TJC - Life Safety Chapter

• Conducted on

  Date

• Prepared by

• Location
  Address

LS.01.01.01 The hospital designs and manages the physical environment to comply with the Life Safety Code.

• EP1 - The hospital assigns an individual(s) to assess compliance with the Life Safety Code and manage the Statement of Conditions (SOC) when addressing survey-related deficiencies.

  Yes

  No

  N/A

• EP2 - In time frames defined by the hospital, the hospital performs a building assessment to determine compliance with the “Life Safety” (LS) chapter.

  Yes

  No

  N/A

• EP3 - The hospital maintains current and accurate drawings denoting features of fire safety and related square footage. Fire safety features include the following:- Areas of the building that are fully sprinklered (if the building is partially sprinklered)- Locations of all hazardous storage areas- Locations of all fire-rated barriers- Locations of all smoke-rated barriers- Sleeping and non-sleeping suite boundaries, including the size of the identified suites- Locations of designated smoke compartments- Locations of chutes and shafts- Any approved equivalencies or waivers

  Yes

  No

  N/A

• EP4 - When the hospital plans to resolve a deficiency through a Survey-Related Plan for Improvement (SPFI), the hospital meets the 60-day time frame. Note 1: If the corrective action will exceed the 60-day time frame, the hospital must request a time-limited waiver within 30 days from the end of survey. Note 2: If there are alternative systems, methods, or devices considered equivalent, the hospital may submit an equivalency request using its Statement of Conditions (SOC). Note 3: For further information on waiver and equivalency requests, see https://www.jointcommission.org/life_safety_code_information_resources/ and NFPA 101-2012: 1.4.

  Yes

  No

  N/A

• EP5 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspections and approvals made by state or local fire control agencies.

  Yes

  No

  N/A

• EP6 - The hospital does not remove or minimize an existing life safety feature when such feature is a requirement for new construction. Existing life safety features, if not required by the Life Safety Code, can be either maintained or removed.

  Yes

  No

  N/A

LS.01.02.01 The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.

• EP1 - The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital implements LS.01.02.01, EPs 2–15 to compensate for increased life safety risk. The criteria include the assessment process to determine when interim life safety measures are implemented.

  Yes

  No

  N/A

• EP2 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. (For full text, refer to NFPA 101-2012: 9.6.1.6; 9.7.6; NFPA 25-2011: 15.5.2)

  Yes

  No

  N/A

• EP3 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Posts signage identifying the location of alternative exits to everyone affected.

  Yes

  No

  N/A

• EP4 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Inspects exits in affected areas on a daily basis. The need for these inspections is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP5 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately 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 on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP6 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP7 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire. The need for these partitions is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP8 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. The need for increased surveillance is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP9 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level. The need for these practices is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP10 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Provides additional training to those who work in the hospital on the use of firefighting equipment. The need for additional training is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP11 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Conducts one additional fire drill per shift per quarter. The need for additional drills is based on criteria in the hospital's interim life safety measure (ILSM) policy. (See also EC.02.03.03, EP 1)

  Yes

  No

  N/A

• EP12 - When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Inspects and tests temporary systems monthly. The completion date of the tests is documented. The need for these inspections and tests is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP13 - The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. The need for education is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• EP14 - The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features. The need for training is based on criteria in the hospital's interim life safety measure (ILSM) policy. Note: Compartmentalization is the concept of using various building components (for example, fire-rated walls and doors, smoke barriers, fire-rated floor slabs) to prevent the spread of fire and the products of combustion so as to provide a safe means of egress to an approved exit. The presence of these features varies, depending on the building occupancy classification.

  Yes

  No

  N/A

• EP15 - The hospital's policy allows the use of other ILSMs not addressed in EPs 2–14. Note 1: The hospital’s ILSM policy addresses Life Safety Code Requirements for Improvement (RFI) that are not immediately corrected during survey. Note 2: The “other” ILSMs used are documented by selecting “other” and annotating the associated text box in the hospital's Survey-Related Plan for Improvement (SPFI) within the Statement of Conditions™ (SOC).

  Yes

  No

  N/A

LS.02.01.10 Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

• EP1 - Buildings meet requirements for construction type and height. In Types I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. All new buildings contain approved automatic sprinkler systems. Existing buildings contain approved automatic sprinkler systems as required by the construction type.

  Yes

  No

  N/A

• EP2 - When building rehabilitation occurs, the hospital incorporates NFPA 101-2012: Chapters 18, 19, and 43. (For full text, refer to 3 Any building undergoing change of use or change of occupancy classification complies with NFPA 101-2012: 43.7, unless permitted by NFPA 101-2012:18/19.1.1.4.2.

  Yes

  No

  N/A

• EP4 - When an addition is made to a building, the building is in compliance with NFPA 101-2012: 43.8 and Chapter 18.

  Yes

  No

  N/A

• EP5 - Buildings without protection from automatic sprinkler systems comply with NFPA 101-2012: 18.4.3.2; 18.4.3.3; and 18.4.3.8. When a nonsprinklered smoke compartment has undergone major rehabilitation, the automatic sprinkler requirements of Chapter 18.3.5 will apply. Note: Major rehabilitation involves the modification of more than 50 percent, or 4500 square feet, of the area of the smoke compartment. (For full text, refer to NFPA 101-2012: 18/19.1.1.4.3.3)

  Yes

  No

  N/A

• EP6 - Fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. For those fire barriers terminating at the bottom side of an interstitial space, the construction assembly forming the bottom of the interstitial space must have a fire resistance rating not less than that of the fire barrier. (For full text, refer to NFPA 101-2012: 8.3.1.2)

  Yes

  No

  N/A

• EP7 - Common walls are fire rated for two hours that are within buildings (occupancy separation), between buildings (two health care occupancy buildings), or the building has a common wall with a nonconforming building (for example, a health care occupancy and a business occupancy). (For full text, refer to NFPA 101-2012: 43.8; 18/19.1.1.4; 18/19.1.3.3; 18/19.1.3.4; 8.2.2.2)

  Yes

  No

  N/A

• EP8 - When multiple occupancies are identified, they are in accordance with NFPA 101-2012: 18/19.1.3.2 or 18/19.1.3.4, and the most stringent occupancy requirements are followed throughout the building. Note 1: If a two-hour separation is provided in accordance with NFPA 101-2012: 8.2.1.3, the construction type is determined as follows: - The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with NFPA 101-2012: 18/19.1.6 and Tables 18/19.1.6.1. - The construction type of the areas of the building enclosing the other occupancies are based on NFPA 101-2012: 18/19.1.3.5; 8.2.1.3. Note 2: Outpatient surgical departments must be classified as ambulatory health care occupancy regardless of the number of patients served. (For full text, refer to NFPA 101-2012: 18/19.1.3.4.1)

  Yes

  No

  N/A

• EP9 - The fire protection ratings for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions are as follows: - Three hours in three-hour barriers and partitions - Ninety minutes in two-hour barriers and partitions - Forty-five minutes in one-hour barriers and partitions - Twenty minutes in thirty-minute barriers and partitions Note 1: Labels on fire door assemblies must be maintained in legible condition. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the applicable provisions of the Life Safety Code Tentative Interim Amendment (TIA) EP10 - In existing buildings that are not a high rise and are protected with automatic sprinkler systems, exit stairs (or new exit stairs connecting three or fewer floors) are fire rated for one hour. In new construction, exit stairs connecting four or more floors are fire rated for two hours. (For full text, refer to NFPA 101-2012: 7.1.3.2.1)

  Yes

  No

  N/A

• EP11 - Fire-rated doors within walls and floors have functioning hardware, including positive latching devices and self-closing or automatic-closing devices (either kept closed or activated by release device complying with NFPA 101- 2012:7.2.1.8.2). Gaps between meeting edges of door pairs are no more than 1/8 of an inch wide, and undercuts are no larger than 3/4 of an inch. Fire-rated doors within walls do not have unapproved protective plates greater than 16 inches from the bottom of the door. Blocking or wedging open fire-rated doors is prohibited. (For full text, refer to NFPA 101-2012: 8.3.3.1; NFPA 80-2010: 4.8.4.1; 5.2.13.3; 6.3.1.7; 6.4.5; 7.2.1.8.2)

  Yes

  No

  N/A

• EP12 - Doors requiring a fire rating of 3/4 of an hour or longer are free of coverings, decorations, or other objects applied to the door face, with the exception of informational signs, which are applied with adhesive only. (For full text, refer to NFPA 80-2010: 4.1.4)

  Yes

  No

  N/A

• EP13 - Ducts penetrating the walls or floors with a fire resistance rating of less than 3 hours are protected by dampers that are fire rated for 1 1/2 hours; ducts penetrating the walls or floors with a fire resistance rating of 3 hours or greater are protected by dampers that are fire rated for 3 hours. (For full text, refer to NFPA 101-2012: 8.3.5.7; 9.2.1; NFPA 90A-2012: 5.4.1; 5.4.2)

  Yes

  No

  N/A

• EP14 - The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes penetrating the walls or floors are protected with an approved fire-rated material. Note: Polyurethane expanding foam is not an accepted fire-rated material for this purpose. (For full text, refer to NFPA 101-2012: 8.3.5)

  Yes

  No

  N/A

• EP15 - The hospital meets all other Life Safety Code requirements related to NFPA 101-2012: 18/19.1.

  Yes

  No

  N/A

LS.02.01.20 The hospital maintains the integrity of the means of egress.

• EP1 - Buildings meet requirements for construction type and height. In Types I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. All new buildings contain approved automatic sprinkler systems. Existing buildings contain approved automatic sprinkler systems as required by the construction type. (For full text, refer to NFPA 101-2012: 18/19.1.6; 18.3.5.1; 19.3.5.3; 18/19.3.5.4; 18/19.3.5.5; 18.3.5.6)

  Yes

  No

  N/A

• EP2 - When building rehabilitation occurs, the hospital incorporates NFPA 101-2012: Chapters 18, 19, and 43. (For full text, refer to NFPA 101-2012: Chapter 43; 18/19.1.1.4.3; 18.4.3.1–18.4.3.5; 19.4.3)

  Yes

  No

  N/A

• EP3 - Any building undergoing change of use or change of occupancy classification complies with NFPA 101-2012: 43.7, unless permitted by NFPA 101-2012:18/19.1.1.4.2.

  Yes

  No

  N/A

• EP4 - When an addition is made to a building, the building is in compliance with NFPA 101-2012: 43.8 and Chapter 18.

  Yes

  No

  N/A

• EP5 - Buildings without protection from automatic sprinkler systems comply with NFPA 101-2012: 18.4.3.2; 18.4.3.3; and 18.4.3.8. When a nonsprinklered smoke compartment has undergone major rehabilitation, the automatic sprinkler requirements of Chapter 18.3.5 will apply. Note: Major rehabilitation involves the modification of more than 50 percent, or 4500 square feet, of the area of the smoke compartment. (For full text, refer to NFPA 101-2012: 18/19.1.1.4.3.3)

  Yes

  No

  N/A

• EP6 - Fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. For those fire barriers terminating at the bottom side of an interstitial space, the construction assembly forming the bottom of the interstitial space must have a fire resistance rating not less than that of the fire barrier. (For full text, refer to NFPA 101-2012: 8.3.1.2)

  Yes

  No

  N/A

• EP7 - Common walls are fire rated for two hours that are within buildings (occupancy separation), between buildings (two health care occupancy buildings), or the building has a common wall with a nonconforming building (for example, a health care occupancy and a business occupancy). (For full text, refer to NFPA 101-2012: 43.8; 18/19.1.1.4; 18/19.1.3.3; 18/19.1.3.4; 8.2.2.2)

  Yes

  No

  N/A

• EP8 - When multiple occupancies are identified, they are in accordance with NFPA 101-2012: 18/19.1.3.2 or 18/19.1.3.4, and the most stringent occupancy requirements are followed throughout the building. Note 1: If a two-hour separation is provided in accordance with NFPA 101-2012: 8.2.1.3, the construction type is determined as follows: - The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with NFPA 101-2012: 18/19.1.6 and Tables 18/19.1.6.1. - The construction type of the areas of the building enclosing the other occupancies are based on NFPA 101-2012: 18/19.1.3.5; 8.2.1.3. Note 2: Outpatient surgical departments must be classified as ambulatory health care occupancy regardless of the number of patients served. (For full text, refer to NFPA 101-2012: 18/19.1.3.4.1)

  Yes

  No

  N/A

• EP9 - The fire protection ratings for opening protectives in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions are as follows: - Three hours in three-hour barriers and partitions - Ninety minutes in two-hour barriers and partitions - Forty-five minutes in one-hour barriers and partitions - Twenty minutes in thirty-minute barriers and partitions (For full text, refer to NFPA 101-2012: 8.3.4; 8.3.3.2; Table 8.3.4.2) Note 1: Labels on fire door assemblies must be maintained in legible condition. Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the applicable provisions of the Life Safety Code Tentative Interim Amendment (TIA) 12-1.

  Yes

  No

  N/A

• EP10 - In existing buildings that are not a high rise and are protected with automatic sprinkler systems, exit stairs (or new exit stairs connecting three or fewer floors) are fire rated for one hour. In new construction, exit stairs connecting four or more floors are fire rated for two hours. (For full text, refer to NFPA 101-2012: 7.1.3.2.1)

  Yes

  No

  N/A

• EP11 - Fire-rated doors within walls and floors have functioning hardware, including positive latching devices and self-closing or automatic-closing devices (either kept closed or activated by release device complying with NFPA 101- 2012:7.2.1.8.2). Gaps between meeting edges of door pairs are no more than 1/8 of an inch wide, and undercuts are no larger than 3/4 of an inch. Fire-rated doors within walls do not have unapproved protective plates greater than 16 inches from the bottom of the door. Blocking or wedging open fire-rated doors is prohibited. (For full text, refer to NFPA 101-2012: 8.3.3.1; NFPA 80-2010: 4.8.4.1; 5.2.13.3; 6.3.1.7; 6.4.5; 7.2.1.8.2)

  Yes

  No

  N/A

• EP12 - Doors requiring a fire rating of 3/4 of an hour or longer are free of coverings, decorations, or other objects applied to the door face, with the exception of informational signs, which are applied with adhesive only. (For full text, refer to NFPA 80-2010: 4.1.4)

  Yes

  No

  N/A

• EP13 - Ducts penetrating the walls or floors with a fire resistance rating of less than 3 hours are protected by dampers that are fire rated for 1 1/2 hours; ducts penetrating the walls or floors with a fire resistance rating of 3 hours or greater are protected by dampers that are fire rated for 3 hours. (For full text, refer to NFPA 101-2012: 8.3.5.7; 9.2.1; NFPA 90A-2012: 5.4.1; 5.4.2)

  Yes

  No

  N/A

• EP14 - The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes penetrating the walls or floors are protected with an approved fire-rated material. Note: Polyurethane expanding foam is not an accepted fire-rated material for this purpose. (For full text, refer to NFPA 101-2012: 8.3.5)

  Yes

  No

  N/A

• EP15 - The hospital meets all other Life Safety Code requirements related to NFPA 101-2012: 18/19.1.

  Yes

  No

  N/A

• EP16 - Each floor of a building has at least two exits that are remote from each other and accessible from every part of the floor. Each smoke compartment has two distinct egress paths to exits that do not require entry into the same adjacent smoke compartment. (For full text, refer to NFPA 101-2012: 18/19.2.4.1–18/19.2.4.4)

  Yes

  No

  N/A

• EP17 - Every corridor provides access to at least two approved exits in accordance with NFPA 101-2012: 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. (For full text, refer to NFPA 101-2012: 18/19.2.5.4)

  Yes

  No

  N/A

• EP18 - In new buildings, exit corridors are at least eight feet wide, unless otherwise permitted by the Life Safety Code. In new psychiatric buildings, exit corridors are at least six feet wide, unless otherwise permitted by the Life Safety Code. (For full text, refer to NFPA 101-2012: 18.2.3.4; 18.2.3.5)

  Yes

  No

  N/A

• EP19 - In existing buildings, exit corridors are at least 48 inches in clear width where serving as a means of egress from patient sleeping rooms. If modifying existing buildings with exit corridors that exceed eight feet, the exit corridors cannot be reduced to less than eight feet. (For full text, refer to NFPA 101-2012: 4.6.12.2; 19.2.3.4)

  Yes

  No

  N/A

• EP20 - Existing exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair. (For full text, refer to NFPA 101-2012: 19.2.3.6, 19.2.3.7)

  Yes

  No

  N/A

• EP21 - New exit access doors and exit doors are of the swinging type and are at least 41 1/2 inches in clear width. In psychiatric hospitals doors are at least 32 inches wide. Doors not subject to patient use, in exit stairway enclosures, or serving newborn nurseries are at least 32 inches in clear width. If using a pair of doors, the doors have a rabbet, bevel, or astragal at the meeting edge, and at least one of the doors provides 32 inches in clear width, while the inactive leaf of the pair is secured with automatic flush bolts. (For full text, refer to NFPA 101-2012: 18.2.3.6; 18.2.3.7)

  Yes

  No

  N/A

• EP22 - Exit access doors and exit doors are free of mirrors, hangings, or draperies that might conceal, obscure, or confuse the direction of exit. (For full text, refer to NFPA 101-2012: 18/19.2.1; 18/19.2.5.1; 7.1.10.2; 7.5.2.2.1)

  Yes

  No

  N/A

• EP23 - Doors to new boiler rooms, new heater rooms, and new mechanical equipment rooms located in a means of egress are not held open by an automatic release device. (For full text, refer to NFPA 101-2012: 18.2.2.2.7)

  Yes

  No

  N/A

• EP24 - The corridor width is not obstructed by wall projections. (For full text, refer to NFPA 101-2012: 18/19.2.3.3) Note: When corridors are six feet wide or more, it is allowable for certain objects to project into the corridor, such as hand rub dispensers or computer desks that are retractable. The objects must be no more than 36 inches wide and cannot project more than 6 inches into the corridor. These items must be installed at least 48 inches apart and above the handrail height. (For full text, refer to NFPA 101-2012: 18/19.2.3.4)

  Yes

  No

  N/A

• EP25 - In new buildings, no dead-end corridor is longer than 30 feet, and the common path of travel does not exceed 100 feet. (For full text, refer to NFPA 101-2012: 18.2.5.2) Note: Existing dead-end corridors longer than 30 feet are permitted to be used if it is impractical and unfeasible to alter them. (For full text, refer to NFPA 101-2012: 19.2.5.2)

  Yes

  No

  N/A

• EP26 - Patient sleeping rooms open directly onto an exit access corridor. Patient sleeping rooms with less than eight beds may have one intervening room to reach an exit access corridor provided the intervening room is equipped with an approved automatic smoke detection system. (For full text, refer to NFPA 101-2012: 18/19.2.5.6.1–18/19.2.5.6.4)

  Yes

  No

  N/A

• EP27 - Patient sleeping rooms that are larger than 1,000 square feet have at least two exit access doors remotely located from each other. Rooms not used as patient sleeping rooms that are larger than 2,500 square feet have at least two exit access doors remotely located from each other. (For full text, refer to NFPA 101-2012: 18/19.2.5.5)

  Yes

  No

  N/A

• EP28 - Suites are separated from the remainder of the building by corridor walls or existing barriers and doors that limit the transfer of smoke. (For full text, refer to NFPA 101-2012: 18/19.2.5.7.1.2; 18/19.3.6)

  Yes

  No

  N/A

• EP29 - Suites are subdivided by means of noncombustible or limited-combustible partitions or partitions constructed with fire retardant–treated wood enclosed with noncombustible or limited-combustible materials. These partitions are not required to be fire rated. (For full text, refer to NFPA 101-2012: 18/19.2.5.7.1.4)

  Yes

  No

  N/A

• EP30 - Suites of patient sleeping rooms larger than 1,000 square feet are provided with at least two exit access doors remotely located from each other, with one exiting directly to a corridor. The second exit may go into another suite (provided the two suites are separated with a corridor wall), an exit stair, exit passageway, or exit door to the exterior. (For full text, refer to NFPA 101-2012: 18/19.2.5.7.2.1(B); 18/19.2.5.7.2.2)

  Yes

  No

  N/A

• EP31 - Suites not used as patient sleeping rooms that are larger than 2,500 square feet have at least two exit access doors remotely located from each other, with one directly exiting to a corridor. The second exit may go into another suite (provided the two suites are separated with a corridor wall), an exit stair, exit passageway, or exit door to the exterior. (For full text, refer to NFPA 101-2012: 18/19.2.5.7.3.2; 18/19.2.5.7.3.1(B))

  Yes

  No

  N/A

• EP32 - For existing buildings, suites of patient sleeping rooms are limited to 5,000 square feet or less. If the existing building has an approved electrically supervised sprinkler system and total coverage automatic smoke detection system, the suite is permitted to be increased to 7,500 square feet. (For full text, refer to NFPA 101-2012: 9.6.2.9; 19.3.4; 19.3.5.7; 19.3.5.8.) If the suite is provided with direct visual supervision, an approved electrically supervised sprinkler system, and a total coverage (complete) smoke detection system, the suite is permitted to be increased to 10,000 square feet. (For full text, refer to NFPA 101-2012: 9.6.2.9; 19.2.5.7.2.1(D)(1)(a); 19.2.5.7.2.3; 19.3.4; 19.3.5.8)

  Yes

  No

  N/A

• EP33 - For new buildings, patient sleeping suites are allowed to be 7,500 square feet. If the suite has total coverage smoke detection and direct visual supervision, the suite can be up to 10,000 square feet. (For full text, refer to NFPA 101-2012: 18.2.5.7.2.3; 18.2.5.7.2.1(D)(1)(a); 18.3.4)

  Yes

  No

  N/A

• EP34 - Patient care suites not used for sleeping are limited to 10,000 square feet. (For full text, refer to NFPA 101-2012: 18/19.2.5.7.3.3)

  Yes

  No

  N/A

• EP35 - For new buildings, sleeping and non-sleeping patient care suites have a travel distance to an exit access door of 100 feet or less from any point in the suite. The travel distance between any point in the suite and an exit is 200 feet. (For full text, refer to NFPA 101-2012: 18.2.5.7.2.4; 18.2.5.7.3.4)

  Yes

  No

  N/A

• EP36 - For existing buildings, sleeping and non-sleeping patient care suites have a travel distance to an exit access door of 100 feet or less from any point in the suite. The travel distance between any point in the suite and an exit is either 150 feet if the building is not protected throughout by an approved electrically supervised sprinkler system or 200 feet if the building is fully protected by an approved electrically supervised sprinkler system. (For full text, refer to NFPA 101-2012: 19.2.5.7.2.4; 19.2.5.7.3.4)

  Yes

  No

  N/A

• EP36 - For existing buildings, sleeping and non-sleeping patient care suites have a travel distance to an exit access door of 100 feet or less from any point in the suite. The travel distance between any point in the suite and an exit is either 150 feet if the building is not protected throughout by an approved electrically supervised sprinkler system or 200 feet if the building is fully protected by an approved electrically supervised sprinkler system. (For full text, refer to NFPA 101-2012: 19.2.5.7.2.4; 19.2.5.7.3.4)

  Yes

  No

  N/A

• EP37 - Travel distances to exits are measured in accordance with NFPA 101-2012: 7.6. - From any point in the room or suite to the exit is 150 feet or less (200 feet or less if the building is fully sprinklered) - From any point in a room to the room door is 50 feet or less

  Yes

  No

  N/A

• EP38 - Means of egress are adequately illuminated at all points, including angles and intersections of corridors and passageways, stairways, stairway landings, exit doors, and exit discharges. (For full text, refer to NFPA 101-2012: 18/19.2.8; 7.8.1.1)

  Yes

  No

  N/A

• EP39 - Illumination in the means of egress, including exit discharges, is arranged so that failure of any single light fixture or bulb will not leave the area in darkness (less than 0.2 foot candles). Emergency lighting of at least 1½-hours duration is provided automatically in accordance with NFPA 101-2012: 7.9. (See also EC.02.05.07, EP 2) (For full text, refer to NFPA 101-2012: 18/19.2.8; 18/19.2.9.1; 7.8.1.4; 7.9.2)

  Yes

  No

  N/A

• EP40 - Exit signs are visible when the path to the exit is not readily apparent. Signs are adequately lit and have letters that are four or more inches high (or six inches high if externally lit). Exit and directional signs displayed with continuous illumination are also served by the emergency lighting system unless the building is one story with less than 30 occupants, and the line of exit travel is obvious. (For full text, refer to NFPA 101-2012: 18/19.2.10; 7.10.1.4; 7.10.1.5.1; 7.10.5; 7.10.6; 7.10.7)

  Yes

  No

  N/A

• EP41 - Signs reading "NO EXIT" are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may be mistaken for an exit. (For full text, refer to NFPA 101-2012: 18/19.2.10.1; 7.10.8.3)

  Yes

  No

  N/A

• EP42 - The hospital meets all other Life Safety Code means of egress requirements related to NFPA 101-2012: 18/19.2.

  Yes

  No

  N/A

LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

• EP1 - In new construction, vertical openings, including exit stairs, are enclosed by one-hour fire-rated walls when connecting three or fewer floors and two-hour fire-rated walls when connecting four or more floors. Existing vertical openings, including exit stairs, are enclosed with a minimum of one-hour fire-rated construction. Note: These vertical openings include, but are not limited to, shafts (including elevator, light and ventilation), communicating stairs, ramps, trash chutes, linen chutes, and utility chases. (For full text, refer to NFPA 101-2012: 8.6; 18/19.3.1; 7.1.3.2.1)

  Yes

  No

  N/A

• EP2 - All new hazardous areas have doors that are self-closing or automatic-closing, except for laboratories using flammable or combustible materials deemed less than a severe hazard and storage rooms greater than 50 square feet, but less than 100 square feet that are used for storage of combustible material. Hazardous areas have a fire barrier with a one-hour fire-resistive rating. These areas include, but are not limited to, boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 square feet, paint shops, repair shops, soiled linen rooms, trash collection rooms with containers exceeding 64 gallons, laboratories considered a severe hazard, and storage rooms larger than 100 square feet that contain combustible material. (For full text, refer to NFPA 101-2012: 18.3.2.1; 18.3.2.2; 18.3.2.3; 18.3.2.4; Table 18.3.2.1) Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Doors to rooms containing flammable or combustible materials are provided with positive latching hardware. Roller latches are prohibited on such doors.

  Yes

  No

  N/A

• EP3 - All existing hazardous areas have doors that are self-closing or automatic-closing. These areas are protected by either a fire barrier with one-hour fire-resistive rating or an approved electrically supervised automatic sprinkler system. Hazardous areas include, but are not limited to, boiler and fuel-fired heater rooms, central/bulk laundries larger than 100 square feet, paint shops, repair shops, soiled linen rooms, trash collection rooms with containers exceeding 64 gallons, laboratories employing flammable or combustible materials deemed less than a severe hazard, and storage rooms greater than 50 square feet used for storage of equipment and combustible supplies. (For full text, refer to NFPA 101-2012: 19.3.2.1; 19.3.2.2; 19.3.2.3; 19.3.2.4) Note: For hospitals that use Joint Commission accreditation for deemed status purposes: Doors to rooms containing flammable or combustible materials are provided with positive latching hardware. Roller latches are prohibited on such doors.

  Yes

  No

  N/A

• EP4 - Laboratories using quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are in accordance with NFPA 101-2012: 8.7 and NFPA 99 requirements applicable to administration, maintenance, and testing. (For full text refer to NFPA 101-2012: 18/19.3.2.2; NFPA 99-2012: 15.4)

  Yes

  No

  N/A

• EP5 - Where residential or commercial cooking equipment is used to prepare meals for less than 31 people in a smoke compartment, one cooking facility is permitted to be open to the corridor provided all criteria in NFPA 101-2012: 18/19.3.2.5 are met. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital meets the applicable provisions of the Life Safety Code Tentative Interim Amendment (TIA) 12-2.

  Yes

  No

  N/A

• EP6 - Alcohol-based hand rubs (ABHR) are stored and handled in accordance with NFPA 101-2012: 8.7.3.1, unless all of the following conditions are met: - Corridor is at least six feet wide - ABHR does not exceed 95% alcohol - Maximum individual dispenser capacity is 0.32 gallon of fluid (0.53 gallon in suites) or 18 ounces of NFPA Level 1–classified aerosols - Dispensers have a minimum of four feet of horizontal spacing between them - Dispensers are not installed within one inch of an ignition source - If floor is carpeted, the building is fully sprinkler protected - Operation of the dispenser complies with NFPA 101-2012: 18/19.3.2.6(11) - ABHR is protected against inappropriate access - Not more than an aggregate of 10 gallons of fluid or 135 ounces of aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room - Storing more than five gallons of fluid in a single smoke compartment complies with NFPA 30

  Yes

  No

  N/A

• EP7 - Existing wall and ceiling interior finishes are rated Class A or B for limiting smoke development and the spread of flames. Newly installed wall and ceiling interior finishes are rated Class A. (For full text, refer to NFPA 101-2012: 18/19.3.3; 10.2)

  Yes

  No

  N/A

• EP8 - Newly installed interior floor finishes in corridors of smoke compartments with an approved automatic sprinkler system is at least Class II. Existing floor finishes are not restricted. (For full text, refer to NFPA 101-2012: 18/19.3.3; 10.2.7)

  Yes

  No

  N/A

• EP9 - Corridors must be separated from all other areas by approved partitions, unless the space is permitted to be open in accordance with NFPA 101-2012: 18/19.3.6.1.

  Yes

  No

  N/A

• EP10 - In existing buildings, corridor wall partitions are fire resistance rated for 1/2 hour, continuous from the floor slab to the floor or roof slab above, extended through any concealed spaces (such as those above suspended ceilings and interstitial spaces), properly sealed, and constructed to limit the transfer of smoke. (For full text, refer to NFPA 101-2012: 19.3.6.2)

  Yes

  No

  N/A

• EP11 - Within corridors in smoke compartments that are protected throughout with an approved supervised sprinkler system, partitions are allowed to terminate at the ceiling if the ceiling is constructed to limit the passage of smoke. The passage of smoke can be limited by an exposed, suspended-grid acoustical tile ceiling with penetrating items such as sprinkler piping and sprinklers that penetrate the ceiling, ducted heating, ventilating, and air-conditioning (HVAC) supply and return-air diffusers, speakers, and recessed lighting fixtures. (For full text, refer to NFPA 101-2012: 18/19.3.6.2)

  Yes

  No

  N/A

• EP12 - In new buildings, all corridor doors are constructed to resist the passage of smoke, hinged so that they swing, and the doors do not have ventilating louvers or transfer grills (with the exception of bathrooms, toilets, and sink closets that do not contain flammable or combustible materials). Undercuts are no larger than one inch. Positive latching hardware is required. Roller latches are prohibited. (For full text, refer to NFPA 101-2012: 18.3.6.3.1; 18.3.6.3.5; 18.3.6.4; 18.3.6.5; 18.3.6.3.10; 18.3.6.3.11)

  Yes

  No

  N/A

• EP13 - In existing buildings, all corridor doors are constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and the doors do not have ventilating louvers or transfer grills (with the exception of bathrooms, toilets, and sink closets that do not contain flammable or combustible materials). Roller latches are prohibited. Note: For existing doors, it is acceptable to use a device that keeps the door closed when a force of five pounds is applied to the edge of the door. (For full text, refer to NFPA 101-2012: 19.3.6.3.1; 19.3.6.3.2; 19.3.6.3.5; 19.3.6.3.6)

  Yes

  No

  N/A

• EP14 - In smoke compartments without sprinkler systems, fixed fire windows in corridor walls are 25% or less of the size of the corridor walls in which they are installed. Existing window installations that conform to previously accepted Life Safety Code criteria (such as a size of 1,296 square inches or less, made with wired glass or fire-rated glazing, and set in approved metal frames) are permitted. (For full text, refer to NFPA 101-2012: 19.3.6.2.7; 8.3.3.8; 8.3.3.9; 8.3.3.11)

  Yes

  No

  N/A

• EP15 - Openings in vision panels or doors in corridor walls (other than in smoke compartments containing patient sleeping rooms) are installed at or below one half the distance from the floor to the ceiling. These openings may not be larger than 80 square inches in new buildings or larger than 20 square inches in existing buildings. Note: Openings may include, but are not limited to, mail slots and pass-through windows in areas such as laboratories, pharmacies, and cashier stations. (For full text, refer to NFPA 101-2012:

  Yes

  No

  N/A

• EP16 - Corridors serving adjoining areas are not used for a portion of an air supply, air return, or exhaust air plenum. Note: Incidental air movement between rooms and corridors (such as isolation rooms) because of the need for pressure differentials in hospitals is permitted. In such cases, the direction of airflow is not the focus for this element of performance. For the purpose of fire protection, air transfer should be limited to the amount necessary to maintain positive or negative pressure differentials. (For full text, refer to NFPA 101-2012: 19.5.2.1; NFPA 90A-2012: 4.3.12.1; 4.3.12.1.3.2)

  Yes

  No

  N/A

• EP17 - In new buildings, at least two smoke compartments are provided for every story with patient sleeping or treatment rooms and for those stories that have an occupant capacity of 50 or more people, regardless of use. Smoke barriers have a minimum one-hour fire resistance rating; the maximum size of each smoke compartment is limited to 22,500 square feet. Space shall be provided on each side of smoke barriers to adequately accommodate the total number of occupants in adjoining compartments. The travel distance from any point within the compartment to a smoke barrier door is no more than 200 feet. (For full text, refer to NFPA 101-2012: 18.3.7.1; 18.3.7.3; 18.3.7.5)

  Yes

  No

  N/A

• EP18 - In existing buildings, at least two smoke compartments are provided for every story that has more than 30 patients in sleeping rooms. Smoke barriers have a minimum ½-hour fire resistance rating; the maximum size of each smoke compartment is limited to 22,500 square feet. Space shall be provided on each side of smoke barriers to adequately accommodate the total number of occupants in adjoining compartments. The travel distance from any point within the smoke compartment to a smoke barrier door is no more than 200 feet. (For full text, refer to NFPA 101-2012: 19.3.7.1; 19.3.7.3; 19.3.7.5)

  Yes

  No

  N/A

• EP19 - Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed spaces (such as those above suspended ceilings and interstitial spaces), and extend continuously from exterior wall to exterior wall. All penetrations are properly sealed. (For full text, refer to NFPA 101-2012: 18/19.3.7.3; 8.2.3; 8.5.2; 8.5.6; 8.7) Note: Polyurethane expanding foam is not an accepted fire-rated material for this purpose.

  Yes

  No

  N/A

• EP20 - Doors in smoke barriers are self-closing or automatic-closing, constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1/8 of an inch. In new buildings, undercuts are no larger than 3/4 of an inch, and doors in a means of egress swing in the opposite direction. (For full text, refer to NFPA 101-2012: 18.3.7.6; 18/19.3.7.8; 8.5.4.1; NFPA 80-2010: 4.8.4.1; 6.3.1.7.1)

  Yes

  No

  N/A

• EP21 - In smoke compartments without sprinkler systems, fixed fire windows in smoke barrier doors are 25% or less of the size of the doors in which they are installed. Existing window installations that conform to previously accepted Life Safety Code criteria (such as 1,296 square inches or less, wired glass or fire-rated glazing, and are set in approved metal frames) are permitted. (For full text, refer to NFPA 101-2012: 19.3.7.6; 8.3.3; 8.5.4.5)

  Yes

  No

  N/A

• EP22 - In new buildings, the smoke damper is not required in the duct passing through a smoke barrier. In existing buildings, ducts that penetrate smoke barriers are protected by approved smoke dampers that close when a smoke detector is activated. The detector is located either within the duct system or in the area serving the smoke compartment. In existing buildings protected by an approved automatic sprinkler system, the damper is not required in the duct. (For full text, refer to NFPA 101-2012: 18/19.3.7.3; 8.3.5.1; 8.5.5; 8.5.5.7)

  Yes

  No

  N/A

• EP23 - Approved smoke dampers protect air transfer openings extending through smoke barriers in ceiling spaces that are used as an unducted common plenum for either supply or return air. (For full text, refer to NFPA 101-2012: 18/19.3.7.3; 8.5.5.2)

  Yes

  No

  N/A

• EP24 - Every patient sleeping room has an outside window or outside door except newborn nurseries or rooms intended for less than 24-hour stays (such as obstetrical labor beds, recovery beds, and observation beds in the emergency department). Note: Windows in atrium walls are considered outside windows.

  Yes

  No

  N/A

• EP25 - In new buildings constructed after July 5, 2016, the window sill height in patient sleeping rooms does not exceed 36 inches from the floor, except in special nursing care areas (for example, intensive care units, coronary care units, hemodialysis units, and neonatal intensive care units), where window sill height does not exceed 60 inches above the floor.

  Yes

  No

  N/A

• EP26 - The hospital meets all other Life Safety Code fire and smoke protection requirements related to NFPA 101-2012: 18/19.3.

  Yes

  No

  N/A

LS.02.01.34 The hospital provides and maintains fire alarm systems.

• EP1 - A fire alarm system is installed with systems and components to provide effective warning of fire in any part of the building in accordance with NFPA 70-2012, National Electric Code and NFPA 72-2010, National Fire Alarm Code.

  Yes

  No

  N/A

• EP2 - The master fire alarm control panel is located in an area with a smoke detector or in an area that is continuously occupied and protected, which is an area enclosed with one-hour fire-rated walls and 3/4-hour fire-rated doors. In areas not continuously occupied and protected, a smoke detector is installed at each fire alarm control unit. In a newly designated occupancy, detection is also installed at notification appliance circuit power extenders and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. (For full text, refer to NFPA 101-2012: 18/19.3.4.1; 9.6)

  Yes

  No

  N/A

• EP3 - Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas are not required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200 feet of travel distance is not exceeded. (For full text, refer to NFPA 101-2012: 18/19.3.4.2.1; 18/19.3.4.2.2; 9.6.2.5)

  Yes

  No

  N/A

• EP4 - In new buildings, occupant notification is provided automatically in accordance with NFPA 101-2012: 9.6.3 by audible and visual signals. Positive alarm sequence in accordance with 9.6.3.4 is permitted in buildings protected throughout by a sprinkler system. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. Annunciation zoning for the fire alarm and sprinklers is provided by audible and visual indicators; zones are not larger than 22,500 square feet per zone. (For full text, refer to NFPA 101-2012: 18.3.4.3–18.3.4.4.3; 9.6.4)

  Yes

  No

  N/A

• EP5 - In existing buildings, occupant notification is provided automatically in accordance with NFPA 101-2012: 9.6.3 by audible and visual signals. Positive alarm sequence in accordance with 9.6.3.4 is permitted in buildings protected throughout by a sprinkler system. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. (For full text, refer to NFPA 101-2012: 19.3.4.3; 9.6.4; 9.7.1.1(1))

  Yes

  No

  N/A

• EP6 - Activation of the required fire alarm control functions occurs automatically and is provided with an alternative power supply in accordance with NFPA 72-2010. (For full text, refer to NFPA 101-2012: 18/19.3.4.4; 9.6.1; 9.6.5)

  Yes

  No

  N/A

• EP7 - The fire alarm signal automatically transmits using one of the provisions of NFPA 101-2012: 9.6.4. (For full text, refer to NFPA 101-2012: 18/19.3.4)

  Yes

  No

  N/A

• EP8 - Smoke detection systems are provided in spaces open to corridors as required by NFPA 101-2012: Chapter 18/19. (For full text, refer to NFPA 101-2012: 18/19.3.4.5.2; 18/19.3.6.1)

  Yes

  No

  N/A

• EP9 - The ceiling membrane is installed and maintained in a manner that permits activation of the smoke detection system. (For full text, refer to NFPA 101-2012: 18/19.3.4.1)

  Yes

  No

  N/A

• EP10 - The hospital meets all other Life Safety Code fire alarm requirements related to NFPA 101-2012: 18/19.3.4.

  Yes

  No

  N/A

LS.02.01.35 The hospital provides and maintains systems for extinguishing fires.

• EP1 - The fire alarm system monitors approved automatic sprinkler system components. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.2.1)

  Yes

  No

  N/A

• EP2 - The fire alarm system is connected to water flow alarms. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.2)

  Yes

  No

  N/A

• EP3 - Piping supports for approved automatic sprinkler systems are not damaged or loose. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; NFPA 25-2011: 5.2.3.1; 5.2.3.2)

  Yes

  No

  N/A

• EP4 - Piping for approved automatic sprinkler systems is not used to support any other item. (For full text, refer to NFPA 25-2011: 5.2.2.2)

  Yes

  No

  N/A

• EP5 - Sprinkler heads are not damaged. They are also free from corrosion, foreign materials, and paint and have necessary escutcheon plates installed. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.5; NFPA 25-2011: 5.2.1.1.1; 5.2.1.1.2; NFPA 13-2010: 6.2.6.2.2; 6.2.7.1)

  Yes

  No

  N/A

• EP6 - There are 18 inches or more of open space maintained below the sprinkler deflector to the top of storage. Note: Perimeter wall and stack shelving may extend up to the ceiling when not located directly below a sprinkler head. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.1.1; NFPA 13-2010: 8.5.5.2; 8.5.5.2.1; 8.5.5.3)

  Yes

  No

  N/A

• EP7 - At least six spare sprinkler heads, with associated wrenches, are kept in a cabinet that will not exceed 100°F. (For full text, refer to NFPA 101-2012: 18.3.5.1; 19.3.5.3; 9.7.1.1; NFPA 25-2011: 5.4.1.4; 5.4.1.6; NFPA 13-2010: 6.2.9; 6.2.9.1; 6.2.9.3; 6.2.9.6)

  Yes

  No

  N/A

• EP8 - In both new buildings and existing buildings, the clothing closets in patient sleeping rooms are not required to have sprinkler protection if the closet does not exceed six square feet. (For full text, refer to NFPA 101-2012: 18/19.3.5.10)

  Yes

  No

  N/A

• EP9 - In new buildings, quick response sprinklers are installed in smoke compartments with patient sleeping rooms. (For full text, refer to NFPA 101-2012: 18.3.5.6)

  Yes

  No

  N/A

• EP10 - The travel distance from any point to the nearest portable fire extinguisher is 75 feet or less. Portable fire extinguishers have appropriate signage, are installed either in a cabinet or secured on a hanger made for the extinguisher, and are at least four inches off the floor. Those fire extinguishers that are 40 pounds or less are installed so the top is not more than 5 feet above the floor. (For full text, refer to NFPA 101-2012: 18/19.3.5.12; 9.7.4.1; NFPA 10-2010: 6.2.1.1; 6.1.3.3.1; 6.1.3.4; 6.1.3.8)

  Yes

  No

  N/A

• EP11 - Class K–type portable fire extinguishers are located within 30 feet of grease-producing ranges, griddles, broilers, or cooking appliances that use vegetable or animal oils or fats, such as deep fat fryers. A placard is conspicuously placed near the extinguisher stating that the fire protection system should be activated prior to using the fire extinguisher. (For full text, refer to NFPA 101-2012: 18/19.3.2.5.1; NFPA 96-2011: 10.10.2; NFPA 10-2010: 5.5.5; 6.6.2)

  Yes

  No

  N/A

• EP12 - Grease-producing cooking devices such as deep fat fryers, ranges, griddles, or broilers have an exhaust hood, an exhaust duct system, and grease removal devices without mesh filters. (For full text, refer to NFPA 101-2012: 18/19.3.2.5.1; NFPA 96-2011: 6.1)

  Yes

  No

  N/A

• EP13 - The automatic fire extinguishing system for grease-producing cooking devices does the following: deactivates the fuel source, activates the building fire alarm system, and controls the exhaust fans as designed. (For full text, refer to NFPA 101-2012: 18/19.3.2.5.1; NFPA 96-2011: 10.4; 10.6.1; 10.6.2; 8.2.3)

  Yes

  No

  N/A

• EP14 - The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA 101-2012: 18/19.3.5.

  Yes

  No

  N/A

LS.02.01.40 The hospital provides and maintains special features to protect individuals from the hazards of fire and smoke.

• EP1 - High-rise buildings have an approved automatic sprinkler system that meets the requirements of NFPA 101-2012: 18/19.4.2. (For full text, refer to NFPA 101-2012: 11.8) Note: Organizations that do not have approved automatic sprinkler systems in high-rise buildings (over 75 feet tall) as of July 5, 2016, have 12 years to install them.

  Yes

  No

  N/A

• EP2 - The hospital meets all other Life Safety Code automatic extinguishing requirements related to NFPA 101-2012: 18/19.4.2.

  Yes

  No

  N/A

LS.02.01.50 The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.

• EP1 - Equipment using gas or gas piping complies with NFPA 54-2012, National Fuel Gas Code; electrical wiring and equipment complies with NFPA 70-2012, National Electric Code. Existing installations can continue in service provided there are no life-threatening hazards. (For full text, refer to NFPA 101-2012: 18/19.5.1.1; 9.1.1; 9.1.2)

  Yes

  No

  N/A

• EP2 - Heating, ventilation, and air conditioning comply with NFPA 101-2012: 9.2 and are installed in accordance with manufacturers’ specifications. (For full text, refer to NFPA 101-2012: 18/19.5.2.1)

  Yes

  No

  N/A

• EP3 - Any heating device (other than a central heating plant) is designed and installed so combustible materials cannot be ignited by the device and safety features stop fuel and shut down equipment if it experiences excessive temperature or ignition failure. (For full text, refer to NFPA 101-2012: 18/19.5.2.2) Note: If fuel fired, the heating device is designed as follows: - Chimney or vent connected - Takes air for combustion from outside - Combustion system is separate from occupied area atmosphere

  Yes

  No

  N/A

• EP4 - A suspended unit heater(s) is permitted provided the following conditions are met: - Not located in means of egress or in patient rooms - Located high enough to be out of reach of people in the area - Has a safety feature to stop fuel and shut down equipment if it experiences excessive temperature or ignition failure

  Yes

  No

  N/A

• EP5 - Direct-vent fireplaces in patient sleeping areas must meet the provisions of NFPA 101-2012: 18/19.5.2.2; 18/19.5.2.3.

  Yes

  No

  N/A

• EP6 - Solid fuel–burning fireplaces are permitted in areas other than patient sleeping rooms when the following occurs: - Areas are separated by a one-hour fire-resistant wall - Fireplace complies with NFPA 101-2012: 9.2.2 - Fireplace enclosure resists breakage up to 650°F and has heat-tempered glass - Area has supervised carbon monoxide detection per NFPA 101-2012: 9.8

  Yes

  No

  N/A

• EP7 - Elevators are equipped with the following: - Firefighters' service key recall - Smoke detector automatic recall - Firefighters' service emergency in-car key operation - Machine room smoke detectors - Elevator lobby smoke detectors Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of firefighters also meet these requirements. (For full text, refer to NFPA 101-2012: 18/19.5.3; 9.4.2; 9.4.3)

  Yes

  No

  N/A

• EP8 - Escalators, dumbwaiters, and moving walks comply with NFPA 101-2012: 9.4. In addition, existing escalators, dumbwaiters, and moving walks (including escalator emergency stop buttons and automatic skirt obstruction stop) conform with the requirements of ASME/ANSI A17.1, Safety Code for Elevators and Escalators and ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. (For full text, refer to NFPA 101-2012: 18/19.5.3; 9.4.2; 9.4.6 )

  Yes

  No

  N/A

• EP9 - In new buildings, the inlet door assemblies for linen- and waste-chute services are fire rated for one hour (or for 1 1/2 hours in chutes of four stories or more). In existing buildings, the inlet door assemblies for linen- and waste-chute services are fire rated for 3/4 of an hour (or for one hour if it opens into a corridor). (For full text, refer to NFPA 101-2012: 18/19.5.4; 8.3.3.1; 9.5; NFPA 82-2009: 5.2.3.1.3)

  Yes

  No

  N/A

• EP10 - All linen and waste chute inlet and discharge service doors have both self-closing and positive-latching devices. Note: Discharge doors may be held open with fusible links or electrical hold-open devices. (For full text, refer to NFPA 101-2012: 18/19.5.4; 8.3.3.1; 9.5; NFPA 82-2009: 5.2.3.2.3)

  Yes

  No

  N/A

• EP11 - Linen- and waste-chute discharge door assemblies are fire rated the same as the chute. (For full text, refer to NFPA 101-2012: 18/19.5.4; 9.5; NFPA 82-2009: 5.2.4; 5.2.3.2)

  Yes

  No

  N/A

• EP12 - In buildings more than two stories high, an approved automatic sprinkler system is located above the top of the linen and waste chute service openings on the lowest service levels and above the service door opening on alternate floor levels. (For full text, refer to NFPA 101-2012: 18/19.5.4.3; 9.7; NFPA 82-2009: 5.2.6)

  Yes

  No

  N/A

• EP13 - Trash chutes discharge into collection rooms that are not used for any other purpose and are separated from the corridor and have a minimum fire resistance rating not less than that specified for the chute. In existing buildings, if the trash collection room is protected with an approved automatic sprinkler system, linen collection may also occur. (For full text, refer to NFPA 101-2012: 18/19.5.4.4; 19.5.4.5; NFPA 82-2009: 5.2.4.1)

  Yes

  No

  N/A

• EP14 - The hospital meets all other Life Safety Code building service requirements related to NFPA 101-2012: 18/19.5.

  Yes

  No

  N/A

LS.02.01.70 The hospital provides and maintains operating features that conform to fire and smoke prevention requirements.

• EP1 - Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored; these areas have signs that read “NO SMOKING” or display the international symbol for no smoking. In facilities where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs that prohibit smoking in hazardous areas are not required. (For full text, refer to NFPA 101-2012: 18/19.7.4) Note: The secondary sign exception is not applicable to medical gas storage areas.

  Yes

  No

  N/A

• EP2 - In areas where smoking is permitted, ashtrays are safely designed and made of noncombustible material. Metal containers with self-closing cover devices in which ashtrays can be emptied are readily available to all areas where smoking is permitted. (For full text, refer to NFPA 101-2012: 18/19.7.4)

  Yes

  No

  N/A

• EP3 - Draperies, curtains (including cubicle and shower curtains), and loosely hanging fabric comply with NFPA 101-2012: 10.3.1. (For full text, refer to NFPA 101-2012: 18/19.7.5.1; 18/19.3.5.11; 10.3.1) Note: Exceptions include shower/bath curtains in addition to window coverings in patient sleeping rooms and non-patient sleeping rooms located in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20% of the wall.

  Yes

  No

  N/A

• EP4 - In buildings without sprinkler protection, upholstered furniture purchased on or after July 5, 2016, meets Class I or char length and heat release criteria in accordance with NFPA 101-2012: 10.3.2.1 and 10.3.3. Mattresses purchased on or after July 5, 2016, meet char length and heat release criteria in accordance with NFPA 101-2012: 10.3.2.2 and 10.3.4. (For full text, refer to NFPA 101-2012: 18/19.7.5.2; 18/19.7.5.4)

  Yes

  No

  N/A

• EP5 - Decorations (for example, photos, paintings, other art) directly attached to the walls, ceiling, and non-fire-rated doors are permitted provided they do not exceed 20% of the wall, ceiling, or door areas in spaces in nonsprinklered smoke compartments; 30% in spaces in sprinklered smoke compartments; 50% inside patient sleeping rooms that do not exceed four people in sprinklered smoke compartments. (For full text, refer to NFPA 101-2012: 18/19.7.5.6)

  Yes

  No

  N/A

• EP6 - Soiled linen and trash receptacles larger than 32 gallons are stored in a room protected as a hazardous area. (For full text, refer to NFPA 101-2012: 18/19.7.5.7) Note: Containers that are 96 gallons or less and are labeled and listed as meeting the requirements of FM Approval Standard 6921 (or equivalent) and are used solely for recycling clean waste (including patient records awaiting destruction) are permitted in an unprotected area. Those containers that are greater than 96 gallons are stored in a hazardous storage area.

  Yes

  No

  N/A

• EP7 - When installed, new engineered smoke control systems are tested in accordance with NFPA 92-2012, Standard for Smoke Control Systems. Existing engineered smoke control systems are tested in accordance with established engineering principles. (For full text, refer to NFPA 101-2012: 18/19.7.7)

  Yes

  No

  N/A

• EP8 - Portable space heaters are prohibited in smoke compartments containing sleeping rooms and patient treatment areas. Non-sleeping rooms that are occupied by staff and separated from the corridor are permitted to have portable space heaters, but must contain heating elements not exceeding 212°F. (For full text, refer to NFPA 101-2012: 18/19.7.8) Note: For this element of performance, nurses stations are considered patient treatment areas.

  Yes

  No

  N/A

• EP9 - The hospital meets all other Life Safety Code operating feature requirements related to NFPA 101-2012: 18.7/19.7.

  Yes

  No

  N/A