ADOPTS WITHOUT AMENDMENTS:

NFPA 101, 2018

Heads up: There are no amended sections in this chapter.
The requirements of this chapter shall apply to new buildings or portions thereof used as ambulatory health care occupancies. (See 1.3.1.)
The provisions of Chapter 1, Administration, shall apply.
The provisions of Chapter 4, General, shall apply.
Buildings, or sections of buildings, that primarily house patients who, in the opinion of the governing body of the facility and the governmental agency having jurisdiction, are capable of exercising judgment and appropriate physical action for self-preservation under emergency conditions shall be permitted to comply with chapters of this Code other than Chapter 20.
It shall be recognized that, in buildings providing treatment for certain types of patients or having detention rooms or a security section, it might be necessary to lock doors and bar windows to confine and protect building inhabitants. In such instances, the authority having jurisdiction shall make appropriate modifications to those sections of this Code that would otherwise require means of egress to be kept unlocked.
The requirements of this chapter shall apply based on the assumption that staff is available in all patient-occupied areas to perform certain emergency control functions as required in other paragraphs of this chapter.
The goals and objectives of Sections 4.1 and 4.2 shall be met with due consideration for functional requirements, which are accomplished by limiting the development and spread of a fire emergency to the room of fire origin and reducing the need for occupant evacuation, except from the room of fire origin.
All ambulatory health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.
Because the safety of ambulatory health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:
  1. Design, construction, and compartmentation
  2. Provision for detection, alarm, and extinguishment
  3. Fire prevention and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building
Additions shall be separated from any existing structure not conforming to the provisions within Chapter 21 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.5 and 4.6.7.)
Doors in barriers required by 20.1.1.4.1.1 shall normally be kept closed, unless otherwise permitted by 20.1.1.4.1.3.
Doors shall be permitted to be held open if they meet the requirements of 20.2.2.2.2.
A change from a hospital or nursing home to an ambulatory health care occupancy shall not be considered a change in occupancy or occupancy subclassification.
Multiple occupancies shall be in accordance with 6.1.14.
Atrium walls in accordance with 6.1.14.4.6 shall be permitted to serve as part of the separation required by 6.1.14.4.1 for creating separated occupancies on a story-by-story basis, provided both of the following are met:
  1. The provision is not used for occupancy separations involving industrial and storage occupancies.
  2. Smoke partitions serving as atrium walls are not permitted to serve as enclosures for hazardous areas.
Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided that they meet both of the following conditions:
  1. They are not intended to serve ambulatory health care occupants for purposes of treatment or customary access by patients incapable of self-preservation.
  2. They are separated from areas of ambulatory health care occupancies by construction having a minimum 1-hour fire resistance rating.
All means of egress from ambulatory health care occupancies that traverse nonambulatory health care spaces shall conform to the requirements of this Code for ambulatory health care occupancies, unless otherwise permitted by 20.1.3.5.
Exit through a horizontal exit into other contiguous occupancies that do not conform to ambulatory health care egress provisions but that do comply with requirements set forth in the appropriate occupancy chapter of this Code shall be permitted, provided that the occupancy does not contain high hazard contents.
Egress provisions for areas of ambulatory health care facilities that correspond to other occupancies shall meet the corresponding requirements of this Code for such occupancies, and, where the clinical needs of the occupant necessitate the locking of means of egress, staff shall be present for the supervised release of occupants during all times of use.
Any area with a hazard of contents classified higher than that of the ambulatory health care occupancy and located in the same building shall be protected as required in 20.3.3.
Non-health care-related occupancies classified as containing high hazard contents shall not be permitted in buildings housing ambulatory health care occupancies.
For definitions, see Chapter 3, Definitions.
The classification of hazard of contents shall be as defined in Section 6.2.
Ambulatory health care occupancies shall be limited to the building construction types specified in Table 20.1.6.1, unless otherwise permitted by 20.1.6.6. (See 8.2.1.)

Table 20.1.6.1 Construction Type Limitations

Stories in Height
Construction Type Sprinklered† 1 ≥2
I (442) Yes X X
No X X
I (332) Yes X X
No X X
II (222) Yes X X
No X X
II (111) Yes X X
No X X
II (000) Yes X X
No X NP
III (211) Yes X X
No X X
III (200) Yes X X
No X NP
IV (2HH) Yes X X
No X X
V (111) Yes X X
No X X
V (000) Yes X X
No X NP
X: Permitted. NP: Not permitted.
†Sprinklered throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (See 20.3.5.)
‡See 4.6.3.
Any level below the level of exit discharge shall be separated from the level of exit discharge by not less than Type II (111), Type III (211), or Type V (111) construction (see 8.2.1), unless both of the following criteria are met:
  1. Such levels are under the control of the ambulatory health care facility.
  2. Any hazardous spaces are protected in accordance with Section 8.7.
Interior nonbearing walls in buildings of Type I or Type II construction shall be constructed of noncombustible or limited-combustible materials, unless otherwise permitted by 20.1.6.4.
Interior nonbearing walls required to have a fire resistance rating of 2 hours or less shall be permitted to be fire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided that such walls are not used as shaft enclosures.
All buildings with more than one level below the level of exit discharge shall have all such lower levels separated from the level of exit discharge by not less than Type II (111) construction.
Where new ambulatory health care occupancies are located in existing buildings, the authority having jurisdiction shall be permitted to accept construction systems of lesser fire resistance than those required by 20.1.6.1 through 20.1.6.5, provided that it can be demonstrated to the authority's satisfaction that prompt evacuation of the facility can be achieved in case of fire or that the exposing occupancies and materials of construction present no threat of fire penetration from such occupancy to the ambulatory health care facility or to the collapse of the structure.
The occupant load, in number of persons for whom means of egress and other provisions are required, shall be determined on the basis of the occupant load factors of Table 7.3.1.2 that are characteristic of the use of the space, or shall be determined as the maximum probable population of the space under consideration, whichever is greater.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 20.2.2 through 20.2.11.
Means of egress components shall be limited to the types described in 20.2.2.2 through 20.2.2.12.
Doors complying with 7.2.1 shall be permitted.
Any door required to be self-closing shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The required manual fire alarm system and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
Where doors in a stair enclosure are held open by an automatic release device as permitted in 20.2.2.2.2, initiation of a door-closing action on any level shall cause all doors at all levels in the stair enclosure to close.
Locks complying with 7.2.1.5.5 shall be permitted only on principal entrance/exit doors.
Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following criteria are met:
  1. Staff can readily unlock doors at all times in accordance with 20.2.2.2.7.
  2. A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
  3. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
  4. The locks are electrical locks that fail safely so as to release upon loss of power to the device.
  5. The locks release by independent activation of each of the following:
    1. Activation of the smoke detection system required by 20.2.2.2.6(2)
    2. Waterflow in the automatic sprinkler system required by 20.2.2.2.6(3)
Doors that are located in the means of egress and are permitted to be locked under other provisions of 20.2.2.2.6 shall comply with both of the following:
  1. Provisions shall be made for the rapid removal of occupants by means of one of the following:
    1. Remote control of locks from within the locked smoke compartment
    2. Keying of all locks to keys carried by staff at all times
    3. Other such reliable means available to the staff at all times
  2. Only one locking device shall be permitted on each door.
Delayed-egress electrical locking system complying with 7.2.1.6.1 shall be permitted.
Sensor-release of electrical locking systems complying with 7.2.1.6.2 shall be permitted.
Elevator lobby exit access door-locking arrangements in accordance with 7.2.1.6.3 shall be permitted.
Horizontal or vertical security grilles or doors complying with 7.2.1.4.1(3) shall be permitted to be used as part of the required means of egress from a tenant space.
Revolving doors complying with 7.2.1.10 shall be permitted.
Stairs complying with 7.2.2 shall be permitted.
Spiral stairs complying with 7.2.2.2.3 shall be permitted.
Smokeproof enclosures complying with 7.2.3 shall be permitted.
Horizontal exits complying with 7.2.4 shall be permitted.
Ramps complying with 7.2.5 shall be permitted.
Exit passageways complying with 7.2.6 shall be permitted.
Fire escape ladders complying with 7.2.9 shall be permitted.
Alternating tread devices complying with 7.2.11 shall be permitted.
Areas of refuge complying with 7.2.12 shall be permitted.
In buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1), two rooms or spaces separated from each other by smoke-resistant partitions in accordance with the definition of area of refuge in 3.3.23 shall not be required.
The capacity of any required means of egress shall be determined in accordance with Section 7.3.
The clear width of any corridor or passageway required for exit access shall be not less than 44 in. (1120 mm).
Where minimum corridor width is 6 ft (1830 mm), projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted for the installation of hand-rub dispensing units in accordance with 20.4.3.
Doors in the means of egress from diagnostic or treatment areas, such as x-ray, surgical, or physical therapy, shall provide a clear width of not less than 32 in. (810 mm).
The number of means of egress shall be in accordance with Section 7.4.
Not less than two exits shall be provided on every story.
Not less than two separate exits shall be accessible from every part of every story.
Not less than two exits of the types described in 20.2.2 shall be accessible from each smoke compartment.
Egress from smoke compartments addressed in 20.2.4.4 shall be permitted through adjacent compartments provided that the two required egress paths are arranged so that both do not pass through the same adjacent smoke compartment.
Means of egress shall be arranged in accordance with Section 7.5.

20.2.5.2

ILLUSTRATION
Dead-end corridors shall be permitted in accordance with 20.2.5.2.1 or 20.2.5.2.2.
In buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1), dead-end corridors shall not exceed 50 ft (15 m).
In buildings other than those complying with 20.2.5.2.1, dead-end corridors shall not exceed 20 ft (6100 mm).
Limitations on common path of travel shall be in accordance with 20.2.5.3.1, 20.2.5.3.2, and 20.2.5.3.3.
Common path of travel shall not exceed 100 ft (30 m) in a building protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1).
Common path of travel shall not exceed 100 ft (30 m) within a single tenant space having an occupant load not exceeding 25 persons.
In buildings other than those complying with 20.2.5.3.1 or 20.2.5.3.2, common path of travel shall not exceed 75 ft (23 m).
Travel distance shall be measured in accordance with Section 7.6.
Travel distance shall comply with 20.2.6.2.1 and 20.2.6.2.2.
The travel distance between any point in a room and an exit shall not exceed 150 ft (46 m).
The maximum travel distance in 20.2.6.2.1 shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7
Emergency lighting shall be provided in accordance with Section 7.9.
Where general anesthesia or life-support equipment is used, each ambulatory health care facility shall be provided with an essential electrical system in accordance with NFPA 99 unless otherwise permitted by any of the following:
  1. Where battery-operated equipment is provided and acceptable to the authority having jurisdiction
  2. Where a facility uses life-support equipment for emergency purposes only
Means of egress shall have signs in accordance with Section 7.10.
Lockups in ambulatory health care occupancies shall comply with the requirements of 22.4.5.
Vertical openings shall be enclosed or protected in accordance with Section 8.6, unless otherwise permitted by 20.3.1.2.
Unenclosed vertical openings in accordance with 8.6.9.1 shall be permitted.
Floors that are below the street floor and are used for storage or other than an ambulatory health care occupancy shall have no unprotected openings to ambulatory health care occupancy floors.
Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.7.
Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 20.2.2.2.2.
High hazard contents areas, as classified in Section 6.2, shall meet all of the following criteria:
  1. The area shall be separated from other parts of the building by fire barriers having a minimum 1-hour fire resistance rating, with all openings therein protected by self-closing fire door assemblies having a minimum 3/4-hour fire protection rating.
  2. The area shall be protected by an automatic extinguishing system in accordance with 9.7.1.1(1) or 9.7.1.2.
Laboratories in which chemicals are handled or stored shall comply with NFPA 45.
Areas where medical gas is stored or administered, and the operation, management, and maintenance of medical gases shall be in accordance with NFPA 99.
Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 20.3.2.7.
Where domestic cooking equipment is used for food warming or limited cooking, protection or separation of food preparation facilities shall not be required.
Where hazardous materials are stored, used, or handled, the provisions of 8.7.3.1 shall apply.
Interior finish shall be in accordance with Section 10.2.
Interior wall and ceiling finish material complying with Section 10.2 shall be Class A or Class B in exits and in exit access corridors.
Interior wall and ceiling finishes shall be Class A, Class B, or Class C in areas other than those specified in 20.3.3.2.1.
Interior floor finish in exit enclosures shall be Class I or Class II.
Interior floor finish shall comply with 10.2.7.1 or 10.2.7.2, as applicable.
Ambulatory health care facilities shall be provided with fire alarm systems in accordance with Section 9.6, except as modified by 20.3.4.2 through 20.3.4.4.
Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any detection devices or detection systems required.
Positive alarm sequence in accordance with 9.6.3.4 shall be permitted.
Occupant notification shall be accomplished automatically, without delay, in accordance with 9.6.3 upon operation of any fire alarm activating device.
Emergency forces notification shall be accomplished in accordance with 9.6.4.
Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically, without delay, any control functions required to be performed by that device. (See 9.6.5.)
Isolated hazardous areas shall be permitted to be protected in accordance with 9.7.1.2.
Where more than two sprinklers are installed in a single area for protection in accordance with 9.7.1.2, water-flow detection shall be provided to sound the building fire alarm or to notify, by a signal, any constantly attended location, such as PBX, security, or emergency room, at which the necessary corrective action shall be taken.
Portable fire extinguishers shall be provided in ambulatory health care facilities in accordance with Section 9.9.
Where access to exits is provided by corridors, such corridors shall be separated from use areas by fire barriers in accordance with Section 8.3 having a minimum 1-hour fire resistance rating, unless one of the following conditions exists:
  1. *Where exits are available from an open floor area
  2. *Within a space occupied by a single tenant
  3. Within buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1)
Openings in corridor walls required by 20.3.6.1 to have a fire resistance rating shall be protected in accordance with Section 8.3, except as otherwise permitted in 20.3.6.2.1 or 20.3.6.2.2.
Miscellaneous openings, such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows, shall be permitted to be installed in vision panels or doors without special protection, provided that both of the following criteria are met:
  1. The aggregate area of openings per room does not exceed 20 in.2 (0.015 m2).
  2. The openings are installed at or below half the distance from the floor to the room ceiling.
For rooms protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, the aggregate area of openings per room, as otherwise limited by 20.3.6.2.1, shall not exceed 80 in.2 (0.05 m2).
Ambulatory health care occupancies shall be separated from other tenants and occupancies and shall meet all of the following requirements:
  1. Walls shall have not less than a 1-hour fire resistance rating and shall extend from the floor slab below to the floor or roof slab above.
  2. Doors shall be constructed of not less than 13/4 in. (44 mm) thick, solid-bonded wood core or the equivalent and shall be equipped with positive latches.
  3. Doors shall be self-closing and shall be kept in the closed position, except when in use.
  4. Any windows in the barriers shall be of fixed fire window assemblies in accordance with Section 8.3.
Every story of an ambulatory health care occupancy shall be divided into not less than two smoke compartments, unless otherwise permitted by one of the following:
  1. This requirement shall not apply where the area of the ambulatory health care occupancy is less than 5000 ft2 (465 m2) per story and that area is protected by an approved automatic smoke detection system.
  2. This requirement shall not apply where the area of the ambulatory health care occupancy is less than 10,000 ft2 (929 m2) per story and the building is protected throughout by an approved, supervised automatic sprinkler system installed in accordance with Section 9.7.
  3. An area in an adjoining occupancy shall be permitted to serve as a smoke compartment for an ambulatory health care occupancy if all of the following criteria are met:
    1. The separating wall and both compartments meet the requirements of 20.3.7.
    2. The ambulatory health care occupancy does not exceed one of the following:
      1. 22,500 ft2 (2100 m2)
      2. 40,000 ft2 (3720 m2) in buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7
    3. Access from the ambulatory health care occupancy to the other occupancy is unrestricted.
Smoke compartments shall not exceed one of the following:
  1. An area of 22,500 ft2 (2100 m2)
  2. An area of 40,000 ft2 (3720 m2) in buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7
The travel distance from any point to reach a door in a smoke barrier shall not exceed 200 ft (61 m).
The area of an atrium separated in accordance with 8.6.7 shall not be limited in size.
Required smoke barriers shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating, unless otherwise permitted by 20.3.7.9.
The provisions of 8.5.6.5 and 8.5.7.2 shall not apply.
Smoke barriers shall be permitted to terminate at the required occupancy separation where the ambulatory health care occupancy is constructed as a separated multiple occupancy in accordance with 6.1.14.4 and the separation also meets the requirements for a smoke barrier.
Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems for buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Windows in the smoke barrier shall be of fixed fire window assemblies in accordance with Section 8.3.
Not less than 15 net ft2 (1.4 net m2) per ambulatory health care facility occupant shall be provided within the aggregate area of corridors, patient rooms, treatment rooms, lounges, and other low hazard areas on each side of the smoke compartment for the total number of occupants in adjoining compartments.
Doors in smoke barriers shall be not less than 13/4 in. (44 mm) thick, solid-bonded wood core or the equivalent and shall be self-closing or automatic-closing in accordance with 20.2.2.2.2.
Latching hardware shall not be required on smoke barrier cross-corridor doors.
A vision panel consisting of fire-rated glazing in approved frames shall be provided in each cross-corridor swinging door and at each cross-corridor horizontal-sliding door in a smoke barrier.
Vision panels in doors in smoke barriers, if provided, shall be of fire-rated glazing in approved frames.
Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers.
Center mullions shall be prohibited in smoke barrier door openings where pairs of cross-corridor doors are provided.
Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
  1. Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1830 mm).
  2. The maximum individual dispenser fluid capacity shall be as follows:
    1. 0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors
    2. 0.53 gal (2.0 L) for dispensers in suites of rooms
  3. Where aerosol containers are used, the maximum capacity of the aerosol dispenser shall be 18 oz (0.51 kg) and shall be limited to Level 1 aerosols as defined in NFPA 30B.
  4. Dispensers shall be separated from each other by horizontal spacing of not less than 48 in. (1220 mm).
  5. Not more than an aggregate 10 gal (37.8 L) of alcohol-based hand-rub solution or 1135 oz (32.2 kg) of Level 1 aerosols, or a combination of liquids and Level 1 aerosols not to exceed, in total, the equivalent of 10 gal (37.8 L) or 1135 oz (32.2 kg), shall be in use outside of a storage cabinet in a single smoke compartment, except as otherwise provided in 20.4.3(6).
  6. One dispenser per room complying with 20.4.3(2) or (3), and located in the room, shall not be required to be included in the aggregated quantity specified in 20.4.3(5).
  7. Storage of quantities greater than 5 gal (18.9 L) in a single smoke compartment shall meet the requirements of NFPA 30.
  8. Dispensers shall not be installed in the following locations:
    1. Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source
    2. To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source
    3. Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source
  9. Dispensers installed directly over carpeted floors shall be permitted only in sprinklered smoke compartments.
  10. The alcohol-based hand-rub solution shall not exceed 95 percent alcohol content by volume.
  11. Operation of the dispenser shall comply with the following criteria:
    1. The dispenser shall not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
    2. Any activation of the dispenser shall occur only when an object is placed within 4 in. (100 mm) of the sensing device.
    3. An object placed within the activation zone and left in place shall not cause more than one activation.
    4. The dispenser shall not dispense more solution than the amount required for hand hygiene consistent with label instructions.
    5. The dispenser shall be designed, constructed, and operated in a manner that ensures that accidental or malicious activation of the dispensing device is minimized.
    6. The dispenser shall be tested in accordance with the manufacturer's care and use instructions each time a new refill is installed.
Utilities shall comply with the provisions of Section 9.1.
Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 20.5.2.2.
If fuel-fired, heating devices shall comply with all of the following:
  1. They shall be chimney connected or vent connected.
  2. They shall take air for combustion directly from the outside.
  3. They shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.
Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient treatment areas, provided that both of the following criteria are met:
  1. Such heaters are located high enough to be out of the reach of persons using the area.
  2. Such heaters are equipped with the safety features required by 20.5.2.2.1.
Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
Waste chutes, incinerators, and laundry chutes shall comply with the provisions of Section 9.5.
The administration of every ambulatory health care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 20.7.1.1.
A copy of the plan required by 20.7.1.1 shall be readily available at all times when the facility is open.
Fire drills in ambulatory health care facilities shall include the simulation of emergency fire conditions.
Patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
Drills shall be conducted quarterly on each shift to familiarize facility personnel (including but not limited to nurses, interns, maintenance engineers, and administrative staff) with the emergency action required under varied conditions.
Employees of ambulatory health care facilities shall be instructed in life safety procedures and devices.
For ambulatory health care facilities, the proper protection of patients shall require the prompt and effective response of ambulatory health care personnel.
The basic response required of staff shall include the following:
  1. Removal of all occupants directly involved with the fire emergency
  2. Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
  3. Confinement of the effects of the fire by closing doors to isolate the fire area
  4. Relocation of patients as detailed in the facility's fire safety plan
A written fire safety plan shall provide for all of the following:
  1. Use of alarms
  2. Transmission of alarms to fire department
  3. Response to alarms
  4. Isolation of fire
  5. Evacuation of immediate area
  6. Evacuation of smoke compartment
  7. Preparation of floors and building for evacuation
  8. Extinguishment of fire
All personnel shall be instructed in the use of and response to fire alarms.
All personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under either of the following conditions:
  1. When the individual who discovers a fire must immediately go to the aid of an endangered person
  2. During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.
Proper maintenance shall be provided to ensure the dependability of the method of evacuation selected.
Ambulatory health care occupancies that find it necessary to lock exits shall, at all times, maintain an adequate staff qualified to release locks and direct occupants from the immediate danger area to a place of safety in case of fire or other emergency.
Smoking regulations shall be adopted and shall include not less than the following provisions:
  1. Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
  2. In ambulatory health care facilities where smoking is prohibited and signs are placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
  3. Smoking by patients classified as not responsible shall be prohibited.
  4. The requirement of 20.7.4(3) shall not apply where the patient is under direct supervision.
  5. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
  6. Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in ambulatory health care occupancies shall be in accordance with the provisions of 10.3.1, and the following also shall apply:
  1. Such curtains shall include cubicle curtains.
  2. Such curtains shall not include curtains at showers.
Newly introduced upholstered furniture shall comply with 10.3.2.1 and one of the following provisions:
  1. The furniture shall meet the criteria specified in 10.3.3.
  2. The furniture shall be in a building protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1).
Newly introduced mattresses shall comply with 10.3.2.2 and one of the following provisions:
  1. The mattresses shall meet the criteria specified in 10.3.3.2.
  2. The mattresses shall be in a building protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7.1.1(1).
Combustible decorations shall be prohibited, unless one of the following criteria is met:
  1. They are flame-retardant.
  2. The decorations meet the flame propagation performance criteria contained in Test Method 1 or Test Method 2, as appropriate, of NFPA 701.
  3. The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289 using the 20 kW ignition source.
  4. *The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:
    1. Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 20.7.5.4(4)(b) or (c).
    2. Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
    3. Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity, and all of the following also shall apply:
  1. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
  2. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
  3. Container size and density shall not be limited in hazardous areas.
Containers used solely for recycling clean waste or for patient records awaiting destruction shall be permitted to be excluded from the requirements of 20.7.5.5.1 where all the following conditions are met:
  1. Each container shall be limited to a maximum capacity of 96 gal (363 L), except as permitted by 20.7.5.5.2(2) or (3).
  2. *Containers with capacities greater than 96 gal (363 L) shall be located in a room protected as a hazardous area when not attended.
  3. Container size shall not be limited in hazardous areas.
  4. Containers for combustibles shall be labeled and listed as meeting the requirements of FM Approval 6921, Approval Standard for Containers for Combustible Waste; however, such testing, listing, and labeling shall not be limited to FM Approvals.
The provisions of 10.3.8, applicable to containers for waste, or linen, shall not apply.
New engineered smoke control systems shall be tested in accordance with established engineering principles and shall meet the performance requirements of such testing prior to acceptance.
Following acceptance, all engineered smoke control systems shall be tested periodically in accordance with recognized engineering principles.
Test documentation shall be maintained on the premises at all times.
Portable space-heating devices shall be prohibited in all ambulatory health care occupancies, unless both of the following criteria are met:
  1. Such devices are used only in nonsleeping staff and employee areas.
  2. The heating elements of such devices do not exceed 212°F (100°C).
Construction, repair, and improvement operations shall comply with 4.6.10.
The means of egress in any area undergoing construction, repair, or improvements shall be inspected daily for compliance with 7.1.10.1 and shall also comply with NFPA 241.
Integrated fire protection and life safety systems shall be tested in accordance with 9.11.4.1.
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