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Ask the expert: Can smoke compartments be removed from plans


October 1, 2019

By Brad Keyes, CHSP (www.keyslifesafety.com)

Q: Section 19.3.7 of the 2012 Life Safety Code® (LSC) discusses smoke compartments in facilities that have greater than 30 sleeping beds per floor or building. If your facility is under 30 beds but greater than 22,500 square feet, are smoke compartments required? Or can they be removed on the life safety plans?

A: No, they cannot be removed, because section of the 2012 LSC says existing life safety features shall not be removed or reduced where such feature is a requirement for new construction. New construction requires it, so you must maintain it for the life of the building.

ASC soiled utility room

Q: How does one handle a “soiled utility” room in an ambulatory surgery center (ASC)? If it is a small storage room without large volumes of flammable liquids but perhaps containing soiled linens, are there any special fire protection features which need to be included?

A: Soiled utility rooms in ASCs are treated differently than they are in hospitals and healthcare occupancies. Where chapters 18 and 19 specifically identify soiled utility rooms as hazardous areas for healthcare occupancies, chapters 20 and 21 do not for ambulatory healthcare occupancies (AHCO). But chapters 20 and 21 refer to chapters 38 and 39 for “Protection from Hazards” and they do identify “storage rooms” as a hazardous area that must comply with section 8.7. Section requires the hazardous room (i.e., a soiled utility room in ASC) to be protected in one of the following two ways:

  1. Enclosing the room with one-hour fire-rated barriers, that would include a ¾-hour fire-rated door assembly that is self-closing and positive latching, or:
  2. Protect the room with sprinklers

Ambulatory suites

Q: Am I allowed to have a suite inside an area designated as an ambulatory occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated?

A: Yes, you are permitted to have a suite in an AHCO. Look at section 20/, which permits suites in an AHCO, but states that any suite over 2,500 square feet must have two remotely located doors from the suite. No, suite boundary walls are not necessarily required to be one-hour fire rated. They are required to be equal to the fire-resistive rating of the corridor walls. For new construction, corridor walls would be a minimum of one-hour fire-rated barriers, unless one of the following applies:

  • Where exits are available from an open floor area
  • Within a space occupied by a single tenant
  • Within buildings that are fully protected with automatic sprinklers

For existing construction, there are no requirements for corridor walls, so there are no requirements for suite boundary walls.

E-size O2 cylinders

Q: Can E cylinders be stored in a closet where people hang their jackets, even if the cylinders are in an acceptable storage cart?

A: Yes, up to a certain number of E cylinders. Storage of compressed medical gases up to 300 cubic feet in accumulative quantity per smoke compartment is unregulated, other than the requirement in section (11) of NFPA 99-2012 to properly secure the cylinders and to not store them in such a way that they obstruct the required egress. But once the accumulative total of stored gases exceeds 300 cubic feet per smoke compartment, then section 11.3.2 of NFPA 99-2012 regulates how they are stored. It states that:

  • The cylinders must be in a designated room constructed with non-combustible or limited-combustible materials
  • This room must have a door that can be secured against unauthorized entry
  • Oxidizing gases cannot be stored with any flammable gas, liquid, or vapor
  • Oxidizing gases must be separated from combustibles by 20 feet, or 5 feet if the room is sprinklered or enclosed in fire-rated cabinets

An E cylinder (which is 25.5 inches tall and 4.3 inches in diameter) contains 24 cubic feet of gas when full, so that means you could have up to 12 E cylinders in a single smoke compartment before you would have to comply with section 11.3.2 for storage.

Generator batteries

Q: I was reviewing the various regulatory requirements and came across the need for weekly visual inspections of the generators. At one campus, we have changed out the batteries to gel type. On the other campus, we still have wet cell type. Yes, we have a hydrometer and, within the weekly PM work order, it does state to check them. But we don’t really use a form to capture that information. We called our contractor who provides the generator service and asked them to quote on gel batteries. They state that the manufacturer does not recommend sealed batteries because they can’t be manually maintained and, because generator batteries are constantly in a state of being charged, the water could dry out and the batteries can explode. They also state that gel batteries for our particular engines will lose 200–300 cranking amps. I saw your Q&A section on generator batteries and wondered, now that the accreditation organizations (AO) have adopted the 2012 version of NFPA 101, are there any formal decisions on the use of gel/sealed batteries?

A: There is no formal decision or interpretation from any national AHJ (that I know of) that prohibits maintenance-free batteries, or gel-type batteries, for generators. However, there are standards that say you must follow the manufacturer’s recommendations regarding plant equipment maintenance and operations (see CMS CFR §482.41(d)(2)) and your AO’s standards. In your case, it appears the manufacturer of your generator says you shouldn’t use maintenance-free batteries. So, CMS and your AO could cite you for not following your manufacturer’s recommendations. By the way, the requirement to test the generator battery electrolyte level is monthly, not weekly, according to NFPA 110-2010, section But you still must document the monthly reading. 

Fire/smoke barriers

Q: According to our life safety drawings, we have a barrier that is identified as a fire/smoke barrier. A surveyor from a recent accreditation survey said we cannot have a combination fire/smoke barrier and it has to be one or the other, not both. This is causing a disagreement among our staff on how we maintain the doors in these barriers. Where can I find the code reference regarding this issue?

A: What the surveyor said is not correct. Take a look at section 8.5.3 of the 2012 LSC, which says fire barriers may be used as smoke barriers provided they meet the requirements of section 8.5 for smoke barriers. To be sure, a smoke barrier does not qualify as a fire barrier because the doors in a smoke barrier are not required to be fire-rated and positive latching, but a fire barrier could be used as a smoke barrier provided it meets all of the requirements of a smoke barrier. Perhaps the surveyor was confused with the label “fire/smoke barrier” on the life safety drawing. This description is not clear, and the surveyor could have been commenting that a barrier should not be labeled as both. I always recommend to my clients to avoid a combination label that reads “fire/smoke barrier.”

Editor’s note: Brad Keyes, CHSP, is founder of Keyes Life Safety Compliance. Follow Keyes’ blog on life safety at www.keyeslifesafety.com for up to date information.  

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