The Life Safety 2008 2009 Crosswalk is an easy-to-use reference tool that crosswalks The Joint Commission s 2009 Life Safety with the 2008 and National Fire Protection Association s This crosswalk excerpt comes from HCPro s book, Life Safety Compliance Manual. The book explains The Joint Commission s 2009 life safety element-by-element, with expert analysis that will help you better comply with the requirements. The book s author is Brad Keyes, CHSP, safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and a former life safety specialist for The Joint Commission. For more information about the Life Safety Compliance Manual or to order a copy, go to www.hcmarketplace.com/prod-6705.html. Life Safety Compliance Manual 2008 HCPro, Inc. 1
Life Safety 2008 2009 Crosswalk Administrative activities Statement of Conditions The design and management of an organization s physical environment must meet the requirements of the LSC. LS.01.01.01 1 Your hospital designates responsibility A EC.5.20, 6 for LSC compliance assessment, electronic Statement of Conditions (e-soc) completion, and deficiency resolution management to an individual or group of individuals. LS.01.01.01 2 Your organization s e-soc is maintained and up to date. Yes A EC.5.20, 2 LS.01.01.01 3 Your organization resolves deficiencies identified in PFIs in accordance with the Joint Commission accepted schedule set forth in the PFI. Also see LS.01.02.01, s 1 14. 2 A EC.5.20, 5 Sufficient Progress CON-04 Interim Life Safety Measures (ILSM) During construction or other scenarios in which there are LSC deficiencies, your facility has mechanisms in place to protect staff members, patients, and visitors. LS.01.02.01 1 During times when a fire alarm or sprinkler system is disabled in excess of four hours (during a 24-hour cycle), your facility contacts the appropriate response agency (e.g., the fire department), sets up a fire watch, and s these actions. Also see LS.01.01.01, 3. LS.01.02.01 2 When obstructed or unusable exits exist, your organization posts signs to clearly identify alternative exits. Also see LS.01.01.01, 3. LS.01.02.01 3 Periods of construction or other scenarios in which your facility cannot immediately meet the requirements in the LSC are addressed by your ILSM policy, in writing. Your policy also outlines when and how you will address any increased risks for life safety issues, including any special measures that must be followed. Also see LS.01.01.01, 3. Yes 3 A EC.5.50, 2 Footnote 3 A EC.5.50, 2 Bullet 1 101-2000; 9.6.1.8 and 9.7.6.1 Yes 2 A EC.5.50, 1 2 2008 HCPro, Inc. Life Safety Compliance Manual
LS.01.02.01 4 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital conducts daily inspections of the exits in affected areas as dictated by its ILSM policy. Also see LS.01.01.01, 3. LS.01.02.01 5 When the hospital identifies LSC deficiencies that cannot immediately be corrected or during periods of construction, the hospital does the following: Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired. The need for equivalent systems is based upon criteria in the hospital s ILSM policy. LS.01.02.01 6 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital maintains an appropriate level of firefighting equipment, as dictated by its ILSM policy. Also see LS.01.01.01, 3. LS.01.02.01 7 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital uses appropriate temporary partitions (smoke-tight, noncombustible, or limited-combustible materials), as dictated by its ILSM policy. Also see LS.01.01.01, 3. LS.01.02.01 8 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital heightens surveillance of its property and equipment, as dictated by its ILSM policy. Construction areas and related uses should be included in the surveillance. Also see LS.01.01.01, 3. 3 C EC.5.50, 2 Bullet 2 3 A EC.5.50, 2 Bullet 3 3 A EC.5.50, 2 Bullet 5 A EC.5.50, 2 Bullet 4 C EC.5.50, 2 Bullet 9 Life Safety Compliance Manual 2008 HCPro, Inc. 3
LS.01.02.01 9 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital ensures practices that maintain the lowest achievable flammable and combustible fire load, as dictated by its ILSM policy. Address proper storage, cleaning, and trash removal in such efforts. Also see LS.01.01.01, 3. LS.01.02.01 10 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital ensures that it gives additional training to staff members to use all types of firefighting equipment, as dictated by its ILSM policy. Also see LS.01.01.01, 3. LS.01.02.01 11 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital runs an additional quarterly fire drill for each shift, as dictated by its ILSM policy. Also see LS.01.01.01, 3, and EC.02.03.03, 1. LS.01.02.01 12 During construction or in other scenarios in which your facility cannot immediately meet the requirements in the LSC, the hospital conducts monthly inspections and tests of temporary measures, as dictated by its ILSM policy. Also see LS.01.01.01, 3. LS.01.02.01 13 The organization educates staff members on temporary fire safety measures, as well as building and construction issues, as dictated by its ILSM policy. Also see LS.01.01.01, 3. C EC.5.50, 2 Bullet 7 A EC.5.50, 2 Bullet 5 A EC.5.50, 2 Bullet 8 Yes C EC.5.50, 2 Bullet 3 3 A EC.5.50, 2 Bullet 11 4 2008 HCPro, Inc. Life Safety Compliance Manual
LS.01.02.01 14 The hospital trains its workers to deal with impairments to building features designed to prevent the spread of fire, as dictated by its ILSM policy. Also see LS.01.01.01, 3. Note: The term compartmentalization refers to how the spread of fire is prevented through the use of building features (e.g., smoke barriers) to provide a safe exit route, dependent on a building s occupancy class. Healthcare occupancy 3 C EC.5.50, 2 Bullet 10 General building requirements Hospitals minimize the impact of fire and related effects through building design and other protective measures. LS.02.01.10 1 National Fire Protection Association () 18/19.1.6.2 requirements for height and construction type are met by the hospital s buildings. LS.02.01.10 2 New healthcare occupancies are protected by appropriate automatic sprinkler systems. Existing healthcare occupancies contain the appropriate automatic sprinkler systems dependent on their construction type. LS.02.01.10 3 Two-hour fire-rated walls adhere to the following guidelines: Such walls run from the floor to the underside of the deck above, and outside wall to outside wall. LS.02.01.10 4 If two-hour fire-rated walls contain an opening, such openings must have a 1 1/2-hour fire rating. See LS.02.01.20, 3, and LS.02.01.34, 2. LS.02.01.10 5 Hardware on fire-rated doors is fully operational (e.g., positive latching devices, automatic closing devices). Where two doors meet, the gap is no wider than 1/8 inch, and undercuts are 3/4 inch or less in size. Also see LS.02.01.30, 2. 3 A EC.5.20, 1 EC.A.1A (1,2) 3 A EC.5.20, 1 EC.A.1A (3) A EC.5.20, 1 EC.A.1B (1,2) A EC.5.20, 1 EC.A.1B (3) C EC.5.20, 1 EC.A.1C (1 5) 18/19.1.6.2 18.3.5.1, 19.1.6.2 8.2.2.2 8.2.3.2.3.1 80-1999: 1-11.4; 2-3.1.7; 2-4.4.3; 8.2.3.2.1; 8.2.3.2.3.1 Life Safety Compliance Manual 2008 HCPro, Inc. 5
LS.02.01.10 6 A fire-rated door cannot feature unapproved protective plates more than 16 inches above its bottom. Note: Nonrated protective plates no higher than 48 inches from the bottom of the door are allowed on doors to hazardous rooms. LS.02.01.10 7 Faces of 3/4-hour (or longer) fire-rated doors are clear of all objects except for informational signs. LS.02.01.10 8 One-and-a-half-hour fire-rated dampers are in place on any ductwork penetrating two-hour FRR (or greater) walls. LS.02.01.10 9 When utility devices penetrate fire-rated walls, regardless of the fire rating, the space surrounding the devices must be properly sealed with materials approved for the rating of that particular fire wall. Note: Expanding polyurethane foam is not acceptable in this scenario. LS.02.01.10 10 The hospital fully complies with all appli cable provisions of the LSC in 18/19.1. EC.A.1D (1) EC.A.1D (2) A EC.5.20, 1 EC.A.1E EC.A.1H (1 6) 80-1999: 2-4.5; 19.3.2.1 80-1999: 1-3.5 90A-1999: 3-3.1; 8.2.3.2.4.1 8.2.3.2.4.2 C EC.1.10, 5 Means of egress requirements Corridors, doors, stairways, and other means of egress are properly designed and maintained by the hospital. LS.02.01.20 1 All doors in the path a person travels to exit the building (i.e., means of egress) are unlocked. LS.02.01.20 2 In hospitals with an occupancy of 50 persons or greater, all doors in the path a person travels to exit the building swing toward the exit. LS.02.01.20 3 Horizontal exit walls are required to be two-hour fire-resistance rated, and such walls run from the floor to the underside of the deck above, and outside wall to outside wall. Also see LS.02.01.10, 4. 3 A EC.5.20, 1 EC.A.5J (1) EC.A.5J (2) EC.A.5N (1 3) 18/19.2.2.2.4 7.2.1.4.2 7.2.4.3.1; 8.2.2.2 6 2008 HCPro, Inc. Life Safety Compliance Manual
7.2.2.6.3 LS.02.01.20 4 Buildings with exterior exit stairs are required to maintain walls that offer the same level of fire resistance between the exterior stairs and the interior of the build ing. Such walls must meet minimum requirements of at least a 10-ft. vertical extension from ground level to the uppermost landing or roof line, and at least 10 ft. horizontally. LS.02.01.20 5 In new buildings, horizontal exit door windows (i.e., vision panels) are approved and do not have a center mullion. LS.02.01.20 6 In new buildings, exterior walls have a one-hour fire rating for a minimum of 10 ft. in instances in which horizontal exit walls end at the exterior wall at less than a 180º angle. Openings in such an exterior wall must have a 3/4 hour fire rating. LS.02.01.20 7 Hospitals are required to install handrails and railings on stairs and ramps on one side for existing healthcare occupancies, and on both sides for new healthcare occupancies. LS.02.01.20 8 The hospital s exits shall discharge at grade level, or via a continuous, approved exit passageway that ends at a public way or an exterior exit discharge LS.02.01.20 9 If your fire alarm or sprinkler system triggers the closing of a stairway door, it also closes the other doors in that stairway. LS.02.01.20 10 Automatic-releasing devices are not permitted to hold open doors to boiler rooms, heater rooms, and mechanical equipment rooms situated in a means of egress in a new healthcare occupancy. LS.02.01.20 11 Exit corridors adhere to the following requirements: 8 ft. wide in new buildings, 4 ft. wide in existing buildings. Modifications to existing corridors that exceed the 8-ft. width cannot reduce corridor width to less than 8 ft. EC.A.5L (1 3) C 18.2.2.5.6 C 7.2.4.3.2 C 7.2.2.4.2, EC.A.5H (1,2) 7.7 C 101-2000: 18/19 2.2.2.7 C 18.2.2.2.6 C 18/19.2.3.3 Life Safety Compliance Manual 2008 HCPro, Inc. 7
LS.02.01.20 12 Objects protruding from corridor walls do not obstruct their width. Note: There are specific exceptions The Joint Commission will make for corridors that meet or exceed 6 ft. in width. Such exceptions (e.g., hand-rub dispensers, retractable desks) must: Be 36 inches or less in width Project 6 inches or less into the corridor Be 48 inches away from other such features Be above handrail height C 18/19.2.3.3 LS.02.01.20 13 All exit paths are free of unattended items that are not considered in use. C EC.5.20, 1, EC.A.6F 7.1.10.1 LS.02.01.20 14 Exit access doors and exit doors do not have objects on them that could in any way conceal, obscure, or confuse access to the exit route. Such items include mirrors, hangings, and draperies. C EC.5.20, 1, EC.A.6G 7.5.2.2 LS.02.01.20 15 A building s floors or compartments must have, at a minimum, two approved exits that are located remotely from each other. C EC.5.20, 1, EC.A.5A 18.19.2.4.1 LS.02.01.20 16 A minimum of two exits, located remotely from one another, exist for patient sleeping rooms or suites of such rooms that exceed 1,000 sq. ft. C EC.5.20, 1, EC.A.2C 18/19.2.5.2 LS.02.01.20 17 A minimum of two exits, located remotely from one another, exist for rooms or suites of rooms that are not used as patient sleeping rooms that exceed 2,500 sq. ft. C EC.5.20, 1, EC.A.2D 18/19.253 LS.02.01.20 18 Suites containing patient sleeping rooms cannot exceed 5,000 sq. ft. Suites that do not contain patient sleeping rooms cannot exceed 10,000 sq. ft. No intervening rooms in the suites can contain hazardous areas. C EC.5.20, 1, EC.A.2E 18/19.2.5.5 to 18/19.2.5.7 8 2008 HCPro, Inc. Life Safety Compliance Manual
LS.02.01.20 19 From any point in suites containing patient sleeping rooms, the hospital maintains a travel distance of 100 ft. or less to an exit access door. LS.02.01.20 20 From any point in suites that do not contain patient sleeping rooms and that have up to one intervening room, the hospital maintains a travel distance of 100 ft. or less to an access door. In such suites with two intervening rooms, the hospital maintains a travel distance of 50 ft. or less to an access door. LS.02.01.20 21 The facility s patient sleeping rooms directly open into an exit access corridor. LS.02.01.20 22 The doors to patient sleeping rooms are unlocked. LS.02.01.20 23 From any point in a patient sleeping room, the hospital maintains a travel distance of 50 ft. or less to a room door. LS.02.01.20 24 The hospital maintains a travel distance of 100 ft. or less from any room door and an exit in existing buildings, or 150 ft. or less when an approved automatic sprinkler system exists. The hospital maintains a travel distance of 150 ft. or less from any room door and an exit in new buildings. LS.02.01.20 25 The hospital maintains a travel distance of 150 ft. or less from any point in a room and an exit in existing buildings, or a minimum of 200 ft. when an approved automatic sprinkler system exists. The hospital maintains a travel distance of 200 ft. or less from any point in a patient room and an exit in new buildings. LS.02.01.20 26 Dead-end corridors in new buildings do not exceed 30 ft. C C EC.5.20, 1, EC.A.2F (1) EC.5.20, 1, EC.A.2F (2,3) C EC5.20, 1 EC.A.2G 18/19.2.5.8 18/19.2.5.8 18/19.2.5.1 3 A 18/19.2.2.2.2 EC.A.5B (1) EC.A.5B (2) / EC.B.5B (2) EC.A.5B (3) / EC.B.5B (3) EC.B.5B (4) 18/19.2.6.2.3 18/19.2.6.2.1 18/19.2.6.2.2 18.2.5.10 Life Safety Compliance Manual 2008 HCPro, Inc. 9
18/19.2.8 LS.02.01.20 27 All points of any means of egress have adequate illumination. This includes angles and intersections of corridors and passageways, stairways, stairway landings, exit doors, and exit discharges. LS.02.01.20 28 The hospital arranges the illumination of all means of egress (including any exit discharges) such that the area will not be left in darkness if a single light bulb or fixture fails. LS.02.01.20 29 For all stairs that serve five or more stories of the building, the hospital posts signs on each floor landing of the stairwell that indicate the following information: the story, the stairwell, the top and bottom, and the direction and story of the exit discharge. The signage must be placed 5 ft. from the floor of the landing so that it can be seen whether the door is open or closed. LS.02.01.20 30 The hospital posts signage on any door, passage, or stairway that someone could mistake for an exit route but is not an exit or access to an exit that says No Exit. LS.02.01.20 31 The facility has exit signs that are visible in circumstances in which the exit is not easily determinable. Such signs must be lit adequately and contain lettering that is a minimum of 4 inches high, or 6 inches high if the sign is lit externally. LS.02.01.20 32 All other LSC requirements pertaining to the means of egress as set forth in 18/19.2 are met by the hospital. EC.A.5C C 7.8.1.4 C 7.2.2.5.4 EC.A.5I 7.10.8.1 EC.A.5K (1 3) 7.10.1.2; 7.10.5; 7.10.6.1; 7.10.7.1 C 18/19.2 10 2008 HCPro, Inc. Life Safety Compliance Manual
Protection The organization protects individuals from fire and smoke by providing and maintaining building features. LS.02.01.30 1 The facility encloses existing vertical openings, not including exit stairs, in construction with a one-hour fire rating. For new construction, the facility en closes vertical openings connecting three or fewer floors, not including exit stairs, with one-hour fire-resistance rated (FRR) walls, and those connecting four or more floors with two-hour FRR walls. See LS.02.01.10, 4. Note: The Joint Commission deems vertical openings to include, but does not limit them to com - municating stairs, ramps, elevator shafts, ventilation shafts, light shafts, trash chutes, linen chutes, and utility chases. LS.02.01.30 2 The hospital protects all hazardous areas (including but not limited to the areas listed below) with walls and doors in a manner consistent with 18/19.3.2.1. Also see LS.02.01.10, 5 and LS.02.01.20, 18. Note: The following subsections of this provide guidance on assessing the protection of hazardous areas and identifying deficiencies. A. Boiler/fuel-fired heater rooms Existing boiler/fuel-fired heater rooms are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR New boiler/fuel fired heater rooms are sprinklered and the walls are one-hour FRR and the doors are 3/4-hour FRR EC.A.4A (1 8); EC.B.4A (1 8) EC.A.2K Table 3.A.3 and 3.A.4 18/19.3.1.1 18/19.3.2.1 18/19.3.2.1 Life Safety Compliance Manual 2008 HCPro, Inc. 11
18/19.3.2.1 B. Central/bulk laundries exceeding 100 sq. ft. Existing central/bulk laundries exceeding 100 sq. ft. are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the laundries walls are one-hour FRR and the doors are 3/4-hour FRR New central/bulk laundries exceeding 100 sq. ft. are sprinklered and the walls are one-hour FRR and the doors are 3/4-hour FRR C. Flammable liquid storage rooms (reference 30-1996: 4-4.2.1, 4-4.4.2) Existing flammable liquid storage room walls are two-hour FRR and doors are 1 1/2-hour FRR 18/19.3.2.1 New flammable liquid storage rooms are sprinklered, walls are two-hour FRR, and doors are 1 1/2-hour FRR D. Laboratories ( 45-1996 contains information to help you determine whether a laboratory should be classified as a severe hazard area) 18/19.3.2.1 Existing laboratories that are not severe hazard areas are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR. New laboratories that are not severe hazard areas are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices. 12 2008 HCPro, Inc. Life Safety Compliance Manual
Existing laboratories that are severe hazard areas (reference 99-1999: 10-3.1.1) have walls that are two-hour FRR and doors that are 1 1/2-hour FRR. When the laboratory is sprinklered, the walls are one-hour FRR, and the doors are 3/4-hour FRR. New laboratories that are severe hazard areas (reference 99-1999: 10-3.1.1) are sprinklered, the walls are one-hour FRR, and the doors are 3/4-hour FRR. Existing flammable gas storage rooms have walls that are two-hour FRR and doors that are 1 1/2-hour FRR (reference 99-1999: 10-10.2.2). New flammable gas storage rooms are sprinklered, have walls that are two-hour FRR and doors that are 1 1/2-hour FRR (reference 99-1999: 10-10.2.2). E. Maintenance repair shops Existing maintenance repair shops are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR 18/19.3.2.1 New maintenance repair shops are sprinklered, walls are one-hour FRR, and the doors are 3/4-hour FRR Life Safety Compliance Manual 2008 HCPro, Inc. 13
F. Piped oxygen tank supply rooms (reference 99-1999: 4-3.1.1.2) Existing piped oxygen tank supply rooms walls are one-hour FRR and the doors are 3/4-hour FRR 99-1999: 4-3.1.1.2 New piped oxygen tank supply rooms are sprinklered, walls are one-hour FRR, and the doors are 3/4-hour FRR G. Paint shops that are not severe hazard areas Existing paint shops that are not severe hazard areas are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR 18/19.3.2.1 New paint shops that are not severe hazard areas are sprinklered, the walls are one-hour FRR, and the doors are 3/4-hour FRR H. Soiled linen rooms Existing soiled linen rooms are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR 18/19.3.2.1 New soiled linen rooms are sprinklered, the walls are one-hour FRR, and the doors are 3/4-hour FRR 14 2008 HCPro, Inc. Life Safety Compliance Manual
18/19.3.2.1 I. Storage rooms Existing storage rooms for combustible materials that exceed 50 sq. ft. are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR New storage rooms for combustible materials ranging in size from 50 100 sq. ft. are sprinklered, resist the passage of smoke, and contain selfclosing doors or doors with automatic closing devices New storage rooms for combustible materials that exceed 100 sq. ft. are sprinklered, the walls are one-hour FRR, and the doors are 3/4-hour FRR J. Trash collection rooms Existing trash collection rooms are sprinklered, resist the passage of smoke, and contain self-closing doors or doors with automatic closing devices; or the walls are one-hour FRR and the doors are 3/4-hour FRR 18/19.3.2.1 New trash collection rooms are sprinklered, the walls are one-hour FRR, and the doors are 3/4-hour FRR LS.02.01.30 3 In gift shops that store or display combustibles in hazardous quantities, the walls are one-hour fire-resistance rated (FRR) and doors are 3/4-hour FRR. In existing buildings, such shops are sprinklered and use walls and doors to limit the passage of smoke. EC.A.2M (1,2) EC.B.2M (1,2) 18/19.3.2.5 Life Safety Compliance Manual 2008 HCPro, Inc. 15
18/19.3.3.2 LS.02.01.30 4 Existing wall and ceiling interior finishes limit smoke development and the spread of flames and have a Class A or B rating. New walls and ceiling interior finishes must have a Class A rating. LS.02.01.30 5 Interior floor finishes in smoke compartment corridors that are not sprinklered have a Class I radiant flux rating when they are newly installed. LS.02.01.30 6 Existing corridor partitions meet the following requirements: 1/2-hour FRR; continue from floor slab to the above floor or roof slab; continue through concealed areas; are sealed properly; and limit the transfer of smoke by design. Note: The Joint Commission permits unsealed spaces not to exceed 1/8-inch around pipes, conduits, ducts, and wires above the ceiling. In sprinklered smoke compartments, it is permissible for corridor partitions to end at the ceiling as long as the ceiling is designed to limit the passage of smoke. Such limitation can be achieved by exposed, suspended-grid acoustical tile ceilings; sprinkler piping and sprinklers that penetrate the ceiling; ducted heating, ventilating, and HVAC supply and return-air diffusers; and lighting fixtures that are recessed. LS.02.01.30 7 Corridor walls in new buildings are built to limit the transfer of smoke. EC.A.1F; EC.B.1F EC.A.1G; EC.B.1G 19.3.3.3 EC.A.2A (1 3) 19.3.6.2.1; 19.3.6.2.2. EC.B2A 18.3.6.2 19.3.6.3.8; 8.2.3.2.2(2) LS.02.01.30 8 Fixed fire windows installed in corridor walls do not exceed 25% of the size of the wall in smoke compartments that are not sprinklered. Note: The Joint Commission permits existing window installations that are in compliance with previously accepted LSC criteria. EC.A.2H (1,2) 16 2008 HCPro, Inc. Life Safety Compliance Manual
19.3.6.3.1; 19.3.6.4 LS.02.01.30 9 Corridor doors in existing buildings contain at least a 1 3/4-inch solid-bonded wood core or equivalent. Such doors do not contain ventilating louvers or transfer grills. Exceptions include bathrooms, toilets, and sink closets that do not have any flammable or combustible material. LS.02.01.30 10 There are no nonrated protective plates positioned higher than 48 inches from the bottom of corridor doors. LS.02.01.30 11 Corridor doors adhere to the following requirements: fitted with positive latching hardware; arranged to restrict the passage of smoke; have hinges that allow them to swing; in paired doors, the meeting edges are 1/8 inch or less apart; undercuts are 1 inch or less; and do not contain roller latches. Note: The Joint Commission permits existing doors to have a device that keeps the door closed when 5-ft.-lb force is applied to the edge of the door. LS.02.01.30 12 The hospital ensures the installment of openings in vision panels or doors in corridor walls (not including compartments containing patient sleeping rooms) are one half the distance from the floor to the ceiling or less. In new buildings, such openings must be 80 square inches or less, and in existing buildings, 20 square inches or less. Note: Examples of such openings include mail slots and pass-through windows in laboratories, pharmacies, and cashier stations. C EC.5.0, 1 EC.A.2I (2,5) EC.A.2I (6) 18/19.3.6.3.5 18/19.3.6.3.2; 18/19.3.6.3.1; 7.2.1.4.1 EC.A.2I (1,3,4) EC.A.2J (1,2) EC.B.2J (1,2) 18/19.3.6.5 Life Safety Compliance Manual 2008 HCPro, Inc. 17
90A-1999: 2-3.11.1 LS.02.01.30 13 The hospital does not use corridors that serve adjoining areas for a portion of an air supply, air return, or exhaust air plenum. Note: The Joint Commission s interpretation of the applicable code permits incidental air movement between rooms and corridors (e.g., isolation rooms). This is in recognition of hospitals need for pressure differentials. See the Joint Commission for specific examples. LS.02.01.30 14 For every story of existing buildings that exceed 30 patients in sleeping rooms, the hospital provides a minimum of two smoke compartments. LS.02.01.30 15 For every story of new buildings with patient sleeping or treatment rooms, stories designated as non-sleeping with an occupant capacity that meets or exceeds 50 people, or on stories that are usable or unoccupied, the hospital provides a minimum of two smoke compartments. LS.02.01.30 16 Smoke barriers are in place so that smoke compartments do not exceed 22,500 sq. ft., and the travel distance does not exceed 200 ft. from any point in the compartment to a smoke barrier door. LS.02.01.30 17 Smoke compartment size is in compliance with 18/19.3.7.4. EC.A.5D; EC.B.5E A EC.5.20, 1 EC.A.3A 19.3.7.1 A EC.5.20, 1 EC.B.3A (1 3) 18.3.7.1; 18.3.7.2 EC.A.3B (1,2) EC.B.3B (1,2) 18/19.3.7.1 C 18/19.3.7.4 LS.02.01.30 18 All smoke compartment barriers must extend from the floor slab below to the floor slab (or roof slab) above and extend continuously from outside wall to outside wall, through all interstitial spaces, and all penetrations are properly sealed. LS.02.01.30 19 Smoke barriers have a 1/2-hour FRR in existing buildings, and one-hour FRR for new buildings. EC.A.3C (1,2) EC.B.3C (1,2) 18/19.3.7.3 EC.A.3C (3) EC.B.3C (3) 18/19.3.7.3 18 2008 HCPro, Inc. Life Safety Compliance Manual
18/19.3.7.3; 8.3.5.2 LS.02.01.30 20 Ducts penetrating any smoke barriers in existing buildings have smoke dampers protecting them that close upon activation of a smoke detector. Such detectors must be located in the duct system or the area that serves the smoke compartment. Note: The Joint Commission does not require dampers in common smoke barriers for existing buildings with two adjacent compartments that are sprinklered. LS.02.01.30 21 Air transfer openings that extend through smoke barriers in ceiling areas and are in use as unducted common plenum for supply or return air are protected by smoke dampers. LS.02.01.30 22 Where smoke barrier walls or doors have fixed fire window assemblies, such assemblies have a 20-minute FRR and do not exceed 25% of the size of the barrier in which they are installed. Note: The Joint Commission will accept existing window installations that have fixed wire glass or fire-rated glazing, are 1,296 square inches in size or smaller, and are set in approved metal frames. LS.02.01.30 23 Smoke barrier doors meet the following requirements: They are self- or automatic closing; they are built with 1 3/4-inch or greater solid-bonded wood core or its equal; they are fit to resist the passage of smoke; where doors are paired, the gap where the doors meet does not exceed 1/8 inch; the undercut does not exceed 3/4 inch; and such doors do not contain nonrated protective plates that are positioned in excess of 48 inches from the door s bottom. EC.A.3F EC.A.3G EC.A.3H EC.B.3H 8.3.5.1 EC.A.3E (1,2) EC.B.3E (1.2) 18.3.7.7; 19.3.7.5; 8.2.3.2.2 EC.A.3D (1 4) EC.B.3D (1 4) 18/19.3.7.5; 18/19.3.7.6; 8.3.4.1 Life Safety Compliance Manual 2008 HCPro, Inc. 19
LS.02.01.30 24 All other LSC requirements for protection from fire and smoke related to 18/19.3 are met by the organization. Note: See The Joint Commission s Web site, www.jointcommission.org/lsc, for requirements related to the accepted amount of alcohol-based hand rub permitted within one smoke compartment. Fire Alarm The organization provides and maintains fire alarm systems. LS.02.01.34 1 The hospital achieves automatic transmission of the hospital s fire alarm signal via at least one of the following: An auxiliary fire alarm system that has a direct connection to the fire department servicing the facility, in compliance with 72-1999: 6-16 A central station service, in compliance with 72-1999: 5-2 A proprietary supervising station system, in compliance with 72-1999: 5-3 According to The Joint Commission policy for a manual transmission system. For details, see www. jointcommission.org/lsc. A remote supervising station fire alarm system as described in 72-1999: 5-4. LS.02.01.34 2 The hospital locates its master fire alarm control panel in a continuously occupied environment that is protected (i.e., enclosed with one-hour FRR walls and 3/4-hour FRR doors), or where there is a smoke detector. Also see LS.02.01.10, 5. 3 A C 18/19.3 72-1999: 6-16 72-1999: 5-2 72-1999: 5-3 9.6.4 72-1999: 5-4 3 A 9.6.4 72-1999: 1-5.6 and 3-8.41 20 2008 HCPro, Inc. Life Safety Compliance Manual
LS.02.01.34 3 The local fire department or equivalent agency approves the location of the remote ancillary annunciator panel. LS.02.01.34 4 All fire alarm requirements pertaining to the LSC related to 18.3.4/19.3.4 are met by the hospital. Extinguishment Hospitals have a system for extinguishing fires and maintain those systems. LS.02.01.35 1 The hospital monitors automatic sprinkler system components with its fire alarm system. LS.02.01.35 2 The hospital connects its fire alarm system to water flow alarms. LS.02.01.35 3 Approved automatic sprinkler system piping supports are free of damage and not loose. LS.02.01.35 4 Approved automatic sprinkler system piping does not support any other item. LS.02.01.35 5 There is no damage, corrosion, foreign materials, or paint present on sprinkler heads. LS.02.01.35 6 The hospital maintains at least 18 inches of space below sprinkler deflectors and the top of any storage. Note: The Joint Commission permits hospitals to extend perimeter wall and stack shelving up to the ceiling in those instances in which such items are not directly below a sprinkler head. LS.02.01.35 7 Isolated, hazardous areas protected by limited area sprinkler systems connected to the domestic water system feature a shutoff valve and have no more than six sprinkler heads. In new installations that have two or more sprinkler heads serving one area, the hospital provides water flow detection. C 9.6.4 C 18/19.3.4 3 A 18/19.3.5.2 9.7.2.2 3 A 9.7.2.2 C 25-1998: 2-2.3 C 25-1998: 2-2.3 C 25-1998: 2-2.1.1 3 EC.A.6B 13-1999: 5-8.5.2.1 3 A 9.7.1.2 Life Safety Compliance Manual 2008 HCPro, Inc. 21
LS.02.01.35 8 The hospital limits the travel distance from any point to the closest fire extinguisher to no more than 75 ft. LS.02.01.35 9 Grease-producing cooking devices (e.g., fat fryers, ranges, griddles, or broilers) have Class K fire extinguishers within 30 ft. LS.02.01.35 10 Exhaust hoods, an exhaust duct system, and grease-removal device that do not have mesh filters are present on greaseproducing cooking devices. LS.02.01.35 11 Grease-producing cooking devices have an automatic fire-extinguishing system that will deactivate the fuel source. LS.02.01.35 12 The automatic fire extinguishing systems for grease-producing cooking devices does the following: Deactivates the fuel source. LS.02.01.35 13 Grease-producing cooking devices have an automatic fire-extinguishing system that will control the exhaust fans according to design. LS.02.01.35 14 All automatic extinguishing requirements in the LSC related to 101-2000: 18/19.3.5 are met by the hospital. C 18/19.3.5.6 10-1998: 3-1.1 C 18/19.3.5.6; 10-1998: 2-3.2 C 18/19.3.5.6; 10-1998: 1-3.1 3 A 18/19.3.2.6; 96-1998: 7-1.1 and 7-6.2 3 A 18/19.3.2.6; 96-1998: 7-1.1 and 7-4.1 C 18/19.3.2.6; 96-1998: 7-1.1 and 8-1.5 C 18/19.3.5 22 2008 HCPro, Inc. Life Safety Compliance Manual
Special provision Special features that protect occupants from fire and smoke hazards exist and are maintained by the hospital. LS.02.01.40 1 Hospitals that have buildings without windows, or portions of buildings without windows, adhere to the requirements set forth in 18/19.4.1. LS.02.01.40 2 Hospitals have an approved automatic sprinkler system, meeting the requirements of 18.4.2, in new high-rise buildings. C 11.7 3 A 11.8 Building services The hospital protects occupants from the hazards of fire and smoke by the provision and maintenance of building services. LS.02.01.50 1 Patient sleeping areas must not have fireplaces, and in those areas where fireplaces are permitted, the hospital maintains one-hour fire-resistance rated (FRR) construction separating the fireplace and patient sleeping spaces. LS.02.01.50 2 The hospital provides fireplace enclosures for all fireplaces. Such enclosures are guaranteed to resist breakage up to 650 F and are built with heat-tempered glass or other material. LS.02.01.50 3 Newly installed fireplace hearths are raised, at a minimum, 4 inches above the floor. LS.02.01.50 4 The hospital equips new elevators with: Firefighters service key recall. Smoke detector automatic recall. Firefighters service emergency in-car key operation. Machine room smoke detectors. Elevator lobby smoke detectors. The hospital must also meet these requirements for existing elevators with a travel distance of 25 ft. or more above or below the level that best serve firefighters needs. C 18/19.5.2.2 C 18/19.5.2.2 C 18.5.2.2 C 18/19.5.3 9.4.3 Life Safety Compliance Manual 2008 HCPro, Inc. 23
LS.02.01.50 5 Trash chutes discharge into designated rooms. Such rooms serve no other purpose. C 18/19.5.4.3 C 18.5.4.1; 82-1999: 3-2.2.4 C 18/19.5.4.2 82-1999: 3-2.5.1 LS.02.01.50 6 In new buildings, vent openings in linen and waste chutes extend through the roof and into the outside atmosphere. LS.02.01.50 7 Buildings that exceed two stories place approved automatic sprinkler systems in the following locations: above the top of openings to the linen and waste chute on the lowest service levels, and above the service door opening on alternating floors. LS.02.01.50 8 Linen and waste chute service inlet door assemblies in existing buildings have a 3/4-hour FRR, or a one-hour FRR if such an assembly opens into a corridor. In new buildings, such assemblies are onehour FRR, or 1 1/2-hour FRR for chutes of four or more stories. LS.02.01.50 9 The hospital places self-closing and positive latching devices on all linen and waste chute inlet and discharge service doors. C 18/19.5.4.1 C 18/19.5.4.1 8.2.3.2.1; 82-1999: 3-2.2.9 C 18/19.5.4.1 8.2.3.2.1 C 18/19.5.4.1 18/19.3.2.1; 82-1999: 3-2.6.1 LS.02.01.50 10 Discharge door assemblies for linen and trash chutes have a one-hour FRR. LS.02.01.50 11 Collection rooms for linen and waste chute discharge are separated from the corridor by one-hour FRR walls. 24 2008 HCPro, Inc. Life Safety Compliance Manual
LS.02.01.50 12 All other LSC building service requirements related to 18/19.5 are met by the hospital. C 18/19.5 Operating features Operating features that conform to fire and smoke prevention requirements are provided and maintained by the hospital. LS.02.01.70 1 Combustible decorations that are not flame-retardant are prohibited by the hospital. LS.02.01.70 2 The hospital locates soiled linen and trash receptacles greater than 32 gal. in a room that has the protections of a hazardous area. Recycling containers are included in this requirement. LS.02.01.70 3 In smoke compartments with patient sleeping and treatment areas, the organization prohibits portable space heaters. LS.02.01.70 4 All other LSC operating feature requirements related to 18.7/19.7 are met by the hospital. Also see EC.02.03.03, 1. C 18/19.7.5.4 C 18/19.7.5.5 C 18/19.7.8 C 18.7 and 19.7 Life Safety Compliance Manual 2008 HCPro, Inc. 25