Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
13.01.03 Corridor Clutter Frequency of the citation: 29%
13.01.04 Suites Frequency of the citation: 26%
Overview of the requirement: Exit access corridor width must meet minimums established by the NFPA Life Safety Code and full required width must be maintained. Comment on deficiencies: The standard is evaluated through direct observation. Surveyors noted corridor obstructions.
Overview of the requirement: Patient sleeping suites are limited to 5,000–10,000 square feet, depending on sprinkler protection and supervision, and must allow direct staff oversight when exceeding 7,500 square feet or have full smoke detection, require two exits if over 1,000 square feet, and have a maximum 100-foot travel distance to an exit door. Non-sleeping suites may be up to 10,000 square feet, require two exits if over 2,500 square feet, and must meet the same corridor separation and latching requirements. Comment on deficiencies: Compliance is verified through review of life safety drawings and direct observation. Most deficiencies related to doors in the suite boundary wall that did not positively latch.
Examples of ACHC Surveyor findings: ■ The materials main storeroom doors are blocked by eight surgery case carts. ■ Miscellaneous pumps and linen carts are stored in the corridor.
Examples of ACHC Surveyor findings: ■ Doors identified as suite boundary doors do not positively latch.
■ The west corridor has a scale, patient lift equipment, and a cart stored in it. Although there are offices in this space, the location is identified on the life safety drawings as part of the healthcare occupancy. ■ Four shipping pallets, with products on the pallets, are stored in the egress corridor near the information services department. ■ In the emergency department, soiled linen hampers, linen carts, and stationary shelving impede the egress passage and reduce the corridor width to less than 36 inches. Compliance tips for:
■ The mother-baby suite is noted on the life safety plan as 9,089 square feet. A suite of greater than 7,500 square feet must be located in a sprinklered building, with automatic smoke detection, and requires direct observation of all sleeping rooms from a normally attended location.
Compliance tips for:
The requirements for suites are different for patient care sleeping and patient care non-sleeping. Patient care sleeping suites have tier-related restrictions based on the size. Understand the differences between suites up to 5,000 square feet, those between 5,000 – 7,500, and those between 7,500 – 10,000. Patient care non-sleeping suites are permitted to be up to 10,000 square feet with fewer restrictions. ■ Review life safety drawings to understand the location of suites. ■ Audit doors in the walls that define the boundary of each suite to ensure positive latching. ■ Ensure that suite sizes are noted on drawings. ■ Many hospitals overlook the flexibility of patient suites. Take time to assess whether your care areas could qualify as suites under the Life Safety Code and gain valuable design and operational advantages. ■ The floor arrangements must allow required sightlines from an attended location and appropriate exit access for suites exceeding 7,500 square feet.
Nerd Newbies (understand the requirement)
Items cannot be left unattended in corridors for more than 30 minutes with limited exceptions for emergency crash carts and isolation supply carts that are wheeled and subject to a written plan for removal in the event of a fire emergency. ■ Use environmental rounding to check for and correct corridor clutter. ■ During environmental rounds, look beyond clutter itself—ask why it’s there. Identify patterns like lack of storage space, workflow design, or staging habits that lead to corridor use. Track recurring problem areas and elevate them for corrective action. ■ Establish a “clear corridor culture” through visual cues and accountability— mark designated parking zones for movable equipment, celebrate zero- clutter units, and include corridor checks in daily safety huddles. Teach that clear corridors equal faster response and safer evacuation.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Nerd Trailblazers (prepare the path for others)
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