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 …

Q: My hospital is preparing for COVID-19. I'm at odds with the clinicians who believe that the pandemic is a special situation, meaning that Life Safety Code can go by …

Yesterday, Compliance One Group shared an insightful video by Carrie Kotecki that discusses her thoughts on how healthcare organizations can prepare now to prevent a future public health emergency. Click here …

Keeping your door inspection on schedule and on budget is a central focus of our projects. To achieve this goal, we need your help and preparation. While you don’t need …

Life Safety Drawings (LSDs) are often an unappreciated hero of an accurate door inspection. Not having accurate LSDs cause the inspection of extra doors and their consequential costly repairs. Let …

I have often been told by ambulatory surgery center staff during surveys that the Life Safety Code surveyor is the person that they fear the most. Keeping up with the …

Q: What is one of the main reasons that ambulatory surgery centers (ASCs) get cited for deficiencies in relation to testing, inspection, and maintenance activities for Life Safety equipment? A: …

Q: My question is in regards to alcohol-based hand rub (ABHR) dispensers in a recovery area in our Cath lab. Does an open bay in the recovery area count as …

Q: What is the most common deficiency that you cite during a Life Safety Code survey? A: Improper inspection, maintenance, and testing of the building features that protect occupants from …

Last week, I shared a brief checklist for evaluating your hospital emergency operations plan and now, I'm here to share a couple of free resources with you to aid in …

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) …

Hospital emergency operations plans can be overwhelming to produce and maintain. Not only can they be time-consuming to develop, but a challenge is to keep it user-friendly too. This resource …

Well, no, it's not my birthday, but 10-years ago today I published my first post on this website. In 10 short years, I have made over 1,150 postings, and answered …

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! …

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 …

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 …

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 …

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 …

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 …

Click on this link for a special Season’s Greetings video from Keyes Life Safety… https://keyeslifesafewpenginecom/wp-content/uploads/2018/10/Seasons_Greetingsmp4 …

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 …

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 …

Q: We are a fully sprinkled hospital. Is it permissible to hang Christmas garland from the ceiling, as long as we stay away from sprinkler heads and abide by the …

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 …

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 …

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 …

Here's a strange observation (on a Tuesday?) that I saw recently at a nurse station... An electric pumpkin powered by an extension cord. Even though the electric pumpkin was UL …

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 …

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 …

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 …

Hello everyone.... By now you've probably noticed a new home-page to my website. We made upgrades and improvements that should make it easier for you to find a specific topic …

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 …

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 …

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 …

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 …

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? …

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 …

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 …

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? …

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 …

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 …

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 …

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, …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

Q: We have a mechanical room door that is ¾-hour rated. The mechanical room is a 10 foot x 10 foot room with two electrical panels and a small gas …

Q: I have portable liquid O2 canisters that need to be refilled from the portable storage dewar. Are there any directions for me to follow in the process to refill …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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 …

Q: Is the Life Safety Surveyor a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and various areas of survey?” …

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 …

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 …

Q: When will we know if CMS will adopt the 2012 version of the NFPA LSC book? A: You will not have to worry about that… Nearly everyone will be …

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 …

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 …

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 …

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, …

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 …

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 …

Q: We recently had a survey where we were cited for not having a paved sidewalk from the exit door of a stairwell, to the parking lot. The surveyor said …

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 …

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 …

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 …

Q: We have many offsite locations that are not hospitals but are clinics for diagnostic imaging, testing and physician’s offices. What, if any Life Safety Code standards apply in these …

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 …

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 …

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) …

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 …

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 …

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 …

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, …

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 …

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 …

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 …

Walking surfaces in the means of egress are required to be even. This is one situation in the NFPA codes and standards where they clearly defined what 'even walking' surface …

I remember being on an assignment at a major hospital in an urban setting, and the Facilities Department was huge. They had multiple managers, supervisors, lead-technicians and so forth, as …

Previously, we discussed the changes that are in store for the patient sleeping suites, which are considerable. Now we are going to look at the few changes the 2012 edition of …

Lots of changes are in store for suites of rooms when the 2012 edition of the Life Safety Code is finally adopted, and the changes are all for the better …

Here is a change in the Life Safety Code that I believe will do more harm than good: Changing what can be left unattended in hospital corridors. Currently, the 2000 …

As we discussed in the previous posting, the healthcare chapters of the Life Safety Code allows for three (3) special locking arrangements: Clincal needs Delayed egress Access control The phrase …

Electrically locked doors. The 2000 edition of the LSC does not discuss them, directly. However, it does talk about the three types of locks that are permitted in hospitals: 1) …

The current edition of the Life Safety Code (2000 edition) does not allow an unoccupied room (such as a mechanical room, janitor's closet, storage room) to have an opening (doorway) …

On December 8, 1961, a smoldering cigarette that was tossed into the hospital trash chute, ignite some combustibles and started a conflagration that exploded onto the 9th floor of the …

Remember the rush we all made in the last 10 years or so to install stairwell identification signs inside our stairwells? Well, with the adoption of the new 2012 Life …

When the 2012 edition of the LSC is finally adopted (sometime in 2013, presumably) one of the more striking changes that facility managers will have to adjust to, is the …

QUESTION: We had a surveyor tell us during our recent survey that our signs over our fire extinguisher cabinets don’t stand out enough. The signs are perpendicular to the wall, …