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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.

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Q: Are clean cores for operating room suites considered hazardous thus required to be separated by a 1-hour fire-rated barriers? I have a client who was informed by their accreditation …

Brad Keyes, CHSP | Jan 17, 2018
Fire AlarmArticle

I was reviewing some new standards and came across the Positive Alarm Sequence (PAS) issue for fire alarm systems, that the 2012 LSC now permits in fully sprinklered healthcare occupancies …

Brad Keyes, CHSP | Jan 16, 2018
Exit SignsArticle

Q: Can illuminated ‘Exit’ signs be replaced with photoluminescent ‘Exit’ signs? If so, does this eliminate the requirement for monthly inspections of ‘Exit’ signs? A: Photoluminescent ‘Exit’ signs are permitted, …

Brad Keyes, CHSP | Jan 15, 2018
Emergency Lights (Life Safety Code)Article

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 | Jan 12, 2018
ArticleSigns (Life Safety Code)

Continuing in a series of strange things that I have seen when consulting at hospitals... Did you notice they did not say 'cigarette butts'? I guess that was to be …

Brad Keyes, CHSP | Jan 11, 2018
Hazardous AreasArticle

Q: Our hospital facility was constructed under the new construction chapter 18 in 2000 Life Safety Code, but is now considered existing conditions under the 2012 Life Safety Code. We …

Brad Keyes, CHSP | Jan 10, 2018
Ambulatory Care OccupancyEmergency DepartmentArticleHealthcare OccupancyCMS

Q: In a hospital emergency department, can the corridors be 6 feet wide? Can the hospital install an 18-inch deep lockable computer cabinet in the 8 foot ED corridor? A: …

Brad Keyes, CHSP | Jan 8, 2018
ArticleCorridorsDoors

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 | Jan 5, 2018
ArticleSigns (Life Safety Code)

Continuing in a series of strange things that I have seen when consulting at hospitals... Okay... who is this sign for? If I touch the wires, then I'm dead... right? …

Brad Keyes, CHSP | Jan 4, 2018
Life Safety CodeArticle

Q: The entry door to a surgery sterilization room has a cabinet that prevents the door from opening a full 90 degrees. Is there a minimum allowed opening requirement for …

Brad Keyes, CHSP | Jan 3, 2018
SafetyConstructionArticle

I learned recently that a hospital is being sued by the family of a woman who fell in a construction zone and subsequently died. The 85-year-old woman walked past an …

Brad Keyes, CHSP | Jan 2, 2018
Life Safety CodeArticle

Q: I have a facility that the ground floor is classified as Industrial occupancy. But we have an area that has an eight-foot corridor, with a offset six-foot opening. The …

Brad Keyes, CHSP | Dec 6, 2017
Life Safety CodeArticle

Q: Do we include information boards/bulletin boards content when calculation of the percentage of wall and ceiling area of combustible decorations in a smoke compartment? A: It depends…. If the …

Brad Keyes, CHSP | Nov 28, 2017
Life Safety CodeArticle

Q: Are existing healthcare occupancies required to have smoke detectors if they are fully sprinklered? A: Smoke detectors are required in certain areas of healthcare occupancies, but they are not dependent …

Brad Keyes, CHSP | Nov 21, 2017
Survey FindingsArticle

In preparation for a survey hospitals frequently train their staff to only answer the questions of the surveyors without providing any more information. This has proven to be good advice …

Brad Keyes, CHSP | Oct 6, 2017
Article

Hello readers... If you are not already aware of this, I am a one-person organization. I do have a partner (Alise Howlett, of Codenity) when I do boot camps, but …

Brad Keyes, CHSP | Oct 3, 2017
ArticleDoors

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 | Sep 5, 2017
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 | Aug 22, 2017
Professional OrganizationsArticle

ASHE MEMBERS Please Vote for Michael Crowley for ASHE Associate Member Director. Michael (Mike) Crowley has been an active associate member of ASHE for over 20 years, many of which …

Brad Keyes, CHSP | Aug 19, 2017
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 | Aug 15, 2017
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 | Aug 8, 2017
ArticleSmoke CompartmentCMS

The following article was published in HCPro's Hospital Safety Insider, on August 3, 2017: More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline …

Brad Keyes, CHSP | Aug 5, 2017
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 | Aug 1, 2017
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 | Jul 25, 2017
ArticleCMSTesting (Accreditation/Certification)

I recently posted on documentation retention, and how long you should keep test/inspection records. A reader contacted me and said they attended a recent ASHE regional event where the speaker …

Brad Keyes, CHSP | Jul 22, 2017
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 | Jul 18, 2017
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 | Jul 11, 2017
Article

In your career, you will meet lots of interesting people. If you're fortunate in life, some of those people will be a blessing to you. That is the case for me …

Brad Keyes, CHSP | Jul 4, 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
ArticleFire Drills

A recent question by a reader asked if fire-rated doors and smoke compartment barrier doors that close on a fire alarm could be opened before the fire alarm is considered …

Brad Keyes, CHSP | Jun 30, 2017
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 | Jun 27, 2017
ArticleEyewash Stations

When and where are eyewash stations required in a healthcare facility? That is one of the more frequent issues that healthcare professionals struggle with. There is a tendency to place …

Brad Keyes, CHSP | Apr 21, 2017
WaiversEquivalenciesArticle

There has been much confusion and differing of opinions regarding the process to submit waiver and equivalency requests, and once they have been approved, how long they are valid. The …

Brad Keyes, CHSP | Apr 10, 2017
Life Safety CodeArticlePatient RoomsDoors

Q: In the 2000 edition of the Life Safety Code, under section 18.3.8 “Special Protection Features -Outside Window or Door”, they have requirements for windows or doors to the outside …

Brad Keyes, CHSP | Mar 21, 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
Life Safety CodeArticleLife 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 28, 2017
ArticleOxygen CylindersStorage Room

Hello readers... I did it again. I made a mistake in my answer to yesterday's posting, which asked the question if signs are required on doors to storage rooms where there is …

Brad Keyes, CHSP | Feb 24, 2017
Life Safety CodeArticleLife 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 14, 2017
CardboardArticle

I have been receiving quite a few questions regarding cardboard shipping boxes and whether or not they can be used for general storage in storage rooms throughout the hospital. We're …

Brad Keyes, CHSP | Feb 7, 2017
Life Safety CodeArticleLife 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 | Jan 31, 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
Extinguishing SystemsArticle

Q: It has been stated that Class 1 and Class 3 fire hose valves are to be tested annually by opening and closing the valve and that full flow is …

Brad Keyes, CHSP | Jan 24, 2017
Life Safety CodeArticleLife 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 | Jan 17, 2017
ArticleSprinklers

The following article is from the National Fire Sprinkler Association (NFSA) TechNotes dated December 27, 2016... Two decades ago the NFPA Committee on Automatic Sprinklers was considering a requirement that all …

Brad Keyes, CHSP | Jan 4, 2017
Life Safety CodeArticleLife 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 | Jan 3, 2017
ArticleCorridorsDoors

Corridor doors are one of the most common components of the means of egress, yet their significance is often overlooked, possibly because there are so many of them in a …

Brad Keyes, CHSP | Jan 2, 2017
Life Safety CodeArticleLife 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 | Dec 19, 2016
Fire DoorsLife Safety CodeArticleSmoke CompartmentCMS

I just found out yesterday that CMS is teaching their state agency LS surveyors that smoke barrier doors need to be tested in healthcare occupancies. This interpretation of the 2012 …

Brad Keyes, CHSP | Dec 9, 2016
Life Safety CodeArticle

Hello all... This fall has been a very busy time for me. I am thankful that I completed my task of reading all 651 pages of the new CMS Final …

Brad Keyes, CHSP | Dec 3, 2016
Life Safety CodeArticleLife Safety Boot CampSafety Management

April 3 & 4, 2017 is the date of the next Keyes Life Safety Boot Camp, to be held in Charleston, SC. This two-day boot camp on the 2012 Life …

Brad Keyes, CHSP | Oct 11, 2016
Life Safety CodeArticleCMS

I need to apologize to you, as I made an error in an earlier post where I stated the expected dates for the new testing/inspection requirements of the new 2012 Life Safety …

Brad Keyes, CHSP | Sep 22, 2016
ArticleOxygen Cylinders

I had a reader question one of my postings on this blog, that I thought you might be interested in reading... Oxygen Cylinder Storage The reader wanted to know if the yellow fire cabinets could …

Brad Keyes, CHSP | Sep 19, 2016
Emergency Response Plan (Accreditation/CertificatiArticleCMS

I have started to review the new CMS Final Rule on Emergency Preparedness. Here are some of the highlights, along with my comments... Comments and Observations in the CMS EM …

Brad Keyes, CHSP | Sep 15, 2016
Emergency Response Plan (Accreditation/CertificatiArticleCMS

Well... here it is. CMS has announced that they will publish their Final Rule on the new standards for Emergency Management. It appears the new rule will not be published …

Brad Keyes, CHSP | Sep 9, 2016
Joint CommissionLife Safety CodeArticleCMS

On July 13, 2016, The Joint Commission issued the following statement: “Effective Aug. 1, 2016, changes will become effective to the Statement of Conditions™ (SOC) process that will affect the …

Brad Keyes, CHSP | Aug 4, 2016
Article

If you tried to ask a question or send me a comment since July 5, 2016 via this website, you probably receive a notice that the email did not transmit properly …

Brad Keyes, CHSP | Jul 17, 2016
ArticleWaste Containers

Q: In the fine print of the new 2012 Life Safety Code, under sections 18/19.7.5.7.2 for containers used solely for recycling clean waste or for patient medical records awaiting destruction, …

Brad Keyes, CHSP | Jun 24, 2016
ArticleSprinklers

Q: Does an electrical closet under 144 square inches need a sprinkler head? A: The answer depends on your facility occupancy type and the requirements associated with that. If your …

Brad Keyes, CHSP | Jun 17, 2016
ArticleEquipment (Fire Suppression Systems)

Q: Please explain why The Joint Commission standard EP 1 identifies control valve signal devices and valve tamper switches as different pieces of equipment? The only difference I can see …

Brad Keyes, CHSP | Jun 10, 2016
Flammable LiquidsArticle

Q: It is my understanding that you are only allowed to have 10 gallons of flammable chemicals in a smoke compartment without having a fire cabinet. Does this amount change …

Brad Keyes, CHSP | Jun 3, 2016
Fire DoorsArticle

When the new 2012 Life Safety Code becomes effective July 5, 2016, CMS will expect all healthcare organizations to be compliant with the requirements of the new 2012 Life Safety …

Brad Keyes, CHSP | Jun 1, 2016
Life Safety CodeArticle

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 | May 31, 2016
Chutes (Life Safety Code)Article

Q: My question relates to fire ratings of linen chute doors. Do linen chute doors in an existing structure have to be rated if the room that houses the linen …

Brad Keyes, CHSP | May 27, 2016
Life Safety CodeArticle

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 | May 24, 2016
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
Life Safety CodeArticle

Q: Just read your latest post on testing of PIVs and backflows in accordance with NFPA25. You referenced the 1998 edition. But aren’t we supposed to be following the newly …

Brad Keyes, CHSP | May 18, 2016
Life Safety CodeArticle

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 | May 17, 2016
ArticleEquipment (Fire Suppression Systems)

Q: Many AHJ's are requiring RPZ backflow devices on sprinkler systems. Is there a testing requirement for these devices? Also, is there a periodic test required for a PIV? A: …

Brad Keyes, CHSP | May 13, 2016
Life Safety CodeArticle

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 | May 10, 2016
ArticleSmoke Detectors

Q: Do IT closets require a smoke detector no matter the size? A: If the IT closet is in the healthcare occupancy (hospital), and under normal circumstances, there is no …

Brad Keyes, CHSP | May 6, 2016
Life Safety CodeArticle

By now most of you have heard that CMS finally adopted the 2012 Life Safety Code, effective July 4, 2016, which is 60 days from the date CMS posted their …

Brad Keyes, CHSP | May 5, 2016
ArticleSmoke CompartmentDoors

Dear Readers... In a recent post I made a comment that architects are making errors and causing facility managers headaches by calling for 20 minute fire-rated doors in smoke barriers …

Brad Keyes, CHSP | May 4, 2016
Life Safety CodeArticle

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 | May 3, 2016
Life Safety CodeArticle

I received the following message from my friends at Russell Phillips and Associates, LLC: For those of you that are awaiting the adoption of the 2012 Life Safety Code: We …

Brad Keyes, CHSP | Apr 29, 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
Life Safety CodeArticle

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 | Apr 26, 2016
VentilationArticle

Q: Is there a code or standard that states how frequent the test intervals must be for air-exchange rates and air-pressure relationships in operating rooms, soiled utility rooms, and central …

Brad Keyes, CHSP | Apr 22, 2016
Life Safety CodeArticle

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 | Apr 19, 2016
Evacuation (Life Safety Code)Article

Q: Are evacuation route maps required in a hospital? We have them in our facility, but I’ve heard some people say they are not required. If they are not required, …

Brad Keyes, CHSP | Apr 15, 2016
Life Safety CodeArticle

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 | Apr 12, 2016
Fire DoorsArticle

Q: I have a question concerning clearances on fire rated doors and smoke compartment barrier doors. The way I read the 1999 Edition of NFPA 80 and the information in …

Brad Keyes, CHSP | Apr 8, 2016
Life Safety CodeArticle

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 | Apr 5, 2016
Fire ExtinguishersArticle

Q: Our hospital was surveyed recently and one of our deficiencies was that our fire extinguisher cabinets were not labeled. I can find nothing in the Life Safety Code stating …

Brad Keyes, CHSP | Apr 1, 2016
Life Safety CodeArticle

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 29, 2016
Business OccupanciesFire AlarmArticle

Q: We have a physician practice that currently has fire extinguishers and a "panic button" that contacts 911. We do not have fire alarms, smoke detectors or a sprinkler system …

Brad Keyes, CHSP | Mar 25, 2016
ArticleOperating RoomFire Drills

Q: We just had an accreditation survey and the surveyor cited us for not having a separate fire drill in the Operating Room Suite. I don't see this in any code …

Brad Keyes, CHSP | Mar 21, 2016
Fire WatchArticle

Q: When the code refers to a fire alarm system or sprinkler system being off-line for four or more hours in a 24 hour period (fire watch and fire department …

Brad Keyes, CHSP | Mar 18, 2016
ArticleDocumentation (Life Safety Code)

Q: Is there a retention requirement for eyewash weekly testing logs? One source I've read indicates at least 2 years. A: You need to retain all evidence that documents you …

Brad Keyes, CHSP | Mar 14, 2016
ArticleInterior Finish

Q: We recently had our annual state survey and the Life Safety surveyor tagged us on some wood chair rails that had been installed in a small dining room. Isn’t …

Brad Keyes, CHSP | Mar 11, 2016
ArticleFacility ServicesFire Drills

Q: For an EEG sleep testing unit with an overnight stay in a business occupancy, are fire drills required quarterly or annually ? A: Annually. The frequency of fire drills …

Brad Keyes, CHSP | Mar 7, 2016
Fire PumpArticle

Q: Recently, I was at a counter-part’s facility in our corporate system and wanted to review the Life Safety Code documentation to ensure everything was in order. Within a matter …

Brad Keyes, CHSP | Mar 4, 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
ElectricalArticle

Q: Can you give me a code reference for the need for electrical panels to be locked? We were cited by a surveyor for not locking our electrical panels. A: …

Brad Keyes, CHSP | Feb 29, 2016
Fire ExtinguishersArticle

Q: I read in one of your posts that the annual maintenance service of fire extinguishers does not require to be conducted by a “certified” individual. I was under the impression …

Brad Keyes, CHSP | Feb 26, 2016
Door LocksExitsArticle

Continuing in a series of strange things that I have seen while consulting at hospitals.... This series of pictures is just plain sad... and wrong. The top picture shows a …

Brad Keyes, CHSP | Feb 24, 2016
ArticleCorridorsDoors

Q: Are all types of corridor doors exempt from having to meet the requirements of NFPA 80? A: The answer is no. If the corridor door is a fire-rated door, …

Brad Keyes, CHSP | Feb 22, 2016
Business OccupanciesArticleCorridors

Q: What is the required width for an exit access corridor in an office building? A: That depends on the occupancy classification of the building. If the building is classified …

Brad Keyes, CHSP | Feb 19, 2016
ExitsArticle

Continuing in a series of strange things that I have seen while consulting at hospitals.... I don't remember where in the hospital I took this picture but it is apparent …

Brad Keyes, CHSP | Feb 17, 2016
ArticleCorridorsDoors

Q: These corridor doors (i.e. patient rooms); if they are in a 1-hour fire barrier then is it okay for them to only be rated20-minute and not ¾ hour? A: …

Brad Keyes, CHSP | Feb 15, 2016
Door LocksArticle

Continuing in a series of strange things that I have seen while consulting at hospitals.... This is a picture of a door to an exit stairwell. Note that there is …

Brad Keyes, CHSP | Feb 10, 2016
ArticleCorridorsDoors

Q: Do you think adding tons of signage, and coat hooks would be acceptable on a patient room door? A: Well…. That depends. Coat hooks on a non-fire rated door? …

Brad Keyes, CHSP | Feb 8, 2016
ArticleSprinklers

Continuing in a series of strange things that I have seen while consulting at hospitals.... This picture shows an architectural design that was mounted from the ceiling to give the …

Brad Keyes, CHSP | Feb 3, 2016
ArticleCorridorsDoors

Q: If the corridor doors are only required to resist fire for 20 minutes and someone plasters signage all over them or loads them up with coat racks adding to …

Brad Keyes, CHSP | Feb 1, 2016
Fire ExtinguishersArticle

Continuing in a series of strange things that I have seen while consulting at hospitals.... This is a picture of a fire extinguisher that was located in a laboratory. The …

Brad Keyes, CHSP | Jan 27, 2016
ArticleCorridorsDoors

Q: I have read that corridor doors to patient rooms are not required to have closers. If they do have closers, I was told they can have the type that …

Brad Keyes, CHSP | Jan 25, 2016
ArticleStairwells

I thought you might be interested in seeing some of the strange things I have observed as a consultant for healthcare organizations. This is a picture of a cage that a …

Brad Keyes, CHSP | Jan 20, 2016
ArticleFire Barrier

Q: We have an old shower room that our administration wants to use for a maintenance workshop. In this room they will be storing paint and supplies. The walls and …

Brad Keyes, CHSP | Jan 18, 2016
Fire AlarmLife Safety CodeInspection & Maintenance (Fire Detection SysteArticle

Q: A question came up recently on the NFPA 72 semi-annual visual inspections required for fire alarm system devices. Would the printed records from an intelligent fire alarm system suffice …

Brad Keyes, CHSP | Jan 15, 2016
ArticleStorage Room

Q: Is it not the case that in new hospital construction, clean storage rooms between 51 and 100 square feet need only have a self-closing door meeting 18.3.6.3.4? Only clean …

Brad Keyes, CHSP | Jan 11, 2016
ArticleDoorsStorage Room

Q: We have an Urgent Care facility that is classified as business occupancy. Do I need to lock the door to a storage room? A: The Life Safety Code does …

Brad Keyes, CHSP | Jan 8, 2016
Life Safety CodeArticle

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 | Jan 2, 2016
Fire AlarmLife Safety CodeInspection & Maintenance (Fire Detection SysteArticle

Q: A question came up recently on the NFPA 72 semi-annual visual inspections required for fire alarm system devices. Would the printed records from an intelligent fire alarm system suffice …

Brad Keyes, CHSP | Jan 1, 2016
SuitesArticle

Q: I can’t seem to find the definition of a suite in the Life Safety Code. What defines a suite? A: Think of a suite as nothing more than a …

Brad Keyes, CHSP | Dec 28, 2015
Evacuation (Life Safety Code)Article

Q: Where in the Life Safety Code does it say evacuation route maps are required to be posted on the floors in a hospital? I cannot find the reference and …

Brad Keyes, CHSP | Dec 25, 2015
Life Safety CodeArticleTesting (Accreditation/Certification)

Q: Do you find that TJC only enforces the quarterly plus or minus 10 days from the MONTH of last test on quarterly inspections (instead of the day)? This is what …

Brad Keyes, CHSP | Dec 23, 2015
Life Safety CodeArticle

Q: How do I determine a project is considered major or minor renovation? This makes a difference on whether we follow chapter 18 or chapter 19 requirements in the Life …

Brad Keyes, CHSP | Dec 21, 2015
Delayed EgressArticleCMS

Q: I have heard you state that once the 2012 edition of the Life Safety Code is finally adopted hospitals will be allowed to have more than one delayed egress …

Brad Keyes, CHSP | Dec 18, 2015
Medical GasArticleOxygen Cylinders

Q: We had a finding from a recent Joint Commission survey on EC. 02.01.01, EP 3. When the surveyor told us about it, he said it related back to an …

Brad Keyes, CHSP | Dec 16, 2015
ArticleFire Drills

Q: We have a building that is a business occupancy with the exception of two ambulatory care units. I know we have to do fire drills four times a year …

Brad Keyes, CHSP | Dec 14, 2015
KitchensHazardous AreasArticle

Q: You recently posted a question about whether or not hospital kitchens are hazardous areas. Your response noted that kitchens are not included in the list of 8 specific scenarios …

Brad Keyes, CHSP | Dec 11, 2015
ConstructionArticle

Q: We have an offsite business occupancy location and need to know what the requirements are for an area of refuge. I have not been able to identify any fire/smoke …

Brad Keyes, CHSP | Dec 7, 2015
SuitesConstruction BarrierArticle

Q: I cannot find anywhere in NFPA on the wall construction of a suite wall. We've been building them as a smoke wall but the code doesn't say anything. A: …

Brad Keyes, CHSP | Dec 4, 2015
Life Safety CodeArticleCMS

Q: When will CMS adopt the new 2012 Life Safety Code? It seems they are taking a long time to do it. A: I don’t know when CMS will finally …

Brad Keyes, CHSP | Dec 2, 2015
Life Safety CodeArticle

This is a re-print of an article posted on the www.FacilityCare.com website: How, When and Where a Life Safety Consultant Can Save Your Healthcare Project By Megan Headley For healthcare …

Brad Keyes, CHSP | Nov 11, 2015
DecorationsArticle

Combustible decorations have been prohibited in healthcare occupancies (i.e. hospitals, nursing homes) for decades; however decorations that are flame-retardant are permitted, according to section 19.7.5.4 of the 2000 Life Safety …

Brad Keyes, CHSP | Oct 14, 2015
Fire AlarmArticle

A reader recently asked me where in NFPA 72 does it say that heat detectors have to be a minimum of 36 inches away from an air diffuser. He could …

Brad Keyes, CHSP | Sep 23, 2015
ArticleOxygen CylindersClarification

My good friend Gloria Legere shared the following clarification that she wrote for a client hospital. The finding by the surveyor read: There were full and non-full e-cylinders of oxygen …

Brad Keyes, CHSP | Jun 11, 2015
Ambulatory Care OccupancyLife Safety CodeArticleFire Drills

I spoke at an Infection Control conference last week in St Louis, sponsored by the Excellentia Advisory Group. There were 13 different presentations made but mine was the only one …

Brad Keyes, CHSP | Apr 30, 2015
Article

Just a note today informing you I need to take a break from my regular blogs for a while. Due to an increase in workload, speaking engagements, a commitment to …

Brad Keyes, CHSP | Apr 9, 2015
Ambulatory Care OccupancyLife Safety CodeArticle

A reader asked me recently what the Life Safety Code differences were between a new construction ambulatory healthcare occupancy, and an existing construction ambulatory healthcare occupancy. I did not immediately …

Brad Keyes, CHSP | Apr 2, 2015
Life Safety CodeArticleStairwellsSigns (Life Safety Code)

If you were a bit surprised by the wording of the sign to the left... You're not alone. I had to do a double-take when I first saw it, as …

Brad Keyes, CHSP | Mar 19, 2015
Cooking AppliancesKitchensArticleFacility Services

A reader recently inquired about a residential style stove/oven used in their new hospital for occupational therapy patients. He wanted to know if this residential style stove was required to …

Brad Keyes, CHSP | Mar 12, 2015
Construction BarrierArticleConstruction Types

I received an email from a reader who described a problem with their temporary construction barriers. He told me the following: During construction and renovation projects our hospital uses drywall …

Brad Keyes, CHSP | Mar 5, 2015
Fire AlarmDoor LocksArticle

I received a telephone call recently from a lawyer that asked me if I would be willing to serve as an expert witness in a pending litigation suit. The situation …

Brad Keyes, CHSP | Feb 26, 2015
Electrical EquipmentElectricalArticle

There are quite of few issues concerning electrical panels that need to be addressed during a survey. Hospitals frequently take electrical panels for granted and overlook some of the more …

Brad Keyes, CHSP | Feb 19, 2015
ArticleTrash Receptacles

An off-site clinic far from the main hospital will be part of the accreditation survey. Currently they have open trash cans (wastebaskets) throughout the building. The staff at the offsite …

Brad Keyes, CHSP | Feb 12, 2015
Fire ExtinguishersArticleDocumentation (Fire Suppression Systems)

A surveyor recently cited an organization stating the hospital did not have a document indicating all of the portable fire extinguishers were inspected on a monthly basis. The surveyor asked for …

Brad Keyes, CHSP | Feb 5, 2015
Fire DoorsArticleDoors

During the building tour a surveyor observed a label on a frame for a fire rated door assembly that read "Fire Resistant Frame - This frame is identical in construction …

Brad Keyes, CHSP | Jan 29, 2015
Emergency Lights (Life Safety Code)Article

I was recently an interested bystander in a group discussion concerning the proper testing and inspection of a battery powered emergency light fixture located in an operating room. A question …

Brad Keyes, CHSP | Jan 22, 2015
ArticlePower StripsCMS

I received a question from a reader that I was unable to immediately answer. The question dealt with the use of power strips in a business occupancy: Did the categorical …

Brad Keyes, CHSP | Jan 15, 2015
Shower Curtains (Life Safety Code)ArticleSprinklers

For bathrooms and shower rooms that are protected with automatic sprinklers, do the shower curtains require the same open mesh at the top as privacy curtains used in patients rooms? This …

Brad Keyes, CHSP | Jan 8, 2015
SafetyLife Safety CodeArticle

A reader recently asked me if lit candles are prohibited in a healthcare occupancy? I've researched this before but apparently I never posted anything about this subject. No, the Life Safety …

Brad Keyes, CHSP | Jan 1, 2015
Evacuation (Life Safety Code)ArticleStairwells

We should all know that storage of items in an exit enclosure, such as a stairwell, is not permitted by the Life Safety Code. Right? Well... there are exceptions that would …

Brad Keyes, CHSP | Dec 25, 2014
Joint CommissionSurvey FindingsConstructionArticle

It has always been my belief that as the surveyor team walks in the front door of the hospital on the first day of the survey, all of the contractors …

Brad Keyes, CHSP | Dec 18, 2014
Joint CommissionArticle

I received an email from a client who was confused about the changes to the Joint Commission Plan for Improvement (PFI) list found in the Statement of Conditions (SOC). He …

Brad Keyes, CHSP | Dec 11, 2014
Control ValvesNFPA 99Medical GasArticle

I was recently a bystander amongst a discussion of healthcare facility industry experts, debating the NFPA requirements concerning the accessibility of medical gas shutoff valves in healthcare institutions. The original …

Brad Keyes, CHSP | Dec 4, 2014
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
Life Safety CodeDecorationsArticle

I received the poem below from Jeff Clouse, Safety Officer at Baptist Health in Lexington, KY. He says it is his way of using humor with the staff of his …

Brad Keyes, CHSP | Nov 21, 2014
Construction BarrierLife Safety CodeArticle

I was a co-presenter in a recent HCPro webinar on the new 2012 Life Safety Code along with my good friend and colleague Jim Murphy, and I received quite a …

Brad Keyes, CHSP | Nov 20, 2014
Fire DoorsArticleSmoke CompartmentFire Drills

I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with: The Life Safety …

Brad Keyes, CHSP | Nov 13, 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
ArticleSprinklers

I was conducting a mock survey at a hospital and during the building tour I came to their maintenance shop. They had a spray paint booth and in the booth was a sprinkler …

Brad Keyes, CHSP | Oct 30, 2014
Door LocksArticleDoors

Hospitals want to keep their nurseries, mother/baby units, and pediatric units secure, so they lock the doors. This causes a problem with the Life Safety Code because you can't lock the …

Brad Keyes, CHSP | Oct 23, 2014
Fire AlarmLife Safety CodeArticle

Out of sight is out of mind. It is the master illusionist's greatest asset. He gets you looking at something that is distracting your attention away from the object at …

Brad Keyes, CHSP | Oct 16, 2014
Electrical EquipmentElectricalArticle

Every surveyor has his/her own specialty that they like to look for during a survey. I know of one surveyor that writes up every hospital he surveys if the fire alarm …

Brad Keyes, CHSP | Oct 9, 2014
Life Safety CodeArticleEquipment (Fire Suppression Systems)Sprinklers

NFPA 25 (1998 edition), section 4-3.1 has a requirement listed to test the Private Fire Service Mains once every 5 years. The standard says the test must be performed on exposed fire …

Brad Keyes, CHSP | Oct 2, 2014
ArticlePower StripsCMS

CMS issued a new S&C memo 14-46 in late September that made allowances for healthcare organizations to utilize power strips in patient care areas. CMS has determined that the 2000 …

Brad Keyes, CHSP | Oct 1, 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
DecorationsArticleBulletin Boards

The 2000 Life Safety Code, section 18/19.7.5.4 is pretty clear when it states combustible decorations are not permitted in healthcare occupancies unless they are flame-retardant. Flame-retardant decorations can be purchased, …

Brad Keyes, CHSP | Sep 18, 2014
ExitsEmergency Lights (Life Safety Code)Article

I was talking to a hospital facility manager recently and he was miffed that a surveyor cited him for not having emergency power lighting on the exit discharge outside the …

Brad Keyes, CHSP | Sep 11, 2014
Exit SignsArticleSignage (Life Safety Code)Signs (Life Safety Code)

Why is it that hospital facility managers are often surprised when surveyors ask to see the documentation that their exit signs were inspected on a monthly basis? Probably because no …

Brad Keyes, CHSP | Sep 4, 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
ArticleDocumentation (Life Safety Code)

I never know who is reading (or not reading) my blog, but recently I received the following comment from a state department of public health individual who inspects hospitals. He …

Brad Keyes, CHSP | Aug 21, 2014
ArticleCorridorsDoors

I have seen many facility managers (and surveyors for that matter) incorrectly refer to a door as a 'corridor door'. It appears that they believe as long as the door …

Brad Keyes, CHSP | Aug 14, 2014
ArticleCeilings (Fire Suppression Systems)

Most healthcare organizations have acoustical tile and grid suspended ceilings in a large part of their facilities. They are relatively inexpensive, and allow access to the many mechanical systems that …

Brad Keyes, CHSP | Aug 7, 2014
ArticleTesting (Fire Suppression Systems)Sprinklers

I would like to do some research for an article that I want to write about and I am addressing this appeal to those of you who have an active role in …

Brad Keyes, CHSP | Aug 5, 2014
ArticleCorridorsSmoke CompartmentDoors

I want to clarify a confusing point in the seven-year old CMS S&C memo 07-18 issued April 20, 2007. This is a memo which CMS wanted to explain that corridor …

Brad Keyes, CHSP | Jul 31, 2014
Life Safety CodeArticle

At times we struggle to decide when do new construction requirements (chapter 18 of the LSC) apply and when do existing conditions (chapter 19 of the LSC) apply. CMS seems …

Brad Keyes, CHSP | Jul 24, 2014
Article

[The following information is taken from an online ASHE Advocacy notice, published July 17, 2014, and reprinted here for your information.] The Federal Communications Commission (FCC) has issued a Report and …

Brad Keyes, CHSP | Jul 18, 2014
Life Safety CodeArticleTesting (Life Safety Code)Documentation (Life Safety Code)

My recent series of articles on Documentation created quite a bit of response. One individual had this question: "What is your opinion of documentation being kept electronically rather than in …

Brad Keyes, CHSP | Jul 17, 2014
KitchensExtinguishing SystemsArticle

The fire suppression system that is required to be mounted in kitchen cooking hoods is typically a wet-chemical extinguishing system that automatically releases the extinguishing agent when the system detects …

Brad Keyes, CHSP | Jul 10, 2014
Life Safety CodeArticleTesting (Life Safety Code)Smoke Dampers

What do we do with smoke dampers now that the hospital is fully protected with sprinklers? That question is asked many times by facility managers who are looking to cut …

Brad Keyes, CHSP | Jul 3, 2014
Joint CommissionArticleCMS

I suspect most of you didn't give this much thought, but ever since 2009, The Joint Commission has had to apply to CMS for their deeming authority to survey hospitals …

Brad Keyes, CHSP | Jul 1, 2014
Electrical EquipmentArticlePower Strips

There has been a lot of discussion about power strips (or relcoatable power taps, as some authorities call them) lately, and most of it is not to our advantage. None …

Brad Keyes, CHSP | Jun 30, 2014
Emergency Response Plan (Accreditation/CertificatiArticleEyewash Stations

Emergency showers are often found in hospital laboratories and at times, in plant operation areas. There seems to be some confusion about emergency showers and eyewash stations, and what is …

Brad Keyes, CHSP | Jun 26, 2014
Survey FindingsArticle

When I was a surveyor for Joint Commission, I had a few surveys where the hospital invited their consultant to join in on the building tour. Back then surveys were …

Brad Keyes, CHSP | Jun 19, 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
Joint CommissionLife Safety CodeEquivalenciesArticleCMS

As a result of the June 4, 2014 online announcement by The Joint Commission which identified major changes for the Statement of Condition Plan for Improvement (PFI) list, they also …

Brad Keyes, CHSP | Jun 6, 2014
Joint CommissionLife Safety CodeArticleCMS

Since yesterday, I have received a lot of emails and calls concerning the Joint Commission announcement on changes to their PFI list. On Wednesday, June 4, 2014, Joint Commission published …

Brad Keyes, CHSP | Jun 6, 2014
Life Safety CodeArticle

The following are the final comments that I will make in response to CMS's proposed rule to adopt the 2012 Life Safety Code. NFPA 101A Guide on Alternative Approaches to …

Brad Keyes, CHSP | Jun 6, 2014
Joint CommissionLife Safety CodeArticleCMS

Yesterday, Joint Commission published an online notice of changes to their survey decision reports effective July 1, 2014, that effectively eliminates the strategic advantage of healthcare organizations self-reporting Life Safety …

Brad Keyes, CHSP | Jun 5, 2014
Life Safety CodeArticleFire/Smoke DampersTesting (Life Safety Code)

Many of you may be familiar with the Joint Commission's standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose …

Brad Keyes, CHSP | Jun 5, 2014
Life Safety CodeArticle

The following is one of many comments that I will make in response to CMS's proposed rule to adopt the 2012 Life Safety Code. CMS statement: “We also propose to …

Brad Keyes, CHSP | Jun 4, 2014
Life Safety CodeArticle

The following is one of many comments that I will make in response to CMS's proposed rule to adopt the 2012 Life Safety Code. CMS statement: Sections 18/19.3.5 of the …

Brad Keyes, CHSP | Jun 3, 2014
Life Safety CodeArticle

The following is one of many comments that I will make in response to CMS's proposed rule to adopt the 2012 Life Safety Code. CMS statement: Sections 18/19.4.2 of the …

Brad Keyes, CHSP | May 30, 2014
GeneratorsArticle

NFPA 110 (1999 edition) requires generators to be located in a dedicated room, separated from all other areas and spaces by 2-hour fire rated barriers. NFPA 110 is very clear …

Brad Keyes, CHSP | May 29, 2014
Life Safety CodeArticle

The following is one of many comments that I will make in response to CMS's proposed rule to adopt the 2012 Life Safety Code. CMS statement: Sections 18/19.2.3.4 (2) 2012 …

Brad Keyes, CHSP | May 28, 2014
Life Safety CodeArticle

The following is one of many comments that I will make in response to CMS's proposed rule to adopt the 2012 Life Safety Code. CMS statement: “We do not consider …

Brad Keyes, CHSP | May 27, 2014
Main DrainLife Safety CodeArticleSprinklers

NFPA 25 (1998 edition) section 9-2.6 says main drain tests are to be conducted annually at each sprinkler system riser to determine if there has been a change in the …

Brad Keyes, CHSP | May 22, 2014
Fire AlarmLife Safety CodeArticleTesting (Life Safety Code)Documentation (Fire Detection Systems)

Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings …

Brad Keyes, CHSP | May 15, 2014
ArticleStairwells

Stairwell interruption gates are those bars or half-size gates that are mounted inside the stairwells on the level of exit discharge. they swing freely allowing exiting in the direction of …

Brad Keyes, CHSP | May 8, 2014
ArticleDocumentation (Life Safety Code)

This is the last in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during …

Brad Keyes, CHSP | May 1, 2014
ArticleDocumentation (Fire Suppression Systems)

This is the third in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during …

Brad Keyes, CHSP | Apr 24, 2014
ArticleDocumentation (Fire Detection Systems)

This is the second in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during …

Brad Keyes, CHSP | Apr 17, 2014
Life Safety CodeArticle

The Centers for Medicare & Medicaid Services (CMS) today announced a proposed rule on the adoption of updated life safety code (LSC) that CMS would use in its ongoing work …

Brad Keyes, CHSP | Apr 14, 2014
ArticleDocumentation (Life Safety Code)

This is the first in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during …

Brad Keyes, CHSP | Apr 10, 2014
Joint CommissionMedical GasArticle

Did you notice the January 29, 2012 issue of the Joint Commission Online? Among other articles, they had an article called "Clarification of storage requirements for freestanding medical gas cylinders" …

Brad Keyes, CHSP | Mar 20, 2014
Fire AlarmGeneratorsArticle

Does your fire alarm system monitor the emergency power generator? It may have to. Section 1-5.8.7 of NFPA 72 (1999) requires the fire alarm system to monitor the primary and …

Brad Keyes, CHSP | Mar 13, 2014
Life Safety CodeFire PumpArticle

A friend of mine contacted me recently and told me that his fire pump caught on fire. It was an engine driven (diesel) fire pump, and I'll let him describe …

Brad Keyes, CHSP | Mar 6, 2014
Ambulatory Care OccupancyDoor LocksArticle

A friend of mine was working on a project involving ambulatory health care occupancy, and they wanted to use a delayed egress lock on an interior door. The 2000 Life Safety …

Brad Keyes, CHSP | Feb 27, 2014
WaiversArticleCMS

I have been receiving some feedback from friends and readers of the Keyes Life Safety Compliance website concerning the CMS categorical waivers. One of the issues seems to focus around …

Brad Keyes, CHSP | Feb 20, 2014
Q&AArticleStairwells

Q: Can evacuation chairs be installed in stairwells? A: The answer is… maybe yes and maybe no. Sorry, that’s not a direct answer, so please allow me to explain. Section …

Brad Keyes, CHSP | Feb 17, 2014
Life Safety CodeArticle

I apologize to you up front if this blog posting is not on the usual topic of life safety for healthcare facilities, but sometimes I just need to say something that …

Brad Keyes, CHSP | Feb 13, 2014
ArticleFire Drills

Take a look at the picture to the left. Here is a container sitting on top of a desk, and it appears to be on fire. Only it is not an …

Brad Keyes, CHSP | Feb 6, 2014
Survey FindingsArticle

Today, I complete my series on clarifications for surveyor findings that I have written for a client. Clarification for LS.02.01.30, EP 11 LS.02.01.30, EP 11: Corridor doors are fitted with …

Brad Keyes, CHSP | Jan 30, 2014
Survey FindingsArticle

I continue my series on clarifications of surveyor findings that I have written for a client. Clarification for LS.02.01.20, EP 30 LS.02.01.20, EP 30: Signs reading “No Exit” are posted …

Brad Keyes, CHSP | Jan 23, 2014
Survey FindingsArticle

I continue my series on clarifications of surveyor findings that I have written for a client. Clarification for LS.02.01.10, EP 9 LS.02.01.10, EP 9: The spaces around pipes, conduits, bus …

Brad Keyes, CHSP | Jan 16, 2014
Survey FindingsArticle

I continue my series on clarifications of surveyor findings that I have written for a client. Clarification for EC.02.06.01, EP 13 EC.02.06.01, EP 13: The hospital maintains ventilation, temperature, and …

Brad Keyes, CHSP | Jan 9, 2014
Emergency Response Plan (Accreditation/CertificatiArticleCMS

The Centers for Medicare & Medicaid Services (CMS) has issued a new proposed rule in the Federal Register on Friday, December 27, 2013. This is a Notice of Proposed Rulemaking …

Brad Keyes, CHSP | Jan 3, 2014
Survey FindingsArticle

I continue my series on clarifications of surveyor findings that I have written for a client. Clarification for EC.02.05.01, EP 8 EC.02.05.01, EP 8: The hospital labels utility system controls …

Brad Keyes, CHSP | Jan 2, 2014
Joint CommissionArticleFire/Smoke DampersSmoke Dampers

There seems to be much discussion lately on how to manage the Joint Commission Statement of Conditions Plans For Improvement (PFI) on inaccessible dampers. Joint Commission has instructed healthcare organizations …

Brad Keyes, CHSP | Dec 27, 2013
Survey FindingsArticle

I continue my series on clarifications of surveyor findings that I recently wrote for a client: Clarification for EC.02.05.01, EP 4 EC.02.05.01, EP 4: The hospital identifies, in writing, the …

Brad Keyes, CHSP | Dec 26, 2013
Article

Merry Christmas and Happy New Year to you and your loved ones! From Brad Keyes …

Brad Keyes, CHSP | Dec 25, 2013
Survey FindingsArticle

I'm going to post some clarifications of surveyor findings that I wrote recently for a client. Some were accepted by the accreditor and some were not. I thought you might …

Brad Keyes, CHSP | Dec 19, 2013
SuitesArticle

An interesting question came up the other day concerning suites: “Just because one room has its path of egress through an intervening room, does it have to be identified as …

Brad Keyes, CHSP | Dec 12, 2013
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 CodeGeneratorsArticleTesting (Life Safety Code)

As mentioned in last week's posting, The Joint Commission announced changes to their standards that takes affect January 1, 2014. We discussed already the change they are making with time …

Brad Keyes, CHSP | Nov 7, 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
Construction BarrierLife Safety CodeArticle

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code …

Brad Keyes, CHSP | Oct 3, 2013
ArticleFire Drills

Published February 24, 2012 in "The Hindu" newspaper: A fire drill at a garment factory went horribly wrong on Friday when a rope snapped sending a woman employee plummeting to …

Brad Keyes, CHSP | Sep 26, 2013
NFPA 99Medical GasArticle

I received this picture recently from a good friend who works in a hospital, and is responsible for plumbing and power plant operation. He wanted to know if the medical …

Brad Keyes, CHSP | Sep 19, 2013
Fire AlarmArticle

For obvious reasons, fire alarm systems are required to have two sources of electrical power sources according to NFPA 72 (1999 edition), section 1-5.2; a reliable primary source and a standby …

Brad Keyes, CHSP | Sep 12, 2013
WaiversLife Safety CodeArticle

CMS just issued another S&C memo describing the process for hospitals and nursing homes can take advantage of additional categorical waivers for some of the new 2012 Life Safety Code issues right away, …

Brad Keyes, CHSP | Sep 6, 2013
Life Safety CodeArticleSprinklers

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code …

Brad Keyes, CHSP | Sep 5, 2013
ArticleHeadroom

Another area of the Life Safety Code that is not well known by many is the requirement for headroom, which is defined as the distance between the floor and the …

Brad Keyes, CHSP | Aug 29, 2013
ArticleCorridors

When does a wide spot in the corridor have to meet the requirements for areas open to the corridor? This question was raised to me in regards to a clean linen …

Brad Keyes, CHSP | Aug 22, 2013
ArticleCorridorsDoors

I was recently asked what the Life Safety Code required for the thickness and composition of a corridor door in new healthcare occupancy construction. The individual asking me the question …

Brad Keyes, CHSP | Aug 15, 2013
Life Safety CodeFire ExtinguishersArticle

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code …

Brad Keyes, CHSP | Aug 8, 2013
Article

I don't normally write about personal things in my life, mainly because I figure no one would be interested. But I feel I owe you some sort of explanation why …

Brad Keyes, CHSP | Aug 2, 2013
ArticleEquipment (Fire Suppression Systems)

I ran across this fire hydrant while I was in southern California. It appears to me that the organization has failed to conduct basic routine inspections since the cap is …

Brad Keyes, CHSP | May 23, 2013
Life Safety CodeElevatorsArticleTesting (Life Safety Code)

One of the requirements that CMS and Joint Commission surveyors is requesting from hospitals and nursing homes is documentation that the elevators have been tested for 'Recall'. Elevator recall is a test …

Brad Keyes, CHSP | May 16, 2013
ArticleEyewash Stations

Eye wash stations are required wherever there is a possibility that caustic or corrosive chemicals could splash into the eye of an individual. It is important to note that blood …

Brad Keyes, CHSP | May 9, 2013
Door LocksArticleDoors

If you search my website on door locks, you will find a few entries concerning dead-bolt locks. For decades hospitals seem to have installed dead-bolt locks on any door they …

Brad Keyes, CHSP | May 2, 2013
Life Safety CodeArticleClarification

The key to life safety compliance is education. Relating better to caregivers will open their eyes about the important of Life Safety Code® (LSC) requirements. The situation with nurses not …

Brad Keyes, CHSP | Apr 25, 2013
Fire AlarmDoor LocksArticle

Outside of the healthcare setting, locks on doors are utilized nearly everywhere we go, and we don’t give it much of a thought. But in the highly regulated industry of …

Brad Keyes, CHSP | Apr 18, 2013
FireplacesArticle

Gas fireplaces inside a hospital, just doesn't seem to be a good idea, at least not to me. I remember telling my COO at the hospital where I used to …

Brad Keyes, CHSP | Apr 11, 2013
Life Safety CodeArticleSprinklers

Why do we need the Life Safety Code? This is a question that I am frequently asked by individuals who do not understand what all the fuss is about that …

Brad Keyes, CHSP | Apr 4, 2013
Electrical EquipmentArticle

I am often asked if locks on electrical panels are required, or where in the world does it say in the Life Safety Code that we need to lock our …

Brad Keyes, CHSP | Mar 28, 2013
VentilationArticleHVAC

I was asked recently if the ventilation requirements for Endoscopy procedure rooms have changed recently, and the answer is yes. But the changes only apply to new construction, meaning you …

Brad Keyes, CHSP | Jan 10, 2013
Portable Space HeatersArticleHVAC

As I write this posting, it is very cold in Northern Illinois. Keeping a healthcare facility warm and cozy for staff is always a challenge in cold weather, but one …

Brad Keyes, CHSP | Jan 6, 2013
Joint CommissionLife Safety CodeArticleCMS

What process should be used to take advantage of the recent CMS correspondence that deals with allowing mobile equipment, such as patient lifts and gurneys in the corridors? To refresh your memory, CMS S&C …

Brad Keyes, CHSP | Dec 27, 2012
ArticleSmokingSafety Management

My good friend Tom Cuthrell, Safety Officer at CarolinaEast Health System in New Bern, NC wanted to know if Joint Commission has said anything about the use of electronic cigarettes …

Brad Keyes, CHSP | Dec 20, 2012
Business OccupanciesArticleFire Drills

Here is a scenario: A hospital has multiple 'quick draw' blood stations scattered across the community in which they are located. These blood draw stations are situated in other occupancies, …

Brad Keyes, CHSP | Dec 13, 2012
ArticleSafety Management

I was recently in a meeting at a regional hospital where the CEO walked in, sat down, and started to address the group. She had this stuffed monkey on her …

Brad Keyes, CHSP | Dec 7, 2012
DecorationsArticle

Holiday season is upon us and hospital and nursing home facility managers begin the struggle with decorations that do not meet the Life Safety Code requirements. The most common deficiency …

Brad Keyes, CHSP | Dec 6, 2012
ArticleStairwellsSignage (Life Safety Code)Signs (Life Safety Code)

A question came up recently as to the proper mounting of the stairwell identification signs that are required in stairwells of a certain height. The  wall-mounted stair identification signs are supposed …

Brad Keyes, CHSP | Dec 6, 2012
Fire ExtinguishersArticle

Fire extinguisher training... Is it required in healthcare organizations? And what level of training is required? Is hands-on training required where the discharge of the extinguisher is acheived? Or is a simple …

Brad Keyes, CHSP | Nov 29, 2012
ArticleInfection Control

This post may not be about a Life Safety Code deficiency, but it may be of some relevance to those healthcare organizations that are Joint Commission accredited, and how their …

Brad Keyes, CHSP | Nov 22, 2012
ArticleEyewash Stations

I was out all last week and when I returned to my office I was inundated with comments (complaints, really) as to why the portable squeeze bottles are not a …

Brad Keyes, CHSP | Nov 15, 2012
ArticleSafety Management

OK... I am not talking about spontaneous HUMAN combustion here, just the good ol' garden variety type. You know... wet towels and blankets starting on fire? Don't think it doesn't …

Brad Keyes, CHSP | Nov 8, 2012
Article

(Just a friendly reminder) …

Brad Keyes, CHSP | Nov 6, 2012
ArticleSafety Management

I frequently get asked to comment on the role of the Safety Officer in healthcare. Who should the Safety Officer report to? What qualifications or background should the Safety Officer have? …

Brad Keyes, CHSP | Nov 1, 2012
Life Safety CodeArticle

I remember when... Doesn't that sound pathetic? If I say "I remember when...", then that makes me one of the old-timers, right? But I actually do remember my dad and my …

Brad Keyes, CHSP | Oct 25, 2012
Fire ExtinguishersArticle

I have a confession to make... I don't know it all. I never have and never will. For those of you who know me, I'm sure you're laughing at me …

Brad Keyes, CHSP | Oct 18, 2012
ArticleSprinklers

Frequently, I am asked why do healthcare organizations need to know where their quick response (QR) sprinkler heads are located? If you facility is similar to most, then you likely …

Brad Keyes, CHSP | Oct 11, 2012
NFPA 99Electrical EquipmentArticle

I was recently asked how Joint Commission and other authorities look at electrical items used by staff that do not come into contact with patients, such as refrigerators, fans, coffee pots …

Brad Keyes, CHSP | Oct 4, 2012
Life Safety CodeArticleSignage (Life Safety Code)

Last July 5 I posted an article on conflicting and confusing signage, in regards to hospitals and nursing homes. The posting dealt with situations where I had observed (and took pictures) …

Brad Keyes, CHSP | Sep 27, 2012
Business OccupanciesLife Safety CodeArticle

Many hospitals have facilities located offsite or adjacent to the main building which are classified as business occupancies. These buildings may be physician's offices, clinics, administrative buildings and storage faclities …

Brad Keyes, CHSP | Sep 20, 2012
Emergency Lights (Life Safety Code)Article

A question came up recently asking what the NFPA requirements are for installing battery-powered emergency lighting in anesthetizing locations. For purposes of clarification, NFPA 99 (1999 edition), section 2-2 defines …

Brad Keyes, CHSP | Sep 13, 2012
Life Safety CodeDoor LocksArticle

NOTE: My good friend Lori Greene from Ingersoll Rand Security Technologies had this comment posted on her website /blog: www.idighardware.com last August 15th, addressing the testing requirements for delayed egress locks I …

Brad Keyes, CHSP | Sep 6, 2012
Life Safety CodeArticle

Please forgive the lack of subtlety but I need you to be aware that there is a webinar/audio-conference next week (Monday, September 10, 2012) at 1:00 pm EDT on the …

Brad Keyes, CHSP | Sep 4, 2012
Life Safety CodeArticleSprinklers

According to the 2000 edition of the Life Safety Code, main drain tests are regulated by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, …

Brad Keyes, CHSP | Aug 30, 2012
Inspection & Maintenance (Fire Suppression SysArticleTesting (Fire Suppression Systems)Sprinklers

Main drain tests are required by section 9.7.5 of the 2000 edition of the Life Safety Code, which requires sprinklers systems to be tested and maintained according to NFPA 25 …

Brad Keyes, CHSP | Aug 28, 2012
Fire DoorsArticle

Free Webinar: NFPA 80, Inspection, Testing, and Maintenance of Swinging Fire Doors Sponsored by DHI, FDAI, Door Security & Safety Foundation, & Intertek August 28, 12:30 – 2:00 pm EST …

Brad Keyes, CHSP | Aug 24, 2012
Business OccupanciesArticleGas Cylinders

I was recently asked what the requirements were for storing compressed gas cylinders in a business occupancy. According to section 1-2, NFPA 99 (1999 edition) applies to all health care facilities, …

Brad Keyes, CHSP | Aug 23, 2012
Door LocksArticle

I was recently asked to explain the difference between delayed egress (DE) locks and access controll (ACE) locks, and what are their applications. The main difference between DE and ACE locks …

Brad Keyes, CHSP | Aug 16, 2012
Life Safety CodeEquivalenciesArticleSprinklersConstruction Types

This may seem basic to some of you, but one of the problems in the healthcare facilities management industry is people don't always have a good solid foundation of the …

Brad Keyes, CHSP | Aug 9, 2012
Fire DoorsArticle

I ran across a vendor called Fire Door Solutions, Inc. (www.firedoorsolutions.com) who has come up with a unique solution for those pesky penetrations in fire rated doors. On older fire …

Brad Keyes, CHSP | Aug 2, 2012
ArticleDocumentation (Life Safety Code)

I get asked this question from time to time..."How long must I keep test and inspections reports?" My answer has always been... Forever. Don't throw anything out. You never know …

Brad Keyes, CHSP | Jul 26, 2012
Professional OrganizationsArticle

I just returned from the American Society for Healthcare Engineering (ASHE) annual conference, this year held in San Antoinio, TX. Great city and a great conference. I always enjoy attending …

Brad Keyes, CHSP | Jul 20, 2012
KitchensHazardous AreasArticle

If you read my Q&A on kitchens being hazardous areas, which was posted last Sunday (July 8th), then you may have been surprised by my position that kitchens are considered …

Brad Keyes, CHSP | Jul 12, 2012
ArticleSigns (Life Safety Code)

Just like a policy or a management plan, CMS, Joint Commission, HFAP and DNV surveyors will hold you accountable to what your signage is telling you. If a sign is …

Brad Keyes, CHSP | Jul 5, 2012
Life Safety CodeArticle

Hospital construction is a highly regulated industry as evidenced by the numerous authorities that have standards and regulations concerning how a hospital is to be constructed. Building and fire safety …

Brad Keyes, CHSP | Jun 20, 2012
Life Safety CodeArticle

A question came up recently: "Is the Life Safety Specialist a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and …

Brad Keyes, CHSP | Jun 15, 2012
ArticleSprinklers

Here's a quick quiz: How many spare sprinkler heads are you required to have on hand at your facility? If you said 6, then you would be partially correct. The …

Brad Keyes, CHSP | Jun 13, 2012
ArticleSafety Management

When I travel around the country and conduct building inspections at hospitals for compliance with the Life Safety Code, I seem to always find things that surprise me. Just when …