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Beginning July 5, 2017, an ASC must be in compliance with Chapter, Doors to hazardous areas.

The May 4, 2016 Federal Register announcement of CMS’s adoption of the 2012 NFPA 101 (aka the Life Safety Code®) draws attention to a requirement for closers on doors to hazardous areas in both new and existing ASCs. The effect of this seemingly simple requirement is magnified by a broad and all-inclusive change in the 2012 edition’s classification of what comprises a hazardous area.

Under the previous CMS reference (2000 ed. of NFPA 101) hazardous areas were characterized by an exceptional quantity of flammable/combustible materials – i.e., a higher density of such storage than was normal or expected in most ASC settings. This definition relied on interpretation, and permitted many storage rooms in sprinklered ASCs to avoid special enclosure requirements.

The 2012 edition carries a far more restrictive standard in terms of which spaces require special protection, and extends that requirement to both new and existing facilities, in all buildings regardless of sprinkler protection. Per appendix clarifications in NFPA 101 (“Annex A”), related to special hazard protection “A. requiring special hazard protection include, but are not limited to, areas such as those used for storage of combustibles or flammables, areas housing heat-producing appliances, or areas used for maintenance purposes.” This new view of hazardous areas in effect defines every storage room in an ASC (except one used solely for office supplies) as requiring “special hazard protection” – because most supplies stored in an ASC involve some degree of material that can burn (such as paper, cloth, or plastic), whether in a wrapper, container, or the components of the supplies themselves.

The final piece of the puzzle is a requirement included in the occupancy chapters for both new and existing ASCs (Chapters 20 & 21, section 3.2.1) that stipulates “Doors to hazardous areas shall be self-closing or automatic-closing…” As a consequence, the now-applicable edition of NFPA 101 carries a retroactive requirement for all ASCs to upgrade storage room door hardware, that is not already so equipped, to be self-closing. CMS gives existing ASCs until July 5, 2017 to come into full compliance with this particular requirement. After that date, non-conforming ASCs will be cited for the deficiency.

Of the many ways in which CMS’s adoption of the 2012 edition of NFPA 101® the “Life Safety Code®” will affect ASCs, the size limitation for soiled linen and trash containers may be one of the most pervasive. While listed separately in Chapter 20 for new facilities and in Chapter 21 for existing facilities, the new requirement for soiled linen and trash containers is nearly the same in all ASCs.

According to both Chapters, in their respective sections 20/, the largest soiled linen or trash “collection receptacles” allowed in an ASC will be 32 gallons. There are, however, subsections that add detail and, more importantly, some relief:

  • The total capacity of all collection receptacles in any given room or space must not exceed ½ gallon per square foot of the room or space. For instance, the smallest room or space that may have a 32-gallon waste or linen receptacle in it would be 64 square feet in area.
  • Mobile collection receptacles larger than 32 gallons will be permitted in rooms protected as hazardous areas (enclosed in 1-hour rated fire walls, or protected by a sprinkler system and, in new ASCs, smoke partition walls). The total combined gallon capacity of soiled linen and trash receptacles in rooms protected as hazardous areas will not be limited.
  • Mobile collection receptacles larger than 32 gallons will be permitted outside of areas protected as hazardous areas while they are attended – meaning for the active transport of soiled materials between spaces and/or out of the facility. Such large mobile containers/carts may not be left unattended (i.e., parked) outside of properly protected areas.