Adopting NFPA 101 in health care buildings

Explore the top 10 things to know about the 2012 edition of NFPA 101 for hospitals and health care facilities.
By Brandon Finzel, PE, and Samuel Flibbert, EIT, JENSEN HUGHES, New York City February 14, 2018

Learning objectives:

  • Identify the impact of the adoption of the 2012 edition of NFPA 101: Life Safety Code by Centers for Medicare & Medicaid Services on health care design.
  • Know the differences in the various editions of NFPA 101.

In May 2016, the Centers for Medicare & Medicaid Services (CMS) released its final rule amending fire-safety requirements for certain Medicare and Medicaid participating health care facilities. The goal of the adoption was to reduce life safety risks for patients and caregivers who occupy these facilities while at the same time modernizing requirements to reflect current health care needs. Effective July 5,, 2016, health care facilities must comply with the provisions of the 2012 edition of the NFPA 101: Life Safety Code and the 2012 edition of the NFPA: 99 Health Care Facilities Code, with some exceptions. Certain sections have been excluded from adoption, most notably Chapter 7 of NFPA 99 on information technology equipment. Previously, the 2000 edition of NFPA 101 and the 1999 edition of NFPA 99 were the adopted codes used for fire protection and life safety purposes in health care occupancies.

Since multiple code-revision cycles occurred between adopted versions, facilities may face some challenges in attempting to meet CMS requirements. Ten of the most salient differences are explored that should be considered between these code editions for health care occupancies. This is not an exhaustive list, and further differences exist and must be considered when attempting to comply with this CMS rule.

Figure 1: Power doors complying with NFPA 101-2012, Section 7.2.1.9, are not required to latch provided the doors can be kept closed if a force of 5 lb is applied in the direction to open the door (swinging or sliding). Courtesy: JENSEN HUGHES1. Risk assessment

The 2012 edition of NFPA 99 requires using a risk-based approach to categorize and design building systems. This assessment is required to be a formal and documented assessment. The code defines four categories (Category 1 to Category 4) based on the effect of system/equipment failure on the well-being of patients and caregivers: 

  • Failure of Category 1 systems is likely to cause "major injury or death."
  • Failure of Category 2 systems is likely to cause "minor injury."
  • Failure of Category 3 systems is likely to cause "discomfort."
  • Failure of Category 4 systems is likely to have "no impact."

While CMS will confirm that facilities are using this type of risk assessment, it is not required that facilities submit a formal assessment to CMS for review.

2. Sprinkler protection

Under the new requirements in NFPA 101-2012, all existing high-rise health care occupancies must be fully protected by an approved, supervised automatic sprinkler system. All new health care occupancies are required to be fully sprinkled already, but this requirement now requires existing buildings to retroactively become fully sprinklered. Retroactive provisions can be difficult and costly to comply with, which is why a phase consisting of a period of 12 years is allowed to provide the required sprinkler system. This change in sprinkler requirements has also impacted the scoring system contained in NFPA 101A for Fire Safety Evaluation Systems (FSES). This change may cause facilities currently using an FSES for justification of an equivalency to no longer achieve a passing score.

3. Building rehabilitation

Health care occupancies are often renovating areas to update for modern medical delivery. In the past, designers often struggled with which components of a renovation must comply with the "new" occupancy requirements and which could comply with the "existing" occupancy requirements. To rectify this, the 2012 edition of NFPA 101 defines explicit criteria relating to building rehabilitation in Chapter 43. In NFPA 101, rehabilitation activities are classified into the following categories: 

  • Repair
  • Renovation
  • Modification
  • Reconstruction
  • Change of use/occupancy
  • Addition.

Each type of activity requires compliance to different requirements. Repairs and renovations only require adherence to the requirements for "existing" occupancies. Modifications require that any new elements follow the "new" occupancy requirements of the code. Reconstruction and addition require that the entire work area meet the requirements of the new occupancies. Changes of use only require adherence to existing occupancy requirements except where hazardous areas are created, in which case the new occupancy requirements apply. Changes of occupancy are dependent on the level of hazard of the "new" occupancy compared to the "existing" occupancy of the building. If the hazard is lesser, then existing requirements govern the area except for life safety features, such as sprinkler, fire alarm, and hazardous areas. If the hazard is greater, then the new occupancy requirements apply.

Figure 2: Additional inspection, testing, and maintenance requirements have been imposed on many hospital features—including doors—as a result of CMS’s adoption of newer editions of NFPA 101 and NFPA 99. Courtesy: JENSEN HUGHES4. Inspection, testing, and maintenance

The adoption of the 2012 editions of NFPA 101 and NFPA 99, as well as the referenced NFPA 25 and NFPA 72 standards, dictates new criteria for inspection, testing, and maintenance (ITM) for various fire protection-related features. Some requirements have been more restrictive over the recent code-revision cycles, while some have been made less restrictive over the same period. Additional requirements have been put in place for features including receptacles, doors, and isolation modules. To ensure that ITM requirements are met, it is important to make sure to test all required systems, maintain accurate and organized records, and have qualified personnel where they are required. For example, fire-resistance-rated doors now require an annual inspection conducted and documented by qualified personnel.

5. Suite criteria

The 2012 edition of NFPA 101 provides several new criteria for suites. The updates provide many more requirements to meet, but they also provide for more flexibility in design to more effectively address the way medical care is currently delivered. The non-patient care suite, defined as "a suite within a health care occupancy that is not intended for sleeping or treating patients," has been introduced to distinguish such spaces from suites that are used for patient care. Non-patient care suites can follow the egress provisions for the primary use and occupancy of the suite.

Suite-arrangement criteria have also been introduced. Suites must be separated from the remainder of the building with the same level of protection as afforded for corridors, by using partitions and positively latching doors that limit smoke transfer. However, the criteria also provide for additional flexibility by allowing for egress from one suite to another and not regulating circulation spaces within suites as corridors. Therefore, circulation spaces are not required to meet the more stringent requirements of corridors.

Sleeping suites greater than 1,000 sq ft in area and non-sleeping suites greater than 2,500 sq ft require two exit access doors. In suites where only one exit access door is required, the door must open directly into a corridor. In suites with two exit access doors, one must open directly into a corridor while the other may open into an adjacent suite, given suite-separation requirements are met, or into an exit stairwell, exit passageway, or the exterior.

Within a suite, the maximum travel distance to an exit access door is limited to 100 ft but may pass through more than one intervening room. This provision applies to both sleeping and non-sleeping suites. This is slightly less restrictive than the 2000 edition requirements, which limited travel distance in non-sleeping suites through multiple intervening rooms to only 50 ft.

Allowable suite sizes have increased because of this rule adoption. New sleeping suites have increased in maximum size from 5,000 to 7,500 sq ft, or to 10,000 sq ft with direct visual supervision and smoke detection. Existing sleeping suites still have a maximum area of 5,000 sq ft. The addition of a sprinkler system and smoke detection or quick-response sprinklers raises the allowance to 7,500 sq ft, while the addition of direct supervision, smoke detection, and quick-response sprinklers raises the allowance to 10,000 sq ft. Both existing and new non-sleeping suites still have a maximum allowable area of 10,000 sq ft. It should be noted, however, that certain larger suites may require three or more exits to meet other applicable egress requirements.

Figure 3: NFPA 101-2012 requires the presence of fire extinguishers in areas dedicated to domestic cooking. Courtesy: JENSEN HUGHES6. Corridor and stair width

NFPA 101-2012 includes updated requirements for the width of corridors and stairways. In treatment areas, corridors must be at least 8 ft wide, while corridors outside of treatment areas must be at least 44 in. wide. However, there are provisions for projections into the required width that are introduced for noncontinuous projections, wheeled/mobile equipment, and fixed furniture, with each having their own specific requirements. The provisions allow for the flexible use of corridor space, which is so important in administering health care services.

Noncontinuous obstructions may extend a maximum of 6 in. into the required corridor width and must be no less than 38 in. above floor level. Wheeled equipment and carts may be placed in 8-ft corridors, provided they do not reduce the corridor width to less than 5 ft. This is applicable to equipment and carts in use, emergency medical equipment not in use, patient lifts, and transport equipment. A fire plan and training must be implemented to relocate mobile equipment in case of an emergency. Fixed furniture may exist in 8-ft corridors given a number of specifications including furniture must be secured to the floor or wall and the corridor width may not be reduced to less than 6 ft. All furniture must exist on one side of the corridor without staggering. Each group of furniture must occupy an area of less than 50 sq ft and be separated from each other by no less than 10 ft. Access to building services and fire protection may not be blocked by any furniture. Corridors with furniture must be directly supervised by staff or by corridor smoke detection.

New stairways serving cumulative occupant load of at least 2,000 must be a minimum of 56 in. wide to account for counterflow and simultaneous evacuation of multiple floors.

7. Locking arrangements

The 2012 edition of NFPA 101 changes locking-arrangement requirements for health care occupancies. To account for security needs in units, such as forensic or detention units, health care occupancies may opt to lock means of egress under certain provisions. Locking means of egress may prove prudent in areas where infants and children, patients under court detention, and patients suffering from dementia and mental health issues are located. However, these locked spaces must meet additional requirements. Staff must be present at all times to unlock the means of egress in the case of an incident. The locked area must be completely protected by a smoke-detection system, or the doors must be able to be manually unlocked remotely from a constantly attended location inside the locked area. The building containing the locked area must be fully sprinklered, locks must fail open upon loss of power, and the activation of either smoke detection or sprinkler systems must release the locks.

8. Special hazards

NFPA 101 provides new allowances for domestic cooking equipment in areas open to the corridor and for alcohol-based hand-sanitizer dispensers within corridors. Domestic cooking for 30 or fewer people is permitted to be open to the corridor provided it: 

  • Exists in a smoke compartment with 30 or fewer beds.
  • Has a cooktop equipped with:
    • A hood sized to the cooking surface.
    • A suppression system.
    • Grease collection.
    • 500-cfm minimum exhaust.
    • An interlocking mechanism that shuts down fuel and electrical power.
  • Is protected with smoke alarms (no closer than 20 ft from the cooktop or range).
  • Does not use solid fuel.
  • Does not perform deep frying.
  • Has a locked switch that can deactivate the cooktop.
  • Has a timed switch that deactivates the cooktop automatically after no more than 120 minutes of no use.
  • Has fire extinguishers located in the cooking area.

As the use of alcohol-based hand-rub dispensers within hospitals has shown to drastically reduce infection-control issues, using them has become prevalent. NFPA 101 has provided very specific requirements for their use to ensure that the fire risk posed by the flammable liquids contained within the dispensers is mitigated. The dispensers may only be placed in corridors with a minimum of 6 ft in width. Maximum capacity of dispensers in rooms, corridors, and areas open to corridors is 0.32 gal, or 0.53 gal in suites. Dispensers must be spaced at 48 in. from one another. No more than 10 gallons of hand rub may be stored in any single smoke compartment outside of storage cabinets. In determining the aggregate, one may exclude the capacity of one dispenser per room. Storage of more than 5 gal in a single smoke compartment requires compliance with NFPA 30: Flammable and Combustible Liquids. Dispensers cannot be installed over or adjacent to ignition sources. Dispensers may only be installed over carpets in sprinkler-protected smoke compartments. Aerosol containers of alcohol-based hand rub may be no larger than 18 oz and shall be Level 1 aerosols per NFPA 30B requirements. No more than 1,135 oz of Level 1 aerosols may be installed in a single smoke compartment outside of storage cabinets.

Figure 4: Under the new requirements in the 2012 Edition of NFPA 101, all existing high-rise health care occupancies must be fully protected by an approved, supervised automatic sprinkler system. Courtesy: JENSEN HUGHES9. Sliding and powered doors

Another design feature that has become more prevalent in health care is the inclusion of sliding and powered doors. The new code states that power doors are not required to latch, given the door may be kept closed when 5 lb of force is applied in the direction of opening and the door-closing method is approved by the authority having jurisdiction. Horizontal sliding doors are now permitted in health care occupancies, given that the room is of low or ordinary hazard and fewer than 10 occupants are served by the door. Breakaway operation is no longer required. Corridor doors, however, must still latch positively and limit the transfer of smoke.

10. Normally unoccupied building service areas

Normally unoccupied building service equipment support areas have a new definition and new requirements in the 2012 edition of NFPA 101. This type of area is now defined as "a building service equipment support area in which people are not expected to be present on a regular basis." Examples of areas like this include interstitial spaces, crawl spaces, chases, tunnels, attics, and service vaults. Requirements are limited for areas of less than 45,000 sq ft and sprinklered spaces less than 90,000 sq ft; however, Section 7.13 of NFPA 101 identifies the requirements of spaces larger than these thresholds. Normally unoccupied building service equipment support areas exceeding these area thresholds, provided that they do not contain fuel-fired equipment or allow storage, are now required to have at least 80 in. of headroom, 28 in. of width, exit signage and lighting, and two exits from the space at minimum. Normally unoccupied building service equipment support areas that contain fuel-fired equipment or allow storage do not fall under the allowances of Section 7.13.

This list highlights important changes to the requirements for the design and construction of health care occupancies due to the adoption of the 2012 editions of NFPA 101 and NFPA 99. However, it is not an extensive or complete list of changes. The new CMS rule also adopts all Tentative Interim Amendments to each code issued between Aug. 11, 2011, and April 16, 2014. These standards also reference other NFPA standards with varying applicable editions. 


Brandon Finzel is the operations manager for JENSEN HUGHES New York and New Jersey region. Samuel Flibbert is an associate with JENSEN HUGHES.