The Life Safety Surveyor Facility Tour
How Should I Prepare
for the Facility Tour?
Healthcare Engineering Consultants
The Life Safety Surveyor Facility Tour
Typical Tour Sequence
1. Start in the operating rooms, central supply and endoscopy
areas, right after the documentation review.
2. Continue to the roof, penthouse, mechanical equipment rooms
3. Take the “most traveled stairwell” from the top to the bottom
4. Take the elevator back up to the top patient floor
5. Check smoke/ fire doors, compartmentation features and
corridor storage on the inpatient areas
6. Continue with an inspection of chutes, storage areas, utility
chases, hazardous areas
7. Evaluate clinical areas of interest, including inpatient areas,
special care units and other special units, such as MRI,
dialysis, physical therapy, ED, behaviroal health, etc.
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The Life Safety Surveyor Facility Tour
Typical Tour Sequence (continued)
8. Continue down to the lower and basement levels to specific
areas on the checklist, such as mechanical equipment rooms,
the kitchen, loading dock, fire pump, emergency generators,
fire annunciator panel, compressed gas and infectious waste
storage, chemical storage areas, manifold rooms, dirty and
clean linen storage rooms, and other areas of interest
9. If construction areas are present, expect a visit to review the
area(s) and question contractor staff who are present
10. Expect a validation of interim life safety measures that have
been implemented and are in effect and “open” and “closed”
PFI’s
11. A walk outside to view storage areas, liquid oxygen bulk tank
storage and smoking compliance may occur
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour
 Operating rooms
Check: 1) Positive pressure for OR’s with “tissue test”
2) Cleanliness of exhaust vents, OR cabinets
3) Type of portable fire extinguishers (ABC, water mist,
carbon dioxide, halotron, Clean-Guard, etc.)
4) Gas scavenging, isolated power panels, redundant
grounding receptacles, medical gas alarms and valves
5) Temperature and humidity logs and policy
6) Area a suite? Corridor storage?
7) Clean supply storage areas
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Suites in Healthcare Facilities
1. Suite perimeter walls and doors must meet the same
requirements as for corridors
2. Walls inside the suite must be non-combustible, but are
not required to meet any fire rating or be full height to
deck above
3. Maximum suite size is 5,000 square feet for sleeping
areas and 10,000 square feet for non-sleeping suites
4. Corridors become “access aisleways” and must only
meet the 36 inch free and clear width
5. Suites must be designated on the compartmentation
drawings and include square footage and whether the
suite is “sleeping” or “non-sleeping’
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour
 Central Sterile Supply
Check: 1) Air movement from “clean to dirty”
2) Clean side positive relative to outside corridor
3) Dirty side negative relative to outside corridor
4) Ethylene oxide monitoring, staff exposure, emergency
procedure for EtO spill
5) Temperature and humidity logs and policy
6) Cross-contamination issues?
7) Unblocked egress from storage areas
Healthcare Engineering Consultants
The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour
 Endoscopy
Check: 1) Are procedure rooms “positive pressure”?
2) Is the equipment re-processing area “negative
pressure”?
3) Bronchoscopy procedures – negative pressure room?
4) Endoscope storage – clear of cabinet bottom and walls?
5) Temperature and humidity logs and policy
6) Cross-contamination issues?
Code Reference: 2010 FGI Guidelines Document, ASHRAE
supplement standard 170
Healthcare Engineering Consultants
The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour
 Roof Area
Check: Evidence of smoking, contractor supplies, safety curbs,
labeling of toxic vapor exhaust fans, unusual items
 Penthouse
Check: Unsealed vertical penetrations, evidence of smoking,
portable fire extinguisher test tags, unlabeled containers
Healthcare Engineering Consultants
The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour
 Exit Stairwells
Check: Floor signage; door, frame and panic hardware rating; exit
discharge signage, door closure and latching, unsealed
horizontal penetrations, stored or mounted items in stairwell
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
 Smoke and Fire Compartments
Check: Proper sealant used for penetrations; open junction boxes;
cables touching or hung from sprinkler pipes; unusual items
on top of lay-in ceiling
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Compartmentation Deficiencies
Repair of Smoke and Fire Wall Penetrations
 Polyurethane foam should never be used as a sealant!
 Intumescent materials should not only be tested, but pass the tests!
 Smoke and fire ratings apply to the entire assembly
 Smoke barriers (1/2 hour) need at least 1/2” sheetrock (each side)
 1-hour fire barriers require at least 1-1/4” of sheetrock (2 layers)
 2-hour fire barriers require at least 2-1/2” of sheetrock (4 layers)
 Insulation or mineral wool requires intumescent capping
 Use the manufacturer applications book for proper installation
 Unusual applications require an “engineering judgment”
 The use of labels describing the seal is recommended
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Compartmentation Deficiencies
What’s wrong with these seals?
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Rated Fire Wall Penetration Examples
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Life Safety Compartmentation
Smoke Barrier Compartmentation Requirements
 Extends from floor to deck above
 Barrier penetrations protected by smoke dampers, although
smoke dampers not required in ducted penetrations where QRS
sprinklers are installed
 All penetrations must be sealed with appropriate materials
 Doors labeled 20-minute or 1-3/4” solid core or equivalent
 Doors must be self-closing
 Positive latching is not required
 ½-hour smoke compartment must be at least two layers of ½” or
more sheetrock (existing construction, one sheet on each side)
 1-hour compartment for new construction, 5/8” on each side
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Life Safety Compartmentation
1-hour Fire Barrier Compartmentation Requirements
 Extends from floor to deck above
 Transfer air grilles protected by fire dampers; fire dampers not
required for ducted penetrations, unless required by AHJ
 All penetrations sealed with appropriate materials
 Doors are labeled 45-minute or 1-hour (except 1-hour smoke
barrier for new construction, 20 minutes on cross-corridor doors)
 Doors are self-closing
 Positive latching is required
 1-hour fire compartment must be at least two layers of 5/8”
sheetrock (X-type, one layer on each side) or equivalent
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Life Safety Compartmentation
2-hour Fire Barrier Compartmentation Requirements
 Extends from floor to deck above
 All duct penetrations protected by fire dampers
 All penetrations sealed with appropriate materials
 Doors are labeled 1.5 hour
 Doors are self-closing
 Positive latching is required
 2-hour smoke compartment must be at least four layers of 5/8”
sheetrock or equivalent (X-type, two layers on each side)
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
 Smoke and Fire Doors
Check: Door, frame and hardware rating; undercuts, warpage,
gaps, closure; latching and “kick plates” on fire doors
 Exit Doors
Check: Exit signs properly placed with direction of travel; doors free
of mirrors, draperies or hangings
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Life Safety Compartmentation
Smoke and Fire Door Requirements
 Undercut to floor not more than ¾” at any one point
 Vertical gap between doors not more than 1/8”
 Warpage to frame less than ½”
 All fire doors, frames and panic hardware must be labeled
 Smoke doors must be labeled or 1-3/4” solid core or equivalent
 Doors must be self-closing
 Positive latching is required for fire doors; not for smoke doors
 Fire door tampering is not permitted; will alter the rating
 Field installed protective plates >16” not permitted on fire doors
(exceptions exist for doors to hazardous rooms and factory installed plates)
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
 Corridors
Check: Equipment on one side only for “in use” items, other than
isolation and emergency “crash” carts; portable fire
extinguishers; wall hangings and decorations; exit signs;
patient chart boxes in “down” position; wall protrusions
Important Note: “Categorical Waiver” from CMS for items in corridor
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Egress Corridor Deficiencies
Are these corridors OK?
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Egress Corridor Deficiencies
Corridor Requirements – 2012 Life Safety Code
19.2.3.4 (4) – Projections into the required width shall
be required for wheeled equipment, provided that
all of the following conditions are met:
1. Clear unobstructed width is not reduced to less
than 5 feet
2. Fire plan requires relocation of wheeled equipment
during a fire or similar emergency
3. Wheeled equipment is limited to equipment and
carts in use, medical emergency equipment not in
use and patient lift and transport equipment
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Egress Corridor Deficiencies
Corridor Requirements – 2012 Life Safety Code
19.2.3.4 (5) – Where the corridor width is at least 8 feet,
projections into the required width shall be permitted for fixed
furniture, provided that all of the following conditions are met:
1. Furniture is securely attached to floor or wall
2. Unobstructed corridor width is less than 6 feet
3. Furniture is located on one side of the corridor only
4. Grouped so that total area is less than 50 square feet and
each grouping is at least 10 feet apart
5. Furniture does not block emergency equipment and valves
6. Smoke compartment with QRS sprinklers and smoke
detection or direct staff supervision of furniture spaces
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Egress Corridor Storage
Additional Joint Commission Interpretations
1. Egress corridors greater than 8 feet in width may be partitioned
to provide alcove storage for computers, equipment
2. Small (less than 50 square feet) dead-end corridors beyond the
exit stairwell doorway may be used to store equipment
3. Where only offices exist in an egress corridor beyond an exit
stairwell door, only 44 inches of clearance is required to be
maintained in the corridor!
Important Note: Although these interpretations were provided
by George Mills (Joint Commission Senior Engineer) at the
2008 ASHE Annual Conference, local AHJ’s may not permit
these exceptions! Be careful!!
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Egress Corridor Storage
Joint Commission Corridor Interpretations
Staff Office
Permitted
Storage Space
(if <50 sq ft)
8’ Width Egress Corridor
Exit
Stair
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Egress Corridor Storage
Joint Commission Corridor Interpretations
Staff Office
44”
Permitted
Storage Space
(if <50 sq ft)
8’ Width Egress Corridor
Exit
Stair
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
 Patient Treatment Areas
Check: Crash cart logs; compressed gas cylinders; blanket
warmer temperatures; refrigerator logs; unlocked
medication carts; portable radiology units with key
installed; trash receptacles greater than 32 gallons,
portable heaters, power strips
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
Patient Treatment Area Clarifications
Compressed Gas Cylinders:
 EMPTY and FULL cylinders must be physically separated
 Segregated = physically separated with separate racks, physical
barriers or color codes to indicate FULL and EMPTY
 Unopened cylinder = FULL; Opened cylinder = EMPTY
 Don’t store partially filled cylinders with FULL cylinders
 Noncompliance cited under EC.02.06.01, EP1
 Solutions?
Reference: EC News, February 2014 issue, pages 5-6
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
Patient Treatment Area Clarifications
Blanket and Liquid Warmers
 Blanket warmer temperatures should not exceed 130 degrees F
 Solution warming cabinets should not exceed manufacturer
recommendations, typically from 104 to 110 degrees F
 A method to determine the temperature is essential
 A daily manual log or electronic monitoring system is suggested
 Noncompliance cited under EC.02.06.01, EP1
References: ECRI Health Devices, 2009; volume 38, issue 7, pages
230-231; AORN Perioperative Standards and Recommended
Practices, 2013, pages 217-242
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The Life Safety Surveyor Facility Tour
Checklist for the Facility Building Tour (continued)
Patient Treatment Area Clarifications
Portable Heaters (LSC 18/19.7.8)
 Permitted only in non-patient, non-sleeping staff areas
 Heating elements may not be “exposed” and not exceed 212 F
 UL listing and tip protection is strongly recommended
 Hospital policy for use is required
Power Strips (G. Mills, BI&T, October, 2012)
 Should not be used in patient care areas and tested before initial use
 Should be “hospital-grade” and never daisy-chained
 Should not be used for high power appliances
 Should be issued/ controlled by a hospital department (biomed, facilities)
 Approved hospital policy for use required
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