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Keyes Life Safety

Our Life Safety educational resource hub is full of healthcare knowledge to help you be better informed of the changing world around you. 

Rather than sit back and act on decisions made by others, we are leading the charge as it relates to identifying best practices for Life Safety Code® and compliance. We have real people that give our clients real information that can be put into practice.

Interested in reading our experts' take on Life Safety? Then subscribe to our free blog below! We discuss readers' questions, share interesting observations from the field, and more.

Brad Keyes, CHSP

Life Safety Advisor

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance gives Brad further insight into the industry’s trends and best practices.

More from Brad Keyes, CHSP

StairwellsDoorsStairs

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 …

Brad Keyes, CHSP | Sep 18, 2020
Hazardous AreasKitchen

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 …

Brad Keyes, CHSP | Sep 16, 2020
Smoke Detectors

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 …

Brad Keyes, CHSP | Sep 14, 2020
Testing (Facilities Management)Fire/Smoke Dampers

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 …

Brad Keyes, CHSP | Sep 11, 2020
Fire Extinguishers

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 …

Brad Keyes, CHSP | Sep 9, 2020
Medical GasStorage (Medical Gas)Gas Cylinders

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 …

Brad Keyes, CHSP | Sep 4, 2020
Medical GasGas Cylinders

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 …

Brad Keyes, CHSP | Sep 2, 2020
Ambulatory Care OccupancyHazardous Areas

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 …

Brad Keyes, CHSP | Aug 31, 2020
Door LocksSoiled Utility Room

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 …

Brad Keyes, CHSP | Aug 28, 2020
Ambulatory Care OccupancyFire/Smoke DampersFire & Smoke Dampers

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 …

Brad Keyes, CHSP | Aug 24, 2020
Door Locks

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 …

Brad Keyes, CHSP | Aug 21, 2020
GeneratorsEyewash Stations

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 …

Brad Keyes, CHSP | Aug 19, 2020
Flammable Liquids

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 …

Brad Keyes, CHSP | Aug 17, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Aug 14, 2020
Alcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Aug 12, 2020
Flammable Liquids

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 …

Brad Keyes, CHSP | Aug 10, 2020
Doors

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 …

Brad Keyes, CHSP | Aug 7, 2020
Door Locks

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 …

Brad Keyes, CHSP | Aug 5, 2020
Flammable Liquids

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 …

Brad Keyes, CHSP | Aug 3, 2020
Equipment (Fire Suppression Systems)Fire Suppression Systems

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 …

Brad Keyes, CHSP | Jul 29, 2020
Flammable Liquids

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 …

Brad Keyes, CHSP | Jul 27, 2020
Doors

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 …

Brad Keyes, CHSP | Jul 24, 2020
Fire Doors

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 …

Brad Keyes, CHSP | Jul 22, 2020
Inspection & Maintenance (Facilities ManagemenElectrical ReceptacleTesting (Facilities Management)

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 …

Brad Keyes, CHSP | Jul 20, 2020
Alcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Jul 17, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Jul 15, 2020
Cooking AppliancesAppliances

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 …

Brad Keyes, CHSP | Jul 13, 2020
Construction BarrierExit SignsSurvey FindingsFire WatchConstructionSmoke DetectorsILSMSprinklersEgress

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 …

Brad Keyes, CHSP | Jul 10, 2020
Emergency Lights (Life Safety Code)Batteries (Facilities Management)Batteries (Life Safety Code)Emergency Lights (Facilities Management)

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 …

Brad Keyes, CHSP | Jul 8, 2020
Electrical RoomsSprinklers

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 …

Brad Keyes, CHSP | Jul 6, 2020
Fire Watch

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 …

Brad Keyes, CHSP | Jul 3, 2020
Fire AlarmInspection & Maintenance (Fire Detection SysteTesting (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Jul 1, 2020
Fire AlarmFire Alarm Notification Devices

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 …

Brad Keyes, CHSP | Jun 29, 2020
Storage (Medical Gas)Oxygen Cylinders

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 …

Brad Keyes, CHSP | Jun 26, 2020
Fire Doors

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 …

Brad Keyes, CHSP | Jun 24, 2020
Corridors

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 …

Brad Keyes, CHSP | Jun 22, 2020
Interior Finish

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 …

Brad Keyes, CHSP | Jun 19, 2020
HVACEquipment (Life Safety Code)

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 …

Brad Keyes, CHSP | Jun 17, 2020
Storage (Life Safety Code)Stairwells

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 …

Brad Keyes, CHSP | Jun 15, 2020
Testing (Fire Detection Systems)Technician (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Jun 12, 2020
Signs (Fire Suppression Systems)Signage (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Jun 10, 2020
Hazardous Areas

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 …

Brad Keyes, CHSP | Jun 8, 2020
Medical GasSigns (Medical Gas)

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, …

Brad Keyes, CHSP | Jun 5, 2020
Doors

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 …

Brad Keyes, CHSP | Jun 3, 2020
Business OccupanciesFire Drills

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 …

Brad Keyes, CHSP | Jun 1, 2020
Alcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | May 29, 2020
Fire Extinguishers

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 …

Brad Keyes, CHSP | May 27, 2020
Operating RoomEgress

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 …

Brad Keyes, CHSP | May 22, 2020
Spare Sprinkler List

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 …

Brad Keyes, CHSP | May 20, 2020
Handrails

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 …

Brad Keyes, CHSP | May 18, 2020
Power StripsCMS

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 …

Brad Keyes, CHSP | May 15, 2020
Fire DoorsFire BarrierDoors

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 …

Brad Keyes, CHSP | May 13, 2020
WaiversAccreditation/CertificationAccreditationCOVID-19CMS

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 …

Brad Keyes, CHSP | May 12, 2020
Fire Doors

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 …

Brad Keyes, CHSP | May 11, 2020
Fire Suppression Systems

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 …

Brad Keyes, CHSP | May 8, 2020
WaiversAccreditation/CertificationAccreditationCOVID-19CMS

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 …

Brad Keyes, CHSP | May 7, 2020
Nursing HomeSignage (Life Safety Code)Signs (Life Safety Code)

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 …

Brad Keyes, CHSP | May 6, 2020
Inspection & Maintenance (Life Safety Code)Fire Doors

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 …

Brad Keyes, CHSP | May 4, 2020
Medical GasStorage (Medical Gas)Gas Cylinders

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 …

Brad Keyes, CHSP | May 1, 2020
Fire Doors

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 …

Brad Keyes, CHSP | Apr 29, 2020
DecorationsEgress

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? …

Brad Keyes, CHSP | Apr 27, 2020
Interior Finish

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 …

Brad Keyes, CHSP | Apr 24, 2020
CorridorsDoors

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, …

Brad Keyes, CHSP | Apr 22, 2020
Construction

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 …

Brad Keyes, CHSP | Apr 20, 2020
Fire Extinguishers

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 …

Brad Keyes, CHSP | Apr 17, 2020
Inspection & Maintenance (Life Safety Code)Joint CommissionTesting (Generators)Testing (Facilities Management)Testing (Fire Suppression Systems)Testing (Life Safety Code)AccreditationTesting (Fire Detection Systems)CMSTesting (Medical Gas)Testing (Accreditation/Certification)Fire Drills

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 …

Brad Keyes, CHSP | Apr 15, 2020
Delayed EgressDoor LocksCMS

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 …

Brad Keyes, CHSP | Apr 13, 2020
Fire DoorsHazardous Areas

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 …

Brad Keyes, CHSP | Apr 10, 2020
Fire/Smoke DampersSmoke DampersFire & Smoke Dampers

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: …

Brad Keyes, CHSP | Apr 8, 2020
Emergency Response Plan (Accreditation/CertificatiWaiversAccreditation/CertificationAccreditationCOVID-19CMS

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 …

Brad Keyes, CHSP | Apr 7, 2020
Air HandlersBatteries (Facilities Management)

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 …

Brad Keyes, CHSP | Apr 6, 2020
Inspection & Maintenance (Fire Detection SysteFire Detection SystemsTesting (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Apr 3, 2020
Life Safety CodeCOVID-19Fire Drills

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 …

Brad Keyes, CHSP | Apr 2, 2020
Behavioral HealthDoor Locks

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 …

Brad Keyes, CHSP | Apr 1, 2020
Fire/Smoke DampersCMSFire & Smoke Dampers

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 …

Brad Keyes, CHSP | Mar 30, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Mar 25, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Mar 19, 2020
Fire ExtinguishersElevators

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 …

Brad Keyes, CHSP | Mar 16, 2020
GeneratorsBatteries (Generators)

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 …

Brad Keyes, CHSP | Mar 13, 2020
Accreditation/CertificationCMS

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 …

Brad Keyes, CHSP | Mar 12, 2020
CorridorsDoors

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 …

Brad Keyes, CHSP | Mar 11, 2020
Sprinklers

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 …

Brad Keyes, CHSP | Mar 9, 2020
Medical GasStorage (Medical Gas)Oxygen CylindersGas Cylinders

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 …

Brad Keyes, CHSP | Mar 6, 2020
Sprinklers

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 …

Brad Keyes, CHSP | Mar 4, 2020
Fire WatchILSM

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 …

Brad Keyes, CHSP | Mar 2, 2020
SuitesAmbulatory Care Occupancy

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: …

Brad Keyes, CHSP | Feb 28, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Feb 27, 2020
Smoke DetectorsTesting (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Feb 26, 2020
Emergency Lights (Electrical)Batteries (Facilities Management)Emergency Lights (Facilities Management)

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 …

Brad Keyes, CHSP | Feb 24, 2020
Ambulatory Care OccupancySmoke Detectors

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 …

Brad Keyes, CHSP | Feb 21, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Feb 20, 2020
Ambulatory Care OccupancyEmergency Lights (Electrical)

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 …

Brad Keyes, CHSP | Feb 19, 2020
HVACAir Handlers

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 …

Brad Keyes, CHSP | Feb 17, 2020
Ambulatory Care OccupancySoiled Utility Room

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 …

Brad Keyes, CHSP | Feb 13, 2020
Storage (Life Safety Code)Patient RoomsStorage Room

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 …

Brad Keyes, CHSP | Feb 12, 2020
Electrical RoomsSmoke Detectors

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 …

Brad Keyes, CHSP | Feb 10, 2020
Smoke Compartment

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 …

Brad Keyes, CHSP | Feb 7, 2020
NFPA 99Risk Assessment

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 …

Brad Keyes, CHSP | Feb 5, 2020
AppliancesTemperature

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 …

Brad Keyes, CHSP | Feb 3, 2020
Facilities ManagementHVACOperating Room

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 …

Brad Keyes, CHSP | Jan 31, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Jan 30, 2020
Mechanical Rooms

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 …

Brad Keyes, CHSP | Jan 29, 2020
Corridors

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 …

Brad Keyes, CHSP | Jan 27, 2020
Smoke Barrier

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 …

Brad Keyes, CHSP | Jan 24, 2020
Life Safety Code

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: …

Brad Keyes, CHSP | Jan 23, 2020
Hazardous AreasDoorsOperating Room

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 …

Brad Keyes, CHSP | Jan 22, 2020
SuitesCorridorsDoors

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 …

Brad Keyes, CHSP | Jan 20, 2020
Life Safety CodeAlcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Jan 17, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Jan 16, 2020
Chutes (Facilities Management)

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 …

Brad Keyes, CHSP | Jan 15, 2020
Smoke DetectorsPatient Rooms

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 …

Brad Keyes, CHSP | Jan 13, 2020
Doors

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 …

Brad Keyes, CHSP | Jan 10, 2020
Construction Types

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, …

Brad Keyes, CHSP | Jan 8, 2020
Storage (Facilities Management)Risk AssessmentAccreditation

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 …

Brad Keyes, CHSP | Jan 6, 2020
Corridors

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 …

Brad Keyes, CHSP | Jan 3, 2020
ElevatorsTesting (Facilities Management)

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 …

Brad Keyes, CHSP | Jan 1, 2020
Smoke DetectorsCeilings (Facilities Management)Sprinklers

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 …

Brad Keyes, CHSP | Dec 30, 2019
SecurityLife Safety CodeEmergency Response Plan (Facilities Management)

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 …

Brad Keyes, CHSP | Dec 24, 2019
Storage (Medical Gas)Gas Cylinders

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 …

Brad Keyes, CHSP | Dec 23, 2019
Manual Stop SwitchTesting (Generators)

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 …

Brad Keyes, CHSP | Dec 20, 2019
Decorations

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 …

Brad Keyes, CHSP | Dec 18, 2019
Sprinklers

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 …

Brad Keyes, CHSP | Dec 16, 2019
Ambulatory Care OccupancyLife Safety CodeFire Drills

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) …

Brad Keyes, CHSP | Dec 13, 2019
Life Safety Code

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 …

Brad Keyes, CHSP | Dec 12, 2019
Fire AlarmSmoke DetectorsOn Call Sleeping Rooms

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 …

Brad Keyes, CHSP | Dec 11, 2019
Hazardous AreasGift Shops

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 …

Brad Keyes, CHSP | Dec 9, 2019
Inspection & Maintenance (Fire Suppression SysFire Extinguishers

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 …

Brad Keyes, CHSP | Dec 6, 2019
Emergency DepartmentSecurity

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 …

Brad Keyes, CHSP | Dec 5, 2019
Automatic Transfer SwitchesTesting (Generators)Inspection & Maintenance (Generators)

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 …

Brad Keyes, CHSP | Dec 4, 2019
Sprinklers

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 …

Brad Keyes, CHSP | Dec 2, 2019
Emergency Lights (Life Safety Code)

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 …

Brad Keyes, CHSP | Nov 27, 2019
Door LocksStairwellsDoors

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 …

Brad Keyes, CHSP | Nov 25, 2019
SuitesEmergency DepartmentCMS

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 …

Brad Keyes, CHSP | Nov 22, 2019
SecuritySafetySafety Management

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 …

Brad Keyes, CHSP | Nov 21, 2019
CorridorsPatient RoomsDoorsCMS

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 …

Brad Keyes, CHSP | Nov 20, 2019
CorridorsDoors

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 …

Brad Keyes, CHSP | Nov 18, 2019
Fire AlarmFire WatchILSM

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 …

Brad Keyes, CHSP | Nov 15, 2019
Fire AlarmFire WatchConstructionSmoke Detectors

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 …

Brad Keyes, CHSP | Nov 13, 2019
Business OccupanciesAccreditationILSM

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 …

Brad Keyes, CHSP | Nov 11, 2019
Equipment (Generators)Documentation (Generators)

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 …

Brad Keyes, CHSP | Nov 8, 2019
Alcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Nov 6, 2019
Equipment (Fire Detection Systems)Fire Alarm

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 …

Brad Keyes, CHSP | Nov 4, 2019
DoorsPositive Latching

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 …

Brad Keyes, CHSP | Nov 1, 2019
Ceilings (Life Safety Code)Ceilings (Fire Suppression Systems)Ceilings (Facilities Management)

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 …

Brad Keyes, CHSP | Oct 30, 2019
Fire Drills

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 …

Brad Keyes, CHSP | Oct 28, 2019
Behavioral HealthDoor LocksFire Drills

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: …

Brad Keyes, CHSP | Oct 25, 2019
Cooking AppliancesRisk Assessment

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 …

Brad Keyes, CHSP | Oct 23, 2019
Flammable LiquidsSafetyFire Rated CabinetsSafety Management

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 …

Brad Keyes, CHSP | Oct 21, 2019
Egress

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 …

Brad Keyes, CHSP | Oct 16, 2019
Inspection & Maintenance (Electrical)Emergency Lights (Electrical)

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 …

Brad Keyes, CHSP | Oct 14, 2019
ILSMFire Drills

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 …

Brad Keyes, CHSP | Oct 11, 2019
UL (Underwriters Laboratories)Electrical ReceptacleETL (Intertek ETL)

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 …

Brad Keyes, CHSP | Oct 9, 2019
Electrical RoomsElectrical Equipment

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? …

Brad Keyes, CHSP | Oct 7, 2019
Electrical RoomsAccreditation

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 …

Brad Keyes, CHSP | Oct 4, 2019
Electrical EquipmentOxygen CylindersNursing Home

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 …

Brad Keyes, CHSP | Oct 2, 2019
Electrical EquipmentPower Strips

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 …

Brad Keyes, CHSP | Sep 30, 2019
Waiting AreaCMS

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 …

Brad Keyes, CHSP | Sep 27, 2019
Exit SignsExitsSignage (Life Safety Code)Signs (Life Safety Code)Egress

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 …

Brad Keyes, CHSP | Sep 25, 2019
Accreditation

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… …

Brad Keyes, CHSP | Sep 23, 2019
Testing (Facilities Management)HVAC

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 …

Brad Keyes, CHSP | Sep 20, 2019
Business OccupanciesTrash Receptacles

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 …

Brad Keyes, CHSP | Sep 18, 2019
Corridors

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 …

Brad Keyes, CHSP | Sep 16, 2019
On Call Sleeping Rooms

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 …

Brad Keyes, CHSP | Sep 9, 2019
Business OccupanciesAlcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Sep 6, 2019
Construction Barrier

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 …

Brad Keyes, CHSP | Sep 4, 2019
Smoke BarrierSmoke Compartment

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 …

Brad Keyes, CHSP | Aug 30, 2019
Door LocksDoors

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 …

Brad Keyes, CHSP | Aug 28, 2019
SuitesAmbulatory Care OccupancyAccreditation

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? …

Brad Keyes, CHSP | Aug 26, 2019
Patient Rooms

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 …

Brad Keyes, CHSP | Aug 23, 2019
New Construction vs. Existing ConstructionCMS

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 …

Brad Keyes, CHSP | Aug 21, 2019
Fire BarrierOccupancies

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 …

Brad Keyes, CHSP | Aug 19, 2019
Corridors

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 …

Brad Keyes, CHSP | Aug 16, 2019
Smoke BarrierFire DoorsAccreditationCMS

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 …

Brad Keyes, CHSP | Aug 14, 2019
Testing (Generators)Inspection & Maintenance (Generators)

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 …

Brad Keyes, CHSP | Aug 12, 2019
Joint CommissionLife Safety Drawings

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 …

Brad Keyes, CHSP | Aug 9, 2019
Inspection & Maintenance (Fire Suppression SysFire PumpTesting (Fire Suppression Systems)

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? …

Brad Keyes, CHSP | Aug 7, 2019
AppliancesElectrical Equipment

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 …

Brad Keyes, CHSP | Aug 5, 2019
Business OccupanciesElevatorsEquipment (Fire Suppression Systems)Equipment (Life Safety Code)Sprinklers

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 …

Brad Keyes, CHSP | Aug 2, 2019
Fire AlarmSmoke DetectorsSprinklers

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 …

Brad Keyes, CHSP | Jul 31, 2019
Parking GarageStorage (Facilities Management)Parking GarageConstruction Types

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 …

Brad Keyes, CHSP | Jul 29, 2019
Fire DoorsDoors

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 …

Brad Keyes, CHSP | Jul 26, 2019
NFPA 99Risk AssessmentAccreditationCMS

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 …

Brad Keyes, CHSP | Jul 24, 2019
Inspection & Maintenance (Fire Suppression SysFire Extinguishers

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: …

Brad Keyes, CHSP | Jul 22, 2019
Door Locks

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 …

Brad Keyes, CHSP | Jul 19, 2019
Fire AlarmSmoke DetectorsILSM

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 …

Brad Keyes, CHSP | Jul 17, 2019
Air HandlersClean Supply Room

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 …

Brad Keyes, CHSP | Jul 15, 2019
Joint CommissionFGI GuidelinesHand Washing Sink

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 …

Brad Keyes, CHSP | Jul 12, 2019
NFPA 99Risk AssessmentCMS

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 …

Brad Keyes, CHSP | Jul 10, 2019
Electrical Equipment

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 …

Brad Keyes, CHSP | Jul 8, 2019
Business OccupanciesFire AlarmSmoke Detectors

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 …

Brad Keyes, CHSP | Jul 3, 2019
Emergency PhonesStairwells

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 …

Brad Keyes, CHSP | Jul 1, 2019
DoorsPositive Latching

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 …

Brad Keyes, CHSP | Jun 28, 2019
Fire AlarmInspection & Maintenance (Fire Detection SysteSmoke DetectorsTesting (Fire Detection Systems)Technician (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Jun 26, 2019
Fire Extinguishers

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 …

Brad Keyes, CHSP | Jun 24, 2019
Business OccupanciesAlcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Jun 21, 2019
Inspection & Maintenance (Fire Suppression SysDocumentation (Fire Suppression Systems)Sprinklers

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 …

Brad Keyes, CHSP | Jun 19, 2019
Medical EquipmentAccreditationCMS

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 …

Brad Keyes, CHSP | Jun 17, 2019
AlcoholStorage (Facilities Management)

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 …

Brad Keyes, CHSP | Jun 14, 2019
Fire Extinguishers

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 …

Brad Keyes, CHSP | Jun 12, 2019
Inspection & Maintenance (Facilities ManagemenEyewash Stations

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: …

Brad Keyes, CHSP | Jun 10, 2019
Fire Watch

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 …

Brad Keyes, CHSP | Jun 7, 2019
VentilationHVAC

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 …

Brad Keyes, CHSP | Jun 5, 2019
Fire Extinguishers

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 …

Brad Keyes, CHSP | Jun 3, 2019
ElevatorsTesting (Facilities Management)

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 …

Brad Keyes, CHSP | May 31, 2019
Medical Gas Alarm Panels

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 …

Brad Keyes, CHSP | May 29, 2019
Business OccupanciesSoiled Utility RoomStorage Room

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 …

Brad Keyes, CHSP | May 24, 2019
Electrical Receptacle

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, …

Brad Keyes, CHSP | May 22, 2019
Door LocksAccreditation

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 …

Brad Keyes, CHSP | May 20, 2019
DoorsPositive Latching

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 …

Brad Keyes, CHSP | May 17, 2019
Equipment (Generators)

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 …

Brad Keyes, CHSP | May 15, 2019
Clearance (Fire Suppression Systems)Sprinklers

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 …

Brad Keyes, CHSP | May 13, 2019
Fire AlarmInspection & Maintenance (Fire Detection SysteTesting (Fire Detection Systems)

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 …

Brad Keyes, CHSP | May 10, 2019
Fire Doors

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 …

Brad Keyes, CHSP | May 8, 2019
Delayed EgressDoor Locks

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 …

Brad Keyes, CHSP | May 6, 2019
SafetySafety Management

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 …

Brad Keyes, CHSP | May 3, 2019
Emergency Response Plan (Facilities Management)CMS

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 …

Brad Keyes, CHSP | May 1, 2019
Inspection & Maintenance (Electrical)Door LocksAccreditationTesting (Fire Detection Systems)CMS

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 …

Brad Keyes, CHSP | Apr 29, 2019
Testing (Generators)Equipment (Generators)Inspection & Maintenance (Generators)

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 …

Brad Keyes, CHSP | Apr 26, 2019
ArticleHVACSprinklers

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 …

Brad Keyes, CHSP | Apr 25, 2019
VentilationHVAC

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 …

Brad Keyes, CHSP | Apr 24, 2019
Joint CommissionPortable Space Heaters

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 …

Brad Keyes, CHSP | Apr 22, 2019
ArticleHVACSprinklers

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 …

Brad Keyes, CHSP | Apr 18, 2019
Fire AlarmFire Alarm Notification DevicesOn Call Sleeping Rooms

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 …

Brad Keyes, CHSP | Apr 17, 2019
Fire ExtinguishersOperating Room

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 …

Brad Keyes, CHSP | Apr 15, 2019
Fire Extinguishers

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: …

Brad Keyes, CHSP | Apr 12, 2019
ArticleUtilities

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 …

Brad Keyes, CHSP | Apr 11, 2019
Fire AlarmDuct DetectosSmoke Dampers

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 …

Brad Keyes, CHSP | Apr 10, 2019
Automatic Transfer SwitchesEquipment (Generators)Storage (Generators)

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 …

Brad Keyes, CHSP | Apr 8, 2019
Storage (Life Safety Code)SeparationFire BarrierParking GarageOccupancies

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 …

Brad Keyes, CHSP | Apr 5, 2019
ArticleStairs

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 …

Brad Keyes, CHSP | Apr 4, 2019
Fire AlarmFire Alarm Notification DevicesOperating Room

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 …

Brad Keyes, CHSP | Apr 3, 2019
StairwellsSignage (Life Safety Code)Signs (Life Safety Code)Egress

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 …

Brad Keyes, CHSP | Apr 1, 2019
SuitesVentilationHVACOperating Room

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 …

Brad Keyes, CHSP | Mar 29, 2019
ArticleInfection Control

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 …

Brad Keyes, CHSP | Mar 28, 2019
Hazardous Areas

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 …

Brad Keyes, CHSP | Mar 27, 2019
Joint CommissionGFCI ReceptaclesElectrical ReceptacleAccreditation

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 …

Brad Keyes, CHSP | Mar 26, 2019
Healthcare OccupancyFire Drills

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 …

Brad Keyes, CHSP | Mar 25, 2019
Nurse Call Systems

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 …

Brad Keyes, CHSP | Mar 22, 2019
ArticleSignage (Life Safety Code)Signs (Life Safety Code)

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 …

Brad Keyes, CHSP | Mar 21, 2019
VentilationSterile Storage

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? …

Brad Keyes, CHSP | Mar 20, 2019
Testing (Medical Gas)

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 …

Brad Keyes, CHSP | Mar 19, 2019
Business OccupanciesAlcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Mar 18, 2019
Life Safety Code

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 …

Brad Keyes, CHSP | Mar 17, 2019
Documentation (Fire Suppression Systems)Spare Sprinkler ListSprinklers

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 …

Brad Keyes, CHSP | Mar 15, 2019
ArticleCorridorsSprinklers

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 …

Brad Keyes, CHSP | Mar 14, 2019
StairwellsStairsSignage (Life Safety Code)Signs (Life Safety Code)

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 …

Brad Keyes, CHSP | Mar 13, 2019
Electrical Receptacle

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 …

Brad Keyes, CHSP | Mar 12, 2019
Electrical EquipmentPower Strips

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 …

Brad Keyes, CHSP | Mar 11, 2019
Nurse Call Systems

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 …

Brad Keyes, CHSP | Mar 8, 2019
Signs (Facilities Management)ArticleCorridorsSignage (Life Safety Code)Signs (Life Safety Code)

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 …

Brad Keyes, CHSP | Mar 7, 2019
Corridors

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 …

Brad Keyes, CHSP | Mar 6, 2019
Testing (Generators)Batteries (Generators)

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 …

Brad Keyes, CHSP | Mar 5, 2019
ConstructionFire BarrierWalls

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 …

Brad Keyes, CHSP | Mar 4, 2019
Exit Enclosure

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 …

Brad Keyes, CHSP | Mar 1, 2019
Ceilings (Life Safety Code)ArticleSmoke DetectorsCeilings (Facilities Management)Sprinklers

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 …

Brad Keyes, CHSP | Feb 28, 2019
Fire CaulkFire Barrier

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 …

Brad Keyes, CHSP | Feb 27, 2019
Ambulatory Care Occupancy

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 …

Brad Keyes, CHSP | Feb 25, 2019
Fire DoorsCorridorsDoors

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 …

Brad Keyes, CHSP | Feb 22, 2019
ArticleConstruction Types

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 …

Brad Keyes, CHSP | Feb 21, 2019
Fire/Smoke Dampers

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 …

Brad Keyes, CHSP | Feb 20, 2019
Alcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Feb 18, 2019
Fire AlarmTesting (Fire Detection Systems)Batteries (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Feb 15, 2019
Storage (Medical Gas)ArticleGas Cylinders

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, …

Brad Keyes, CHSP | Feb 14, 2019
Door Locks

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, …

Brad Keyes, CHSP | Feb 13, 2019
Boot Camp

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 …

Brad Keyes, CHSP | Feb 12, 2019
SecurityDoor Locks

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 …

Brad Keyes, CHSP | Feb 11, 2019
Storage (Life Safety Code)Clean LinenCorridors

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 …

Brad Keyes, CHSP | Feb 8, 2019
ArticleSmoke Detectors

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, …

Brad Keyes, CHSP | Feb 7, 2019
Ambulatory Care OccupancyFire Drills

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? …

Brad Keyes, CHSP | Feb 6, 2019
Fire Pump

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 …

Brad Keyes, CHSP | Feb 4, 2019
Fire DoorsFire BarrierDoors

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 …

Brad Keyes, CHSP | Feb 1, 2019
Storage (Medical Gas)ArticleOxygen Cylinders

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 …

Brad Keyes, CHSP | Jan 31, 2019
Storage (Medical Gas)Gas Cylinders

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 …

Brad Keyes, CHSP | Jan 30, 2019
Fire PumpTesting (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Jan 28, 2019
Ambulatory Care OccupancyFire Extinguishers

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 …

Brad Keyes, CHSP | Jan 25, 2019
ArticleZone Valves

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 …

Brad Keyes, CHSP | Jan 24, 2019
Storage (Medical Gas)Gas Cylinders

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 …

Brad Keyes, CHSP | Jan 23, 2019
ArticleFire-Proofing

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 …

Brad Keyes, CHSP | Jan 22, 2019
Ambulatory Care OccupancyBusiness OccupanciesHealthcare Occupancy

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 …

Brad Keyes, CHSP | Jan 21, 2019
Fire AlarmFire Alarm Notification Devices

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 …

Brad Keyes, CHSP | Jan 18, 2019
Exit AccessArticleEquipment (Life Safety Code)

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 …

Brad Keyes, CHSP | Jan 17, 2019
Automatic Transfer SwitchesTesting (Generators)Inspection & Maintenance (Generators)Batteries (Generators)

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 …

Brad Keyes, CHSP | Jan 16, 2019
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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! …

Brad Keyes, CHSP | Jan 15, 2019
Fire Drills

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 …

Brad Keyes, CHSP | Jan 14, 2019
Smoke Detectors

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 …

Brad Keyes, CHSP | Jan 11, 2019
Exit EnclosureArticleFire Barrier

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 …

Brad Keyes, CHSP | Jan 10, 2019
Door LocksDoors

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 …

Brad Keyes, CHSP | Jan 9, 2019
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Jan 8, 2019
Control Valves

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 …

Brad Keyes, CHSP | Jan 7, 2019
DrawingsCorridorsDoors

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 …

Brad Keyes, CHSP | Jan 4, 2019
ArticleFire Barrier

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] …

Brad Keyes, CHSP | Jan 3, 2019
Accreditation/CertificationConstruction Types

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 …

Brad Keyes, CHSP | Jan 2, 2019
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Jan 1, 2019
ExitsArticle

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 …

Brad Keyes, CHSP | Dec 31, 2018
ElectricalArticle

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 …

Brad Keyes, CHSP | Dec 28, 2018
Fire CaulkArticleFire Barrier

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 …

Brad Keyes, CHSP | Dec 27, 2018
Fire & Smoke Dampers

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 …

Brad Keyes, CHSP | Dec 22, 2018
ArticleAccreditation

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 …

Brad Keyes, CHSP | Dec 21, 2018
ArticleSignage (Life Safety Code)

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 …

Brad Keyes, CHSP | Dec 20, 2018
ArticleFire Hoses

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 …

Brad Keyes, CHSP | Dec 19, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Dec 18, 2018
ArticleFacility Services

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 …

Brad Keyes, CHSP | Dec 17, 2018
ArticleSmoke Dampers

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 …

Brad Keyes, CHSP | Dec 14, 2018
ArticleDoors

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 …

Brad Keyes, CHSP | Dec 13, 2018
Fire DoorsArticleSmoke Compartment

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 …

Brad Keyes, CHSP | Dec 12, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Dec 11, 2018
ArticleInfection ControlAccreditation

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 …

Brad Keyes, CHSP | Dec 10, 2018
ArticleCorridorsSmoke Dampers

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 …

Brad Keyes, CHSP | Dec 7, 2018
ArticleCeilings (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Dec 6, 2018
ExitsEquivalenciesArticle

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 …

Brad Keyes, CHSP | Dec 5, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Dec 4, 2018
Business OccupanciesArticle

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 …

Brad Keyes, CHSP | Dec 3, 2018
Life Safety Code

Click on this link for a special Season’s Greetings video from Keyes Life Safety… https://keyeslifesafewpenginecom/wp-content/uploads/2018/10/Seasons_Greetingsmp4 …

Brad Keyes, CHSP | Dec 2, 2018
ArticleFacility Services

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 …

Brad Keyes, CHSP | Nov 30, 2018
Fire DoorsArticle

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 …

Brad Keyes, CHSP | Nov 29, 2018
Fire DoorsArticle

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 …

Brad Keyes, CHSP | Nov 28, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Nov 27, 2018
GeneratorsArticle

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 …

Brad Keyes, CHSP | Nov 26, 2018
ArticleTemperature

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 …

Brad Keyes, CHSP | Nov 23, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Nov 22, 2018
ArticleInfection Control

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, …

Brad Keyes, CHSP | Nov 21, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Nov 20, 2018
ArticleCorridors

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, …

Brad Keyes, CHSP | Nov 19, 2018
Life Safety CodeDecorations

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 …

Brad Keyes, CHSP | Nov 17, 2018
ArticlePatient RoomsSprinklers

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 …

Brad Keyes, CHSP | Nov 16, 2018
ElectricalArticle

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 …

Brad Keyes, CHSP | Nov 15, 2018
Fire AlarmArticleSmoke Detectors

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 …

Brad Keyes, CHSP | Nov 14, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Nov 13, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Nov 12, 2018
Electrical EquipmentElectrical

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 …

Brad Keyes, CHSP | Nov 10, 2018
ElectricalArticle

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 …

Brad Keyes, CHSP | Nov 9, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Nov 8, 2018
Extinguishing SystemsArticle

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 …

Brad Keyes, CHSP | Nov 7, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Nov 6, 2018
ArticleDoors

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 …

Brad Keyes, CHSP | Nov 5, 2018
DecorationsArticle

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 …

Brad Keyes, CHSP | Nov 2, 2018
Fire AlarmArticle

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, …

Brad Keyes, CHSP | Nov 1, 2018
ArticleWaste Containers

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 …

Brad Keyes, CHSP | Oct 31, 2018
Boot CampLife Safety CodeArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Oct 30, 2018
Fire DoorsArticle

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, …

Brad Keyes, CHSP | Oct 29, 2018
Accreditation

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 …

Brad Keyes, CHSP | Oct 27, 2018
Fire WatchArticle

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 …

Brad Keyes, CHSP | Oct 26, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Oct 25, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Oct 24, 2018
Life Safety Code

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 …

Brad Keyes, CHSP | Oct 23, 2018
Fire DoorsArticle

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 …

Brad Keyes, CHSP | Oct 22, 2018
ArticleFire Drills

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 …

Brad Keyes, CHSP | Oct 19, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Oct 18, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Oct 17, 2018
Decorations

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 …

Brad Keyes, CHSP | Oct 16, 2018
ArticleFacility Services

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 …

Brad Keyes, CHSP | Oct 15, 2018
Fire ExtinguishersArticle

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 …

Brad Keyes, CHSP | Oct 12, 2018
ElectricalArticle

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 …

Brad Keyes, CHSP | Oct 11, 2018
ArticleTesting (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Oct 10, 2018
Decorations

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 …

Brad Keyes, CHSP | Oct 9, 2018
ArticleCorridorsDoors

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 …

Brad Keyes, CHSP | Oct 8, 2018
Emergency Lights (Life Safety Code)Article

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 …

Brad Keyes, CHSP | Oct 5, 2018
ArticleStairs

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 …

Brad Keyes, CHSP | Oct 4, 2018
Fire DoorsArticle

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 …

Brad Keyes, CHSP | Oct 3, 2018
Article

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 …

Brad Keyes, CHSP | Oct 1, 2018
GeneratorsArticle

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 …

Brad Keyes, CHSP | Sep 28, 2018
ArticleConstruction Types

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 …

Brad Keyes, CHSP | Sep 27, 2018
Business OccupanciesAlcohol Based Hand Rub DispensersArticle

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 …

Brad Keyes, CHSP | Sep 26, 2018
ArticleFire Drills

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 …

Brad Keyes, CHSP | Sep 24, 2018
Fire ExtinguishersArticle

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 …

Brad Keyes, CHSP | Sep 21, 2018
ArticleStairwells

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 …

Brad Keyes, CHSP | Sep 20, 2018
Fire AlarmArticleTesting (Fire Detection Systems)

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 …

Brad Keyes, CHSP | Sep 19, 2018
Construction BarrierArticleConstruction Types

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 …

Brad Keyes, CHSP | Sep 17, 2018
ArticleFire Drills

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 …

Brad Keyes, CHSP | Sep 14, 2018
Behavioral HealthArticleCorridors

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, …

Brad Keyes, CHSP | Sep 13, 2018
Fire DoorsArticle

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 …

Brad Keyes, CHSP | Sep 12, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Sep 10, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Sep 7, 2018
ArticleInterior Finish

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 …

Brad Keyes, CHSP | Sep 6, 2018
Door LocksArticle

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 …

Brad Keyes, CHSP | Sep 5, 2018
Hazardous AreasArticle

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 …

Brad Keyes, CHSP | Sep 3, 2018
Alcohol Based Hand Rub DispensersArticle

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: …

Brad Keyes, CHSP | Aug 31, 2018
ArticleStairs

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 …

Brad Keyes, CHSP | Aug 30, 2018
ArticleILSM

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 …

Brad Keyes, CHSP | Aug 29, 2018
ArticleCeilings (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Aug 27, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Aug 24, 2018
Emergency DepartmentArticle

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 …

Brad Keyes, CHSP | Aug 23, 2018
ArticleOxygen Cylinders

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 …

Brad Keyes, CHSP | Aug 22, 2018
Life Safety Code

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 …

Brad Keyes, CHSP | Aug 21, 2018
HumidityArticleTemperature

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 …

Brad Keyes, CHSP | Aug 20, 2018
Life Safety CodeGeneratorsArticle

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 …

Brad Keyes, CHSP | Aug 17, 2018
ArticleHVAC

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 …

Brad Keyes, CHSP | Aug 16, 2018
VentilationArticle

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 …

Brad Keyes, CHSP | Aug 15, 2018
Q&AOxygen Cylinders

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 …

Brad Keyes, CHSP | Aug 13, 2018
Q&AExit Signs

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 …

Brad Keyes, CHSP | Aug 10, 2018
ArticleEgress

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 …

Brad Keyes, CHSP | Aug 9, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Aug 8, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Aug 6, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Aug 3, 2018
Electrical EquipmentArticle

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 …

Brad Keyes, CHSP | Aug 2, 2018
ArticleDoors

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 …

Brad Keyes, CHSP | Aug 1, 2018
Hazardous AreasArticle

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 …

Brad Keyes, CHSP | Jul 30, 2018
Fire AlarmArticle

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 …

Brad Keyes, CHSP | Jul 27, 2018
ArticleEyewash Stations

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 …

Brad Keyes, CHSP | Jul 26, 2018
Joint CommissionArticle

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 …

Brad Keyes, CHSP | Jul 25, 2018
Main DrainArticle

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 …

Brad Keyes, CHSP | Jul 23, 2018
ConstructionArticleEquipment (Life Safety Code)

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 …

Brad Keyes, CHSP | Jul 20, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Jul 19, 2018
Fire ExtinguishersArticle

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 …

Brad Keyes, CHSP | Jul 18, 2018
Business OccupanciesExitsArticleHealthcare 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 …

Brad Keyes, CHSP | Jul 16, 2018
WaiversEquivalenciesArticle

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 …

Brad Keyes, CHSP | Jul 13, 2018
Walking Surface

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 …

Brad Keyes, CHSP | Jul 12, 2018
Fire DoorsFire AlarmArticle

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 …

Brad Keyes, CHSP | Jul 11, 2018
Life Safety CodeArticle

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? …

Brad Keyes, CHSP | Jul 9, 2018
Emergency DepartmentArticleCorridors

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 …

Brad Keyes, CHSP | Jul 6, 2018
Fire ExtinguishersElectricalArticle

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 …

Brad Keyes, CHSP | Jul 5, 2018
Exit SignsArticle

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? …

Brad Keyes, CHSP | Jul 2, 2018
Signs (Fire Suppression Systems)Fire ExtinguishersArticle

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 …

Brad Keyes, CHSP | Jun 29, 2018
Fire ExtinguishersArticle

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 …

Brad Keyes, CHSP | Jun 28, 2018
SeparationArticleOccupancies

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 …

Brad Keyes, CHSP | Jun 27, 2018
ArticleNurse Call SystemsFacility Services

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 …

Brad Keyes, CHSP | Jun 25, 2018
Alcohol Based Hand Rub DispensersArticle

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 …

Brad Keyes, CHSP | Jun 22, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Jun 21, 2018
HumidityArticleTemperature

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 …

Brad Keyes, CHSP | Jun 20, 2018
Testing (Electrical)ElectricalArticle

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 …

Brad Keyes, CHSP | Jun 18, 2018
Electrical EquipmentArticle

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 …

Brad Keyes, CHSP | Jun 15, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Jun 14, 2018
Life Safety CodeElevatorsArticle

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 …

Brad Keyes, CHSP | Jun 13, 2018
Door LocksArticle

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 …

Brad Keyes, CHSP | Jun 12, 2018
Door LocksArticleStairwells

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 …

Brad Keyes, CHSP | Jun 11, 2018
Medical GasArticleEquipment (Medical Gas)

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 …

Brad Keyes, CHSP | Jun 8, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Jun 7, 2018
Fire PumpArticleTesting (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Jun 6, 2018
ArticleOccupancies

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 …

Brad Keyes, CHSP | Jun 5, 2018
Fire AlarmArticle

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 …

Brad Keyes, CHSP | Jun 4, 2018
Signs (Facilities Management)NFPA 99Article

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 …

Brad Keyes, CHSP | Jun 1, 2018
Door LocksArticle

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 …

Brad Keyes, CHSP | May 31, 2018
Testing (Generators)GeneratorsArticle

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 …

Brad Keyes, CHSP | May 30, 2018
Fire AlarmArticle

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 …

Brad Keyes, CHSP | May 29, 2018
Fire DoorsArticleGas CylindersStorage Room

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 …

Brad Keyes, CHSP | May 28, 2018
NFPA 99ArticleAccreditation

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 …

Brad Keyes, CHSP | May 25, 2018
SafetyArticle

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 …

Brad Keyes, CHSP | May 24, 2018
Testing (Electrical)ElectricalArticle

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 …

Brad Keyes, CHSP | May 23, 2018
NFPA 99Electrical EquipmentElectricalArticle

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 …

Brad Keyes, CHSP | May 22, 2018
ArticleFire/Smoke DampersNursing Home

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 …

Brad Keyes, CHSP | May 21, 2018
Fire AlarmArticleClarification

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 …

Brad Keyes, CHSP | May 18, 2018
Portable Space HeatersArticle

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 …

Brad Keyes, CHSP | May 17, 2018
Fuel TestGeneratorsArticle

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 …

Brad Keyes, CHSP | May 16, 2018
ArticleCMS

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 …

Brad Keyes, CHSP | May 15, 2018
ArticleFire Drills

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 …

Brad Keyes, CHSP | May 14, 2018
Electrical EquipmentArticleStorage Room

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) …

Brad Keyes, CHSP | May 11, 2018
ArticleSmoke Detectors

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 …

Brad Keyes, CHSP | May 10, 2018
Hazardous WasteArticleWaste Containers

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 …

Brad Keyes, CHSP | May 9, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | May 8, 2018
Fire DoorsArticleDoors

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 …

Brad Keyes, CHSP | May 7, 2018
Life Safety CodeArticle

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? …

Brad Keyes, CHSP | May 4, 2018
SafetyArticle

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 …

Brad Keyes, CHSP | May 3, 2018
ArticleNurse Call Systems

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, …

Brad Keyes, CHSP | May 2, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | May 1, 2018
CardboardArticleStorage Room

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 …

Brad Keyes, CHSP | Apr 30, 2018
ArticleNurse Call Systems

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 …

Brad Keyes, CHSP | Apr 27, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Apr 26, 2018
Door LocksArticleFacility Services

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 …

Brad Keyes, CHSP | Apr 25, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Apr 24, 2018
ConstructionArticleILSM

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 …

Brad Keyes, CHSP | Apr 23, 2018
ArticleEyewash StationsAccreditation

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 …

Brad Keyes, CHSP | Apr 20, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Apr 19, 2018
ArticleEgress

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 …

Brad Keyes, CHSP | Apr 18, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Apr 17, 2018
Life Safety CodeArticleEquipment (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Apr 16, 2018
AppliancesArticle

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 …

Brad Keyes, CHSP | Apr 13, 2018
ArticleCorridors

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 …

Brad Keyes, CHSP | Apr 12, 2018
ArticleAccreditation

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 …

Brad Keyes, CHSP | Apr 11, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Apr 10, 2018
Survey FindingsArticleFacility Services

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 …

Brad Keyes, CHSP | Apr 9, 2018
ArticleSprinklers

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 …

Brad Keyes, CHSP | Apr 6, 2018
Fire AlarmArticle

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 …

Brad Keyes, CHSP | Apr 5, 2018
ArticleEquipment (Fire Suppression Systems)Sprinklers

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 …

Brad Keyes, CHSP | Apr 4, 2018
ArticleCMS

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 …

Brad Keyes, CHSP | Apr 3, 2018
Fire ExtinguishersArticleCorridors

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 …

Brad Keyes, CHSP | Apr 2, 2018
ArticleCeilings (Fire Suppression Systems)

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 …

Brad Keyes, CHSP | Mar 31, 2018
Fire AlarmArticle

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 …

Brad Keyes, CHSP | Mar 30, 2018
Business OccupanciesArticleFacility Services

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 …

Brad Keyes, CHSP | Mar 28, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Mar 27, 2018
Door LocksArticleFacility Services

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 …

Brad Keyes, CHSP | Mar 26, 2018
ArticleILSM

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 …

Brad Keyes, CHSP | Mar 23, 2018
Fire AlarmArticle

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, …

Brad Keyes, CHSP | Mar 22, 2018
SuitesArticle

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 …

Brad Keyes, CHSP | Mar 21, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Mar 20, 2018
ExitsArticleOperating Room

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 …

Brad Keyes, CHSP | Mar 19, 2018
ArticleSoiled Utility Room

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 …

Brad Keyes, CHSP | Mar 16, 2018
Door LocksArticle

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 …

Brad Keyes, CHSP | Mar 15, 2018
ExitsArticle

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 …

Brad Keyes, CHSP | Mar 14, 2018
Construction BarrierFire WatchArticleSprinklers

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 …

Brad Keyes, CHSP | Mar 13, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Mar 12, 2018
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | Mar 9, 2018
ElectricalArticle

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 …

Brad Keyes, CHSP | Mar 8, 2018
Business OccupanciesArticleFire Drills

Q: I'm responsible for doing annual fire drills in our blood draw stations located throughout several communities. Some are in physician’s offices and some are in office buildings. I can …

Brad Keyes, CHSP | Mar 7, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Mar 6, 2018
Door LocksArticleDoors

Q: As I understand the Life Safety Code, doors opening from a patient floor corridor into a patient room do not have to latch. I have a room next to …

Brad Keyes, CHSP | Mar 5, 2018
ArticleDoorsOperating Room

Q: We have two open-heart OR's. Each has a full 42" wide door leaf that open to the corridor, and each has a 3'0" door in the rear of the …

Brad Keyes, CHSP | Mar 2, 2018
ArticleStairwellsSprinklers

Continuing in a series of strange things that I have seen when consulting at hospitals... This is an evacuation chair or sled that is hanging from a sprinkler drain pipe …

Brad Keyes, CHSP | Mar 1, 2018
ArticleTesting (Accreditation/Certification)

Q: On annual testing requirements, how many days do you have on either side of the test date? A: If the NFPA standard simply says the test is required ‘annually’, …

Brad Keyes, CHSP | Feb 28, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Feb 27, 2018
Fire DoorsArticle

Q: My hospital is a behavioral health hospital converted from an acute hospital. The doors on patient rooms and mostly all doors in this building are solid core doors....which are …

Brad Keyes, CHSP | Feb 26, 2018
Chutes (Life Safety Code)Article

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 …

Brad Keyes, CHSP | Feb 23, 2018
Door LocksExitsArticle

Continuing in a series of strange things that I have seen when consulting at hospitals... Isn't this a winner...? I should submit this picture to Lori Greene so she can …

Brad Keyes, CHSP | Feb 22, 2018
SuitesArticle

Q: We have two adjacent suites that are not separated by a smoke wall. My question is; does a door along that separation have to meet the requirements of a …

Brad Keyes, CHSP | Feb 21, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Feb 20, 2018
ArticleDoors

Q: I’m confused… does the door frame in a fire door have to be labeled, when 100% sprinkled with 1-hour fire-rated assemblies are in place with a 45-minute labeled door …

Brad Keyes, CHSP | Feb 19, 2018
ArticleConstruction Types

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” …

Brad Keyes, CHSP | Feb 16, 2018
Fire ExtinguishersArticle

Continuing in a series of strange things that I have seen when consulting at hospitals... Believe it or not, there is a fire extinguisher buried behind all of the trash …

Brad Keyes, CHSP | Feb 15, 2018
AppliancesArticle

Q: Are toaster ovens with a grounded third prong plug acceptable in a hospital staff lounge? The plug should allow for any short-circuit. A: Actually, according to section 19.3.2.5.2 of …

Brad Keyes, CHSP | Feb 14, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Feb 13, 2018
ArticleOperating RoomFire Drills

Q: Back in March 2016, you answered a reader's question that fire drills are not specifically required for operating rooms. While reviewing NFPA 99-2012, I came across a section that …

Brad Keyes, CHSP | Feb 12, 2018
Life Safety CodeElevatorsArticle

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 …

Brad Keyes, CHSP | Feb 9, 2018
ArticleDoors

Continuing in a series of strange things that I have seen when consulting at hospitals... Boxes and supplies blocking a door, preventing it from closing. Don't know what the circumstances …

Brad Keyes, CHSP | Feb 8, 2018
Life Safety CodeArticle

Q: Can a patient bed or gurney be left in front of a fire extinguisher or a medical gas shutoff valve in a procedural area, such as an operating room, …

Brad Keyes, CHSP | Feb 7, 2018
ArticleLife Safety Boot Camp

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 …

Brad Keyes, CHSP | Feb 6, 2018
ArticleTrash Receptacles

Q: Can you tell me where to find the code reference for trash cans in healthcare, ambulatory, and business occupancies? I have reviewed the respective chapters in the 2012 LSC …

Brad Keyes, CHSP | Feb 5, 2018
DecorationsArticlePatient Rooms

Q: Where does "Homelike Environment" end and fire safety begin? We have a resident who likes to push-pin everything she makes in activities to her wall. On a recent Life/Safety …

Brad Keyes, CHSP | Feb 2, 2018
Hazardous AreasArticle

Continuing in a series of strange things that I have seen when consulting at hospitals... This may be hard to see but there is an 'Exit' sign over the door …

Brad Keyes, CHSP | Feb 1, 2018
AppliancesArticleOxygen Cylinders

Q: Can you tell me what the rules are for oxygen usage around hair dryers might be? A: As you can imagine, the codes and standards cannot have rules for …

Brad Keyes, CHSP | Jan 31, 2018
Electrical EquipmentTesting (Electrical)Article

Do you ever have the feeling for every step forward, you take two steps backward? Regulatory compliance in the healthcare industry is getting tougher and tougher each year with new …

Brad Keyes, CHSP | Jan 30, 2018
ArticleCMS

Q: In regards to your answer last week requiring plastic coffee pots to be inspected, is this a code requirement or just a ‘best practice’? I’m not talking about equipment …

Brad Keyes, CHSP | Jan 29, 2018
ArticleFacility Services

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 …

Brad Keyes, CHSP | Jan 26, 2018
ElectricalArticle

Continuing in a series of strange things that I have seen when consulting at hospitals... Access to this electrical panel was obstructed. Staff that was with me did not understand …

Brad Keyes, CHSP | Jan 25, 2018
Joint CommissionArticle

A lot has been said and written concerning the changes that Joint Commission has made in regards to their Life Safety chapter for acute-care hospitals, and for good reason. CMS …

Brad Keyes, CHSP | Jan 23, 2018
Electrical EquipmentArticle

Q: What's the standard to test small electrical appliances such as plastic coffee pots, etc. with no ground and the patients do not handle in a health care environment? A: …

Brad Keyes, CHSP | Jan 22, 2018
Testing (Generators)GeneratorsArticle

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 …

Brad Keyes, CHSP | Jan 19, 2018
ElectricalArticle

Continuing in a series of strange things that I have seen when consulting at hospitals... The odd thing about this situation is the receptacle has been changed out since the fire, …

Brad Keyes, CHSP | Jan 18, 2018
Hazardous AreasArticle