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Keyes Life Safety

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Business OccupanciesFire Drills

Q: Is there a requirement to activate the fire alarm system in a patient/non-patient care business occupancy building during a scheduled fire drill? A: I would say so. Section 38/3972 …

Brad Keyes, CHSP | Jun 1, 2020
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
Life Safety CodeCOVID-19Fire Drills

Q: As the world faces this pandemic, can fire drill requirements be suspended or replaced with staff education type in-services? A: Fire drills are a mandatory requirement that is regulated by …

Brad Keyes, CHSP | Apr 2, 2020
Ambulatory Care OccupancyLife Safety CodeFire Drills

Q: We have 13 off-site Ambulatory Surgery Centers and some are in stand-alone buildings where they are the only occupant and some are in high rise Medical Office Buildings (MOB) …

Brad Keyes, CHSP | Dec 13, 2019
Fire Drills

Q: Can accidental fire alarm activations, such as burnt popcorn, be counted toward a quarterly fire drill requirement if documentation of staff response is received in regard to said accidental …

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

Q: I work at a hospital that has just partnered with a Behavioral Health organization. We have renovated a floor and will be opening up soon. My question is this: …

Brad Keyes, CHSP | Oct 25, 2019
ILSMFire Drills

Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I …

Brad Keyes, CHSP | Oct 11, 2019
Healthcare OccupancyFire Drills

Q: There is a lot of confusion on how many fire drills we have to complete. We have 3 towers where there is healthcare, all connected, but different building names …

Brad Keyes, CHSP | Mar 25, 2019
Ambulatory Care OccupancyFire Drills

Q: My question is with an ambulatory healthcare occupancy classification. Do you need just one fire drill per quarter or do you need one fire drill per shift per quarter? …

Brad Keyes, CHSP | Feb 6, 2019
Fire Drills

Q: Is it required to activate the fire alarm system in our hospital whenever a fire drill is conducted for AM or PM Shift? A: Yes. According to section 19714 …

Brad Keyes, CHSP | Jan 14, 2019
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
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
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
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
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
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
Q&ABusiness OccupanciesFire Drills

Q: For clinics that are listed as business occupancies is there a requirement to activate the fire alarm system (chimes and strobes) and send a signal to a third party …

Brad Keyes, CHSP | Dec 7, 2017
Q&ABusiness OccupanciesFire Drills

Q: Our hospital has several "out buildings" or offsite Doctor's offices. Are we required to do fire drills at these offices? Three of our buildings have fire alarm systems that …

Brad Keyes, CHSP | Oct 20, 2017
Q&AOperating RoomFire Drills

Q: What are the requirement for operating room fire drills per Joint Commission, CMS, and AORN? Are operating room fire drills required to evacuate patients? A: I cannot speak to …

Brad Keyes, CHSP | Oct 2, 2017
Q&AFire Drills

Q: I have a question that is still a little fuzzy regarding fire drills. My hospital is partners with a separate clinic. Several of the clinics throughout the community have …

Brad Keyes, CHSP | Aug 16, 2017
Q&AFire Drills

Q: Somewhere I read that at least 50% of fire drills had to be unannounced. I don't find that requirement in NFPA Life Safety Code so it may have been …

Brad Keyes, CHSP | Aug 14, 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
Q&AJoint CommissionFire Drills

Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, …

Brad Keyes, CHSP | Mar 29, 2017
Q&AFire Drills

Q: We are required to conduct a fire drill every quarter. If I did one on March 22, when is the earliest and the latest dates that I can do the next …

Brad Keyes, CHSP | Mar 23, 2017
Q&AFire Drills

Q: We have a building adjacent to our main hospital (separated by a two hour fire wall) that is a mixed occupancy. There are three stairwells that serve this building, …

Brad Keyes, CHSP | Jan 16, 2017
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
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
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
Q&AFire Drills

Q: Do table top exercises count as a fire drill? We are updating our old policies and traditionally it has been allowed to have tabletops count as a fire drill, …

Brad Keyes, CHSP | Oct 2, 2015
Q&AILSMFire Drills

Q: Joint Commission standard LS.01.02.01, EP 11 requires the hospital to perform an additional fire drill during periods of Life Safety Code deficiencies that cannot be immediately corrected or during …

Brad Keyes, CHSP | Sep 25, 2015
Q&AFire Drills

Q: We are getting ready to complete our fire drill schedule and need clarification. When conducting fire drills how many remote fire zone/smoke areas are required to be observed and …

Brad Keyes, CHSP | Sep 14, 2015
Q&ABusiness OccupanciesFire Drills

Q: We were recently cited by a surveyor for not conducting annual fire drills at our offsite blood draw locations. I have reviewed the Life Safety Code for business occupancies …

Brad Keyes, CHSP | Jul 6, 2015
Q&AFire Drills

Q: I am new to this position and I am working on updating my management plan on fire safety. Currently it states "The fire department's Fire Prevention Bureau will conduct …

Brad Keyes, CHSP | Jun 22, 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
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
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
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
Q&AFire Drills

Q: Do we have to conduct a fire drill in every department and unit at least once per shift per quarter throughout our hospital? Some staff is telling me that …

Brad Keyes, CHSP | Apr 22, 2013
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
Q&AFire Drills

Q: How would you define unannounced when it comes to fire drills? There doesn’t appear to be anything in the standard that explains what this means. What do you say? …

Brad Keyes, CHSP | Jun 17, 2012
Q&AFire Drills

Q: Are we required to conduct fire drills on every unit and in every department once per quarter per shift in our hospital? Are we required to make sure everyone …

Brad Keyes, CHSP | Dec 1, 2011
Q&AFire Drills

Q: We recently had a consultant advise us to always activate our fire alarm system whenever we conduct a fire drill. We don’t always do that because we perform so …

Brad Keyes, CHSP | Jul 1, 2010
Q&AFire Drills

Q: Is every nursing unit in our hospital required to have one fire drill per shift per quarter? Our Director of Quality says we are required to do so, but …

Brad Keyes, CHSP | May 1, 2010

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