 2008 HCPro, Inc. Current subscribers to Healthcare Life Safety Compliance may copy
this quiz for use at their facilities. Use by others, including those who are no longer subscribers, is a viola-
tion of applicable copyright laws. ® Registered trademark, the National Fire Protection Association, Inc.