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Answers about plywood head walls, K cylinders, converting rooms


December 21, 2019

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

Plywood head walls

Q: Are head walls made out of plywood considered an interior wall finish? Do these head walls need to be constructed from flame-retardant plywood?

A: I don’t know what you mean when you say “head walls,” but plywood attached to the gypsum-covered walls in a healthcare occupancy is considered an interior finish. The Life Safety Code® (LSC) allows Class A and Class B interior finish in rooms of healthcare occupancies.

  • Class A interior finish is material having a 0–25 flame spread rating
  • Class B interior finish is material having a 26–75 flame spread rating
  • Class C interior finish is material having a 76–200 flame spread rating  

Plywood typically has a flame spread rating around 150 or so—some are less and some are more. So on the first take, you would think plywood would not be permitted on walls of rooms in healthcare occupancies since it is a Class C interior finish. But wait … Section of the 2012 LSC says if the room is protected with sprinklers, then Class C materials are permitted where Class B materials are required. So if the room where the plywood is attached to the gypsum-covered wall is sprinklered, then you should be fine. There is no requirement for the plywood to be fire-resistance rated.

K cylinder of oxygen

Q: Our hospital has an off-site sleep lab where patients are treated for sleep-related issues. Most patients need to be hooked to oxygen during these tests. The lab is located in a business occupancy building, with no sprinklers and no fire ratings. There are four separate sleep rooms in the lab, all of them containing a K tank of oxygen, which holds 297 cubic feet when full. The patient volume and oxygen need definitely justifies the need for this volume of oxygen, as it is replaced almost daily. Would these O2 tanks be classified as “in use” or storage? I want to ensure that we are being compliant with code expectations.

A: If the patient is connected to the K cylinder, then it is definitely in use. However, according to the CMS S&C memo 07-10, an individual cylinder placed in a patient room for immediate use by a patient is not required to be stored in an enclosure and is considered in use. It should be secured to prevent tipping or damage to the cylinder. If the resident does not need the use of oxygen for an extended period of time, such as several days, then the medical gas container should be removed and properly secured in an approved storage room. But if you have spare K cylinders in the building, then they would have to be stored in accordance with 11.3.2 of the NFPA 99-2012, which applies to all healthcare facilities, including sleep labs in business occupancies.

Fire watch

Q: Our disaster manual reads “An emergency fire watch will be initiated in the event the facility fire alarm/sprinkler system is out of service for more than four (4) hours in a 24-hour period.” I have been seeing other places where the requirement is that an emergency fire watch must be initiated immediately in the event of fire alarm or sprinkler failure. Those same sources say that you only must contact the fire department and the state agency if the sprinkler system has been out for 10 hours and if the fire alarm system has been out for four. Hopefully, you can help me make sense of what the requirement actually is.

A: Different authorities having jurisdiction (AHJ) may have their own individual interpretations regarding when to start the fire watch. But the 2012 LSC, section states: “Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided.” That’s pretty clear to me: The fire watch does not start until the first four hours in a 24-hour period is up. Otherwise, you would have to start a fire watch exactly when the fire alarm system (or a circuit) is turned off to replace a device. The code is allowing a four-hour window before you need to start the fire watch. NFPA 25-2011, section 15.5.2, says something similar for a sprinkler system impairment, but allows 10 hours before a fire watch is required. But if you have an AHJ that is interpreting this differently, then you need to comply with the requirements they set for you. You can always appeal their decision using logic, common sense, and code references, but don’t count on it.

Alcohol-based hand rub (ABHR) dispenser spacing

Q: My question is in regard to the spacing between sanitizer dispensers when they are placed inside and outside patient rooms. In that situation, does the 4-foot rule apply? The sanitizers are not on the same horizontal plane. They are also separated by a door. It does not seem appropriate to place the 4-foot distance rule when the sanitizers are being measured from a corridor into a room—for example, inside and outside a patient room. Please advise.

A: I see your point and understand your concern. Looking at section (4), the 2012 LSC simply states: “Dispensers shall be separated from each other by horizontal spacing of not less than 48 inches.”

One could make the point that as long as the door is closed to the room, the dispensers are separated from each other by the door and the wall that the door serves, and the 48-inch rule does not apply. However, another could make the point that when the door is opened, the separation is no longer present, and the 48-inch clearance should be maintained. To be sure, the 2012 LSC and the official handbook are silent on the subject. When the code is silent on an issue, it is up to the AHJ to decide how to interpret the LSC. I contacted CMS officials in Baltimore, and they provided an informal interpretation that says the distance around the door opening between ABHR dispensers must be maintained to be no less than 48 inches. 

Power-assist doors

Q: We were cited during a recent survey for not having our power-assist doors to our ICU suite connected to the fire alarm system. I thought that was only required on fire-rated doors. Is this a requirement for a corridor door?

A: Section of the 2012 LSC discusses powered door leaf operation, and it applies to power-assist and power-operated doors. This section is not limited to any specific type of door, such as fire-rated, smoke-resistant, etc. As such, the section applies to all power-assist and/or power-operated doors. The six criteria listed under must all be met in order to comply with Subsection (4) under states that where a door leaf is required to be self-closing or positive latching and is equipped with power operation and is left in an open position, there must be a smoke detector near the door that would activate and cause the door leaf to close and cease operation. Therefore, the power-assist function would have to be connected to the fire alarm system. Subsection (4) says the smoke detector must be placed in accordance with NFPA 72, so there are a couple of options:

  1. A smoke detector within 5 feet on one side of the door if the height of the transom above the door is less than 24 inches
  2. A smoke detector within 5 feet on both sides of the door if the height of the transom is 24 or more inches above the door
  3. A smoke detector within 14 feet of the door if the entire area on that side of the door (i.e., corridor) is 100% smoke-detected

All of the above applies to any door, regardless of fire rating, that is required to be either self-closing or positive latching and is equipped with power-assist or power-operated equipment. Yes, it applies to suite entrance doors, because the suite is a room that is separated from the corridor and according to, corridor doors must latch.

Vision panel frosting

Q: Can you place frosting on the vision panel glazing (windows) of the doors?

A: That’s a good question. If the vision panel is required in the door, then I would say it cannot be frosted. If the vision panel is not required, then I would say it could be frosted. The only vision panels in doors that are required (that I am aware of) are in doors in new-construction smoke barriers. See section of the 2012 LSC.

Converting a room

Q: We are a 49-bed hospital facility (changed over from a 68-bed in 2017). Currently, we have a room that was originally used for three patient beds. We want to change that into an infusion treatment room, setting up three recliners and a small desk area for the individual watching the patients. Looking through the different code books, it seems to me that we should be fine with this scenario as long as we put a door closer on the door. If we try and store stuff in the room, we will have to make it a 1-hour fire-resistance rated and treat it as a hazardous area. Is that correct? If not, what else needs to be done? Can we put a lock on this door to secure the room at night?

A: If you are using the room to store combustibles, you might have a problem with some AHJs if the room is also used to treat patients. While I could not find a direct standard in the LSC that prohibits patient care and treatment activities in hazardous rooms, you may find some surveyors who will consider that an unsafe practice for the patients. An AHJ may cite you under a general duty clause, such as CFR §482.41, that says the hospital must be constructed, arranged, and maintained to ensure patient safety.

But to answer your question, assuming the room is larger than 250 square feet, the room would have to be constructed to 1-hour fire-rated construction, with a ¾-hour self-closing and positive latching fire-rated door, and the room needs to be protected with sprinklers. You may put a lock on the door as long as it does not require more than one action to operate the door on the egress side (see of the 2012 LSC). This means a dead-bolt lock would not be permitted unless the dead-bolt automatically retracts when you turn the latch-set handle.

Editor’s note: This is an excerpt from HSL sibling publication, Healthcare Life Safety Compliance, where each month, Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, answers questions about life safety. Follow Keyes’ blog on life safety at www.keyeslifesafety.com

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