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Q: We have a dental clinic that has an E-size O2 tank in a wheeled cart. According to NFPA 99, this is not considered "In Storage." Are there any requirements …
Q: I am in a medical arts building. All that I have in this building is a hospital-based lab satellite station, and a physical therapy (PT) area; otherwise the rest …
Q: Can you tell me when a sign saying "Fire Extinguisher Inside" is required? I cannot seem to find the guidelines for installing this sign. For instance, if there are …
Q: I have a 2-story building that has not previously been used for healthcare. It is not sprinkled. The lower level will be changed to a healthcare occupancy with overnight …
Q: My question is related to emergency generator testing. On my last building (and my current one) the emergency generator was really small for the building, therefore only supplying power …
Q: Our facility stocks 70% Isopropyl Alcohol in 16-oz. containers. We generally keep in stock 12 or less bottles. Are there any certain storage requirements for this (such as an …
Q: Can we use deadbolt locks on a closet door located within an office? Would they need to be a latch style versus a bolt-style? A: As long as the …
Q: Our Environmental Health & Safety (EH&S) compliance officer asked me to check into the recommended life-span of smoke detectors. His understanding is that ALL detectors are to be replaced …
Q: Is it permissible to place window film over rated glass assemblies on fire-rated doors, so you cannot look through them? If so, does the film also needed to be …
On Tuesday, March 30, we posted this picture of a vacuum pump in a hospital and asked you to speculate on what happened and what caused this situation. We had …
Q: Does the placard identified in NFPA 96-2011, section 10.2.2, which states that the exhaust hood fire suppression system needs to be activated prior to using the fire extinguisher, need …
Take a look at the accompanying photo provided to me by a reader. Something happened to a vacuum pump in a hospital. Can you figure out what happened, and what …
Q: I have a hospital client that wants to use cushions placed on the floor to reduce the risk of injury from patients falling out of bed. There is no …
Q: In regards to negative pressure for patient isolation rooms, I understand that the negative pressure has to be verified before you can place a patient in the room but …
Q: What are the requirements for testing electrical outlets in nursing home patient rooms? A: According to NFPA 99-2012, section 6.3.4.1, receptacles not listed as hospital-grade at patient bed locations …
Q: Recently, I have been instructed to fill out an Interim Life Safety Measure (ILSM) assessment each month when conducting fire alarm system testing with our contractor. I have been …
Q: I cannot find any code stating what, if any, clearance you need around a fire alarm pull station on the actual wall. We need to mount a nurse call …
Q: Since CMS has adopted NFPA 99-2012 edition, is it necessary to do the risk assessment in order to maintain RH levels in ORs > to 20%. A: Yes. The …
Q: One of our AHJs is looking for verification that all hospital personnel participates in fire drills, not just in the vicinity of the system activation. One fire drill form …
Q: Has a clarification been issued for what “varying conditions” means in 2012 edition of the NFPA 101 Life Safety Code 19.7.1.6? Our accreditation organization requires fire drills vary by …
Q: If a lower level of a hospital is declared business occupancy, can their doors be propped open with books and wastebaskets? I think that the doors were rated when …
Over the past year, most traditional on-site surveys have been delayed or interrupted due to COVID-19 restrictions, but now that the caseloads across the country are decreasing, The Joint Commission …
Q: We have a dressing room that is part of our Ultrasound room that uses accordion doors and they want us to install the sliding barn door type door on …
Q: Currently, I conduct one fire drill per shift per quarter in our hospital for a total of 12 drills a year. I am also required to conduct fire drills …
Q: Are there any HVAC requirements for clean supply/storage rooms in business occupancies? I am working with contractors constructing a health care clinic and there seems to be some confusion …
Q: We had built a temporary surge space due to the COVID pandemic. This surge space was attached to the hospital to provide flow for our ED patients. We had …
Q: We have a pharmacy in our critical access hospital. It was recently moved to another location within the hospital building. When some base cabinets and counters for work space …
Q: How often do employees require training on fire extinguishers? We teach RACE/PASS during employee orientation at our Hospital/Nursing home. Is it required to have a company come out yearly …
Q: A recent post makes me ask, “What is meant by ‘transmission of a fire alarm signal’ under section 19.7.1.4 of the 2012 Life Safety Code?” A: Section 19.7.1.4 of …
Q: We recently had a consultant come in and go over our documentation in preparation for a survey. He said we are supposed to conduct weekly inspections of our fire …
Q: If I have fire alarm system pull stations at all the doors entering a stairwell, do I need a pull station inside the stairwell at the door which exits …
Q: Any thoughts as to when hospitals will resume performing traditional fire drills? A: According to a CMS communication issued May 8, 2020, they stated: COVID-19 Emergency Declaration Blanket Waivers …
Q: Due to a state energy code, there is an entry air lock/vestibule at our hospital’s main entrance. Is the existing travel distance measured to the first inside set of …
Q: We have oxygen and vacuum shutoff valves on many of our patient floors. On the 2nd, 3rd, and 4th floors (and maybe the 5th floor), the valves serving medical …
Q: Is a generator required in a dental clinic that does deep sedation? A: That depends on whether or not the dental clinic is classified as a business occupancy or …
Q: Can I count a real fire response in a patient room as a fire drill? The fire alarm system was activated at the pull station, and the fire department …
Q: What month or year did the load-bank generator testing change from 25% within 30-60 minutes to newer standard 30% at the 30-minute mark? One source stated load-bank test only …
Q: I recently was cited by our accreditation organization for having incorrect letter size on delayed egress signs. My existing sign has lettering that is 5/8-inch tall. It is my …
Q: We have a facility that does not have battery operated lights within its OR rooms. Our building was designed in compliance with the 2000 Edition of the Life Safety …
Q: We order all of our bed linen from a medical supply company for our patient beds. We have recently started performing sleep studies and have two (2) full beds …
Q: Our auxiliary ladies' gift shop has an accordion-style door on one side that opens into the corridor. This door is made out of wood. The gift shop is smaller …
Q: Are self-testing emergency egress lighting allowable? If so, how do you satisfy the documentation required of both the monthly and annual testing? A: Yes, they are permitted. Section 7931 …
Q: Our hospital has a nurse station enclosed between two corridors. There is a door that opens into the corridor on each side. I have read Chapter 19 Corridor Separation …
Q: Are door hold-open devices that do not release in a fire alarm activation allowed in any area of the hospital? A: Yes, but only on non-rated corridor doors. Section …
Q: Do emergency egress lights with battery backup that are connected to emergency power need to be tested annually for 90 minutes? Are there any alternatives? A: Well, yes and …
Q: Can you tell me what the verbiage should be on a sign attached to a door to a room that holds oxygen and medical air? One consultant told us …
Q: Does the person doing the annual inspection on portable fire extinguishers need to be certified? We do not maintain them, per se. For example, if they need any maintenance, …
Q: We are a nursing home and our local health department is advising us to install plastic barriers with zippers in corridors to provide an area of isolation for COVID-19 …
Q: In regard to our 2-hour fire-rated walls, they are required to go all the way to roof line on both sides, correct? What about 1-hour fire-rated walls and smoke …
Q: We have a brand new free-standing patient tower addition to our hospital coming online and scheduled to open in 12 months. The contractors will be performing PM's on the …
Q: Does a diesel-fueled generator belly tank require an NFPA 704 safety signage when located outdoors? A: Yes. While I do not find any reference to NFPA 704 signage in …
Q: Does an eyewash station need to be within OSHA time/distance travels for an outdoor generator having batteries that are not a sealed “maintenance-free” style? A: That is to be …
Q: Does an outdoor diesel-fueled generator need a light fixture? If so, does a flashlight or wired fixture meet that standard? A: Yes. Section 7.3.2 of NFPA 110-2010 does discuss …
Q: Do electrical receptacles serving a water cooler need to be a Ground Fault Circuit Interrupter (GFCI) type? In addition to that, the surveyors also cited us for not having …
Q: We got dinged on not doing a weekly inspection of emergency transfer switches. What exactly does one do to inspect an Automatic Transfer Switch (ATS)? A: According to NFPA …
Q: We are an intermediate care facility with medical treatment rooms with oxygen cylinders. Are we required to have the Caution oxidizing gases sign on the doors where we have …
Q: What code or standard are you citing when you say any ceiling that has sprinklers or smoke detectors must be maintained to resist the passage of smoke? Is this …
Q: The accreditation standard states that we must test, inspect and maintain critical components of piped medical gas systems. The standard does not have a prescribed frequency, but it does …
Q: What Life Safety Code standard are you citing when you say a hazardous room created before March 11, 2003 must be sprinklered, and the walls must be one-hour fire …
Q: Does A/C power on a fire pump have to be monitored by the fire alarm panel? If yes, then where can I find the requirement in the NFPA standards …
Q: Are there any restrictions to storing medical gas cylinders in the same room as industrial gas cylinders? Specifically, can we store oxygen cylinders used for cutting torch in the …
Q: I am looking for an Above Ceiling Inspection Form; something I can give to my Facilities guys that tells them what to look for when doing an above ceiling …
Q: NFPA 80-2010, section 19.4.1.1 indicates the required testing and inspection of fire dampers to be 1-year after installation, afterwards the inspection frequency to be 4-years, except in hospitals it shall …
Q: In regards to the 4-foot separation of alcohol-based hand rub (ABHR) dispensers and the wrap-around the door frame requirement. I would like to pose the following: As part of …
Q: When doing monthly generator testing, do you have to maintain 30% for 30 minutes or does hitting the 30% sometime during the 30 minutes suffice? In other words, if …
Q: My facility is a Rehab Hospital that may at times have patients with a memory disability. My facility has a patient Wander Guard system which is located at the …
Q: Ever since I've been working in healthcare, I keep hearing about fire alarm strobes being required in offices with more than one person. In other words, if there's a …
Q: What are the requirements or standards for a remote power tap (RPT) preventive maintenance procedure? A: NFPA 99-2012, section 10.3.1 requires the physical integrity of power cords to be …
Q: Joint Commission recently posted a revision to LS.02.01.35 EP7 stating in part "at least six spare sprinkler heads of each type and temperature rating installed in the facility are …
Q: What is the regulation for testing the retention force on electrical outlets? A: According to section 6.3.3.2.4 of the NFPA 99-2012, the retention force of the grounding blade of …
Q: Is there a standard that says we need to write the start and stop time on our monthly generator load test for 30 minutes? A: In so many words …
Q: It is my understanding that all sprinkler heads in the same compartment must be of the same rating. Is NFPA referring to temperature rating or response time? A: According …
Q: I have a question regarding medical gas cylinder storage. We have a gas manifold room in a business occupancy that meets the room requirements for quantities that exceed 3,000 …
Q: Section 7.2.2.5.3 of the 2012 Life Safety Code (LSC), says there shall be no enclosed, usable space within an exit enclosure, including under the stairs, nor shall any open …
Q: For oxygen cylinders (full and empty), are there any regulations in storing them in clean utility room or med rooms? A: Yes. According to NFPA 99-2012, section 11.3.2, you …
Q: We have an existing healthcare occupancy hospital that is fully sprinklered. My questions are: 1) Are the corridor walls required to be smoke tight? 2) Are the corridor doors …
Q: Who can do the annual and monthly checks on a generator in an Ambulatory Surgery Center? A: Well, those are not checks, but actual load tests. According to NFPA …
Q: If I have a new freestanding business occupancy that is licensed, would CMS enforce the provisions of the 2012 Edition of NFPA 101 (Life Safety Code)? I wasn't able …
Q: In looking over NFPA 110, edition 2010, it does not make any distinction to the emergency generator prime mover being anything but diesel powered. Because of the equipment section …
Q: We were just surveyed (healthcare occupancy) and were cited for not having ground fault circuit-interrupter (GFCI) outlets installed within 6-inches of a sink location. At the time of construction …
Q: Are smoke detectors required in existing business occupancies that do not have a fire alarm system or automatic sprinkler system if the occupancy load is less than 500 persons? …
Q: We have a project scheduled for next year to build a significant addition onto our facility that will double our square footage. During the planning-stage, it was raised by …
Q: Presently there is an interpretation at our facilities that "E" cylinders of oxygen that are "In Use" or "Not Empty" is an allowable title for storing oxygen tanks versus …
Q: We are a physician’s clinic building and we have a section of wall in a corridor above a door where the drywall on both sides of the smoke barrier …
Q: Is it a violation to have security cameras in stairwells? I have heard of possible citations at other facilities due to the video cable creating a penetration. Please help …
Q: We ask staff this question when we do Environmental Rounding: "Can you identify the closest area of refuge?" The answer we have used is "shelter-in-place," but I believe this may …
Q: My question is related to NFPA 25 and the frequency for annual testing. Our state authority will issue a citation if the pump is not tested within 365 days …
Q: My question is about an electrical panel. Is an electrical panel, which is located in a special care unit of a skilled nursing home facility, required to be locked …
Q: How often do we have to do our smoke detector sensitivity test? Is it every two years or three years? A: According to NFPA 72-2010, section 14.4.5.3, the test …
Q: Does the inactive door on a set of double doors protecting a hazardous area require a door closer? Can the latching mechanism on the inactive door be an automatic …
Q: My question involves the electric wax warmers that provides a pleasant fragrance, which are called ‘scentsy pots’. Are scentsy pots aloud in healthcare facilities and if they are not, …
Q: We have to replace our fire alarm panel. The change-out will affect the supervisory devices for the sprinkler valve tamper switches and the waterflow switches as well. Unfortunately, we …
Q: I have several ceiling tiles (approximately 52) that are scratched or damaged that has sprinkler heads in them. Is there a code that references or mandates the replacement of …
Q: I have a question on microwave use and signage. Are "Caution: Microwave in Use" signs required at all entrance locations where microwaves are being used (i.e. staff lounge, nourishment …
Q: What is the rule on parking beds (gurneys) outside ORs in corridors? A: In a hospital, the required width of the corridor must be 8 feet where an inpatient …
Q: Do you have any suggestions for satisfying the accreditation documentation requirements to prove we conducted a building assessment for compliance with the Life Safety Code? I had thought about …
Q: We are installing a new HVAC system in the basement of the hospital. Now a building inspector is telling us we need to install fire-dampers in the ductwork that …
Q: One of our exit stairwells at our hospital has a door the leads outside at ground level. The exterior door is not fire rated. Does it need to be …
Q: In a single-story facility that has both Ambulatory Healthcare and Business occupancies, is there a requirement for a smoke barrier in this same separation? I am aware of the …
Q: So, I have an odd question for you regarding lighting within an air handling unit that is not sprinkled within a building that is sprinkled. Recently our HVAC department …
Q: I see several fixes for doors with excessive undercut. My problem is I have a building that is ten years old that has excessive clearance over 1/8-inch at the …
Q: I recently heard that we have to have two re-entry points in stairwells that are four stories or more, and all doors have to be labeled either "NO RE-ENTRY" …
Q: In my hospital, they have installed electronic hardware on stairwell doors that allows the door to latch on activation of the fire alarm only. The reason was patient complaints …
Q: Is an existing or new kitchen that has cooking equipment such as stove, oven, steamer, etc. consider a hazardous area in a hospital? A: No, not necessarily. According to …
Q: Is there anywhere in the Life Safety Code that says you have to have a smoke detector inside the MRI control room? I was told that another hospital in …
Q: Does CMS and the accreditation organizations require fire/smoke damper testing every four years in a hospital with mixed occupancy? If my hospital penthouse is business and the rest of …
Q: I work for a counseling agency, and in order to get a new license, I was required to get a life safety inspection. We have been licensed and providing …
Q: How many E-cylinders are permitted per smoke compartment and do "partials" count as part of the quantity? A: Basically, you can have an unlimited number of ‘E’ cylinders per …
Q: One of our Surgery centers recently had a DOH life safety inspection and they were told they need to individually chain each Medgas compressed gas cylinder. If I remember correctly …
Q: Do soiled utility rooms in business occupancies (non-sprinklered) require self-closing doors and 1-hour fire rated construction? A: Yes, but not because it is a soiled utility room (like a …
Q: During a recent consultation survey, the nurse consultant traced a patient to a general medical floor. She made the comment that all soiled work room doors require locks. Is …
Q: We are looking for some clarification on fire damper testing requirements as we recently had inspections done at our surgery center. One contractor says dampers with fusible links require …
Q: We have private patient rooms with private bathrooms that have deadbolts with thumb turn locks SEPARATE from the latching mechanism. It is not the "hotel suite" type. Is this …
Q: We recently took a webinar that informed us that accreditation organizations have cited hospitals for not having "emergency eye/shower stations" at the generator for the lead-acid batteries (this could …
Q: We would like to store alcohol-based hand rub replacement cartridges in the Central Supply storage room which is located on the lower level of the hospital. We were told …
Q: We are a 49-bed hospital facility (changed over from a 68-bed in 2017). Currently we have a room that was originally used for three patient beds. We are wanting …
Q: NFPA 101, 2012, requires that in health care occupancies, alcohol-based hand-rub dispensers "shall be tested in accordance with the manufacturer's care and use instruction each time a new refill …
Q: In regards to storing flammable liquids, NFPA 30 says no more than 120 gallons can be stored in a fire compartment. Does a fire-rated cabinet act as its own …
Q: Can you place frosting on the vision panel glazing (windows) of the doors? A: That’s a good question. If the vision panel is required in the door, then I …
Q: In a business office section of the hospital, there are two means of access to the front and rear of the suite. The suite is less than 900 square …
Q: Our supply manager was being asked to stock more alcohol and in larger containers in their distribution area. According to NFPA 30, the maximum allowable quantity of flammable liquids …
Q: Our hospital facility is 800,000 square feet with several of our buildings connected by tunnels. We have fire alarm panels (slaves) in each of the buildings that are connected …
Q: I have a flexible sprinkler pipe question. Can flexible sprinkler pipe penetrate a 2-hour rated fire wall separating a Business Occupancy and an Ambulatory Occupancy? A: According to section …
Q: According to NFPA 30, the maximum allowable quantity of flammable liquids in an appropriate storage cabinet is 120 gallons, regardless of whether the room where it is stored is …
Q: We were cited during a recent survey for not having our power assist doors to our ICU suite connected to the fire alarm system. I thought that was only …
Q: Is wired glass vision panels allowed in smoke or fire barrier doors? A: NFPA 80-2010, section 4.4.1 says only labeled fire-resistance-rated or fire-protection-rated glazing materials is permitted in fire …
Q: One of our health care facilities has just completed their annual Life Safety Survey and during the brief exit conference the Fire Marshall indicated that a yearly test on …
Q: My question is in regards to the spacing between alcohol-based hand-rub (ABHR) sanitizer dispensers when they are placed inside and outside patient rooms. In that situation, does the 4-foot …
Q: I have been asked to install "AREA OF REFUGE" signs on top of the doorframe on both sides on several areas of the hospital. Is there a specific per code …
Q: I currently work in a long-term care facility capable of being home to eighty residents, but we have sold off multiple beds and are now down to forty-eight residents …
Q: What would a surveyor would be looking for if they were to show up at our hospital and find that there is construction going on? What steps would the …
Q: We are trying to correct the terminology we use in our automated PM system, in this case, we have ‘battery exit light fixture’, ‘battery can light fixture’, ‘battery back-up …
Q: I am aware that there is an exception for sprinklers not to be required in a dedicated electrical room that is protected with 2-hour construction. My question: Is a …
Q: Our disaster manual reads "An emergency fire watch will be initiated in the event the facility fire alarm/sprinkler system is out of service for more than four (4) hours …
Q: A local authority stated that when performing the annual fire alarm inspection our service contractor needs to write up areas that have no smoke detection. Smoke detection was not …
Q: We are currently in the process of installing a new fire alarm system in our hospital. The old system has an annunciator panel at every nurse station and multiple …
Q: Our hospital has an offsite Sleep Lab where patients are treated for sleep-related issues. Most patients need to be hooked to oxygen during these tests. The lab is located …
Q: The vendor that did our annual fire door inspection cited a deficiency that the viewer/window in our existing fire doors did not have a label. Are viewers/windows in existing …
Q: NFPA 101-2012; 19.2.3.4(2) allows "non-continuous projections not more than 6 in. from the corridor wall, above the handrail height", but the ADA-2010 Standard [§204] only allows projections of 4 …
Q: Are headwalls made out of plywood consider an interior wall finish? Do these headwalls need to be constructed from flame-retardant plywood? A: I don’t know what you mean when you …
Q: Are healthcare facilities required to have the heating and cooling systems on the emergency back-up generators by code? A: The answer is yes for some heating equipment, but no …
Q: My question relates to storage in stairwells. Emergency Management is requesting patient transfer devices, (Sleds and Stair Chairs) to be stored in the stairwell. This would locate the device …
Q: Have I misinterpreted the new NFPA-25-2010 Testing and Inspection criteria for sprinkler systems? It’s my understanding that the technician performing the T&I services for water flow testing of sprinkler …
Q: I have a client that needs to set up hydraulic placards on their sprinkler main vertical risers. I'm trying to get more information but can you help me with where …
Q: Would a sterile processing room be considered a hazardous area? There are not a lot of combustible supplies and the only flammable liquid is ethyl alcohol. There is glutaraldehyde …
Q: What signs are needed for a manifold room with Oxygen, Nitrous Oxide, Medical Air, and Carbon Dioxide that is behind 2 doors? A: According to NFPA 99-2012, section 11341, …
Q: Are new cross-corridor doors that are strictly privacy doors (not part of any smoke or fire barrier) required to be double egress? I can't seem to find it in code …
Q: Is there a requirement to activate the fire alarm system in a patient/non-patient care business occupancy building during a scheduled fire drill? A: I would say so. Section 38/3972 …
Q: Are there any rules on alcohol-based hand rub (ABHR) dispensers being mounted in non-sprinklered patient care areas? A: Yes. According to section 19.3.2.6 of the 2012 LSC, ABHR dispensers …
Q: In a recent Life Safety survey the state surveyor said that fire extinguishers under a certain weight must be mounted no higher than 5 feet high at the handle …
Q: Our surgery staff is worried about an active shooter entering the operating rooms. We are looking at having a drill soon and the question came up about how to …
Q: We have been requested by management to keep a sprinkler head inventory. I understand this is for spare heads. What are the requirements from NFPA and what would be …
Q: We are installing new handrails and I assumed they would extend a couple of inches from the wall for gripping purposes. However, my maintenance man ordered the flush mount …
Q: Our company provides nursing home services. Now that the 2012 LSC has been adopted, does the CMS Survey and Certification Letter 14 - 46 still apply? In reviewing the …
Q: Is there a standard ratio from the firewall to the fire door (Ex. 2-hour firewall should have a XX min fire door)? A: Well, yes and no. Table 8342 …
As reported on this website last week, CMS issued a formal communication on April 29, 2020, that granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance …
Q: Do I have to use auto flush bolts and coordinators on a pair of double doors that are fire-rated (one active leaf and one inactive leaf) to a mechanical …
Q: We have dry standpipe systems in stairwells in the older areas of our hospital. Are dry systems required to be inspected/tested under pressure? I do not notice inspection tags …
In a formal communication issued April 29, 2020, CMS granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance (ITM). Refer to page 23 of the following …
Q: I have a question regarding the use of Oxygen in a beauty shop. When the state was in our facility (nursing home) they indicated that we need to post …
Q: We are a service company and we are doing door inspections at a hospital where a lot of the doors have fire labels that are in smoke partitions or …
Q: We recently had our triennial accreditation survey and the surveyors are saying that each individual oxygen tank must be labeled as being ‘Full’ or ‘Empty’, even though the rack …
Q: I work in an old hospital and we have quite a few fire rated openings that are missing labels, I'm having a company come in and rate the frames for …
Q: Have you heard of a code or standard where you cannot use decorative paint on glass (i.e. Christmas decoration) within an ICU outside door with glass and glass windows? …
Q: Are IT closet plywood backboards required to be fire rated with the rating showing in closets that are sprinklered? A: No. Section 19.3.3.2 of the 2012 LSC requires all …
Q: We have quite a few rooms throughout our facility that initially required automatic closing and latching hardware for fire requirements. These rooms have now been 'converted' to office use, …
Q: Is fire-retardant-treated wood permitted in a healthcare occupancy for roof construction, including girders and trusses, in Type II (000) construction? Background: NFPA 101-2012 Section 18.1.6.2 and 18.1.6.3 allows FRTW …
Q: During a review of NFPA 10 chapter 6 dealing with the installation of portable fire extinguishers, I couldn't find anything that addressed the installation requirements for ABC extinguishers, such as …
Q: Has there been an update to the definition of time by TJC/CMS? I'm looking at quarterly fire drills right now, but any changes/clarification on the definition for all intervals …
Q: I have a question about delayed egress locks in nursing homes. Can you have more than one door equipped with delayed egress locks in a path of egress? I …
Q: I believe you may have answered aspects of this question before but I was having trouble locating it again. I understand the difference between hazardous areas when considering new …
Q: Do the NFPA standards for fire damper testing require the testing to be performed by a certified vendor/specialist or can it be performed internally by our engineering staff? A: …
During this period of COVID-19 crisis, many readers have written asking if they can discontinue conducting routine Life Safety tests and inspections in order to limit service technicians from entering …
Q: Are there any Life Safety Code requirements for a battery charging room, such as HVAC pressurization and air changes per hour (ACH) rates? These rooms are where I charge …
Q: What is the testing requirement for a fire alarm system in a nursing home? Is it annual or semiannual? A: The testing frequencies for a fire alarm system differ …
Q: As the world faces this pandemic, can fire drill requirements be suspended or replaced with staff education type in-services? A: Fire drills are a mandatory requirement that is regulated by …
Q: We have a Geri-Psych unit and the stairwells are locked on that unit. Back in 2009, you surveyed our facility and wrote in your findings, "The housekeeper person on …
Q: A California Life Safety Code surveyor enforcing the 2012 edition of the LSC asked for a map of all of the smoke and fire dampers in the building (skilled …
Q: My hospital is preparing for COVID-19. I'm at odds with the clinicians who believe that the pandemic is a special situation, meaning that Life Safety Code can go by …
Yesterday, Compliance One Group shared an insightful video by Carrie Kotecki that discusses her thoughts on how healthcare organizations can prepare now to prevent a future public health emergency. Click here …
Q: What are the rules for fire extinguishers in elevator mechanical rooms? Is it good enough to have the extinguisher outside the room in the hallway? A: Yes… Based on …
Q: I was reviewing the various regulatory requirements and came across the need for weekly visual inspections of the generators. At one campus, we have changed the batteries to the …
According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud financial losses are in the tens of billions of dollars each year. A conservative estimate is 3% of total …
Q: Is it allowed to disable a corridor door's closer by removing the arm in order to keep it open while working inside of the office in a healthcare facility? I …
Q: Our hospital recently purchased a few lactation pods like they have in airports. I can't help wondering if they need to have fire alarm notification devices and sprinklers. Has …
Q: Can E-cylinders be stored in a closet where people hang their jackets even if they are in an acceptable storage cart? A: Yes… up to a certain number of …
Q: We are building a new ER and an area of the existing building had to have some work done so that the new ER could connect to the old …
Q: With regards to a fire watch, the code is specific about requiring one in an occupied building when a fire alarm system or suppression system is out of service …
Q: Am I allowed to have a suite inside an area designated as an Ambulatory Occupancy? And for clarification, do suite boundary walls need to be one-hour fire rated? A: …
Keeping your door inspection on schedule and on budget is a central focus of our projects. To achieve this goal, we need your help and preparation. While you don’t need …
Q: In regards to the sensitivity testing of smoke detectors, I believe my fire alarm system is capable of complying with NFPA 72 for the sensitivity testing of smoke/heat initiating …
Q: I have a question on the requirement for the battery backup lighting inside the MRI suites. We are in the process of building two new MRI centers and I …
Q: We are a service contractor that is attempting to obtain a contract with a new client that is an Ambulatory Surgery Center. The ASC told us they never had …
Life Safety Drawings (LSDs) are often an unappreciated hero of an accurate door inspection. Not having accurate LSDs cause the inspection of extra doors and their consequential costly repairs. Let …
Q: We have out-patient clinics classified as business occupancies. Are we required to have emergency egress lighting? If so what section of the 2012 or 2015 NFPA Life Safety Code …
Q: We are presently undergoing our 3-year licensure inspection by the Dept. of Health. One of the inspectors asked to see our air change records for the morgue. We have …
Q: How does one handle a "Soiled Utility" room in an Ambulatory Healthcare Occupancy? If it is a small storage room without large volumes of flammable liquids, but perhaps containing …
Q: Nursing staff has a tendency to stuff patient rooms that are not used as often with extra beds, furniture etc. Building does not have sprinklers on these patient floors …
Q: Do you have to have smoke detectors in emergency electrical rooms or electrical rooms? A: In a hospital? Only if you have an FSES equivalency that requires it, or …
Q: Section 19.3.7 of the 2012 LSC discusses smoke compartments in facilities that have greater than 30 sleeping beds per floor or building. If your facility is under 30 beds, but …
Q: A question came up concerning NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never …
Q: Do we need to post the temperature ranges on the outside of our blanket and fluid warmers? A: Well… no, I don’t believe you do. But the expectation is …
Q: We have operating rooms with two doors, one that is adjoining to the sterile corridor and one to the common corridor in the Surgery department. We monitor the common …
I have often been told by ambulatory surgery center staff during surveys that the Life Safety Code surveyor is the person that they fear the most. Keeping up with the …
By Brad Keyes... Q: I have a storage question for you that relates to storing beds and other hospital equipment in our mechanical rooms. Is this allowed or would I be …
Q: I just would like to confirm: When you say a 4-inch projection is allowed into the corridor is that for one side of the corridor or is that for …
Q: Our Emergency Operations team does regulatory rounding every 2 weeks in a different unit or clinic. Our department is responsible for Life Safety. Recently, we did some rounding in …
Q: What is one of the main reasons that ambulatory surgery centers (ASCs) get cited for deficiencies in relation to testing, inspection, and maintenance activities for Life Safety equipment? A: …
Q: We have two open-heart OR's. Each has a full 42" wide door leaf that opens to the corridor, and each has a 3'0" door in the rear of the …
Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have …
Q: My question is in regards to alcohol-based hand rub (ABHR) dispensers in a recovery area in our Cath lab. Does an open bay in the recovery area count as …
Q: What is the most common deficiency that you cite during a Life Safety Code survey? A: Improper inspection, maintenance, and testing of the building features that protect occupants from …
Q: I have a 3-story linen chute in our facility. The chute is enclosed within a 1-hour shaft from the 1st floor deck through the roof of the facility. In …
Q: Are smoke detectors required in individual hospital patient rooms, and what are the exemptions to not have a detector in individual rooms? A: There is no Life Safety Code …
Q: I need you to settle an argument for us, and your answer will settle this situation for all. We have a fire door to a hazardous room, that has …
Q: What is the allowed distance a non-sprinkled stick-built building can be located beside a hospital? A: Your question encompasses a couple of different issues. When you say “stick-built” building, …
Q: Housekeeping products like germicidal, glass cleaner, air freshener are stored in a locked metal box on housekeeping cart. All of our stock of these and other products are stored …
Q: In regards to corridor width, section 19.2.3.4 of the 2012 LSC discusses that a corridor has to be at least 48-inches outside of a sleeping room in clear width …
Q: How do I perform the elevator recall test? A: If you have never performed an elevator recall test, I suggest you have your elevator maintenance company show you how …
Q: My facility is installing perforated ceiling tiles because it looks "modern" and does not look like the old healthcare setting. With the perforation in the ceiling tiles, does this …
Last week, I shared a brief checklist for evaluating your hospital emergency operations plan and now, I'm here to share a couple of free resources with you to aid in …
Q: In healthcare, when calculating the 300 cubic feet of oxidizing gases like oxygen and nitrous oxide, do "air" tanks figure into the calculation? A: Yes… According to 3.3.128 of …
Q: Are there any regular testing requirements for Generator Remote Shutdown Switches? A: Yes… sort of. Section 8.4.1 of NFPA 110-2010 says generators, including all appurtenant components, shall be inspected …
Q: Where does "Homelike Environment" end and fire safety begin? We have a resident in our nursing home who likes to push-pin everything she makes in activities to her wall …
Q: Is there presently a date in place in which existing Healthcare Occupancies (remaining portions or in their entirety) must be fully sprinklered? A: Yes and no. All existing high-rise …
Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB) …
Hospital emergency operations plans can be overwhelming to produce and maintain. Not only can they be time-consuming to develop, but a challenge is to keep it user-friendly too. This resource …
Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that …
Q: Are gift shops stilled classified as hazardous areas if they have quantities of combustibles? I do not see the standard for gift shops to be classified as hazardous areas in …
Q: For annual fire extinguisher inspection how long before and how long after do you have to re-tag? A: NFPA 10-2010 section 7.3.1.1.1 says fire extinguishers shall be subjected to …
Q: What resources can hospitals use to manage workplace violence? A: The law enforcement department in your community is a significant resource for healthcare in designing a united front in …
Q: We have a generator that doesn’t meet the 30% load for the monthly run so we have to do an annual run with the load at 50% for 30 …
Q: How would I go about cleaning the dust off the sprinkler heads? A: Use a portable vacuum cleaner. If the dirty heads are located in the kitchen, then you …
Q: We have chosen to install some extra battery egress lights in our hospital that are not required. One of these areas is our stairways. 100% of the lighting in …
Q: I'm a Facilities Director overseeing an existing 8-story (basement included) acute care hospital fully sprinklered. We wish to mechanically lock (no auto unlock feature) floors 2-7 (Floor one being …
Q: If an Emergency Department is greater than 7500 square feet but less than 10,000 square feet and is deemed to have "sleeping accommodations", do the requirements of direct visual …
Q: How do I decrease workplace violence incidents in the hospital where I work? A: In my experience working within a healthcare setting, the best way to decrease workplace violence incidents …
Q: A deficiency was found by CMS on a recent survey that stated 'staff failed to provide a safe and hazard free environment by not having all doors protecting corridor …
Q: Someone just asked me a question and I haven’t thought about this one before. This AHJ is enforcing the IBC but I’m looking for an NFPA viewpoint and of …
Q: If we put the fire alarm system in test by-pass but we are still monitoring the alarms so we can troubleshoot or test the system so we avoid nuisance …
Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space …
Q: Is there a code requirement for implementing an Interim Life Safety Measure (ILSM) for occupancies other than healthcare (i.e. business occupancies) if a life safety code deficiency has been …
Q: I have a question regarding emergency generators and Level 1 classification. I'm at a sister hospital and they went through a State Surveyor and he asked for proof that …
Q: In the 2012 LSC concerning alcohol based hand rub (ABHR) dispensers in a hospital setting, is there a limit to the number of dispensers that can be in a …
Q: My fire alarm installer tells me that NFPA 72 does not require strobe synchronization of two (only two) devices. The sync is required if there are more than two …
Q: I read recently that Joint Commission allows a door with a power operator to not have to positively latch as long as it has 5-lbs. of force keeping it …
Q: I am looking for the 1/8-inch gap reference for ceiling tiles. If the ceiling has broken tiles, or misaligned tiles, or gaps greater than 1/8-inch caused by anything (such …
Q: Can accidental fire alarm activations, such as burnt popcorn, be counted toward a quarterly fire drill requirement if documentation of staff response is received in regard to said accidental …
Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: …
Q: I was having a discussion regarding toaster ovens use in healthcare and the frequency of fires was a factor for not favoring them. We have a few on campus …
Q: Our nursing home just completed a state survey and while we were not cited we were "warned" that all aerosols are to be put into fireproof cabinet. The metal …
Q: Is there a standard on lighting of offices and exam room in the ambulatory or clinics? A: The Life Safety Code is primarily concerned about egressing the facility under …
Q: In the standards manual from our accreditation organization it states that every 12 months the critical access hospital either performs a functional test of battery powered lights on the …
Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I …
Q: My question involves childproof outlets in healthcare. Where are they required and where in the code does it discuss not using snap-in covers? A: According to NFPA 70-2011, Article …
Q: Is it required to keep electrical panels locked even if they are behind doors that are restricted by card-access readers? Does it depend on which AHJ is inspecting it? …
Q: Please clarify if electrical closets and /or electrical rooms can be accessible to anyone. The NFPA70 National Electrical Code seems to require warning signs limiting access to authorized personnel …
Q: I am curious if you know of any regulations that deal specifically with LTC residents with oxygen supply and beauty salons. We have a salon in house, and the …
Q: What would be the appropriate standard for a daisy chain? A: I’m not entirely sure of what you are asking…. But when you say “What would be the appropriate …
Q: I am looking at a hospital facility with an Ambulatory Surgery Center in an existing building that is a Business Occupancy and construction type – II (222). We are …
Q: Are there any life safety requirements concerning courtyards? We have an outdoor courtyard, surrounded on all sides by our building, with one door entering and exiting the area. As …
Q: I heard a rumor that the accreditation organizations (AO) are going to 18 month visits vs. the 3 years it has been. Is there truth to this? A: No… …
Q: Do you know if the ambulatory health care facilities are required to do an annual Test and Balance of the HVAC system? A: No… I am not aware of …
Q: I have a question about the limits on the size of trash containers in healthcare facilities, including ambulatory healthcare facilities. Consider larger collection bins, that are housed in one-hour …
Q: Do transaction windows in a smoke resistive non-rated corridor wall in a healthcare occupancy need be self-closing? A: It depends on what space the window is open to. Section …
Q: Are non-patient sleeping rooms (i.e. physician sleep rooms) that are located in a hospital occupancy considered part of that hospital occupancy classification? A: Well…. There is no occupancy classification …
Q: I have a Medical Office Building with multiple exam rooms, and it is constructed with 5-foot wide corridors. This building followed design reviews including Life Safety expertise from the …
Q: We have a medical office building attached to the hospital using a 2-hour fire-rated separation. Two questions: 1) Our 8th floor is under renovations for a new auditorium and …
Q: In an EXISTING hospital, when the corridor walls are ALSO a smoke compartment barrier, can the penetrations above the ceiling be sealed with a non-rated sealant or are they …
Q: I have been asked by a clinic manager at one of our primary care clinics to install a door knob on a split Dutch type door that goes into …
Q: We recently had a surveyor tell us that suites are not allowed in ambulatory healthcare occupancies. Can you help explain this and any code references that support your opinion? …
Q: In our hospital the nurses found the architectural room numbers too confusing and wanted all patient care rooms to be in numerical order, so about 15 years ago they …
Q: How do we classify existing versus new construction? Do we look at the date of adoption of the current Life Safety Code as the cutoff? Anything constructed before that …
Q: I have a client that is building a new Women’s and Children’s Hospital. The women's component will be licensed to one organization, and the children's component will be licensed …
Q: We previously built personal protective equipment (PPE) cabinets that are permanently mounted to the wall. These cabinets protrude in to the hallway 5-inches. The previous NFPA guidelines allowed 6-inch …
Q: The Joint Commission standard for annual door testing states "The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of …
Q: Do generators for healthcare need to be load-bank tested annually if they meet the 30% nameplate load requirement during each monthly test? A: No. Load bank testing is only …
Q: The hospital where I work is leased, and the landlord is not a healthcare architect and pushes back on everything. My need is to have the life safety plan …
Q: Is it required to dropped power to your electric driven fire pump while it is running to ensure it starts back up and continues to run on emergency power? …
Q: Our facility is a nursing home. I have been asked a question if a resident can have a clothes iron in their room? I said no and would check …
Q: In a physician’s clinic that is claimed to be fully protected with sprinklers, the building elevator control room is not sprinklered. Must I install or can I leave it …
Q: Are there any exceptions in NFPA 13 for smoke detectors in lieu of sprinklers in areas such as radiology rooms or other high tech equipment rooms and still be …
Q: Can you have a parking garage under a health care occupancy/patient sleeping areas, that does not have smoke separations but does have a 2-hour fire rated barrier between the …
Q: My boss has hired an outside company that has advised him to rip fire rating labels off of doors and frames that we have maintained properly for decades. We …
Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has …
Q: In regards to fire extinguisher inspections… when the annual fire extinguisher maintenance is done, say in June, does the monthly fire extinguisher inspection still need to be completed? A: …
Q: When deactivating a magnetic lock but leaving it in place, what is the exact/excepted wording used noting that this magnetic lock is no longer in use? A: What you …
Q: We are seeking to reduce activation of smoke heads contained in our construction areas. In your opinion, if the construction area has existing sprinkler coverage or if new active …
Q: Can we have a fan unit installed in a clean supply room? We have a room where an air handler unit is installed for cooling another equipment room. The …
Q: We have a relatively new Infection Control team. They are performing rounds and having mock surveys with a nurse-consultant that cites issues from the 2014 FGI in areas that …
Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk …
Q: What is the clearance required in front of electrical distribution panels? A: According to NFPA 70-2011, article 110.26, a minimum of 36 inches clearance is required in front of …
Q: What are the requirements for the use of smoke detectors in a business occupancy physician office that does not have an automatic sprinkler system? The fire marshal is telling …
Q: I have been reading about stairwells and what the code addresses. I am interpreting that the AHJ's are stringent of what can be placed in a stairwell. Is it …
Q: My department is assisting with a fire/smoke barrier door assessment. I have noticed that some of the ¾-hour corridor doors have had the lower bottom rods removed from the …
Q: I have a question regarding testing and repair of fire alarm system in a hospital setting. Is a maintenance person who is employed by the hospital as an electrician but …
Q: We recently were cited for not having the placard placed on the wall above the K Fire Extinguisher, however, the "warning" on the front of the extinguisher is in …
Q: Do you know of any other information on alcohol-based hand-rub (ABHR) dispensers not allowed in the egress corridors of business occupancies? I need more information than what you have …
Q: We are a life safety service company that provides consultation services for multiple hospitals. We had a hospital go through a survey recently, and the surveyor wrote them up …
Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the …
Q: A question for you about alcohol storage. If we have over 5 gallons of alcohol, 70% isopropyl rubbing alcohol in a 1-hour rated room, is that acceptable? A: It …
Q: I can find a lot of information about portable fire extinguishers but nowhere can I find what size is required for use in a hospital. Can you point me …
Q: Is there a requirement to test eyewash stations annually? We do a weekly test for various items but are we required to conduct an annual test as well? A: …
Q: We have a complete gut renovation project that consist of two buildings (Admin. Bldg. & Lab Bldg.). The buildings are connected in all three levels and will be unoccupied …
Q: This question concerns isolation room negative pressure parameters. Our ICU isolation rooms have two sensors for air pressure; one located inside the room and the other located outside the …
Q: In regards to portable fire extinguishers, I have a fully sprinkled building but my room that my hot water heaters are in are on the outside of the building …
Q: We have multiple hospitals that we provide fire-safety testing services to. With the new requirement for testing elevator fire-fighters emergency operations, we all have a different opinion about what …
Q: Is it a requirement to keep access to the medical gas alarm panel clear in a similar manner that access to medical gas shutoff valves must remain clear? These …
Q: Do business occupancy buildings with soiled utility rooms have to be one-hour fire-rated or just sprinkled if the building falls under a hospital license and will be inspected by …
Q: Do hospital grade receptacles need to be tested yearly in an ambulatory setting? A: Section 6.3.4.1 of NFPA 99-2012 says hospital-grade receptacle testing shall be performed after initial installation, …
Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required …
Q: My question is regarding a 2-hour fire-rated wall that is separating our physical therapy department and the main hospital. In between the two is a long glass hallway with …
Q: We got a hit on our life safety inspection because we were told the manual shutdown switch be detached from the generator. The deficiency report says “The manual shutdown …
Q: My question is in regard to NFPA 13 sprinkler obstruction compliance...We want to install some surveillance monitors in our security office along a wall. How much vertical clear space …
Q: Is the alarm transmission verification test generally performed by a fire alarm testing company on every device during an annual test/inspection? I also thought that this was a quarterly …
Q: I had a company put in the fire plugs on the doors to replace the lower bottom rods. Was this okay? They say that the plugs have a thermal-pin …
Q: Lately, due to many different construction projects within this hospital, contractors install crash bars (aka panic bars) on doors that have locks for security reasons. The doors do lead …
Q: I work at an ICF facility. We have a person with arthritis and I was just asked if a heated pad massaging seat could be purchased for them. I …
Q: Regarding the new CMS rule on emergency preparedness, are they telling us that we must have full heating and cooling support for the entire hospital during a power outage …
Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director? A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (ie …
Q: We are going to have temporary generators onsite for two months that we will use during our construction project to replace the main power distribution gear for our bed …
Continuing in a series of strange things that I have seen while consulting at hospitals... This is another picture of sprinkler pipe supported from HVAC ductwork, similar to last week's …
Q: We have two small processing rooms in a hospital where they clean and reprocess vaginal probes, using the chemical RESERT. Should these rooms be held to the same standard …
Q: Could you please clear up a concern related to section 19.7.8 of the 2012 Life Safety Code, that addresses Portable Space-Heating Devices? Section 19.7.8 (1) states such devices are …
Continuing in a series of strange things that I have seen while consulting at hospitals... Some organizations fail to install sprinklers underneath the ductwork that is 48-inches wide or wider …
Q: In regards to audio/visual strobes in staff sleeping rooms, is it required for them to hear the fire alarm system? A: According to section 26.3.4.5.1 of the 2012 Life …
Q: At our hospital there is some question about which type of portable fire extinguisher should be installed in our operating rooms. We can't find an actual requirement for this …
Q: Do fire extinguishers that are placed in patient care areas of a hospital have to be placed in a wall cabinet, or can they hang from the wall? A: …
Continuing in a series of strange things that I have seen while consulting at hospitals... Ah... This is plain ugly. As you can see, water ran into this electrical junction-box …
Q: With regard to testing duct detectors in a hospital, I understand that on an annual basis the automatic shutdown of the AHU's must be verified when duct detectors are …
Q: I am a consultant and I visited an ASC that had a natural gas generator housed indoors, located in the basement of the facility. The ATS switch was located …
Q: We have a three-story parking structure attached to a hospital. The top floor of the parking structure is not covered and is open to the atmosphere. Is the exterior …
Continuing in a series of strange things that I have seen while consulting at hospitals... The maximum rise in a existing construction step is 8-inches. The step in the picture …
Q: Can you explain the fire alarm notification appliance location requirements as it pertains to the operating room? I seem to recall that there's no requirement to have them in …
Q: Can signage, other than that specifically required for inside a fire exit stairwell according to the LSC, be placed inside a fire exit stairwell? A: Technically… no. According to …
Q: I have a small 28 bed hospital with one OR suite. Within the OR suite are sterile rooms, a soiled room, and of course the Operating Room, etc. We …
Continuing in a series of strange things that I have seen while consulting at hospitals... When I consult at a hospital or an ambulatory surgical center, I always gown-up and …
Q: When dividing hazardous areas (particularly storage rooms exceeding 100 square feet), if there are several rooms in one area, is the one-hour fire rating allowed to surround the perimeter …
Q: We had our Joint Commission inspection today and they cited us for water coolers and ice machines not being plugged into GFCI (ground-fault circuit interrupter) receptacles. One of our …
Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names …
Q: My facility is upgrading from a hard-wired to a wireless nurse call system. Our safety and supply manager is concerned that call systems have to have a form of …
Continuing in a series of strange things that I have seen while consulting at hospitals... The door in the picture is to a courtyard where patients may go and enjoy …
Q: What are the ventilation, air exchange and air pressure standards for an area in a very old basement that is being used to sanitize equipment in a hospital facility? …
Q: In regards to medical gas system testing, our local AHJ uses NFPA 99-2015 edition. My corporate office has stated that there are no PM’s that have to be done …
Q: In a business occupancy building, can alcohol based hand-rub dispensers be placed over carpeted area with no sprinklers? A: Maybe yes and maybe no… It all depends on which …
Well, no, it's not my birthday, but 10-years ago today I published my first post on this website. In 10 short years, I have made over 1,150 postings, and answered …
Q: NFPA 13, 2010 edition, sections 6.2.9.7 & 6.2.9.7.1: Do I read this to mean every sprinkler in every room and hallway in a hospital should be on an itemized …
Continuing in a series of strange things that I have seen while consulting at hospitals... The good news is you have an alcove in the corridor where you can store …
Q: With the new 2012 Life Safety Code adoption, my question is around the stairwell signage and 7.2.2.5.4.1. Hospitals are confused whether they have to replace all their signs to …
Q: There seems to be some confusion on the use of multiplug outlet adaptors such as changing the receptacle from 2 outlet to 6 in our hospital. I have been …
Q: Are there any life safety rules regarding the use of extension cords in the operating room? A: According to NFPA 70-2011, Article 400.8 (1), extension cords are permitted as …
Q: Can you reference the standard, code or any information from Joint Commission, CMS or any other regulatory organization on the length of the emergency pull cord in a patient …
Continuing in a series of strange things that I have seen while consulting at hospitals... The discharge door for a stairwell opened out onto the 1st floor corridor, where egress …
Q: Is there a limit to the size an alcove can be in a smoke compartment right off of the corridor? I understand equipment can be stored in alcoves but …
As you may be aware, you are now permitted to have maintenance free batteries to start your generators. Previous to the adoption of the 2012 edition of the Life Safety …
Q: I have a surgery suite that had a hole punched into the wall by the door knob. Is there anything in LSC that states " if a hole is …
Q: We have an enclosed room in an exit enclosure that is being used as a classroom. I'm using NFPA 101, 2015 LSC, section 7.2.2.5.3 Usable Space. Is this a …
Continuing in a series of strange things that I have seen while consulting at hospitals... This picture was taken in an electrical room. Where the conduits extend upwards and penetrate the suspended …
Q: What are the code requirements for penetrations in plumbing chases? During the water fountain project we found openings in the floor in the back of the plumbing chases from …
Q: We have a building that is next to our hospital that is an imaging center, that is not a healthcare occupancy. Are we allowed to take patients from the …
Q: We have an engineer who is telling us that the 2012 Life Safety Code requires our corridor doors to be fire-rated. He is referencing Table 8.3.4.2 which says exit-access …
Continuing in a series of strange things that I have seen while consulting at hospitals... So... I'm above a ceiling in a pre-assessment testing area and I see in the …
Q: I have a building that is fully sprinklered and has full protection from the fire alarm system, with multiple floors. The age of the building is 40+ years and …
Q: What is your opinion on alcohol based disinfectant wipes and their inclusion in the aggregate amount of flammable liquids in a smoke compartment? We are considering a product that …
Q: We have a difference of opinion in our organization that I hope you can settle for us. I believe the sealed lead-acid batteries in our fire alarm system are …
Continuing in a series of strange things that I have seen while consulting at hospitals... Yes... we are looking at oxygen cylinder storage issues again... Yuck. The sad thing is, …
Q: In a multi-tenant office building, can restrooms in the common areas have controlled card access and mag locks tied into the fire system on the entry/exit doors? A: Well, …
Here is a group photo of those individuals who attended the Keyes Life Safety Boot Camp this past week in Jackson, TN. Everyone seemed to have enjoyed themselves and based on …
Q: Our hospital is not fully sprinklered and is not fully smoke detected, but we want to install an infant security locking system in our Mother/Baby unit. I discussed this …
Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and carts of clean linen are being stored on …
Continuing in a series of strange things that I have seen while consulting at hospitals... According to NFPA 72-2010, Annex A.17.7.4.1 smoke detectors should not be located in direct airflow, …
Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? …
Q: On our fire pump, we monitor the "Fire Pump Run" and "Fire Pump Loss of Power" on our supervisor points, but the fire pump control panel has a point …
Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read …
Continuing in a series of strange things that I have seen while consulting at hospitals... This room contained more than 300 cubic feet of compressed medical gases (but less than …
Q: My Facilities Director just attended a state association of healthcare facilities managers. He stated that the presenter said that for oxygen cylinder storage and segregation, if a cylinder is …
Q: How long is a grace period for the annual fire pump test to be past due? A: Well, technically, there is no grace period. Either you are compliant or …
Q: We have a 1400 square foot ambulatory surgical center (ASC). In the plans there are only 5 Fire Extinguishers throughout the facility. I looked at 2012 Life Safety Code …
Continuing in a series of strange things that I have seen while consulting at hospitals... If you look closely enough, you will notice a set of medical gas shutoff valves …
Q: Is there a code from NFPA or Joint Commission in regards to "cloth" curtains hanging in around/in front of oxygen cylinders. And if so would it make a difference …
Q: Since our last survey we were introduced to an epoxy based intumescent fire proofing product to repair damaged areas of vermiculite fireproofing on our structural steel that had bare …
Q: If an inpatient in a hospital (healthcare occupancy) is taken into a building that is not a healthcare occupancy for say CT or MRI, does this building have to …
Q: Our EP manager was discussing removing the code words like Code pink for a missing infant to missing child and the conversation about code red for fire came up …
Continuing in a series of strange things that I have seen while consulting at hospitals... This is an equipment room. It appears to be a water room of some sort …
Q: I am new in my position and I would like to know what the weekly generator inspection consists of? I also would like to know what the monthly generator …
TODAY IS THE LAST DAY TO REGISTER! Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! …
Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift? A: Yes. According to section 19714 …
Q: Can I provide a smoke detector in an existing hospital patient restroom? The smoke detector was recommended by the hospital safety committee to avoid smoking in these rooms. Our …
Continuing in a series of strange things that I have seen while consulting at hospitals... This is not corridor, but rather an exit enclosure to a stairwell. There was a construction …
Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not "hook" passing clothing, straps, purses during emergency evacuations? I swear …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: Are we allowed to remove the 1½-inch fire hose valves in our hospital? The local fire department would not even have a means of using them? A: Section 46122 …
Q: Are closet doors located inside a corridor considered corridor doors and do they have to meet life and safety codes referring to corridor doors? A: It depends…. What does …
Continuing in a series of strange things that I have seen while consulting at hospitals... Apparently, sidewall sprinkler heads can also be used to hang pictures.... NOT. [That was sarcasm] …
Q: I have an interesting one for you. We have an architect propose a construction type of Type V (111) for a 3-story building with the first-floor being Healthcare occupancy …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: I could not find in the 2012 Life Safety Code if there is a specific width requirement for a sidewalk as an exit discharge. A: You are describing the …
Q: We recently underwent a mock survey in preparation for a full survey soon. The Life Safety mock surveyor cited us for failure to cover low voltage junction boxes. We …
Continuing in a series of strange things that I have seen while consulting at hospitals... Holes in rated walls that are too large to be sealed with fire-rated materials, cannot …
Just a quick note to let you know there is a new form available to you for free, on the 'Tools' webpage called "Fire/Smoke Damper Test". Due to multiple requests …
Q: My understanding is we should be following the 2010 FGI Guidelines because that’s what is recognized by the 2012 LSC that was adopted by CMS. But I have read …
Continuing in a series of strange things that I have seen while consulting at hospitals... What we have here is conflicting signage. The 'Exit' sign is saying "Hey, in an …
Q: We have an email confirmation from the State Fire Marshal that approves of our removal of the occupant-use fire hoses in our hospital. What exactly do we have to …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: Do occupational therapy kitchens need to meet NFPA 96 standards? This unit will be a new build and will fall under business occupancy requirements, but the Life Safety Code …
Q: When comparing smoke dampers in smoke barriers vs smoke partitions, section 8.5.5.2 requires smoke dampers (with exemptions) for penetrations by ducts or air-transfer openings in a smoke barrier. Section …
Continuing in a series of strange things that I have seen while consulting at hospitals... Boy... I bet you've never had this problem at your facility, eh? [Sarcasm] This is …
Q: We are reviewing fire policy, and are wondering if it is a Life Safety Code requirement to have fire and smoke barrier doors labeled as such? By this I …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: For clinics that are in a facility classified as business occupancy, is an ICRA required? A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations …
Q: In regards to suite separations, section 18.2.5.7.1.2 of 2012 LSC requires walls separating suites to meet requirements for corridor walls, which have to be constructed to limit transfer of …
Continuing in a series of strange things that I have seen while consulting at hospitals... Ceilings that contain smoke detectors and/or sprinkler heads have to resist the passage of smoke …
Q: We have a hospital with a number of exit enclosures. These passageways have a large number of unrelated utilities running above the ceiling. Modification will not only be very …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: I just got done with a triennial accreditation survey at one of my facilities and the engineer surveyor requested LSC drawings for all buildings that support patients, not just …
Click on this link for a special Season’s Greetings video from Keyes Life Safety… https://keyeslifesafewpenginecom/wp-content/uploads/2018/10/Seasons_Greetingsmp4 …
Q: Do all of the screw heads in a psych ward need to be tamper proof? A: There is no specific code or standard that addresses screw heads in a …
Continuing in a series of strange things that I have seen while consulting at hospitals... Doors to medical gas storage rooms are required to be fire-rated. Fire-rated doors cannot have …
Q: We have metal "bumpers" (for lack of a better term) that were fabricated onsite at our hospital, that are used to keep carts and beds for damaging the doors …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: I have two questions regarding spark-ignited emergency power generators: What maintenance tests are required for natural or propane Generators? Are load bank test required for Natural gas or Propane …
Q: I work in the Central Processing department and yesterday they upped the temperature to 72 - 73 degrees in decontam and the clean side. I always thought it had …
Continuing in a series of strange things that I have seen while consulting at hospitals... These portable X-ray units were double-parked in the adjunct corridor to the radiology control room …
Q: I’m butting heads with our Infection Control group regarding holes in construction barriers. They have started requiring the contractors to make the construction sites negative air-pressure, which is fine, …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: Is there a codified requirement for doors in a cabinet mounted in a hospital egress corridor? We have worked on projects when a nurse server; i.e., pass through cabinet, …
Q: We are a fully sprinkled hospital. Is it permissible to hang Christmas garland from the ceiling, as long as we stay away from sprinkler heads and abide by the …
Q: Are sprinklers required in patient room lockers for existing facilities? A: No… Section 8.1.1 (7) of NFPA 13-2010 says furniture not intended for occupancy is not required to be …
Continuing in a series of strange things that I have seen while consulting at hospitals... Remember I have been saying that clearance must be maintained in front of electrical panels …
Q: If a smoke detecting device is disabled for a breathing treatment (often for several days), what sort of fire watch, notification or signage is necessary? A: None. Fire watches …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: It appears that the LSC allows up to 50 square feet of unprotected storage but also includes language that suggests it may need to be protected in accordance with …
On October 23, 2018, I posted a picture of this illuminated pumpkin and wrote that the extension cord could not be used since Article 400.8 (3) of NFPA 70-2011 says …
Q: Under CMS, is it possible to use a UL listed power cord (extension cord), permanently attached to the equipment assembly providing it meets the ampacity requirements? If yes, what …
Continuing in a series of strange things that I have seen while consulting at hospitals... Do you ever think about your corridor wall sconce light fixtures projecting more than 4-inches into …
Q: We recently had our fire sprinkler inspection and was informed by the vendor that with the new 2012 LSC updates, every fire hose connection valve weather it is 1½ …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: I had an independent Life Safety inspection and during the inspection the inspector cited me for my 2-hour fire door frames not having a fire rating visible. I explained …
Q: You once said this regarding bulletin board decorations: If the bulletin board is decorated then yes; it is counted as decorations. But if the bulletin board is simply communication …
Continuing in a series of strange things that I have seen while consulting at hospitals... We already talked about this issue on 'Strange Observations - Part 20' posted April 5, …
Q: I have a question regarding recycling containers referenced in section 19.7.5.7.2 of the 2012 LSC. It outlines the requirements for clean recycling and patient records awaiting destruction. Do the …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive …
Q: I have a concern regarding the use of fire pins in fire rated door leaves: Since the latching feature of these devices is not testable (that I'm aware of, …
This is a special posting to let you know there are 6 new forms on the 'Tools' webpage for you to download for free: Advantages if the Building is Sprinklered …
Q: We are looking for guidance now that the language of "If a fire watch is required, fire/smoke detection or alarm system outage" has become a point of conversation with …
Continuing in a series of strange things that I have seen while consulting at hospitals... Sorry for another out-of-focus picture. I was still having difficulty adjusting to my new smart …
Q: We have a behavioral health unit and our administration would like to install lockers for visitors. However, there is only one location for these lockers and that is in …
Here's a strange observation (on a Tuesday?) that I saw recently at a nurse station... An electric pumpkin powered by an extension cord. Even though the electric pumpkin was UL …
Q: We used our recently updated Life Safety drawings to have our fire doors inspected. The inspector cited us for aluminum astragals on 13 doors. His report stated that they …
Q: A question was brought up today about whether or not what we are doing for fire drills meets code. Currently, as a high-rise hospital (12 floors), we are conducting …
Continuing in a series of strange things that I have seen while consulting at hospitals... I apologize for the photo being out of focus. I only had my new smart …
Q: I have a CEO that wants furnishings (seating) in the corridor. I informed her that would be acceptable if we maintained five feet and the furnishings are bolted to …
Q: I enjoyed your recent post regarding Christmas decorations. However, can you please simplify for me the rules on Christmas decorations in hospitals? The percentages are a little confusing, I …
Q: Within our X-ray department we have a room (7 1/2 ft. by10 ft.) that was our dark room for film reading years ago. We would like to make this …
Q: What are your thoughts on using CO2 extinguishers in an HVAC mechanical room, instead of an ABC type? A: It likely would be a situation where you would be …
Continuing in a series of strange things that I have seen while consulting at hospitals... Clearance to all electrical equipment (i.e. panels and disconnect switches) must be maintained for 36 …
Q: During our inspection our surveyor was looking for 3/8" holes, 3 feet upstream, before the smoke detectors in the ductwork. He requested testing procedures for the duct detectors from …
Q: I notified our administration that Christmas decorations are basically forbidden in a healthcare occupancy. We do have a few floors that are business occupancy and they were wondering what …
Q: I have a healthcare occupancy under existing construction. The building was built back in the 50's and 60's, with a major renovation in 1992. The available plans have indicated …
Q: NFPA 101-2012, section 7.9.3 requires 1½-hour testing of battery powered emergency lights annually. The Joint Commissions wording of EC.02.05.07 EP-2 states to do that OR the hospital replaces all …
Continuing in a series of strange things that I have seen while consulting at hospitals... The step up (or down) is more than 8-inches permitted for a riser. Steps will …
Q: If I replace a smoke barrier door with a fire door, does the wall now have to be brought up to fire-rated wall code or will it still be …
Q: Can clean paper towels/toilet paper be stored in a Housekeeping closet with an EVS cart and service sink? A: It depends on the interpretation of an EVS janitor’s sink …
Q: I'm getting conflicting answers as to when generator batteries need to be replaced. Some say in a hospital they need to be replaced every 5 years unless the hospital …
Continuing in a series of strange things that I have seen while consulting at hospitals... In a Type I or Type II construction type structure (which most hospitals are) you …
Q: In the 2012 edition of the Life Safety Code, section 19.3.2.6 (9) states dispensers of alcohol based hand rub (ABHR) solution are permitted to be installed directly over carpeted …
Q: We are a hospital and if there was a fire, say at the northeast part of the building does everyone throughout the whole building have to evacuate the building …
Q: What is the standard on fire extinguishers in work vehicles? We have them in our transit vans to our home health nurses. Do we need them inspected and retagged …
Continuing in a series of strange things that I have seen while consulting at hospitals... I believe those electrical panels installed in this stairwell were for new access-control lock badge …
Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or …
Q: Years ago, our state health department approved an addition to a hospital that I supervise. The addition is wood framed, not sprinkler protected, and does not have the required …
Q: Do you know anything about fire drills on weekends? What is the requirement? A: Section 19.7.1.6 of the 2012 LSC says fire drills must be conducted quarterly on each …
Continuing in a series of strange things that I have seen while consulting at hospitals... Where do you see public pay-phones in a hospital, anymore....? In the behavioral health unit, …
Q: Do fire door inspection records need to be maintained for 3 years? A: I would say at least 3-years, and longer as needed. NFPA 80-2010 section 5.2.1 says fire …
Q: I have a contractor coming in to put up a wall in our nursing home dining room. He is wanting to use fire treated wood. Would this be acceptable …
Q: What are the requirements (if any) on co-mingling staff in a break room from an ASC located within mixed use facility? I have construction coming up that will kick …
Continuing in a series of strange things that I have seen while consulting at hospitals... This northern hospital was going for a woodsy theme in their Pediatric department. I wasn't …
Q: I have a question regarding access-control locks. I’m told that a PUSH TO EXIT button is required. My question: Is a PULL TO EXIT lever equivalent? A: No… I …
Q: Our original hospital was constructed in 1968, then we had an addition in 1992 and our newest addition completed in 2013. Do the hazardous rooms in our buildings that …
Q: Are alcohol-based hand rub (ABHR) dispensers allowed in Operating Rooms or Operating Room suites. We could not find a prohibition of them in LSC -- just double checking. A: …
Continuing in a series of strange things that I have seen while consulting at hospitals... No... this picture is not an optical illusion. That step between the floor and the …
Q: Our hospital has a few offsite locations – family practice clinic, occupational health clinic, and soon to be an urgent care clinic. It is my understanding that these facilities …
Q: Do missing ceiling tiles in a suspended ceiling create a Life Safety Code deficiency in an existing business occupancy? Should section 4.6.12.2 of the 2012 Life Safety Code apply …
Q: One of our doctors wants me to mount a large sharps container just inside the wall. It won't hinder the door, but I'm wondering if there are any safety …
Continuing in a series of strange things that I have seen while consulting at hospitals... This is not only strange... but this is morbid. Right across the street from the …
Q: Can oxygen tanks be stored under a stretcher or on a wheelchair when no patient is present.? Would this be considered in use? A: Yes… As long as the …
Hello everyone.... By now you've probably noticed a new home-page to my website. We made upgrades and improvements that should make it easier for you to find a specific topic …
Q: How often are we required to log the room temperature, humidity levels, and air changes in our OR's? Is this required daily, each shift, hourly? What about the other …
Q: My client installed a generator in a Phase 1 project that does not and will not for some time be able to meet the requirements for the 30% load during …
Continuing in a series of strange things that I have seen while consulting at hospitals... Okay... this was not taken at a hospital. This AC condensing unit was suspended from 2x4s …
Q: In the 1999 Edition of NFPA 99, it mentions for medical gas storage systems more than 3,000 cubic feet, if the door opens to an exit access corridor, louvered …
Q: Can full oxygen cylinders be stored in a hospital soiled utility room? A: Yes… however, anything stored in a soiled utility room is considered soiled. That would require staff …
Q: Is there a code that states every mechanical room needs an ‘Exit’ sign? I am being pressed to do so and I understand if the exit is obvious you …
Continuing in a series of strange things that I have seen while consulting at hospitals... This hospital wanted to 'fence off' access to the MRI when it was not staffed …
Q: Is there a regulation that requires lighting in the oxygen tank farm at a healthcare facility? A: From a means of egress point of view, perhaps not. It would …
Q: Several residents in our LTC home have had a screw installed in the track for the privacy curtain, so that they do not slide. My concern is that this …
Q: Does CMS or Joint Commission require Administration and Board information to be kept archived? For how long? A: I am not aware of any CMS or Joint Commission regulation …
Continuing in a series of strange things that I have seen while consulting at hospitals... See anything unsafe about this electrical panel...? Here is another example that equipment rooms are …
Q: Can you verify what a window frame rating should be in a 1-hr load bearing wall? Does the frame need to maintain the 1-hr rating of the wall or …
Q: What is the guidance on clean utility rooms and door closers? Under 50 square feet no closer is required, but over 50 square feet a closer is required? Does …
Q: I work in a healthcare facility and we are in need to find an answer to a question regarding strobe lights. When we test our fire alarm system, and …
Continuing in a series of strange things that I have seen while consulting at hospitals... Oh gross.... How would you like to have to use an eyewash station and this …
Q: We are expecting Joint Commission at our hospital soon. Since they will no longer look at the PFI lists, is it advisable to keep our current open PFIs open …
Q: Has the frequency for the main drain testing changed from annually to quarterly? A: Yes… but not for all the main drain test locations. The new 2012 LSC now …
Q: We have an alcove in our surgery center that we are wanting to place patient refrigerator, ice machine, coffee pot. Currently there isn't a door- it is an alcove …
Continuing in a series of strange things that I have seen while consulting at hospitals... This is pretty easy to spot... A sprinkler hanger used to support copper medical gas …
Q: Are portable fire extinguishers required in business occupancies? A: Yes… Section 38.3.5 of the 2012 Life Safety Code says portable fire extinguishers must be provided in every business occupancy …
Q: A main circulation corridor in a Hospital (Institutional Use I-2, 8' wide) passes thru the 2-Hr Use Group separation of adjacent medical offices (Business Use B) and re-enters the …
Q: When do I complete an FSES equivalency request, before the survey or after the survey? Where do I find the forms need to complete an FSES equivalency? What is …
Continuing in a series of strange things that I have seen while consulting at hospitals... Section 7.1.6.2 of the 2012 LSC says there shall be no abrupt changes in elevation …
Q: My accreditation organization has a standard that says "testing and inspection of fire door assemblies needs to be conducted by a qualified person." By what specifically do they mean …
Q: What are the time frames for repairing life safety deficiencies found during routine inspections? How much time would be allowed to repair emergency exit signs, or failed smoke detectors? …
Q: What is the minimum acceptable clearance required in an Emergency Department corridor? Currently there is a crash cart stored for rapid accessibility and the distance directly in front of …
Continuing in a series of strange things that I have seen while consulting at hospitals... Equipment rooms can be a major source of findings for surveyors. Mostly because equipment rooms …
Q: Do ‘Exit’ signs with battery backup require the same testing as emergency lighting in the path of egress as indicted in section 7.10.9.1 of the 2012 Life Safety Code? …
Q: I was wondering if there was a specific regulation that states exactly where fire extinguisher signs need to be located. Is there a difference between patient area and staff …
Continuing in a series of strange things that I have seen while consulting at hospitals... I get it... I understand that many people like to decorate their work area to …
Q: I am a consultant hired by a health system to review a potential building they want to purchase. The architect on this project tells me that the building is …
Q: We have a behavioral health unit and want to know if pull-cords are required on the nurse-call system in the patient bathroom? Is there an alternative to cords so …
Q: We currently have ABHR installed on the outside of our patient bays and would like to install an additional dispenser in the patient bay itself (at the point of …
Continuing in a series of strange things that I have seen while consulting at hospitals... This one is confusing... You have a standard backflow preventer in the water supply line …
Q: Where do I find in the code that tells me where required temperature and humidity must be monitored? We have our accreditation organization here, and they mentioned our Sterile …
Q: Is there a code in the 2012 LSC about testing electrical receptacles around hospital beds? A: Well… actually, that would be in the NFPA 99-2012 code/standard, and the answer …
Q: What required inspections are needed for non-patient care electrical equipment and at what intervals should they be completed in. I cannot find anything definitive in NFPA 99 - 2012 …
Continuing in a series of strange things that I have seen while consulting at hospitals... This picture is a cousin to last week's picture.... you have a ball valve in …
Q: We have a hospital that was built in 2008. We believe there is an elevator construction issue. When they built the elevator shafts they put smoke detectors inside at …
Q: A while ago, you made a posting that said a deadbolt lock on a door in the means of egress (such as an aluminum-framed glass sliding door at the …
Q: Can a stairwell door that leads to the outside of a hospital be locked with a lock that requires a code to unlock it? I seem to recall that …
Q: As a hospital security assessor, I am concerned about the availability of hospital gases in Behavioral Health Units. It would be easy for a patient to pull the tab …
Continuing in a series of strange things that I have seen while consulting at hospitals... Ugh. How did this ever get installed? All sprinkler control valves are required to have …
Q: I have always tested my fire pumps on a weekly basis, but now I’ve heard from a consultant there is a new standard that says only a monthly run …
Q: Back in June of 2017, you posted an article about “Inpatients in Outpatient Locations”, but I am unable to access that posting. Can you re-post that article as I …
Q: Are you aware of any accrediting organization requiring the hospital to have an addressable fire alarm system installed? If so, what organizations? Please explain the rationale and any supporting …
Q: According to Joint Commission standard EC.02.05.09 EP4 it is requiring this sign: “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow …
Continuing in a series of strange things that I have seen while consulting at hospitals... Dead-bolt locks... Up until the 2012 edition of the Life Safety Code, dead-bolt locks were …
Q: Does our hospital have to test the generator for 30 minutes every week, and then 1-hour once a month? We have programmed our generators to operate every Wednesday at …
Q: I can't seem to find anything in NFPA 72-2010 that says a facility is required to transmit a fire alarm signal to an off-site supervisory station. Our health care …
Q: I have an oxygen/med gas storage room that is attached to the hospital, and can only gain access to the room by way of the exterior of building. Does …
Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a …
Continuing in a series of strange things that I have seen while consulting at hospitals... Older mechanical equipment rooms are going to be a problem for many hospitals. Ultimately, you …
Q: What are the requirements for receptacle testing for hospital grade receptacles for existing and new health care facility? A: Section 6.3.4.1.3 of NFPA 99-2012 addresses this issue by saying …
Q: All of our receptacles in patient care rooms are hospital grade and therefore do not have to be tested annually, correct? What I don't understand is section 6.3.4.1.2 of …
Q: I work in a long-term care facility. It used to be that fire dampers had to be tested/inspected every four years, but I’ve heard that has changed with the …
The answer to this question was provided by my good friend Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL Q: With the impending discontinuation …
Continuing in a series of strange things that I have seen while consulting at hospitals... Ah.. Portable electric heaters. A problem for nearly every hospital. Staff gets cold and Facilities …
Q: What are the guidelines on the diesel fuel test for the generator as far as having it treated or a sample sent off for testing? A: The new 2012 …
The following is a response I received from a reader after my posting on April 3, 2018 titled Lawmakers Want More Oversight on AOs. This reader put into words the …
Q: I work in a hospital. When we conduct our routine scheduled fire drills are we required to actually activate the fire alarm pull station, horns or strobes? Are we …
Q: Are ladders allowed to be stored in electrical closets as long as the egress path is maintained and the 3ft clearance is applied? We had an inspector site 1910303(g)(1)(ii) …
Continuing in a series of strange things that I have seen while consulting at hospitals... I guess I like my smoke detectors mounted tight to the ceiling …
Q: Our facility has a soiled utility room near the main laundry that also holds bagged, sealed, boxed, then sealed again bio-hazardous wasted awaiting removal by the contractor. Is this …
Just to keep you informed, I have updated one of the more popular forms on my website, and I have added two new forms. The updated form is the Life …
Q: You have stated in previous Q&As that all fire-rated door assemblies must be tested and inspected. I don’t think that is true on fire-rated door assemblies that are not …
Q: We are renovating a smoke compartment in an existing health care building. There is no change of use or occupancy, should we apply the existing requirements for hazardous rooms? …
Continuing in a series of strange things that I have seen while consulting at hospitals... This picture was taken in a staff lounge on a general med-surge unit. I thought it …
Q: Are pull cords required on nurse call stations in outpatient facilities (physical therapy, outpatient surgery centers, etc? A: Based on the FGI Guidelines, nurse call stations in hospital bathrooms, …
Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed... Did you want to attend this educational event but missed your chance …
Q: We have a battle going on at our hospital regarding whether cardboard boxes can remain in a Pharmacy clean storage room. Some staff is saying the boxes must go …
Q: Could you please tell me or point me to the requirements for nurse call systems in a hospital? I am particularly interested in the application requirements for nurse call …
Continuing in a series of strange things I have seen while consulting at hospitals... This may be a little difficult to see, but we have a picture of a domestic water …
Q: Is it a common practice to keep pharmacy access controlled doors so they will not unlock on a fire alarm activation? Texas Pharmacy board requirements to secure medications is …
Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed... Did you want to attend this educational event but missed your chance …
Q: Can an existing 8-foot wide corridor be reduced in width to 4 feet by temporary construction barriers? A: Yes, but you will need to conduct an assessment for Alternative …
Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document? A: There is no set form to use …
Continuing in a series of strange things I have seen while consulting at hospitals... I used to work in the construction trades. I like to think that workers in the …
Q: We have a chapel/activity room that is used for bingo and worship services. Can you please tell me what the minimum illumination of the walking surface in foot-candles is …
Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed... Did you want to attend this educational event but missed your chance …
Q: I am a consultant and I have a client who has a new high rise hospital that is not fully sprinklered. The plans for this hospital were approved and …
Q: Generally, is it permitted to use a refrigerator in offices in healthcare facilities when considering fire safety? I ask because more and more offices are starting to request refrigerators …
Continuing in a series of strange things I have seen while consulting at hospitals... This looks like an adjunct corridor, one that is not used by patients. It doesn't have …
Q: I have read, or thought I read, that the environmental tours were no longer required with the adoption of the life safety code. Is this correct? A: No… The …
Registration for the Keyes Life Safety Boot Camp in Atlanta on April 24 & 25, 2018 has closed... Did you want to attend this educational event but missed your chance …
Q: When I came into this new position the medical equipment program was run by a third party managing our own Bio-med technicians. We changed the 3rd party contractor and …
Q: Does the Life Safety code require a sprinkler under a 4' canopy? I find this hard to believe so I would like to know if you have a reference …
Continuing in a series of strange things I have seen while consulting at hospitals... Did you know that you cannot make home-made devices and connect them to the fire alarm …
Q: My question has to do with the pressure gauges for our fire sprinkler system. We just had some out of date pressure gauges replaced by a new sprinkler contractor …
In a letter to CMS Administrator Seema Verma, the committee on Energy and Commerce is asking for what could be reams of information from the agency about patient harm and …
Q: With the adoption of the new 2012 Life Safety Code by CMS, we had a discussion about projections from the corridor wall. Since the LSC only allows projections to …
Continuing in a series of strange things that I have seen when consulting at hospitals... Ceilings that have smoke or heat detectors mounted on them, and ceilings that have sprinkler …
Q: I have a question regarding fire alarm manual pull stations. In our multi-level long term health care facility, we added a new building onto the existing building. At the …
Q: Are sleep labs considered healthcare occupancies or business occupancies? I have a fire marshal who says it has to be a healthcare occupancy. A: These types of things are …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination …
Q: I am a consultant and I have a 30% sprinklered high rise hospital with locked psychiatric units. The state authority made them unlock the stairwell doors under the 2000 LSC …
Q: At our hospital, we had numerous fire dampers that failed their 6-year test. What ILSM measures for that many dampers would you recommend putting in place? A: You are …
Continuing in a series of strange things that I have seen when consulting at hospitals... It's thoughtful that they put a protective bar infront of the fire alarm pull station, …
Q: In a newly designated ICU suite, do the doors to the patient rooms have to be positive latching? A: No… The doors to patient rooms that are located inside …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination …
Q: Are operating rooms required to have two (2) exit doors? I have not seen this room but am under the assumption it is between 400 and 500 square feet …
Q: Is it a requirement that all units have a soiled utility room? A: It is not a Life Safety Code requirement or a NFPA requirement that all units must …
Continuing in a series of strange things that I have seen when consulting at hospitals... So, here we have another exit door that is equipped with a manual latch-bolt. I …
Q: We have converted our old hospital building into a combination of outpatient facilities and office (business) uses. There are three exits that have no fire listings on the door …
Q: My question is about removing ceiling tiles in a construction area, and not having adequate fire protection in a 6' to 8' high ceiling plenum. The suggestion had been …
Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination …
Q: I am a healthcare consultant working mostly with home health and hospice clients. I have recently picked up two facilities that are smaller hospitals and am utterly clueless when …
Continuing in a series of strange things that I have seen when consulting at hospitals... Another storage room with a bunch of empty boxes obstructing access to the electrical panel …