The 2012 edition of the Life Safety Code was recently adopted by the U.S. Centers for Medicare & Medicaid Services, a federal agency under the U.S. Department of Health & Human Services. In over-simplified terms, this means medical facilities, such as hospitals, nursing homes or skilled nursing facilities (SNFs), ambulatory surgical centers (ASCs), and free-standing emergency departments (EDs), must comply with the 2012 edition of NFPA 101 in order to receive Medicare or Medicaid reimbursement. (I’m not an expert on Medicare or Medicaid, so I’ll stick to the Code issues.)
NFPA 101 is an occupancy-based code, so it’s very important to classify occupancies correctly. Otherwise, the wrong requirements will be applied. This could result in occupants being provided with insufficient life safety features, or conversely, a building owner spending more money than necessary on life safety features that aren’t warranted. Three occupancy classifications exist in the Code that could apply to medical facilities; they are: Business Occupancies, Ambulatory Health Care Occupancies, and Health Care Occupancies. The NFPA 101 definitions and a brief description of each, as they apply to medical facilities, follow.
Business Occupancy. An occupancy used for the transaction of business other than mercantile.
While this might not sound like a medical facility, the definition does capture the correct classification for facilities such as doctors’ offices, dentists’ offices, and urgent care clinics, provided that no more than three occupants are incapable of self-preservation at any time (as will become apparent momentarily). In these types of medical facilities, patients are fully capable of evacuating under their own power in the event of an emergency. The occupant life-safety risk is no different than that found in an office building. Granted, when I was a call-fire fighter/EMT back in the day, we ran the occasional ambulance call to the local doctor’s office, usually for someone who was brought there because they weren’t feeling well, only to find out they were having an MI (myocardial infarction, or heart attack… I remember some of what I learned in EMT school nearly 30 years ago!). While those patients were incapable of self-preservation due to their medical condition, that did not make the doctor’s office anything other than a business occupancy. Those patients simply went to the wrong facility. (They should have dialed 911 and gone to the hospital.)
Ambulatory Health Care Occupancy. An occupancy used to provide services or treatment simultaneously to four or more patients that provides, on an outpatient basis, one or more of the following:
(1) Treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others
(2) Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others
(3) Emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others
The big difference between business occupancies and ambulatory health care occupancies is the presence of four or more patients who are incapable of self-preservation because of a variety of reasons. The other key to this definition, and what differentiates it from health care, is the phrase “on an outpatient basis.” This means that a doctor has not signed an order admitting the patient to a facility for longer-term care with housing and sleeping accommodations. When patients are outpatients, they receive medical treatment or observation and are then subsequently admitted to a facility as inpatients, or they go home.
Part (1) of the definition describes something like a dialysis clinic. The treatment renders the patient incapable of self-preservation because of the lack of ability to evacuate without the assistance of staff due to being hooked up to a dialysis machine.
Part (2) of the definition describes something like an ASC, in which the patient walks into the facility, is then rendered incapable of self-preservation by anesthesia for a procedure, is moved to a recovery area for observation, and then walks out of the facility, typically on the same day. A dentist’s office could be classified as ambulatory health care if, at any time, four or more patients are rendered incapable of self-preservation.
Part (3) of the definition, which was new in the 2003 edition of the Code, can apply to an emergency department (ED), whether it is attached to a hospital, or a detached, free-standing facility. If attached to a hospital and classified as ambulatory health care, it must be separated from the remainder of the building by two-hour fire barriers (see 220.127.116.11 of the 2012 edition and 18.104.22.168 of the 2015 edition). The advantages to classifying an ED as ambulatory health care include: it is not subject to suite size limitations applicable to health care occupancies, patient rooms can be open to the corridor, and the health care occupancy corridor protection requirements don’t apply. Again, the key is the patients in the ED are outpatients; once four or more inpatients who are incapable of self-preservation are present, the facility is classified as health care.
Health Care Occupancy. An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants’ control.
Health care occupancies are like ambulatory health care occupancies in that they contain four or more patients who are incapable of self-preservation; however, health care patients are inpatients, rather than outpatients, and are provided with housing and sleeping accommodations to facilitate extended care. Examples are hospitals, nursing homes (SNFs), and limited-care facilities, which could include something like psychiatric hospitals. These facilities are provided with the highest level of life safety features due to the number of patients expected to be unable to evacuate themselves on an around-the-clock basis. For health care occupancies, the Code utilizes a defend-in-place strategy, in which patients are moved from the area of fire origin to an adjacent, protected smoke compartment, without requiring vertical travel in the building.
While all three of these occupancies provide varying degrees of health care services, the protection requirements for life safety from fire vary significantly, all dependent on the occupant risk. It’s important to note that it’s always the authority having jurisdiction’s (AHJ’s) responsibility to determine occupancy classification. The AHJ always has the authority to apply the Code in the manner it deems appropriate. My discussion is based on how the Code is intended to be applied as developed by NFPA’s Technical Committees on Safety to Life. If you have any thoughts on the occupancy classification of medical facilities, please post them in the comments below. Thanks for reading, and until next time, stay safe!
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Did you know NFPA 101 is available to review online for free? Head over to www.nfpa.org/101 and click on “Free access to the 2015 edition of NFPA 101.”
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