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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.

CorridorsDoors

Q: We have an existing healthcare occupancy hospital that is fully sprinklered. My questions are: 1) Are the corridor walls required to be smoke tight? 2) Are the corridor doors …

Brad Keyes, CHSP | Nov 18, 2020
Doors

Q: Does the inactive door on a set of double doors protecting a hazardous area require a door closer? Can the latching mechanism on the inactive door be an automatic …

Brad Keyes, CHSP | Oct 19, 2020
Fire DoorsDoors

Q: One of our exit stairwells at our hospital has a door the leads outside at ground level. The exterior door is not fire rated. Does it need to be …

Brad Keyes, CHSP | Sep 30, 2020
StairwellsDoorsStairs

Q: In my hospital, they have installed electronic hardware on stairwell doors that allows the door to latch on activation of the fire alarm only. The reason was patient complaints …

Brad Keyes, CHSP | Sep 18, 2020
Doors

Q: Can you place frosting on the vision panel glazing (windows) of the doors? A: That’s a good question. If the vision panel is required in the door, then I …

Brad Keyes, CHSP | Aug 7, 2020
Doors

Q: We were cited during a recent survey for not having our power assist doors to our ICU suite connected to the fire alarm system. I thought that was only …

Brad Keyes, CHSP | Jul 24, 2020
Doors

Q: Are new cross-corridor doors that are strictly privacy doors (not part of any smoke or fire barrier) required to be double egress? I can't seem to find it in code …

Brad Keyes, CHSP | Jun 3, 2020
Fire DoorsFire BarrierDoors

Q: Is there a standard ratio from the firewall to the fire door (Ex. 2-hour firewall should have a XX min fire door)? A: Well, yes and no. Table 8342 …

Brad Keyes, CHSP | May 13, 2020
CorridorsDoors

Q: We have quite a few rooms throughout our facility that initially required automatic closing and latching hardware for fire requirements. These rooms have now been 'converted' to office use, …

Brad Keyes, CHSP | Apr 22, 2020
CorridorsDoors

Q: Is it allowed to disable a corridor door's closer by removing the arm in order to keep it open while working inside of the office in a healthcare facility? I …

Brad Keyes, CHSP | Mar 11, 2020
Hazardous AreasDoorsOperating Room

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

Brad Keyes, CHSP | Jan 22, 2020
SuitesCorridorsDoors

Q: Does the 2012 edition of the Life Safety Code permit existing suite doors that open into the corridor to be compliant if they do not latch shut? We have …

Brad Keyes, CHSP | Jan 20, 2020
Doors

Q: I need you to settle an argument for us, and your answer will settle this situation for all. We have a fire door to a hazardous room, that has …

Brad Keyes, CHSP | Jan 10, 2020
Door LocksStairwellsDoors

Q: I'm a Facilities Director overseeing an existing 8-story (basement included) acute care hospital fully sprinklered. We wish to mechanically lock (no auto unlock feature) floors 2-7 (Floor one being …

Brad Keyes, CHSP | Nov 25, 2019
CorridorsPatient RoomsDoorsCMS

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

Brad Keyes, CHSP | Nov 20, 2019
CorridorsDoors

Q: Someone just asked me a question and I haven’t thought about this one before. This AHJ is enforcing the IBC but I’m looking for an NFPA viewpoint and of …

Brad Keyes, CHSP | Nov 18, 2019
DoorsPositive Latching

Q: I read recently that Joint Commission allows a door with a power operator to not have to positively latch as long as it has 5-lbs. of force keeping it …

Brad Keyes, CHSP | Nov 1, 2019
Door LocksDoors

Q: I have been asked by a clinic manager at one of our primary care clinics to install a door knob on a split Dutch type door that goes into …

Brad Keyes, CHSP | Aug 28, 2019
Fire DoorsDoors

Q: My boss has hired an outside company that has advised him to rip fire rating labels off of doors and frames that we have maintained properly for decades. We …

Brad Keyes, CHSP | Jul 26, 2019
DoorsPositive Latching

Q: My department is assisting with a fire/smoke barrier door assessment. I have noticed that some of the ¾-hour corridor doors have had the lower bottom rods removed from the …

Brad Keyes, CHSP | Jun 28, 2019
DoorsPositive Latching

Q: My question is regarding a 2-hour fire-rated wall that is separating our physical therapy department and the main hospital. In between the two is a long glass hallway with …

Brad Keyes, CHSP | May 17, 2019
Fire DoorsCorridorsDoors

Q: We have an engineer who is telling us that the 2012 Life Safety Code requires our corridor doors to be fire-rated. He is referencing Table 8.3.4.2 which says exit-access …

Brad Keyes, CHSP | Feb 22, 2019
Fire DoorsFire BarrierDoors

Q: If the health care facility is fully sprinklered do doors in a corridor, where the walls are fire rated, do the doors have to be fire rated? I read …

Brad Keyes, CHSP | Feb 1, 2019
Door LocksDoors

Q: Is there a Life Safety Code requirement for door lever hardware to have a return, so as to not "hook" passing clothing, straps, purses during emergency evacuations? I swear …

Brad Keyes, CHSP | Jan 9, 2019
DrawingsCorridorsDoors

Q: Are closet doors located inside a corridor considered corridor doors and do they have to meet life and safety codes referring to corridor doors? A: It depends…. What does …

Brad Keyes, CHSP | Jan 4, 2019
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
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
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
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
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
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
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
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
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
Q&AHardwareDoors

Q: I heard in a webinar that under the 2012 edition of the Life Safety Code, I can you have two releasing devices on doors. Is this true? A: Yes, …

Brad Keyes, CHSP | Dec 18, 2017
SuitesQ&ACorridorsDoors

Q: A hospital has 2 different suites with double egress entry doors and the Joint Commission surveyor noted that these doors are supposed to have latching hardware because they are …

Brad Keyes, CHSP | Dec 15, 2017
Q&AHardwareDoors

Q: Do entrance doors to x-ray rooms and CT scanner rooms have to be controlled by door closers? A: According to the Life Safety Code, they only need closers if …

Brad Keyes, CHSP | Dec 13, 2017
Q&AFire DoorsDecorationsDoors

Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape …

Brad Keyes, CHSP | Dec 12, 2017
Q&AHardwareDoors

Q: Our hospital has round door knobs to latch cross corridor smoke doors. I am thinking this is not okay. Does the Life Safety Code address this? A: Other than …

Brad Keyes, CHSP | Nov 6, 2017
SuitesQ&ACorridorsDoors

Q: We have a double egress, cross-corridor door which will enter a suite under a renovation project. The suite wall is also an existing smoke barrier wall, separating smoke compartments …

Brad Keyes, CHSP | Oct 23, 2017
Q&ADoorsAnteroom

Q: We have an isolation room next to a nurse station in the Emergency room. The corridor door to the Anteroom has a door closer on it. My question: does …

Brad Keyes, CHSP | Oct 18, 2017
Q&ADoor LocksDoors

Q: Is it allowed to use door wedges to keep the exam doors locked? If an intruder enters our hospital, there was some talk about using the door wedges to …

Brad Keyes, CHSP | Sep 14, 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
Smoke BarrierQ&ADoors

Q: Are smoke barrier doors and frames required to have a fire rating label? A: No. This seems to be a difficult issue for many people (including surveyors) to grasp …

Brad Keyes, CHSP | Aug 25, 2017
Smoke BarrierQ&ATesting (Life Safety Code)Doors

Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 7.2.1.15.2 of the 2012 Life Safety Code says smoke door assemblies have to be …

Brad Keyes, CHSP | Aug 23, 2017
Q&AFire DoorsDoors

Q: What is the maximum you can have between the bottom of door and the thresholds for a fire-rated door assembly? I have some stairwell doors with 1 inch to …

Brad Keyes, CHSP | Jul 12, 2017
Q&AFire DoorsDoors

Q: It has been our practice to not allow door hold open wedges on any door within the hospital. As far as code requirements go is it rated doors only, …

Brad Keyes, CHSP | Jul 5, 2017
Q&AFire DoorsDoorsWalls

Q: Is it permissible to completely cover a fire rated door in a hospital with a polyvinyl picture/mural? Also, is it permissible to cover a fire rated wall, from floor …

Brad Keyes, CHSP | Jun 5, 2017
Q&AHardwareDoors

Q: I have been asked about the requirements for the use of the lower bottom rod hardware in cross-corridor egress doors which provide positive latching and building separation. For aesthetic …

Brad Keyes, CHSP | May 1, 2017
Q&ADoorsPositive Latching

Q: Is positive latching required for any fire rated door in any occupancy classification? If so, are there any exceptions? What about double egress corridor doors; are they required to …

Brad Keyes, CHSP | Apr 7, 2017
Q&ADoors

Q: Does a corridor door that serves an office have to swing into the office? The office is on a patient floor and the door does not serve as any …

Brad Keyes, CHSP | Apr 5, 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
Q&AConstructionDoors

Q: Does a door that accesses a construction site within a hospital need to have an automatic closer installed on the access door? What if the door is constructed within …

Brad Keyes, CHSP | Mar 3, 2017
Q&AHardwareDoors

Q: We have “clinic” type areas within suites. Some of these doors that lead to the main corridor for egress, have regular “turn handle” type handles. Not panic hardware. What …

Brad Keyes, CHSP | Feb 27, 2017
Q&ACorridorsDoors

Q: Is there a code that says anything about adding a vent through a door that is in the corridor of our hospital? A: Well… you might be able to …

Brad Keyes, CHSP | Feb 8, 2017
Q&AHardwareDoors

Q: I am a consultant and I am surveying a system where the bottom strike rod and the floor receiver have been removed. I think this "field" modification may void …

Brad Keyes, CHSP | Jan 19, 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
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
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
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
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
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
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
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
Q&AMedical GasStorage (Medical Gas)Doors

Q: I have an existing medical gas storage room in an outpatient surgery center that was constructed with 1-hour barriers and ¾ hour fire rated door. A surveyor cited me …

Brad Keyes, CHSP | May 25, 2015
Q&ADoorsSoiled Utility RoomSigns (Life Safety Code)

Q: Are you aware of any door signage requirements for soiled utility rooms and/or trash rooms? A: There is no Life Safety Code requirement for signs on a soiled utility …

Brad Keyes, CHSP | Apr 20, 2015
Q&AFire DoorsDoorsSigns (Life Safety Code)

Q: Are hand-made temporary directional signs permitted to be taped to fire doors? We had a surveyor tell us that nothing can be taped to a fire door. A: Yes, …

Brad Keyes, CHSP | Mar 30, 2015
Q&AFire DoorsDoors

Q: What is the permitted force to open a fire door? What kind of means can be used to test this onsite? A: The answer to your question is found …

Brad Keyes, CHSP | Feb 16, 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
Q&ADoors

Q: With regards to installing a hook on a fire rated door, would an adhesive backed hook be considered a modification to the door? A: As far as I can …

Brad Keyes, CHSP | Dec 1, 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
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
SuitesQ&ADoors

Q: Are there any NFPA regulations which require doors serving as exits from suites must swing in the direction of egress? I have identified smoke barrier double doors in corridors …

Brad Keyes, CHSP | Aug 11, 2014
Q&ADoorsOperating Room

Q: Concerning latching hardware for a surgical suite, I could not locate any exceptions in the Life Safety Code to the positive latching requirements concerning operating room doors. From an …

Brad Keyes, CHSP | Aug 4, 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
Q&AFire BarrierDoorsILSM

Q: If renovation requires replacement of fire doors in multiple areas of the hospital, and must be completed in a short period of time, what would be appropriate interim life …

Brad Keyes, CHSP | Apr 28, 2014
Q&ADoors

Q: Is there a right way and a wrong way for fire doors to swing? During evacuations, one is encouraged to stay to the right in hallways and stairways. Thus …

Brad Keyes, CHSP | Dec 30, 2013
Q&AFire BarrierDoors

Q: We are in the process of installing a door in a 2 hour fire barrier with an automatic door operator and positive latching. The door operator will be activated …

Brad Keyes, CHSP | Sep 23, 2013
Q&AFire BarrierDoors

Q: Do existing fire rated doors (in a 2-hour fire rated barrier) have to have a vision panel (window) in the door? A: No, I do not believe that they …

Brad Keyes, CHSP | Aug 19, 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
Q&ADoor LocksDoors

Q: A surveyor cited us for not having positive latching doors to our entrance of the ICU suite. We have magnetic-locks on those doors and pointed out that they serve …

Brad Keyes, CHSP | Jul 1, 2013
Q&ACorridorsDoors

Q: We have wall mounted recessed cabinets in our corridors next to the patient room doors that have access doors on both the corridor side and the patient room side …

Brad Keyes, CHSP | May 6, 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
Q&ADoorsOperating Room

Q: We just had an outside company update our SOC (Statement of Conditions) and even though we haven't changed anything in 20 years he noted what he considered to be a …

Brad Keyes, CHSP | Mar 11, 2013
Q&ADoors

Q: Are existing corridor doors required to be positive latching? Section 19.3.6.3.2 of the 2000 edition of the Life Safety Code does not require corridor doors to be positive latching, …

Brad Keyes, CHSP | Feb 14, 2013
Q&ADoorsSigns (Life Safety Code)

Q: Are signs permitted on fire rated doors? We posted a sign on a fire rated stairwell door that instructed our staff to temporarily not use the door, and a …

Brad Keyes, CHSP | Feb 11, 2013
Q&AHazardous AreasDoors

Q: A consultant has mentioned that several of our doors to hazardous areas are non-compliant. The door configuration is such that there is a normal 3’x7’ door paired with a …

Brad Keyes, CHSP | Feb 4, 2013
Q&ADoors

Q: Do corridor doors have to have door closers on them? I know they have to latch, but an architect said all corridor doors have to have closures on them …

Brad Keyes, CHSP | Sep 10, 2012
Q&ADoors

Q: Are we allowed to install a hook on the inside of a patient room corridor door? Our nurses would like a hook installed on our wood patient room doors …

Brad Keyes, CHSP | Sep 3, 2012
Q&ADoors

[NOTE: The following Q&A is from my good friend Lori Greene, Manager of Codes and Resources for Ingersoll Rand Security Technologies, Needham, MA. Check out her blog at www.idighardware.com ] Q: …

Brad Keyes, CHSP | Aug 27, 2012
ArticleDoors

Roller latches.... Many of us already know that the Centers for Medicare & Medicaid Services (CMS) banned the use of roller latches in hospitals by March 13, 2006. So that …

Brad Keyes, CHSP | Jun 6, 2012
Q&ADoors

Q: I have a supply room on a medical surgical floor and the door opens into the corridor. The corridor and the room are protected with automatic sprinklers. Because it …

Brad Keyes, CHSP | May 21, 2012
Q&ADoors

Q: We recently failed a licensing inspection because the gap at the bottom of the door exceeded 1/8". The inspector stated "no gap between surfaces greater than one-eighth of an inch is …

Brad Keyes, CHSP | Apr 25, 2012
Q&ADoors

Q: We recently did a survey on our fire rated doors and found many of the frames on the doors had issues with the labels. Some of the door labels …

Brad Keyes, CHSP | Apr 16, 2012
Q&ADoors

Q: Can a door that opens onto the corridor have a magnet hold-open device that is not connected to the building fire alarm system, and does not release when the …

Brad Keyes, CHSP | Feb 1, 2012
Q&ADoors

Q: I have a supply room on a medical surgical floor and the door opens into the corridor. The corridor and the room are protected with automatic sprinklers. Because it …

Brad Keyes, CHSP | Jan 1, 2012
SuitesQ&ADoor LocksDoors

Q: We recently had an inspection in our hospital where the inspector cited us for our suite doors not having positive latching. The suite doors have 1500 pound access-control magnets …

Brad Keyes, CHSP | Dec 6, 2011
Q&ADoors

Q: As we work through deficiencies that were found by a consultant, there is one question we need to have clarified regarding doors. The reference to the deficiency is LSC …

Brad Keyes, CHSP | Jun 1, 2011
Q&ADoors

Q: We are considering the use of storage devices that hook over the top of the patient room corridor doors that will store supplies that we use for contact precautions …

Brad Keyes, CHSP | Jan 1, 2011
Q&ADoors

Q: We had a mock survey recently and the life safety surveyor indicated that the lab -- because it is a hazard area -- is required to have all the …

Brad Keyes, CHSP | Nov 1, 2009
Q&ADoors

Q: Is there a maximum time required for doors to automatically close? This question came up in a recent department meeting and we cannot find any code reference that specifies …

Brad Keyes, CHSP | Sep 1, 2009
Q&AFire AlarmDoors

Q: In our hospital, we have smoke compartment doors in the corridor that are held open with magnetic hold-open devices. When the fire alarm system is activated, the magnetic devices …

Brad Keyes, CHSP | Sep 1, 2009

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