Life Safety Update for Nursing Homes

(Aug. 19, 2024) In June 2024, the Healthcare Interpretations Task Force (HITF), a unique coalition of health care organizations and authorities having jurisdiction that convenes annually to assess and discuss interpretations of specific questions related to National Fire Protection Association (NFPA) codes and standards, met during the NFPA's annual conference in Orlando. The HITF's overall goal is to ensure consistency in how these codes and standards are understood and implemented.

During the meeting, discussions and subsequent voting by members led to several interpretations that directly impact health care organizations required to maintain compliance with the Life Safety Code (LSC) under Centers for Medicare and Medicaid Services (CMS) oversight. An overview of the meeting prepared by a LeadingAge representative is available here.

While there were numerous topics discussed during the meeting, providers should be aware of the following three interpretations:

1. Alcoves/Hazardous Areas

• Alcoves off the corridor are often a key location for storing small quantities of carts, wheelchairs, and various other items. The HITF clarified that it is not the intent of the LSC to limit the number of alcoves in an exit access corridor in a health care occupancy. They also agreed that it is not the intent of the LSC to aggregate the areas of alcoves. This interpretation clarifies that each alcove is an individual space, and if each space is not more than 50 square feet, it can be utilized for limited storage.

2. Delayed Egress Locking Systems 

• The LSC permits health care occupancies to have delayed egress locking systems. These are generally systems where a push bar on a door is engaged, an alarm sounds, and 15 to 30 seconds later the door automatically unlocks. The HITF clarified that items such as card readers can be utilized to bypass doors and reset door locks. A key is not the only permissible method. The interpretation also clarifies that the locking hardware is not limited to a push bar even though the requirement for the signage indicates “push” until the alarm sounds.

3. Alcohol-Based Hand Rub Dispensers

• The LSC requires alcohol-based hand rub dispensers to be horizontally separated by 48 inches. However, it is not uncommon to have a dispenser on the wall adjacent to a room door with another dispenser found on the wall inside the room. The HITF clarified that the 48-inch separation requirement is not intended to apply when one dispenser is in the corridor and another dispenser is located right around the corner by the door inside a room.

Contact: Carrie Mosley, cmosley@leadingageny.org, 518-867-8383 ext. 147