At its June 18, 2024 meeting in Orlando, FL, the Healthcare Interpretations Task Force (HITF), whose participants represent organizations that significantly influence fire protection issues in the healthcare sector, focused on key issues around fire- and life-safety issues, including egress, alcoves/hazardous areas, delayed egress locking systems.

Life safety experts from Jensen Hughes, representing LeadingAge, attended the meeting. Through thorough and thoughtful debate—often incorporating historical context, background, or case studies—the group works toward a unified understanding. The outcome is an interpretation or position that is clear and practical, one that can be effectively applied by the various enforcement agencies responsible for overseeing fire protection and life safety measures in healthcare facilities. Below, key issues of interest to our nonprofit and mission-driven nursing home provider members:

 Egress:

LSC section 7.12 specifies egress provisions for mechanical equipment rooms, boiler rooms, furnace rooms, and “similar spaces.”

Question:  Is it the intent of this section to apply the egress provisions to other building service equipment rooms such as for electrical, IT, or elevator equipment?

Answer:  Yes

Commentary: This should not have any consequential impact on LTC as the answer was assumed by most authority having jurisdiction (AHJs).  

Alcoves / Hazardous Areas:

Question:  Is it the intent to limit the number of alcoves in exit access corridors in a healthcare occupancy?

Answer: No

Question:  Is it the intent of the LSC to aggregate the areas of alcoves that individually are not more than 50SF, if each alcove does not contain the elements that designate it as a hazardous area?

Answer: Yes

Commentary: This is an important and beneficial interpretation for all healthcare occupancies including LTC. Some AHJs have been aggregating alcove areas off the corridor. Once they get to 50SF, they consider the alcoves as hazardous areas. This does not allow them to be used for limited storage. This interpretation clarifies that each alcove is an individual space and the LSC does not limit alcoves.

Delayed Egress Locking Systems:

Question:  Can a card reader be used to bypass the delay in a delayed egress locking system?

Answer:  Yes – Provided that the delayed egress locking system complies with 7.2.1.6.1.

Question:  On a delayed egress system, LSC Section 7.2.1.6.1.1(3)(d) requires the system to be relocked “by manual means only”. Does “manual means” include items such as a magnetic card reader swipe and proximity care readers?

Answer:  Yes– provided that resetting the system requires human intervention.

Question:  Is a door with delayed egress hardware in accordance with 7.2.1.6.1 required to have a push bar due to the delayed egress signage instructions instructing “push until alarm sounds”?

Answer:  No

Commentary: This is a beneficial interpretation for all healthcare occupancies including LTC. The LSC language has not caught up with technology as it relates to delayed egress locking hardware. This interpretation clarifies 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. There other delayed egress door locking arrangements on the market that could be utilized.

Vertical Evacuation Equipment Storage:

Question:  Does building evacuation equipment storage (sleds/stretchers) attached to the wall within an exit stairwell “interfere” with the use of the exit?

Answer:  The question was withdrawn.

Question:  Is this equipment required to be noncombustible?

Answer:  The question was withdrawn.

Commentary: Some AHJs do not permit the placement and/or storage of vertical evacuation equipment in stair enclosures. The ability to keep the equipment in the stairwell can be beneficial as it is easily accessible to staff in the location where they will need it. However, there was not enough support by the AHJ members during the meeting to formalize an interpretation that would clarify that such equipment is permitted in stair enclosures. As such, the question was withdrawn to ensure there was not an interpretation that would essentially prohibit locating such equipment in stair enclosures. This will continue to be up to AHJ interpretation.

Alcohol Based Hand Rub Dispensers

Question:  Does the horizontal separation requirement of 48” for an alcohol-based hand rub dispenser still apply when a dispenser is within a room (with a door) and is less than 48” from the adjacent dispenser in the corridor?

Answer: No

Commentary: This interpretation clarifies that the 48” separation rule between dispensers is not intended to apply when one dispenser is in the corridor and another is right around the corner by the door inside a resident room. This is a common arrangement.

More areas of discussion were on the agenda at the June meeting.  However, the ones listed above pertain to nursing homes.   The authorities having jurisdiction will now have a clear interpretation of the questions debated and discussed.  These interpretations went through a post meeting ballot and were final.  National Fire Protection Association (NFPA) has a robust website that includes a page on the HITF.

Established in July 1998, the HITF is the result of a unique collaboration among key organizations that significantly influence fire protection issues in the healthcare sector. The task force’s goal is to unite the entities responsible for enforcing, implementing, complying with, or evaluating the fire protection measures required in almost every healthcare facility across the U.S.

Among its initiatives, the HITF played a key role in ensuring that the 2000 and 2012 editions of the Life Safety Code® became the formally adopted references for the Centers for Medicare & Medicaid Services (CMS). Another vital area of focus has been fostering clear communication regarding the interpretation and application of various NFPA codes and standards in healthcare environments. This includes navigating the relationship between NFPA criteria, state regulations, and how these codes align with the policies of groups like CMS and The Joint Commission (TJC), which can sometimes be challenging.

The mission of the HITF, found on the website states: To provide consistent interpretations on national codes and standards referenced by CMS, JCAHO and state and territorial authorities having jurisdiction. This will be accomplished through the evaluation of field conditions, surveyor/inspector/fire marshal interpretations, and questions by consumers of these services generated through a member of the task force.

Full meeting minutes and interpretations are posted on the NFPA website.  LeadingAge will continue to monitor the HIFT and work with members on life safety concerns and challenges.