Author(s): Wiilliam Koffel, Jennifer Frecker. Published on January 1, 2012.

Deficiencies + Equivalencies
Tips on using the 2012 Life Safety Code for achieving compliance in health care facilities

NFPA Journal®, January/February 2012 

By William Koffel and Jennifer Frecker 

While the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) continue to enforce the 2000 edition of NFPA 101®, Life Safety Code®, both organizations will consider the use of a newer edition of the code for compliance purposes. If a health care facility chooses this option, it must comply in most cases with everything in the newer edition of the code — the intent is to prevent facilities from selecting only specific provisions in a newer edition of the code, resulting in a level of safety that may be lower than intended.

But there are exceptions. CMS calls them waivers, while TJC calls them "traditional equivalencies," but both processes allow health care facilities to select specific provisions of a newer edition of the code, including the 2012 edition, to achieve compliance with the 2000 edition. During the approval process, either CMS or TJC can determine whether compliance with selective provisions of a newer edition results in an acceptable level of safety. The code recognizes this concept of allowing the use of alternative methods to achieve compliance with the code when approved by the authority having jurisdiction.

The following is a selection of common design, maintenance, and operational deficiencies for health care occupancies, along with provisions of newer editions of the Life Safety Code, including the 2012 edition, that can help those facilities comply with current CMS and TJC requirements. This includes existing facilities as well as the design of new facilities. All references are to the 2012 edition of the code unless otherwise noted.

Means of Egress: Corridors
According to TJC, several life safety requirements continue to be among the most frequently cited requirements where health care organizations were "not compliant." During the first six months of 2011, for example, 57 percent of the hospitals accredited by TJC received recommendations for improvement in maintaining the integrity of the means of egress.

The code says that certain wheeled equipment can be located in corridors, provided that the clear width of the corridor is not less than five feet (1.5 meters). This is permitted only in sprinkler-protected facilities. The 2012 edition of the code still does not permit beds to be stored in corridors — an ongoing issue for managers, since this is a common practice, especially in hospitals.

Means of Egress: Normally Unoccupied Support Areas
These are support areas where people are not expected to be present on a regular basis and are typically found in older facilities with steam tunnels, crawl spaces, interstitial spaces, and so on. Areas with equipment that needs regular maintenance, such as air handling units and boilers, would not fall into this classification.

Under the new edition of the code, these areas are no longer required to meet specific egress requirements such as minimum width and head room, exit signage, illumination, and number of means of egress.

Means of Egress: Travel Distance
In the past, the code separated travel distance rules within patient rooms and from room doors to the exit. Travel distance to the door inside a room could be no more than 50 feet (15 meters), and the distance from the room door to an exit could be no more than 100 feet (30 meters), or 150 feet (45 meters) if sprinklered, with a total travel distance of no more than 150 feet (45 meters) or 200 feet (60 meters) if sprinklered.

This has changed in the new edition of the code. Egress travel within the room to the door is still limited to 50 feet (15 meters), but if egress travel within the room is 30 feet (10 meters), for example, the travel distance from the room door to the exit can increase up to 170 feet (52 meters). The codes states that the total travel distance cannot exceed 200 feet (60 meters) when sprinklers are present.

Rehabilitation Projects
The 1991 edition first mandated sprinkler protection in all new health care facilities and for major renovations where the work was being performed. Since 2000, this has been clarified. If a rehabilitation project involves modification of 50 percent or more of the facility, or more than 4,500 square feet (418 square meters) of an area of a smoke compartment, sprinkler protection is required. "Modification" includes any work that changes the egress paths in the space.

In the past, the code required complying with the provisions for new construction. The 2012 edition, though, specifically addresses requirements for any type of rehabilitation work in a health care facility where sprinkler protection is not provided. It now identifies what those requirements are, mostly based on older editions of the code when it provided sprinklered and nonsprinklered options. In the case of a major renovation project, sprinkler protection will typically be required.

Storage Areas
This applies to the common hospital practice of turning existing space, such as a patient room, into a storage room. In the past, if the room was larger than 100 square feet (9 meters), the code called for protecting that space as if it were a severe hazardous area. But a new provision in the code, specific to health care, changes that. In an existing health care occupancy — one protected throughout by a supervised sprinkler system, where there’s a change in the way the space or room is being used, and where the room does not exceed 250 square feet (23 square meters) — the facility may apply the requirements for an existing hazardous area (chapter 19) to these change-of-use spaces. This is significant. Since the requirements already state that the room has to be protected with a sprinkler system, it means that a one-hour fire barrier does not have to be provided around that room. Instead, a facility would have to ensure that the door to that room has a self-closing device, as required for an existing hazardous area. And that might be the only change required, other than a possible evaluation of the sprinkler system to see if the design criteria have been met for the change of use for that space, which was likely "light hazard" but may have to be upgraded to handle ordinary hazards.

Change in Occupancy Classification
This is especially targeted at changes that result in multiple occupancies within a building. In the past, the most restrictive requirements of all of the various occupancies would apply to the entire floor or building. If a medical office building had a large waiting area, which would be classified as an assembly occupancy, as well as exam rooms and doctors’ offices, which would be a business occupancy, the more restrictive egress requirements of the assembly occupancy would apply to the entire floor.

A change to the 2012 edition clarifies the intent of the code regarding multiple occupancies. Areas that do not serve as means of egress from the area protected as an assembly occupancy do not need to meet the assembly egress requirements.

Alcohol-Based Hand-Rub Dispensers
Earlier editions of the code could be interpreted as saying that the quantity of hand-rub solution contained in dispensers in patient rooms had to be included in the aggregate amount of solution contained in the smoke compartment. The original intent was to allow the dispensers primarily in corridors, recognizing that it’s probably the best approach for infection control. Now the belief is that dispensers should also be provided in individual patient rooms. A new provision allows one dispenser that complies with the code as if the dispenser were in a corridor to be located in a patient room. The hand-rub solution contained in that dispenser is not to be considered in the aggregated quantity of solution permitted within a single smoke compartment.

While the 2000 code did not address aerosol containers, the 2012 edition also recognizes aerosol dispensers as an acceptable type of alcohol-based hand rub dispenser.

Restroom Partitions
In earlier editions, it was questionable as to whether restroom partitions were, or should be treated as, an interior finish material. Some argued they were furniture. The new edition clarifies this, saying that they are, in fact, interior finishes. The clarification is based on testing as to whether commonly used partition materials such as polypropylene or high-density polyethylene could drive a room to flashover. Based on the test procedure outlined in NFPA 286, Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth, some of these partitions could take the room to flashover. Thus, the newer edition of the code now mandates compliance with NFPA 286.

High-Rise Provisions: Sprinklers
The 2009 version required that all high-rise buildings, including existing buildings and health care facilities, be protected by automatic sprinkler systems. The 2009 code provided a 12-year period for health care facilities to come into compliance. The sprinkler requirement is retained in the 2012 edition, but the period of time for compliance has been changed to nine years if the facility is using the 2012 edition of the code.

High-Rise Provisions: Standby Power
The Life Safety Code has historically included requirements for standby power to offer redundant power sources for certain systems of a building, such as fire pumps and mechanical equipment for smoke-proof enclosures. There are two additions to that list of features in the 2012 edition that will only affect new high-rise buildings. Standby power now needs to be provided to jockey pumps that are used to maintain pressure in fire pump systems and to air compressors used to maintain air pressure in a dry-pipe or pre-action sprinkler system.

Manual Sliding Doors
The new code addresses manual sliding doors, a popular feature in new hospitals, for spaces designed for 10 or fewer occupants. The rooms can include no high-hazard contents; the force to operate the door must be no more than 30 pound (14 kilograms) of force to set the door in motion, and no more than 15 pounds (7 kilograms) to open or close the door to the minimum required width; the latch must keep the door from rebounding if forcefully closed; and the assembly must comply with any needed fire protection ratings.

Door Locking Arrangements
Previous editions did not specifically address the issue of door locking arrangements in areas where patients faced potential security threats, such as a maternity ward or a neonatal intensive care unit.

A new set of rules that address door locking provisions for security needs — not just clinical needs — were added in 2009. The 2012 edition includes two provisions to clarify this: staff must be able to readily unlock the doors at all times, and facilities must meet all requirements in the applicable section of the code.

For this second point, the code requires that staff can readily unlock doors at all times, that smoke detection is provided throughout the locked space, or that doors can be remotely unlocked from an approved and constantly attended location in the locked space. The building must be completely sprinkler-protected. Electric locks must be of the fail-safe design, and locks should release by independent activation of smoke detection or by water flow from the automatic sprinkler system. Provisions for rapid removal of occupants from locked areas must be by remote control of the locks, by the keying of locks so that they can be unlocked by staff, or by other reliable means.

Corridor Projections
The 2000 edition allowed non-continuous projections of not more than 6 inches (15 centimeters) from the wall, and projections were required to have a certain amount of distance between them. While not specifically permitted by the 2000 edition of the code, common practice typically resulted in special exceptions for telephones, medical records holders, and other items, without a separation requirement.

A rigid adherence to distances between projections was never intended to apply to these other projections, and the 2012 code has eliminated the distance requirement. The intent here is not that hospitals end up with cluttered corridors, but rather that the word "noncontinuous" will identify the need for some kind of break between these various projections.

Cooking Equipment
This mostly addresses long-term care facilities where "culture change" considerations — steps to provide residents with a more "home-like" environment — are in play. This can include more flexibility in how residents eat and prepare meals, where the kitchen/dining area can resemble a residential design. Kitchens in health care facilities are hazardous areas that require NFPA 96,

Ventilation Control and Fire Protection of Commercial Cooking
Operations, protection of the cooking surfaces and exhaust hoods, but do not require one-hour separation from other areas, such as the dining room. In past editions of the code, the requirements for the protection of corridors did not permit any hazardous area, not just those that require one-hour separation, to be open to the kitchen. Thus, kitchens were not permitted to be open to the corridor.

The 2012 edition takes a new
approach to kitchens, allowing them to be completely open to the corridor, provided certain criteria are met for detection, that cooking facilities are limited, and that the number of residents served by the cooking facilities are limited.

Sprinklers in Patient Room Closets
The code used to require sprinklers in closets in patient rooms based on testing conducted almost 40 years ago, which concluded that a patient room could reach untenable conditions as a result of a fire in the closet. But things have changed, including mandates for quick response or residential sprinklers in smoke compartments containing patient sleeping rooms.

As a result, the 2012 edition allows the omission in new construction of sprinkler protection from certain clothes closets in patient sleeping rooms in hospitals only, provided the closets do not exceed 6 square feet (0.5 square meters) and that the back walls of such closets are within the coverage area of a sprinkler in the room.

Waste Containers
The code previously required that all waste containers be made of non-combustible materials. But the disposal of materials that contained bodily fluids raised issues of corrosion in these containers, and it was proposed in an earlier edition of the code to allow alternatives to non-combustible containers, such as plastic. The technical committee decided it was more a matter of how much material was in the waste container than the material of the container itself. The 2000 edition limits container size to 32 gallons (121 liters) and to address the density of containers in health care spaces.

Then came recycling containers, which are typically much larger than the 32-gallon (121-liter) limit. The code required that these larger containers be located in spaces protected as hazardous areas, which also meant that people weren’t likely to use them for holding recyclables. The 2012 edition allows containers up to 96 gallons (363 liters), provided the containers have been tested to show that they can confine a fire to the container and that they are used solely for recycling clean waste or for storing patient records awaiting destruction.

Suites help permit the delivery of care in a more efficient manner, with more open areas, reduction or elimination of corridors, relaxation of door hardware requirements, and more. Designers can easily incorporate suites into new designs, and for maintenance purposes, suites can be easier to retrofit into existing facilities.

Means of Egress
The 2000 edition did not clarify one point: when two means of egress were required from a suite, could a second means of egress be through an adjoining suite? In the new edition, though, it’s clear: as long as one means of egress goes to an egress corridor, the other can go through an adjoining suite. This can be very helpful in operating room areas, for example, which can be composed of clumps of suites. This is a good example of where using the 2012 edition of the code can help process a traditional equivalency through TJC.

Intervening Rooms in Suites
The 100-foot (30-meter) travel distance still applies, but the number of intervening rooms is no longer limited. This has been a common problem, especially in areas using privacy doors, which could be construed as enclosures of distinct intervening rooms, such as MRI rooms and adjoining prep and recovery rooms, thereby limiting the distance to the door to 50 feet (15 meters).

Sleeping Suites in New Construction
In the 2000 edition, the size limit for sleeping suites was 5,000 square feet (464 square meters). In the 2009 edition, that was increased to 7,500 square feet (697 square meters) with no additional protection. The 2012 edition allows for up to 10,000 square feet (929 square meters), but with additional protection: sleeping spaces must have automatic sprinklers, direct visual supervision, and total-coverage automatic smoke detection.

Sleeping Suites in Existing Facilities
In past editions of the code, suite size was potentially justified by doing a Fire Safety Evaluation System analysis of that space, which often extended beyond the area of the suite to include the rest of the building — a lot of work. In the 2012 edition, though, that’s been simplified. Sleeping suites are now limited to 5,000 square feet (464 square meters) with no additional special protection; to 7,500 square feet (697 square meters) where the smoke compartment has a sprinkler system and complete smoke detection, or quick-response sprinklers; and up to 10,000 square feet (929 square meters) with direct visual supervision, complete automatic smoke detection, and quick-response sprinkler protection.

William Koffel, P.E., FSFPE, is president of Koffel Associates and chair of the Safety to Life Technical Correlating Committee for NFPA 101. Jennifer Frecker is a project team manager at Koffel Associates.