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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.

Business OccupanciesJoint CommissionLife Safety CodeAccreditation/CertificationCMS

Q: If I have a new freestanding business occupancy that is licensed, would CMS enforce the provisions of the 2012 Edition of NFPA 101 (Life Safety Code)? I wasn't able …

Brad Keyes, CHSP | Nov 13, 2020
Life Safety Code

Q: We ask staff this question when we do Environmental Rounding: "Can you identify the closest area of refuge?" The answer we have used is "shelter-in-place," but I believe this may …

Brad Keyes, CHSP | Oct 28, 2020
Life Safety CodeAccreditation

Q: Do you have any suggestions for satisfying the accreditation documentation requirements to prove we conducted a building assessment for compliance with the Life Safety Code? I had thought about …

Brad Keyes, CHSP | Oct 5, 2020
Life Safety Code

Q: We are a 49-bed hospital facility (changed over from a 68-bed in 2017). Currently we have a room that was originally used for three patient beds. We are wanting …

Brad Keyes, CHSP | Aug 14, 2020
Life Safety Code

Q: I have been asked to install "AREA OF REFUGE" signs on top of the doorframe on both sides on several areas of the hospital. Is there a specific per code …

Brad Keyes, CHSP | Jul 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
Life Safety Code

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 …

Brad Keyes, CHSP | Mar 25, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Mar 19, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Feb 27, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Feb 20, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Jan 30, 2020
Life Safety Code

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: …

Brad Keyes, CHSP | Jan 23, 2020
Life Safety CodeAlcohol Based Hand Rub Dispensers

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 …

Brad Keyes, CHSP | Jan 17, 2020
Life Safety Code

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 …

Brad Keyes, CHSP | Jan 16, 2020
SecurityLife Safety CodeEmergency Response Plan (Facilities Management)

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 …

Brad Keyes, CHSP | Dec 24, 2019
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
Life Safety Code

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 …

Brad Keyes, CHSP | Dec 12, 2019
Life Safety Code

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 …

Brad Keyes, CHSP | Mar 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
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
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
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
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
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
Life Safety Code

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

Brad Keyes, CHSP | Dec 2, 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
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
Life Safety CodeDecorations

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 …

Brad Keyes, CHSP | Nov 17, 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
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
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
Life Safety Code

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 …

Brad Keyes, CHSP | Oct 23, 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
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
Life Safety Code

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 …

Brad Keyes, CHSP | Aug 21, 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Fire DoorsLife Safety Code

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 …

Brad Keyes, CHSP | Jan 13, 2017
Life Safety CodeLiquid Oxygen

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 …

Brad Keyes, CHSP | Jan 6, 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 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
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
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
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
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 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
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
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
Q&ALife Safety Code

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?” …

Brad Keyes, CHSP | Mar 17, 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
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
Q&ALife Safety CodeLSC

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 …

Brad Keyes, CHSP | Jan 6, 2014
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
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
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
Q&ALife 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 …

Brad Keyes, CHSP | Jun 17, 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
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
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
Q&ABusiness OccupanciesLife Safety Code

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 …

Brad Keyes, CHSP | Feb 21, 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
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
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
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
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
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
Life Safety CodeFire WatchArticle

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 …

Brad Keyes, CHSP | May 18, 2012
Life Safety CodeArticle

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 …

Brad Keyes, CHSP | May 11, 2012
SuitesLife Safety Code

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 …

Brad Keyes, CHSP | Mar 2, 2012
SuitesLife Safety Code

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 …

Brad Keyes, CHSP | Feb 29, 2012
Life Safety CodeCorridors

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 …

Brad Keyes, CHSP | Feb 26, 2012
Life Safety CodeDoor Locks

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 …

Brad Keyes, CHSP | Feb 24, 2012
Life Safety CodeDoor Locks

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) …

Brad Keyes, CHSP | Feb 22, 2012
Life Safety CodeExits

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) …

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

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 …

Brad Keyes, CHSP | Feb 9, 2012
Life Safety CodeSigns (Life Safety Code)

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 …

Brad Keyes, CHSP | Feb 3, 2012
Fire DoorsLife Safety Code

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 …

Brad Keyes, CHSP | Jan 13, 2012
Q&ALife Safety Code

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, …

Brad Keyes, CHSP | Mar 17, 2009

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