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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.

Power StripsCMS

Q: Our company provides nursing home services. Now that the 2012 LSC has been adopted, does the CMS Survey and Certification Letter 14 - 46 still apply? In reviewing the …

Brad Keyes, CHSP | May 15, 2020
WaiversAccreditation/CertificationAccreditationCOVID-19CMS

As reported on this website last week, CMS issued a formal communication on April 29, 2020, that granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance …

Brad Keyes, CHSP | May 12, 2020
WaiversAccreditation/CertificationAccreditationCOVID-19CMS

In a formal communication issued April 29, 2020, CMS granted 1135 blanket waivers on Physical Environment items for Inspection, Testing & Maintenance (ITM). Refer to page 23 of the following …

Brad Keyes, CHSP | May 7, 2020
Inspection & Maintenance (Life Safety Code)Joint CommissionTesting (Generators)Testing (Facilities Management)Testing (Fire Suppression Systems)Testing (Life Safety Code)AccreditationTesting (Fire Detection Systems)CMSTesting (Medical Gas)Testing (Accreditation/Certification)Fire Drills

Q: Has there been an update to the definition of time by TJC/CMS? I'm looking at quarterly fire drills right now, but any changes/clarification on the definition for all intervals …

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

Q: I have a question about delayed egress locks in nursing homes. Can you have more than one door equipped with delayed egress locks in a path of egress? I …

Brad Keyes, CHSP | Apr 13, 2020
Emergency Response Plan (Accreditation/CertificatiWaiversAccreditation/CertificationAccreditationCOVID-19CMS

During this period of COVID-19 crisis, many readers have written asking if they can discontinue conducting routine Life Safety tests and inspections in order to limit service technicians from entering …

Brad Keyes, CHSP | Apr 7, 2020
Fire/Smoke DampersCMSFire & Smoke Dampers

Q: A California Life Safety Code surveyor enforcing the 2012 edition of the LSC asked for a map of all of the smoke and fire dampers in the building (skilled …

Brad Keyes, CHSP | Mar 30, 2020
Accreditation/CertificationCMS

According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud financial losses are in the tens of billions of dollars each year. A conservative estimate is 3% of total …

Brad Keyes, CHSP | Mar 12, 2020
SuitesEmergency DepartmentCMS

Q: If an Emergency Department is greater than 7500 square feet but less than 10,000 square feet and is deemed to have "sleeping accommodations", do the requirements of direct visual …

Brad Keyes, CHSP | Nov 22, 2019
CorridorsPatient RoomsDoorsCMS

Q: A deficiency was found by CMS on a recent survey that stated 'staff failed to provide a safe and hazard free environment by not having all doors protecting corridor …

Brad Keyes, CHSP | Nov 20, 2019
Waiting AreaCMS

Q: I am looking at a hospital facility with an Ambulatory Surgery Center in an existing building that is a Business Occupancy and construction type – II (222). We are …

Brad Keyes, CHSP | Sep 27, 2019
New Construction vs. Existing ConstructionCMS

Q: How do we classify existing versus new construction? Do we look at the date of adoption of the current Life Safety Code as the cutoff? Anything constructed before that …

Brad Keyes, CHSP | Aug 21, 2019
Smoke BarrierFire DoorsAccreditationCMS

Q: The Joint Commission standard for annual door testing states "The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of …

Brad Keyes, CHSP | Aug 14, 2019
NFPA 99Risk AssessmentAccreditationCMS

Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has …

Brad Keyes, CHSP | Jul 24, 2019
NFPA 99Risk AssessmentCMS

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk …

Brad Keyes, CHSP | Jul 10, 2019
Medical EquipmentAccreditationCMS

Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the …

Brad Keyes, CHSP | Jun 17, 2019
Emergency Response Plan (Facilities Management)CMS

Q: Regarding the new CMS rule on emergency preparedness, are they telling us that we must have full heating and cooling support for the entire hospital during a power outage …

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

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director? A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (ie …

Brad Keyes, CHSP | Apr 29, 2019
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
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
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
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
Q&AWaiversCMS

Q: If a building changes ownership, do waivers stay active with their 1-year window or do the new owners have to resubmit if the building is cited the same deficiency? …

Brad Keyes, CHSP | Oct 31, 2017
Q&APower StripsCMS

Q: There is so much discussion on the proper use of power strips that it can cause confusion amongst even the seasoned facility managers. There is absolutely no guarantee that …

Brad Keyes, CHSP | Oct 10, 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
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
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
Q&ACMS

Q: I recently had a state validation inspection and wanted to get some clarification on a few their findings: “K 353: The facility failed to provide complete visual observation checklist …

Brad Keyes, CHSP | Mar 7, 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
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 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
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
Q&AJoint CommissionCMS

Q: Can you provide some clarification? The NFPA 101 2012 edition was adopted July 5th is that correct? Joint Commission and CMS will not be reviewing using this current edition …

Brad Keyes, CHSP | Aug 31, 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
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
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
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
Q&AVentilationCMS

Q: The Centers for Medicare & Medicaid Services (CMS) standard §482.41(c)(4) states in their Interpretative Guidelines that hospitals must comply with the Facilities Guidelines Institute (FGI) for ventilation in anesthetizing …

Brad Keyes, CHSP | Oct 9, 2015
Q&AVentilationCMS

Q: What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals? I see where we are supposed to test and know what …

Brad Keyes, CHSP | Sep 11, 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
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
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
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
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
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
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
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
ArticleCMS

The Centers for Medicare & Medicaid Services (CMS) released a new memo (S&C-12-21-LSC) to their State Survey Agencies on Friday, March 9, 2012. In the memo was instructions on how …

Brad Keyes, CHSP | Mar 15, 2012

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