Ask an Expert
Discuss My Needs
Menu
Discuss My Needs
Ask an Expert

Ask a Life Safety Expert / Accreditation

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.

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Q&AAccreditation

Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient …

Brad Keyes, CHSP | Aug 10, 2017
Emergency DepartmentArticleAccreditationCMS

If you've been reading my blog postings over the past few months ( see http://keyeslife.wpengine.com/?s=emergency+department), you've read were I have reported that CMS has issued informal, non-public letters to the …

Brad Keyes, CHSP | Jul 1, 2017
Emergency DepartmentArticleAccreditationCMS

The following article was published today online by the HCPro newsletter 'Healthcare Life Safety Compliance', and is reprinted here with permission. In a rather surprising interpretation by the Centers for …

Brad Keyes, CHSP | Mar 2, 2017
ArticleAccreditationOccupancies

In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments are now required to be classified as healthcare occupancies only. For most of …

Brad Keyes, CHSP | Jan 24, 2017
VentilationArticleBronchoscopyAccreditation

Q: Are Bronchoscopy procedures to be performed in negative pressure rooms under all circumstances, or can they be performed in OR suites? Does the negative pressure rule only apply to …

Brad Keyes, CHSP | May 20, 2016
ArticleAccreditation

Q: We were using the 2006 edition of the FGI Guidelines for Design and Construction of Health Care Facilities but we have both the 2006 and the 2010 version of …

Brad Keyes, CHSP | Apr 29, 2016
Joint CommissionArticleAccreditationCMS

I received the following comment from a reader: During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even …

Brad Keyes, CHSP | Mar 2, 2016
DecorationsArticleAccreditation

The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that …

Brad Keyes, CHSP | Nov 27, 2014
ArticleCorridorsAccreditation

The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment …

Brad Keyes, CHSP | Nov 6, 2014
ArticleAccreditation

Recently, the issue of whether or not the FGI guidelines were enforceable in certain situations came up for discussion. To be sure, the FGI guidelines are guidelines: They are not …

Brad Keyes, CHSP | Sep 25, 2014
ArticleCorridorsAccreditation

Randy Snelling, the Chief Physical Environment Officer, for DNV-GL Healthcare Inc. spoke at the recent ASHE annual conference in Chicago, and I thought his views on corridor clutter were worth …

Brad Keyes, CHSP | Aug 28, 2014
ArticleAccreditationOccupancies

I’m no expert on the differences between a Critical Access Hospital (CAH) and an Acute Care Hospital (hospital), but I’m learning. Having been an advisor to American Osteopathic Association/Healthcare Facilities …

Brad Keyes, CHSP | Jun 12, 2014
ArticleAccreditation

A surveyor recently cited an organization for having potential suicide hanging points in a behavioral health unit, in the form of door hinges and other hardware issues in the patient …

Brad Keyes, CHSP | Nov 21, 2013
Life Safety CodeArticleTesting (Life Safety Code)Accreditation

Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define …

Brad Keyes, CHSP | Oct 31, 2013

Real people. Real solutions.

We help you be better informed of the changing world around you.  Our life safety blog answers your real world questions! 

More...

More...

Subscribe to Updates

We care and want to help.

We want to help coach, guide, and navigate you through all things Life Safety.
DISCUSS MY NEEDS