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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.

Q&AOxygen Cylinders

Q: Can full oxygen cylinders be stored in a hospital soiled utility room? A: Yes… however, anything stored in a soiled utility room is considered soiled. That would require staff …

Brad Keyes, CHSP | Aug 13, 2018
Q&AExit Signs

Q: Is there a code that states every mechanical room needs an ‘Exit’ sign? I am being pressed to do so and I understand if the exit is obvious you …

Brad Keyes, CHSP | Aug 10, 2018
Q&ACorridorsWalls

Q: Our life safety drawings identify the corridors in our hospital as being smoke partitions. My question is do wall penetrations above the dropped ceiling need to be sealed with …

Brad Keyes, CHSP | Dec 29, 2017
Q&AOxygen Cylinders

Q: What are the requirements for a small storage room becoming a transfer station for filling oxygen cylinders? What code would there be? What type of ventilation do we need …

Brad Keyes, CHSP | Dec 28, 2017
Q&AConstruction

Q: Regarding the 2012 Life Safety Code referencing the 2009 edition of NFPA 241 Standard for Safeguarding Construction, Alteration and Demolition Operations which does not allow "tarps" for construction barriers, …

Brad Keyes, CHSP | Dec 27, 2017
Q&AWaiversSprinklers

Q: Our facility is a four story facility, and is a combination of different structures built in different years. All of the different structures are protected with sprinklers except for …

Brad Keyes, CHSP | Dec 26, 2017
Mechanical RoomsStorage (Life Safety Code)Q&AAmbulatory Care Occupancy

Q: I'm trying to find out particular rules regarding storage and what is allowed to be done in a penthouse. We have a new-construction Ambulatory Care occupancy. The question is …

Brad Keyes, CHSP | Dec 22, 2017
Q&AAlcohol Based Hand Rub Dispensers

Q: Could you clarify the placement of alcohol based hand dispensers in corridors and waiting rooms. I was just looking for clarification. A: For healthcare occupancies (i.e. hospitals, nursing homes, …

Brad Keyes, CHSP | Dec 21, 2017
Q&ADoor Locks

Q: Regarding a recent question on access-control locks, you said the egress side of the door is required to have motion sensors and a wall-mounted “Push to Exit” button. Does …

Brad Keyes, CHSP | Dec 20, 2017
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&ASoiled Linen

Q: We have a long-term care facility and want to know if we can place soiled linen containers in dining rooms and activity rooms? A: From a Life Safety Code …

Brad Keyes, CHSP | Dec 14, 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&ATesting (Generators)Generators

Q: In a business occupancy and an ambulatory occupancy do we need to test our generator on load each month or can we do a load bank test once per …

Brad Keyes, CHSP | Dec 11, 2017
Q&ASeparationOccupancies

Q: There is an existing clinic which is classified as business occupancy that leases space within a rehabilitation and nursing center. Does this need to be separated by a 2 …

Brad Keyes, CHSP | Dec 8, 2017
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
Storage (Life Safety Code)Q&AAlcohol Based Hand Rub Dispensers

Q: Our hospital bulk stores alcohol based hand-rub (ABHR) sanitizer containers of 1000 ML (33.8 fl. oz.) per container & 750 ML (25 fl. oz.) per container in its housekeeping …

Brad Keyes, CHSP | Dec 4, 2017
Q&ADoor Locks

Q: In follow up to your articles on locks on doors, we are a mental health facility and have mag-locks operated by swipe cards / fobs. The same doors also …

Brad Keyes, CHSP | Dec 1, 2017
Q&AStairwellsCarpeting

Q: I have several hospitals that have been cited by surveyors for having carpet in the stairwells. Can you tell me if there is any code requirement that states that …

Brad Keyes, CHSP | Nov 30, 2017
Q&AStandpipe Flow TestsSprinklers

Q: We have a water-flow switch on the line that rises through a nursing wing stairwell and feeds the hose cabinets. There are no longer any hoses in the cabinets …

Brad Keyes, CHSP | Nov 29, 2017
Q&AStairwells

Q: Can I install security cameras in stairwells A: You can…. But be prepared to remove them. Many Accreditation Organizations (AOs) and most states who survey on behalf of CMS …

Brad Keyes, CHSP | Nov 27, 2017
Q&ACollectionTrash

Q: What if anything can be stored in a room called trash chute collection room? We have housekeeping wanting to store boxes of new waste receptacles in there. I think …

Brad Keyes, CHSP | Nov 24, 2017
Q&AFire Doors

Q: We are planning to install double egress doors within the corridor for the purpose of separating the clean OR area from the dirty side. The doors and frame that …

Brad Keyes, CHSP | Nov 23, 2017
Q&AConduit

Q: I am being told by a building engineer that low voltage cable cannot be attached (i.e. wire-tied) to existing conduits in the hospital. In ten-plus years in this business …

Brad Keyes, CHSP | Nov 22, 2017
Q&AEyewash Stations

Q: I have been told several different ways that our facility didn't have an eye wash station in our janitor’s closet. So, I was told to purchase the single-use portable …

Brad Keyes, CHSP | Nov 20, 2017
Q&AOxygen Cylinders

Q: I am a consultant and I have a hospital that was cited for co-mingling full and not-full ‘E’ size oxygen cylinders on a rack located on the loading dock …

Brad Keyes, CHSP | Nov 17, 2017
Q&ADoor LocksStairwells

Q: We have a potential elopement risk at the nursing home where I work. A patient gets into the stairwell and down to the first floor and exits the building …

Brad Keyes, CHSP | Nov 16, 2017
Q&AConstruction

Q: We are looking to construct a surgery center which will be classified as Healthcare Occupancy on the third floor of an existing five story building which is classified as …

Brad Keyes, CHSP | Nov 15, 2017
Emergency Response Plan (Accreditation/CertificatiQ&A

Q: Is there a specific time-limit required by the accreditation organizations for decontamination purposes, from activation of a drill to being able to put victims through a decontamination tent? A: …

Brad Keyes, CHSP | Nov 13, 2017
Storage (Life Safety Code)Q&AUnder SInk

Q: Is there a Life Safety Code requirement for cabinet doors to be locked underneath sinks in patient rooms, in a hospital? A: No… There is no Life Safety Code …

Brad Keyes, CHSP | Nov 10, 2017
Q&ADoor Locks

Q: I currently serve as plant operations director at a nursing home in east Tennessee. State surveys questioned the locking arrangement on bathroom doors used both by the public and …

Brad Keyes, CHSP | Nov 9, 2017
Q&AHazardous Areas

Q: I recently heard that a hospital was cited for leaving a construction cart unattended in the hall and the surveyor inventoried the entire cart and cited the hospital for …

Brad Keyes, CHSP | Nov 8, 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
Smoke BarrierQ&AFire Barrier

Q: Are doors in fire rated barriers also required to be listed and installed as a smoke barrier? A: No… Fire rated barriers are not necessarily smoke barriers. They are …

Brad Keyes, CHSP | Nov 3, 2017
Q&ABusiness OccupanciesEmergency Lights (Life Safety Code)

Q: I have a question concerning an ambulatory surgery center that is now converted over to a business office only. We are not doing any patient care in this facility …

Brad Keyes, CHSP | Nov 2, 2017
Q&AStairwells

Q: We are being told by our local AHJ that a stairwell in a 2 story building has to be 2-hour fire resistance rated so that it meets the requirements …

Brad Keyes, CHSP | Nov 1, 2017
Q&AWaiversCMS

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

Brad Keyes, CHSP | Oct 31, 2017
Q&AHazardous Areas

Q: Is it okay to store latex paint in a mechanical/air handler room? The mechanical room is located in the hospital and is in a 2 hour fire rated wall …

Brad Keyes, CHSP | Oct 30, 2017
Q&AOxygen Cylinders

Q: Our Respiratory Therapist has brought this question to me and I wanted your input. We have the new ‘E’ size oxygen cylinders that are called Oxytote. They are the …

Brad Keyes, CHSP | Oct 27, 2017
Q&AFire Doors

Q: Other than the annual fire door inspection that is required in the 2012 Life Safety Code, are there other inspections required? Fire doors that are included are also single …

Brad Keyes, CHSP | Oct 26, 2017
Q&ALaundry

Q: Do hospitals and nursing homes need to have a Laundry Policy? If so, what should the policy cover and what specific information should the policy contain? A: From a …

Brad Keyes, CHSP | Oct 25, 2017
Q&AFire DoorsTesting (Life Safety Code)LSC

Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any …

Brad Keyes, CHSP | Oct 24, 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&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&ADoor Locks

Q: Is it legal for a deadbolt lock to have a thumb turn on the inside where the user needs to "push and turn" to open rather than just turn …

Brad Keyes, CHSP | Oct 19, 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&AInfection Control

A 'Conversation' Regarding Environmental Services Closets Q #1: Are housekeeping closets considered clean or dirty rooms and what type of supplies can you store in them? EVS is being advised by …

Brad Keyes, CHSP | Oct 17, 2017
Storage (Life Safety Code)Q&ASprinklers

Q: We have a surveyor that says if we have portable storage racks against the perimeter walls and have items stored closer than 18 inches of the ceiling but the …

Brad Keyes, CHSP | Oct 16, 2017
Storage (Life Safety Code)Q&ACorridors

Q: If I had a hallway (breezeway which connects two healthcare occupancies) which is greater than 8 feet wide (approximately 12ft) and beds and other equipment (usually broken chairs) are …

Brad Keyes, CHSP | Oct 13, 2017
Q&AFire AlarmAEM Program (Accreditation/Certification)Sprinklers

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the …

Brad Keyes, CHSP | Oct 12, 2017
Q&AFireplaces

Q: Are gas-fired ventless fire places permitted in nursing homes? A: I would say they are not permitted, but it has a lot to do whether or not the gas …

Brad Keyes, CHSP | Oct 11, 2017
Q&APower StripsCMS

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

Brad Keyes, CHSP | Oct 10, 2017
Q&AEgress

Q: Where in the ambulatory health care occupancy chapter of the Life Safety Code does it permit to have a means of egress from an ASC or a suite within …

Brad Keyes, CHSP | Oct 9, 2017
Q&ATrailerOperating Room

Q: A hospital is building a small addition that will serve as a corridor to a mobile OR unit. ICC construction type of addition is I-B. The mobile OR will …

Brad Keyes, CHSP | Oct 5, 2017
Q&AFire Safety Plan

Q: Can testing and inspections of features of life safety be completed in-house or does a third party need to complete them? I would like to know which areas need …

Brad Keyes, CHSP | Oct 4, 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&AConstructionEgress

Q: Are there any problems with maintaining an emergency exit for a hospital OR area that travels through an adjacent construction project? Also, can these doors be taped or sealed …

Brad Keyes, CHSP | Sep 29, 2017
Q&AFire DoorsTesting (Fire Detection Systems)

Q: With regards to the 2012 edition of the Life Safety Code and the requirement to perform annual inspections of smoke/fire doors, would it be safe to assume that annual …

Brad Keyes, CHSP | Sep 28, 2017
Q&AHazardous Areas

Q: Does section 19.3.2.1 of the 2012 Life Safety Code allow hazardous rooms to not be constructed with one-hour fire rated barriers if it is fully fire sprinklered? If healthcare …

Brad Keyes, CHSP | Sep 27, 2017
Storage (Life Safety Code)Q&A

Q: What is the storage height requirement in buildings that are not sprinkled? In other words, how high can we stack items on shelves in storage areas in a non-sprinkled …

Brad Keyes, CHSP | Sep 25, 2017
Q&ACalibration Gas

Q: Are there any storage requirements for full small calibration gas cylinders? The tanks are secure in that they are in holders; however, they are stored under a shelf in …

Brad Keyes, CHSP | Sep 22, 2017
Q&AHeadroom

Q: Is there a minimum height requirement for a fully sprinklered corridor? A: Yes… you will find the minimum headroom height requirement in section 7.1.5.1 of the 2012 LSC. Means …

Brad Keyes, CHSP | Sep 21, 2017
Q&AFire DoorsTesting (Life Safety Code)

Q: I'd like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter 7.2.1.15 States "Where required by Chapters 11 through 43, the following door …

Brad Keyes, CHSP | Sep 20, 2017
Q&AConstruction

Q: Is there a fire rating requirement for a temporary construction barrier that will separate a construction area from a patient care area which will be an occupied space throughout …

Brad Keyes, CHSP | Sep 18, 2017
Q&ACorridors

Q: I understand that with the adoption of the new 2012 Life Safety Code there is a change in corridor projections from 6 inches to 4 inches. Would this new …

Brad Keyes, CHSP | Sep 15, 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
Q&ASleep Rooms (Life Safety Code)

Q: Do doctor’s sleep rooms have to be separated from other areas on a patient floor by a 2 or 1 hour fire-rated barrier? A: No… There is no requirement …

Brad Keyes, CHSP | Sep 13, 2017
Q&AElevators

Q: There’s a lot of confusion surrounding this topic; primarily when and where elevator lobbies are required. The consensus of the architects and fire protection engineers I’ve talked to is …

Brad Keyes, CHSP | Sep 11, 2017
SuitesQ&AWalls

Q: We have a suite inside of a smoke compartment. We are trying to find out if the dividing wall needs to be the same as the 1-hour smoke barrier …

Brad Keyes, CHSP | Sep 8, 2017
Q&AFire PumpTesting (Fire Suppression Systems)

Q: Electric fire pumps needed to be run once a week. Then that was changed to once a month. Now the new NFPA 25 has the pump being run once …

Brad Keyes, CHSP | Sep 7, 2017
Q&AFire Extinguishers

Q: Our hospital is wondering if it is a requirement to have fire extinguishers in our linen/trash chute room? If so where can I find the code reference? A: No… …

Brad Keyes, CHSP | Sep 6, 2017
Q&AWaiversEquivalencies

Q: During a recent webinar, the presenter said waivers and equivalencies are only valid until the next triennial survey. Does that really mean if CMS approved a waiver or an …

Brad Keyes, CHSP | Sep 4, 2017
Q&AOzone

Q: Are you aware of any regulation that would disallow the use of Ozone machines in hospitals? Are ozone machines allowed in hospitals? We had thought about using ozone machines …

Brad Keyes, CHSP | Sep 1, 2017
Mechanical RoomsQ&AStairwells

Q: With the elimination of the CMS Waivers, I was trying to clarify what now applies for mechanical room combustibles storage (i.e. mechanical areas with only stairway and elevator access …

Brad Keyes, CHSP | Aug 31, 2017
Q&ADecorations

Q: What (if any) is the regulation on the governance of holiday lights in a healthcare occupancy? A: Section 19.7.5.6 of the 2012 LSC only address combustible decorations, and does …

Brad Keyes, CHSP | Aug 30, 2017
Q&AFire AlarmBatteries (Fire Detection Systems)

Q: Can you tell me where I could find the code reference for how often batteries serving fire alarm panels (booster panels, control panels, etc.) need to be replaced based …

Brad Keyes, CHSP | Aug 28, 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
Q&AFire Alarm

Q: Recently we had an actual fire that set off our fire alarm. Our operators did not silence the audible horns, which are very loud, before announcing the code and …

Brad Keyes, CHSP | Aug 24, 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
Storage (Life Safety Code)Q&ABusiness Occupancies

Q: I am struggling with the Life Safety Code and need some clarification. I have an offsite clinic that is classified as a business occupancy with a basement measuring approximately …

Brad Keyes, CHSP | Aug 21, 2017
Q&ASecurityCamerasStairwells

Q: What is the Life Safety Code ruling on cameras and speakers in stairwells? Joint Commission was in and cited us on having cameras in the stairwells. We were told …

Brad Keyes, CHSP | Aug 18, 2017
Q&ADoor LocksOperating Room

Q: Our operating rooms were constructed with deadbolt locks on each surgical room. I'm told they did this to keep someone from entering the room during a case. Since this …

Brad Keyes, CHSP | Aug 17, 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
Q&ABehavioral Health

Q: I have a behavioral health unit where the lab technicians have placed a chair in the corridor to draw blood samples from the patients. This chair is left in …

Brad Keyes, CHSP | Aug 11, 2017
Q&AAccreditation

Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient …

Brad Keyes, CHSP | Aug 10, 2017
Cooking AppliancesQ&A

Q: We have an assisted living and basic care units at our facility. We have 48 total units: 24 on the east side and 24 on the west side. On …

Brad Keyes, CHSP | Aug 9, 2017
Q&ASoiled Utility Room

Q: Is it required that all soiled utility rooms have a dedicated sink for handwashing only? A: The NFPA Life Safety Code and related standards do not address this issue, …

Brad Keyes, CHSP | Aug 7, 2017
Q&ATesting (Fire Suppression Systems)Sprinklers

Q: I reside in California. Do I need a special license or certificate to perform monthly and quarterly sprinkler systems tests and/or inspections? Primarily, I am interested in main drain …

Brad Keyes, CHSP | Aug 4, 2017
Q&ASprinklers

Q: How many spare sprinkler heads are we required to keep on hand in our hospital? Some people have told us we need 6 of each kind of head we …

Brad Keyes, CHSP | Aug 3, 2017
Q&APower Strips

Q: As always I enjoy reading your articles and appreciate your opinions. My question this time focuses on special relocatable power taps and is centered around the AIV PowerMate special …

Brad Keyes, CHSP | Aug 2, 2017
Storage (Life Safety Code)Q&AClean Supply Room

Q: In an OB (obstetrics) supply room, can beverages such as apple juice, water or an ice machine be stored in the room with central supply items? A: The Life …

Brad Keyes, CHSP | Jul 31, 2017
Q&AUL (Underwriters Laboratories)ETL (Intertek ETL)

Q: While I realize that the UL label is accepted by most all AHJs, what about the ETL label from Intertek? Recently I had a fan purchased by a member …

Brad Keyes, CHSP | Jul 28, 2017
Q&AFire DoorsTesting (Accreditation/Certification)

Q: Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections? A: Yes they do …

Brad Keyes, CHSP | Jul 27, 2017
Q&AFire Doors

Q: If a fire door is in a wall that is not a fire-rated wall, will the wall need to be brought to be a fire-rated wall? A: No… not …

Brad Keyes, CHSP | Jul 26, 2017
Q&AHumidityTemperature

Q: During our mock inspection this week at our hospital, they are asking for temp and humidity checks in the surgery hallways. We do monitor the surgery rooms and center …

Brad Keyes, CHSP | Jul 24, 2017
Q&ABusiness OccupanciesAlcohol Based Hand Rub Dispensers

Q: For business occupancies, does the requirement that alcohol based hand sanitizers cannot be installed above a carpeted floor apply? The business occupancy does not have an automatic fire suppression …

Brad Keyes, CHSP | Jul 21, 2017
Q&AFire DoorsTesting (Life Safety Code)

Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection? A: NFPA 80-2010, section 5.2.3.1 says fire doors must be tested by …

Brad Keyes, CHSP | Jul 20, 2017
Q&ATesting (Life Safety Code)Documentation (Life Safety Code)

Q: Our organization is accredited by Joint Commission. I know for inspection purposes we need to have the current year plus that past three years of documentation for LS and …

Brad Keyes, CHSP | Jul 19, 2017
Q&ABusiness OccupanciesTesting (Generators)Generators

Q: Does a diesel generator that is located in a business occupancy require the same testing frequencies as the one at our hospital requires? A: It depends if the generator …

Brad Keyes, CHSP | Jul 17, 2017
Q&AILSM

Q: During our last survey the life safety code specialist discovered that 2 of our stairwells were deficient as far as the fire-rating. The contractor did a lousy job as …

Brad Keyes, CHSP | Jul 14, 2017
Q&AFire Alarm

Q: What code states that quarterly communication between our fire panel and our local fire department must be completed? A: What used to be called the off-site monitoring transmission equipment …

Brad Keyes, CHSP | Jul 13, 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
Storage (Life Safety Code)Q&AAlcohol Based Hand Rub Dispensers

Q: I am looking for clarification on the storage of alcohol based hand rub (ABHR) solution. I know the standard indicates that no more than 10 gallons of ABHR can …

Brad Keyes, CHSP | Jul 10, 2017
Q&ASafetyElectrical

Q: I work in a psychiatric hospital. One of the therapies used here involves our clients doing their own personal laundry, so we have multiple laundry rooms off the units …

Brad Keyes, CHSP | Jul 7, 2017
Q&AFire Extinguishers

Q: Do the accreditation organizations require a fire extinguisher inside the MRI room, or can it be located in the MRI control room? A: The accreditation organizations would follow what …

Brad Keyes, CHSP | Jul 6, 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&ACardboard

Q: Is there a specific code reference in regards to storage of boxes on the floor? I am trying to locate any specific code language for preventing the use of …

Brad Keyes, CHSP | Jul 3, 2017
Q&AEvacuation (Life Safety Code)

Q: Our fire plan says if there were ever a fire in our hospital, we would evacuate our patients horizontally to the other side of the smoke barrier. It then …

Brad Keyes, CHSP | Jun 29, 2017
Storage (Life Safety Code)Q&A

Q: I have a procedure room in our Cath Lab that Administration wants to convert to a storage room. The building is fully sprinkled and as I look at NFPA …

Brad Keyes, CHSP | Jun 28, 2017
Q&ACorridorsWallsCarpeting

Q: I have a nursing home that is over 20 years old that has carpet on the corridor walls below the handrails. I am been told that this carpet must …

Brad Keyes, CHSP | Jun 26, 2017
Q&ACorridors

Q: We have a corridor that connects an existing elevator lobby on the 2nd floor of a three story hospital to a new addition. The corridor is used for the …

Brad Keyes, CHSP | Jun 23, 2017
Q&AConstruction

Q: We are planning to update a pair of fire-rated automatic corridor doors which happened to be located in our Emergency Room and in a 2-hour rated wall. The work …

Brad Keyes, CHSP | Jun 21, 2017
Q&AAmbulatory Care OccupancyHealthcare Occupancy

Q: A surgery suite (5 ORs), PACU (8 bays), and ASU (17 rooms), newly built on the 3rd floor of a business occupancy building. A 2 hour box was constructed …

Brad Keyes, CHSP | Jun 19, 2017
Q&ASeclusion Rooms

Q: Our firm has designed several Psychiatric Units lately and there is a question regarding the seclusion room construction. There is a concern as to whether or not the Seclusion …

Brad Keyes, CHSP | Jun 16, 2017
Mechanical RoomsQ&ADoor Locks

Q: The computer server is located in the mechanical room. IT wants the room locked for HIPAA compliance. Is it permissible to lock a mechanical room? Doesn't locking compromise access …

Brad Keyes, CHSP | Jun 15, 2017
Q&AFire DoorsTesting (Life Safety Code)

Q: In regards to the new annual fire rated door assembly inspection, are we to inspect every door that has a fire rating or the doors that are located in …

Brad Keyes, CHSP | Jun 14, 2017
Q&AEvacuation (Life Safety Code)Stairwells

Q: I just got cited by the Joint Commission for having evacuation chairs at tops of our stairwells. The chairs were not causing any egress issues in my opinion, but …

Brad Keyes, CHSP | Jun 12, 2017
Q&ASoiled Utility Room

Q: What is the protocol to maintain a soiled utility room on a patient floor? What guidelines have to be met? A: As far as what guidelines have to be …

Brad Keyes, CHSP | Jun 9, 2017
Q&AStairwells

Q: We are being told that section 7.2.2.5.4.3 of the 2012 Life Safety Code requires us to install paint on the nose tread on stairs in existing egress stairways as …

Brad Keyes, CHSP | Jun 8, 2017
Q&AFire ExtinguishersOperating Room

Q: Our facility recently installed water-mist fire extinguishers in all of our operating rooms, which is the sole fire suppressant. Is this acceptable? A: It could be okay to have …

Brad Keyes, CHSP | Jun 7, 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&AExit Signs

Q: This question was recently brought to my attention: “Why do rooms, offices, and work areas do not have “Exit” signs over the doors leaving the rooms?” I could not …

Brad Keyes, CHSP | Jun 2, 2017
Q&ADecorations

Q: Must combustible decorations have a flame-retardant coating and sticker affixed (or documentation provided) as long as the total area does not exceed the 30% wall surface threshold for fully-sprinklered …

Brad Keyes, CHSP | Jun 1, 2017
Q&ABusiness OccupanciesAlcohol Based Hand Rub DispensersCorridors

Q: Can you give me some direction in the Life Safety Code on where alcohol-based hand rub (ABHR) dispensers are not allowed in business occupancy corridors? A: Take a look …

Brad Keyes, CHSP | May 31, 2017
Q&AEmergency Lights (Life Safety Code)Generators

Q: In regards to emergency generator backup lights, I seek clarity how long does the battery have to last? I'm assuming that the battery should be able to be tested …

Brad Keyes, CHSP | May 29, 2017
Q&AEmergency Lights (Life Safety Code)

Q: The egress lighting in our facility is connected to our generator through the life safety circuit and the light fixtures have no batteries. The task lighting in our operating …

Brad Keyes, CHSP | May 26, 2017
Q&AAlcohol Based Hand Rub Dispensers

Q: In regards to the new CMS requirements regarding corridor projections, will alcohol based hand-rub (ABHR) dispensers have to comply? Currently, our ABHR dispensers exceed the 4-inch limit for items …

Brad Keyes, CHSP | May 25, 2017
Q&AWallsOverhead Rolling Fire Doors

Q: We have an existing overhead rolling fire door acting as a curtain-window between a phlebotomy area and the egress corridor that is no longer needed (like to those found …

Brad Keyes, CHSP | May 24, 2017
Q&ADocumentation (Life Safety Code)

Q: How long does Joint Commission require records to be kept on inspections like fire alarm systems, fire drills, sprinklers, fire dampers, and PM records for beds and refrigerators, etc? …

Brad Keyes, CHSP | May 22, 2017
Q&ASprinklers

Q: I just had a survey and received a finding for dust on some of the sprinkler heads. I understand that foreign material is not permitted, but minute amounts of …

Brad Keyes, CHSP | May 19, 2017
Q&AConstruction

Q: Is there a specific date for construction that is a cut-off point between chapter 18 and chapter 19, or does chapter 19 always applies once the new construction is …

Brad Keyes, CHSP | May 18, 2017
Q&AEmergency Phones

Q: Are firefighter emergency call phones still required in new construction? We have an existing hospital and management is wanting to add a whole new patient tower and the construction …

Brad Keyes, CHSP | May 17, 2017
Q&AElectrical

Q: My questions are in relation to access control into electrical closets and life safety equipment closets. We have several electrical closets "locked down" by our IT department because they …

Brad Keyes, CHSP | May 15, 2017
Q&ADoor Locks

Q: Does section 7.2.1.5.10.2 of the 2012 edition of the LSC, which prohibits more than one releasing actions to operate the door apply to office doors within a healthcare occupancy? …

Brad Keyes, CHSP | May 12, 2017
Q&AFire Pump

Q: Do we have to conduct a monthly flow test on fire pumps in healthcare? A: No… NFPA 25-2011, section 8.3.1.2 requires monthly test of the electric-driven fire pump at …

Brad Keyes, CHSP | May 11, 2017
Q&ASprinklers

Q: I listened in on your webinar when you introduced all of us to the changes with the new 2012 Life Safety Code. In regards to the section involving fire sprinklers …

Brad Keyes, CHSP | May 10, 2017
Q&AElectrical

Q: We are in the process of designing a new building for our ASC. I have been asked to mark the building plans with where I want the red outlets …

Brad Keyes, CHSP | May 8, 2017
Q&AOxygen Cylinders

Q: In regards to oxygen cylinder storage on the nursing units, is there a code or standard that restricts the distance between a storage rack of 6 E size cylinders …

Brad Keyes, CHSP | May 5, 2017
Q&AFire Alarm

Q: In regards to multi-sensor devices, such as rate of rise/fixed temp combo heat detectors; if the rate of rise portion of the device is testable, but the fixed temp …

Brad Keyes, CHSP | May 4, 2017
Q&AFire PumpTesting (Fire Suppression Systems)

Q: I read where the annual fire pump test requires a 30-minute churn test but does not differentiate between a diesel or electric pump (as in the weekly test). NFPA …

Brad Keyes, CHSP | May 3, 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&AExit Signs

Q: We have just remodeled a suite and are planning on moving the chemo infusion department into it. There are 5 bays but total occupancy would never be more than …

Brad Keyes, CHSP | Apr 28, 2017
Q&AFire Alarm

Q: We are in the process of putting manual pull station covers on most if not all of our stations. Some of the stations are dual action. Will putting a …

Brad Keyes, CHSP | Apr 27, 2017
Q&AFire Rated CabinetsOxygen Cylinders

Q: In regards to oxygen cylinder storage, if the quantity of gas in storage is between 300 and 3000 cubic feet in a smoke compartment and the full cylinders are …

Brad Keyes, CHSP | Apr 26, 2017
Q&AILSMSprinklers

Q: We have some sprinkler piping that runs the length of the hall with multiple wires wrapped around the pipe. There is no way of removing the wiring from the …

Brad Keyes, CHSP | Apr 24, 2017
Q&AExits

Q: I have an existing 3 story building in an urban environment with an exterior stair which discharges into an enclosed rear yard. The access to a public way is …

Brad Keyes, CHSP | Apr 20, 2017
Q&AFire WatchConstructionSprinklers

Q: We have a construction project in our cafeteria. We have an ILSM and additional measures in place. However, it was determined last week that we need to remove the …

Brad Keyes, CHSP | Apr 19, 2017
Q&AFire Extinguishers

Q: We are doing a fire extinguisher annual maintenance on a Hospital and find that there is a high volume of ABC dry powder units through the site and very …

Brad Keyes, CHSP | Apr 17, 2017
SuitesQ&A

Q: Are recovery rooms and observation units considered sleeping suites or non-sleeping suites? What is the definition of what constitutes a sleeping suite? A: Recovery rooms, surgical suites and pre-op …

Brad Keyes, CHSP | Apr 14, 2017
Cooking AppliancesQ&A

Q: What is the standard in hospitals regarding use of toasters or popcorn machines up in nursing units where patient care areas are located? Is there an issue or concern …

Brad Keyes, CHSP | Apr 13, 2017
Q&ATunnels

Q: We have an underground tunnel that feeds and branches out three ways into three different hospitals. We are defining the tunnel as a business occupancy. There is a 2-hour …

Brad Keyes, CHSP | Apr 12, 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&AFire Alarm

Q: Is Class 'A' wiring required in new construction for new fire alarm systems? A: Per NFPA 72-2010, chapter 23.4.3.1, unless a class of wiring is determined by a local …

Brad Keyes, CHSP | Apr 6, 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
Q&ADoor LocksPatient Rooms

Q: Are locks permitted on patient room doors? Where can I locate the NFPA requirements for adding new hardware to patient room doors? A: Section 19.2.2.2.2 of the 2012 Life …

Brad Keyes, CHSP | Apr 3, 2017
Q&AFire DoorsFire AlarmSmoke Detectors

Q: I have a life safety consultant doing our annual inspection, and he keeps saying that I need to have individual smoke detectors for my corridor fire rated doors. The …

Brad Keyes, CHSP | Mar 31, 2017
Q&APatchingPenetrationFire BarrierWalls

Q: In regards to penetrations through fire separations: Our latest survey from Joint Commission identified that "Hot Patches" (a piece of 5/8 sheet rock placed over a hole and the …

Brad Keyes, CHSP | Mar 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&ABridge Between Buildings (Life Safety Code)Corridors

Q: We have a connecting bridge between two of our buildings. On one side of the bridge is healthcare occupancy and on the other side is business occupancy. There is …

Brad Keyes, CHSP | Mar 27, 2017
Mechanical RoomsQ&AEmergency Lights (Life Safety Code)

Q: Is emergency lighting required for mechanical rooms? A: The answer depends on whether the mechanical room has a designated aisle, the occupancy classification of the building, and whether it …

Brad Keyes, CHSP | Mar 24, 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&AConstruction

Q: Per NFPA 101 2012 edition: are plastic barriers (w/zippers) no longer acceptable around construction areas though the facility is fully sprinkled? A: No… I wouldn’t say that. But the …

Brad Keyes, CHSP | Mar 22, 2017
Q&AInterior Finish

Q: I would like to know the 2012 Life Safety Code requirements for an audio testing room in a high rise hospital building. The floor, wall and ceilings are covered …

Brad Keyes, CHSP | Mar 20, 2017
Q&AAir HandlersSprinklers

Q: Does a roof top air handler require sprinkler heads if it is unoccupied? We have large walk-in style air handlers on the roof of our hospital and they are …

Brad Keyes, CHSP | Mar 17, 2017
Storage (Life Safety Code)Q&AConstruction

Q: A question that keeps coming my way pertains to out-buildings like sheds that LTC providers want to place next to their nursing homes to use for storage. Is there any …

Brad Keyes, CHSP | Mar 16, 2017
Q&ADecorations

Q: We have a large wall 15 ft. x 12 ft. in our public cafeteria in the hospital that gets decorated with a different theme every quarter. This was started …

Brad Keyes, CHSP | Mar 15, 2017
Q&AWalls

Q: Is there an NFPA code requirement for labeling fire / smoke rated walls above ceiling and if so what is it? A: No… there is not a NFPA code …

Brad Keyes, CHSP | Mar 14, 2017
Q&AWaste Containers

Q: The 2012 Life Safety Code allows for 96 gallon containers outside a hazardous area for clean waste. Unfortunately, our vendor that handles recycling does not have a 96 gallon …

Brad Keyes, CHSP | Mar 13, 2017
Mechanical RoomsQ&AFire Extinguishers

Q: Are fire extinguishers required to be placed in mechanical rooms in our hospital? I've searched NFPA 10 and the Life Safety Code and haven't found anything concrete. The mechanical …

Brad Keyes, CHSP | Mar 10, 2017
Q&AStairwells

Q: I have a question about putting pictures up in stairwells. Someone in our administration department at our hospital wants to put pictures up in a stairwell. We have already …

Brad Keyes, CHSP | Mar 9, 2017
Q&ACardboard

Q: I am pushing to get all corrugated cardboard out of all areas of the hospital - not allowing materials management to send any items out of their department in …

Brad Keyes, CHSP | Mar 8, 2017
Q&ACMS

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

Brad Keyes, CHSP | Mar 7, 2017
Q&AClearance (Life Safety Code)Equipment (Life Safety Code)

Q: What does the NFPA codes and standards require for clearances around electrical panels, fire alarm pull stations, and med gas panels? A: The National Electrical Code (NFPA 70, 2011) …

Brad Keyes, CHSP | Mar 6, 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
Environmental RoundsQ&A

Q: I am wondering where I can find the Joint Commission/CMS requirements regarding Environment of Care rounds? We have always practiced twice a year for clinical areas, once a year …

Brad Keyes, CHSP | Mar 1, 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&AHumiditySterile Storage

Q: What supplies qualify as having to be stored in a “sterile storage” room? The 2014 FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities requires these rooms …

Brad Keyes, CHSP | Feb 24, 2017
Q&ABusiness Occupancies

Q: Our life safety drawings list the basement level at the Hospital as healthcare. There are no patient services in the basement and only support services. I would like to …

Brad Keyes, CHSP | Feb 23, 2017
Q&AStorage (Medical Gas)Oxygen CylindersSigns (Medical Gas)

Q: If there are oxygen tanks stored on a unit that does not exceed the 12 tank threshold, does the door to the storage area where the tanks are stored …

Brad Keyes, CHSP | Feb 22, 2017
Q&AOccupancies

Q: A Hospital System that I do work for is in the process of constructing a Medical Office Building off-campus (over 250 yards from the Hospital). The building will house …

Brad Keyes, CHSP | Feb 21, 2017
Q&AVentilationEndoscopy

Q: What are the ventilation requirements for the scope room in endoscopy? This is the room where the clean instrumentation is kept. A: It all depends if you’re talking about …

Brad Keyes, CHSP | Feb 20, 2017
Q&AEvacuation (Life Safety Code)Stairwells

Q: I understand it would be best to not place something affixed to the walls of the exit stairwell that protrudes in to the path of egress, which in turn, …

Brad Keyes, CHSP | Feb 17, 2017
Q&AFire Extinguishers

Q: I work in a 420 bed Hospital and during a recent survey we got cited for our yearly inspection dates on our fire extinguishers, which I understand. But on …

Brad Keyes, CHSP | Feb 16, 2017
Q&ASeparationOccupancies

Q: I have a 3 story hospital and I would like to have a mixed occupancy classifications for different floors. The basement floor is for support - no patients are …

Brad Keyes, CHSP | Feb 15, 2017
Q&AEyewash Stations

Q: Where are eyewash stations required in a hospital/ambulatory care facility? A: They are required in areas where corrosive or caustic materials (i.e. chemicals) are used, stored or handled and …

Brad Keyes, CHSP | Feb 13, 2017
Q&AEmergency Department

Q: Should Emergency Departments be classified as healthcare, ambulatory healthcare, or business occupancies? A: According to the 2012 Life Safety Code, a typical Emergency Department (ED) may be classified as healthcare …

Brad Keyes, CHSP | Feb 10, 2017
Q&ATesting (Life Safety Code)Documentation (Life Safety Code)

Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher …

Brad Keyes, CHSP | Feb 9, 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&AFire Extinguishers

Q: During a recent survey, we were cited for not having monthly inspections on our extinguishers during the month of the annual inspection. We have never run into this before …

Brad Keyes, CHSP | Feb 6, 2017
Q&AFire Alarm

Q: Is there a specific distance that fire alarm audible/visible notification appliances are required to be mounted from other similar devices? We have multiple strobe devices in some rooms, but …

Brad Keyes, CHSP | Feb 3, 2017
Q&ABusiness OccupanciesFire Alarm

Q: We are converting a facility that was used as a physician’s office into our women’s clinic and OB/GYN facility. There were previously 4 exam rooms and we are making …

Brad Keyes, CHSP | Feb 2, 2017
Q&AStairwells

Q: Can a chair lift device be installed in an exit stairwell? What are the regulations? A: The Life Safety Code and the local building codes set minimum widths of …

Brad Keyes, CHSP | Feb 1, 2017
Q&AExitsOccupancies

Q: If I want to classify my building as a healthcare occupancy, even though I have a business or ambulatory healthcare occupancy in it, I know I need to meet …

Brad Keyes, CHSP | Jan 30, 2017
Q&AHumidityTemperature

Q: I'm working with a hospital on their temperature and humidity monitoring in their Central Supply area, and was wondering what specific parameters they should follow in the two different …

Brad Keyes, CHSP | Jan 27, 2017
Q&AFire Doors

Q: I recently attended a conference where the speaker in the Life Safety session talked about the fire rating of the doors. She spoke of having the fire information labels …

Brad Keyes, CHSP | Jan 26, 2017
Storage (Life Safety Code)Q&AUnder SInk

Q: What standard in the Life Safety Code prohibits storage under sinks? A: There is no direct standard in the Life Safety Code or any of the standards the LSC …

Brad Keyes, CHSP | Jan 25, 2017
Q&AWon DoorsBatteries (Life Safety Code)

Q: Are Won-Door control panel batteries required to be tested annually with other fire alarm system batteries? A: I don’t believe so. The batteries in the fire alarm control panels …

Brad Keyes, CHSP | Jan 23, 2017
Q&AWaste Containers

Q: Are bins holding patient records waiting to be shredded required to have a FM fire rating in a hospital? A: Yes. Section 19.7.5.7.2 of the 2012 edition of the …

Brad Keyes, CHSP | Jan 20, 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
Q&AFire Doors

Q: If a door is a fire-rated door is it required to be maintained as a rated door in compliance with NFPA 80, regardless if its location doesn't require a …

Brad Keyes, CHSP | Jan 18, 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
Q&AFire Alarm

Q: Our hospital has an outpatient clinic attached via a hallway and connected to the hospital directly. When I am in the out-patient clinic you cannot hear the fire alarms …

Brad Keyes, CHSP | Jan 12, 2017
Q&AFire Alarm

Q: We have audible notification devices for the fire alarm system installed in our physician sleep rooms. We have a physician requesting the one in his area be removed. Are …

Brad Keyes, CHSP | Jan 11, 2017
Electric BlanketsQ&A

Q: My mother suffers from a syndrome which causes her feet to turn white and feel extremely icy. She is not allowed to use an electric blanket which allows her …

Brad Keyes, CHSP | Jan 10, 2017
Q&ABronchoscopy

Q: Could you clarify whether bronchoscopy procedures should be performed in a negative pressure room or positive pressure? It's seems as though many folks are doing them bedside and using …

Brad Keyes, CHSP | Jan 9, 2017
Q&AAlcohol Based Hand Rub Dispensers

Q: In the 2012 edition of the Life Safety Code, section 19.3.2.6 (9) states dispensers of ABHR are permitted to be installed directly over carpeted floors in fully sprinkled smoke …

Brad Keyes, CHSP | Jan 5, 2017
Q&ALine Isolation Monitors (Electrical)Conduit

Q: Can fiber optic and low voltage cables be attached or strapped to conduit? Also, what certification is needed for individuals who perform the annual line isolation monitor (LIM) tests …

Brad Keyes, CHSP | Dec 30, 2016
Q&APower Strips

A reader has an objection to one of the answers I provided in yesterday's blog concerning Power Strips... Brad: In the Sept. 2, 2016 article on Power Strips the following …

Brad Keyes, CHSP | Sep 3, 2016
Q&APower Strips

A client of mine sent me the following questions regarding power strips. The answers were taken from the CMS S&C memo 14-46 regarding the use of power strips in accordance …

Brad Keyes, CHSP | Sep 2, 2016
Q&AJoint CommissionCMS

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

Brad Keyes, CHSP | Aug 31, 2016
Q&AJoint Commission

Q: Hello Brad, I hear the SOC as of 8/4/2016 will no longer be used. If time is needed to do a repair for a life safety item we need …

Brad Keyes, CHSP | Jul 23, 2016
Q&AFire Extinguishers

Q: I could’ve sworn I read somewhere that a monthly fire extinguisher inspection shall be done within 30 days AND that there is to be a 10 day grace period… …

Brad Keyes, CHSP | Jul 4, 2016
Automatic Transfer SwitchesQ&AFire Pump

Q: A state surveyor cited us for not doing a monthly fire pump automatic transfer switch (ATS) test. We are doing a weekly churn test and an annual fire pump …

Brad Keyes, CHSP | Jun 27, 2016
Q&AFire Caulk

Q: In the past our hospital has used different brands of fire caulk on the same fire wall assembly. The fire caulk is two different brands and different colors and …

Brad Keyes, CHSP | Jun 20, 2016
SuitesQ&A

Q: Are surgery rooms considered to be patient sleeping rooms or non-sleeping rooms? In reference to allowable suite sizes, what is the maximum area of the suite? A: Surgery rooms …

Brad Keyes, CHSP | Jun 13, 2016
Q&AAmbulatory Care OccupancyFire Barrier

Q: Our ambulatory healthcare occupancy was constructed without a fire barrier separating the other business in the building. Now I have been asked to find out if we have to …

Brad Keyes, CHSP | Jun 6, 2016
Q&AAmbulatory Care OccupancyFire Barrier

Q: We have built a new Wellness Center with physician offices, diagnostic areas, cafe, etc. and included in the facility is an Ambulatory Endoscopy Center. A question has been raised …

Brad Keyes, CHSP | May 30, 2016
Q&AAmbulatory Care OccupancyFire AlarmTesting (Fire Detection Systems)

Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that …

Brad Keyes, CHSP | May 23, 2016
Q&ADoor Locks

Q: I’ve read from your column that dead-bolt locks are not permitted on doors in hospitals, but I’ve seen in other facilities where dead-bolt locks are installed on bathroom doors …

Brad Keyes, CHSP | May 16, 2016
Q&AHazardous Areas

Q: There appears to be many different ways a hazardous room is maintained: If it is sprinklered, does it have to be 1-hour rated? If it is existing construction, does …

Brad Keyes, CHSP | May 9, 2016
Q&ASprinklers

Q: Why does the escutcheon plate on a sprinkler need to be required when the ceiling is not rated and the corridor walls extend to the deck? If a basement …

Brad Keyes, CHSP | May 2, 2016
Mechanical RoomsQ&A

Q: We have an old dark room that was converted into an air handler room. What’s the requirement for a door to this room? A: It all depends where this …

Brad Keyes, CHSP | Apr 25, 2016
Q&AFire PumpTesting (Fire Suppression Systems)

Q: The Joint Commission standard for weekly testing of the fire pump only requires us to record the test date of the inspection. We were cited for not recording the …

Brad Keyes, CHSP | Apr 18, 2016
Q&AEgress

Q: Can a sterile supply corridor that feeds the back of Surgical OR's have a corridor of less than 8' if the patient access is from the front of the …

Brad Keyes, CHSP | Apr 11, 2016
Q&AFire AlarmTesting (Fire Detection Systems)

Q: Does NFPA 72-1999 edition specifically state that annual fire system inspection documentation include an itemized inventory of each system device as passed or fail? Does a report stating that …

Brad Keyes, CHSP | Apr 4, 2016
Q&AExit Signs

Q: My question is in regards to illumination of the means of egress, specifically, illumination provided outside the building to a public way. I was told by a consultant that …

Brad Keyes, CHSP | Mar 28, 2016
Q&AFire & Smoke Dampers

Q: Our pneumatic tube vendor is telling our Engineering folks that they have to install dampers inside the system everywhere that a pneumatic tube run penetrates a fire wall or …

Brad Keyes, CHSP | Feb 12, 2016
Q&AEyewash Stations

Q: Is it better to have an eye wash station that doesn't comply with ANSI standards or to remove eyewash stations from ambulatory clinics setting which may contradict Joint Commission …

Brad Keyes, CHSP | Feb 5, 2016
Q&AInfection Control

Q: I know it is inappropriate to place a flushing hopper sink in a trauma room between the hand washing sink and clean storage cabinets but I can't find the …

Brad Keyes, CHSP | Jan 29, 2016
Q&AStandpipe Flow Tests

Q: Is it mandatory that we perform a “Standpipe Hydrostatic and Flow Test” every 5 years? We do not have a dry system. Our system is full of water and …

Brad Keyes, CHSP | Jan 22, 2016
Q&AGenerators

Q: Recently I attended a meeting with our State Fire Marshall Department. One item which became a HOT topic of discussion was the monthly Specific gravity testing of the battery …

Brad Keyes, CHSP | Jan 21, 2016
Q&ASnow Removal

Q: During the winter season how much time would a surveyor give us to remove all snow from the exit discharge leads out of the hospital? Since it could be …

Brad Keyes, CHSP | Dec 9, 2015
Q&AFire Alarm

Q: I am doing a renovation project in our hospital and the area of renovation is 50% of the total building area. Part of the renovation scope is a fire …

Brad Keyes, CHSP | Nov 13, 2015
Q&AFire & Smoke Dampers

Q: Are fire dampers required in 1-hour fire rated walls if the facility is fully sprinkled? Also, we have a couple of inaccessible dampers and I was wondering if I …

Brad Keyes, CHSP | Nov 6, 2015
Q&AFire AlarmClearance (Fire Detection Systems)

Q: Where in the Life Safety Code does it require clearance in front of a fire alarm control panel? I have a situation in our hospital where we want to …

Brad Keyes, CHSP | Oct 30, 2015
Q&AJoint CommissionTesting (Accreditation/Certification)

Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not …

Brad Keyes, CHSP | Oct 23, 2015
Q&AFire & Smoke Dampers

Q: Do you need a fire smoke damper at floor level in an open duct shaft? Or where the duct comes out through the shaft wall? A: Section 19.7.5.1 of …

Brad Keyes, CHSP | Oct 19, 2015
Q&AShower Curtains (Life Safety Code)Curtains

Q: Our facility uses full shower curtains mounted to tracks in the ceiling for all behavioral health units. These curtains and tracks are ‘break-away’ type for suicide prevention. Our administration …

Brad Keyes, CHSP | Oct 16, 2015
Q&ADoor Locks

Q: While conducting fire drills in the hospital, one of the questions on our drill evaluation sheet is, "Did the security doors in the fire zone release properly?" We have …

Brad Keyes, CHSP | Oct 12, 2015
Q&AVentilationCMS

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

Brad Keyes, CHSP | Oct 9, 2015
Q&ABusiness OccupanciesTesting (Life Safety Code)

Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual …

Brad Keyes, CHSP | Oct 5, 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&ASmoke Detectors

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 | Sep 28, 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&APortable Space Heaters

Q: Are portable heaters permitted in long term care facilities in offices and other locations? A: Portable space-heating devices are prohibited in healthcare care occupancies (such as hospitals, nursing homes, …

Brad Keyes, CHSP | Sep 21, 2015
Q&ASprinklers

Q: Got any tips for a novice on how to navigate through the Life Safety Code? I’m interested in specifics on sprinkler placement for water curtains. A: NFPA 13 (1999 …

Brad Keyes, CHSP | Sep 18, 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&AVentilationCMS

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

Brad Keyes, CHSP | Sep 11, 2015
Q&ADrawingsLSC

Q: Should the official Life Safety drawings for an existing space within a hospital show the rating on a fire barrier as it was originally built or as it is …

Brad Keyes, CHSP | Sep 7, 2015
Q&AJoint CommissionClarification

Q: We recently had a survey which resulted in multiple Life Safety findings. We want to clarify away some of these findings, and were told we can only clarify the …

Brad Keyes, CHSP | Sep 4, 2015
Q&AStairwellsSigns (Life Safety Code)

Q: I am looking for a code reference which specifies the installation height for stairwell signage. It appears that NFPA 101 indicates 5 feet above the stairwell landing but does …

Brad Keyes, CHSP | Aug 31, 2015
Q&AFire Extinguishers

Q: Brad, how does the date need to be recorded on the fire extinguisher tags for the monthly inspection? Does the year need to be included on the inspection tag …

Brad Keyes, CHSP | Aug 28, 2015
Q&AMedical EquipmentImmediate JeopardyBed Maintenance

Q: We recently heard of a facility receiving an “immediate jeopardy” because their beds and stretchers had not had annual preventative maintenance. This is part of our Equipment Management plan and …

Brad Keyes, CHSP | Aug 24, 2015
Q&AAlcohol Based Hand Rub Dispensers

Q: I read an article you wrote on alcohol based hand rub (ABHR) dispensers for FacilityCare. We have had a question come up about changes in the regulations concerning the locations …

Brad Keyes, CHSP | Aug 21, 2015
Q&AFake Smoke Detectors

Q: Are fake smoke detectors permitted to be installed in a hospital according to NFPA codes and standards? I discovered that our Security department installed a manufactured security camera that …

Brad Keyes, CHSP | Aug 17, 2015
Q&ANursing HomeTemperature

Q: My loved one is in a nursing home and needs additional heat in the winter time, what do I do? The building seems to be at a comfortable temperature, …

Brad Keyes, CHSP | Aug 14, 2015
Q&ACorridors

Q: Can you give me the NFPA Life Safety Code (2000 edition) reference showing 8 foot required width in egress corridors in an existing healthcare occupancy? A: There is no …

Brad Keyes, CHSP | Aug 10, 2015
Q&AControl ValvesSprinklers

Q: I have 3 Post Indicator Valves (PIV) and 1 Wall Post Indicator Valve (WPIV). I'm not finding anything in NFPA in regards to the testing frequency. My PIVs and …

Brad Keyes, CHSP | Aug 7, 2015
Mechanical RoomsQ&ASprinklers

Q: Do air handler mechanical rooms located at the top of a hospital, and are healthcare occupancies, require sprinkler systems? A: Yes… if the rest of the hospital is required …

Brad Keyes, CHSP | Aug 3, 2015
Q&ANursing HomeSprinklers

Q: Can you clarify for me if the elevator equipment room is required to be sprinklered and have a shunt trip installed in our nursing home. A: Yes, elevator equipment …

Brad Keyes, CHSP | Jul 31, 2015
Q&AAmbulatory Care Occupancy

Q: How do I determine if our outpatient facility is an ambulatory healthcare occupancy? A: Based on what the 2000 Life Safety Code says, an ambulatory healthcare occupancy is a …

Brad Keyes, CHSP | Jul 27, 2015
Q&AEyewash Stations

Q: Does an eye wash station need to be mounted over a designated “clean sink” or can it be in any sink? Some of our Labs only have one sink, …

Brad Keyes, CHSP | Jul 22, 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&ABusiness OccupanciesFire Alarm

Q: We have an offsite physician’s clinic with a fire alarm system that is tied into our main hospital campus control center and is monitored 24/7. Are we required to …

Brad Keyes, CHSP | Jun 29, 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
Signs (Fire Suppression Systems)Q&AFire Extinguishers

Q: I have a question regarding fire extinguishers. We have our extinguishers located in cabinets that are flush with the wall. Is it required to have signage above the extinguisher? …

Brad Keyes, CHSP | Jun 15, 2015
Q&ANurse Call Systems

Q: We are looking at the difference between a "wired" and "wireless" nurse call system in our healthcare facility addition. Our current health center has a "wired" call system however …

Brad Keyes, CHSP | Jun 8, 2015
Q&AKitchensEyewash Stations

Q: Are we required to have an eyewash station inside a kitchen? A: Maybe yes and maybe no…. It all depends on whether or not there are caustic or corrosive …

Brad Keyes, CHSP | Jun 1, 2015
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&AEvacuation (Life Safety Code)Maps

Q: Are evacuation route drawings required to be posted at nurse stations or anywhere else per Joint Commission or CMS requirements? A: No. There is no Joint Commission standard or …

Brad Keyes, CHSP | May 18, 2015
Cooking AppliancesQ&AFlammable LiquidsGas Cylinders

Q: Can we store compressed butane gas cylinders used for food-warming and heating in the kitchen or do they require special storage? A: NFPA 30 requires all flammable gases and …

Brad Keyes, CHSP | May 11, 2015
Q&AOn Call Sleeping Rooms

Q: Does the Life Safety Code require hospital staff sleeping rooms have smoke detection inside the room and door closers installed? We have an on-call sleeping room for physicians in …

Brad Keyes, CHSP | May 4, 2015
Q&AAlcohol Based Hand Rub DispensersGift ShopsHelium

Q: Can we have a helium tank if secured properly in gift shop? And what are requirements for hand sanitizer locations- location to switches or outlets? A: Provided the tank …

Brad Keyes, CHSP | Apr 27, 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&ACorridorsHandrails

Q: I am working on an aesthetic corridor remodel for a hospital. Can you please tell me if there are specific requirements as to handrail locations (i.e- one side of the …

Brad Keyes, CHSP | Apr 13, 2015
Q&AConstructionSprinklers

Q: We have a construction project that involves removing all of the ceiling tiles in the area. Do we have to relocate the sprinklers heads to within 12" from the …

Brad Keyes, CHSP | Apr 6, 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
Storage (Life Safety Code)Q&AStairwells

Q: Is there any specific regulation that addresses storing items under stairwells and if so does it differentiate between public stairs and stairs which are utilized to access areas not …

Brad Keyes, CHSP | Mar 23, 2015
Q&AOxygen Cylinders

Q: A local fire inspector approved our outdoor storage shed for full oxygen cylinders. Now a surveyor says it is not compliant because the shed is made of wood, and …

Brad Keyes, CHSP | Mar 16, 2015
Q&AGenerators

Q: A consultant told me that emergency generator rooms are required to be maintained at least 40 degrees F. Do I need to maintain that temperature if I have block …

Brad Keyes, CHSP | Mar 9, 2015
Q&AEvacuation (Life Safety Code)

Q: Are stairway evacuation chairs required in all high rises, or business occupancies in general? A: According to the Life Safety Code, there is no requirement to provide stairway evacuation …

Brad Keyes, CHSP | Mar 2, 2015
Q&AHVACSmoke Compartment

Q: I have never been able to understand what a fully ducted heating system is and when a damper is not required. Can you explain this matter to me? A: …

Brad Keyes, CHSP | Feb 23, 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
Q&AMedical Records

Q: Do medical records in an off-site, business occupancy building have to be fire protected? This was not cited during our survey, but I heard from another hospital that this …

Brad Keyes, CHSP | Feb 9, 2015
Q&AFire Alarm

Q: I am having trouble with locating in the 2000 edition of the Life Safety Code where single station battery powered smoke alarms are being addressed for maintenance. I know …

Brad Keyes, CHSP | Feb 2, 2015
Q&APortable Space Heaters

Q: As the cold weather starts to creep up on us I'm continuously asked by staff if they can have a personnel heater in their office space (not patient care …

Brad Keyes, CHSP | Jan 26, 2015
Q&ACurtains

Q: Are there any requirements regarding outer hospital windows to have curtains or blinds? Some seem to think that they are required in case of severe weather as curtains are …

Brad Keyes, CHSP | Jan 19, 2015
Q&AAmbulatory Care OccupancyBusiness OccupanciesClinics

Q: We have multiple outpatient centers and clinics, and I would like to know how the Life Safety Code classifies them. Are they all treated as business? A: The Life …

Brad Keyes, CHSP | Jan 12, 2015
Q&ADoor Locks

Q: We have a separate building on our campus that includes our behavioral health unit, along with related offices and meeting rooms for the support staff. The behavioral health unit …

Brad Keyes, CHSP | Jan 5, 2015
Electric BlanketsQ&ALSC

Q: Are electric blankets permitted to be used by patients in long term care facilities? I cannot find any references to electric blankets in any NFPA codes or standard. A: …

Brad Keyes, CHSP | Dec 29, 2014
Q&AGeneratorsLSC

Q: Which edition of NFPA 110 are we expected to follow? I read that we’re expected to comply with the 1999 edition, the 2005 edition and now the 2010 edition …

Brad Keyes, CHSP | Dec 22, 2014
Q&AEvacuation (Life Safety Code)Fire AlarmHotel

Q: We own and operate a hotel on our hospital campus and are revamping our fire plan. Are we required to have all the hotel guests evacuate their rooms upon …

Brad Keyes, CHSP | Dec 15, 2014
Q&AAmbulatory Care OccupancyWaiting Areas

Q: Can an Ambulatory Surgical Center (ASC) have a waiting room that is shared with another physician’s practice that is not associated with the ASC, but is located in the …

Brad Keyes, CHSP | Dec 8, 2014
Q&ADecorations

I have received quite a few questions concerning combustible decorations this season and thought I would run this special Q&A today... Q: My administration is decorating our hospital lobby and has …

Brad Keyes, CHSP | Dec 4, 2014
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
Q&ABusiness OccupanciesFire Extinguishers

Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital? A: The monthly inspection and annual …

Brad Keyes, CHSP | Nov 24, 2014
Q&ASprinklers

Q: We completed our hospital sprinkler installation in 1994, and most of the sprinklers that were installed were quick response sprinklers. Now I hear at an ASHE conference that we …

Brad Keyes, CHSP | Nov 10, 2014
Q&AFire Alarm

Q: Are we supposed to have smoke detectors in the corridors of our hospital? I see the Statement of Conditions ask if we have smoke detectors in our corridors, which …

Brad Keyes, CHSP | Nov 3, 2014
Q&ABusiness Occupancies

Q: We have an attached building that houses an ambulatory surgical center and the building is classified as a business occupancy. We want to convert it from business occupancy to …

Brad Keyes, CHSP | Oct 27, 2014
Q&AFire Extinguishers

Q: Our administration wants us to discontinue applying bar-code labels on each extinguisher in our facility, and begin applying the labels on the cabinets and walls where the extinguishers are …

Brad Keyes, CHSP | Oct 20, 2014
Q&AAmbulatory Care OccupancyOccupancies

Q: We have an Ambulatory Surgical Center (ASC) located in a one story nonsprinklered building, and is separated from a physician’s office. The exit access from the ASC leads into …

Brad Keyes, CHSP | Oct 13, 2014
Portable FansQ&A

Q: Are portable fans permitted in patient care areas? At times, a patient may become too warm and the normal HVAC system does not provide adequate cooling. A: The use …

Brad Keyes, CHSP | Oct 6, 2014
Q&APatientAppliances

Q: How are we supposed to deal with patient owned equipment that is brought into the hospital, such as laptop computers, hairdryers, and electric razors? Are we required to maintain …

Brad Keyes, CHSP | Sep 29, 2014
Q&AAppliancesConsumer

Q: How does CMS and the accreditation organizations look at preventive maintenance of household electrical items, such as lamps and coffee makers used by staff in the hospital? Do I …

Brad Keyes, CHSP | Sep 22, 2014
Mechanical RoomsStorage (Life Safety Code)Q&A

Q: I was always under the impression that no storage was allowed in mechanical rooms within hospitals. Now I work at a hospital that allows ladders and supplies to be …

Brad Keyes, CHSP | Sep 15, 2014
Q&ADoor Locks

Q: We have been asked to install a lock on a door in the path of egress through an office. For security reasons they would like to lock the doors …

Brad Keyes, CHSP | Sep 8, 2014
Q&AElectrical RoomsStorage (Electrical)

Q: Can cardboard boxes be stored in an electrical room that is over 50 square feet, fully sprinklered, and has only dry transformers under 112 1/2 kVA? A: Yes, only …

Brad Keyes, CHSP | Sep 1, 2014
Q&AAmbulatory Care OccupancyOxygen Cylinders

Q: Since the Life Safety Code addresses ambulatory surgery centers in chapters 20-21, which does not reference oxygen storage requirements, do they have to abide by NFPA 99 concerning storage …

Brad Keyes, CHSP | Aug 25, 2014
Q&AKitchensFire Extinguishers

Q: Do we have to have a special placard on our fire extinguishers in our kitchen, alerting people to activate the cooking hood fire suppression system first, before using the …

Brad Keyes, CHSP | Aug 18, 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
Q&AEmergency Lights (Life Safety Code)

Q: Is there a NFPA standard for emergency lighting placement in an anesthetizing location? A specific requirement where on the wall or ceiling it must be mounted? Do the self-check …

Brad Keyes, CHSP | Jul 28, 2014
Q&ABusiness Occupancies

Q: Our new clinic integration program has made us look closely at the clinic's life safety process. The clinic is classified as a business occupancy. Is the assessment for life …

Brad Keyes, CHSP | Jul 21, 2014
Q&ASprinklers

Q: During a recent survey, the life safety surveyor wrote a finding that my refrigerator and freezer walk-in coolers are not in compliance with the building having full sprinkler coverage …

Brad Keyes, CHSP | Jul 14, 2014
Q&AMain DrainTesting (Fire Suppression Systems)Sprinklers

Q: Where are main drain tests required to be done? This is a large medical facility with nine story towers. Several fire mains feed the various campus buildings. Is the …

Brad Keyes, CHSP | Jul 7, 2014
Q&ABusiness OccupanciesStorage (Medical Gas)Oxygen Cylinders

Q: Our hospital has an offsite building for our cardiac rehab, physical therapy, and pulmonary rehab programs. It also houses our business office and some physician offices. The building is …

Brad Keyes, CHSP | Jun 30, 2014
Q&AGeneratorsStorage (Generators)

Q: I cannot find a code reference that prohibits storage in the generator enclosure. Is there a specific reference for this in the 2000 edition of the Life Safety Code? …

Brad Keyes, CHSP | Jun 23, 2014
Q&AHazardous Areas

Q: If hazardous areas like a carpentry shop and a paint shop are combined in a separate building distant from hospital building, what can be an appropriate reference to determine …

Brad Keyes, CHSP | Jun 16, 2014
Emergency Response Plan (Accreditation/CertificatiQ&AFire Safety Plan

Q: We are going to prepare an action card for fire safety as part of our major emergency response plan. What information regarding fire safety would you suggest we include …

Brad Keyes, CHSP | Jun 9, 2014
Q&AElectrical Rooms

Q: Are there any requirements to firestop penetrations in Information Technology (IT) closets and electrical rooms in business occupancies? A: Only if the barriers surrounding the IT closets are designated …

Brad Keyes, CHSP | Jun 2, 2014
Storage (Life Safety Code)Q&AFlammable Liquids

Q: Are there any special storage requirements for flammable liquids and flammable aerosol cans in the work area? A: Yes, flammable liquids in all forms and capacities must be stored …

Brad Keyes, CHSP | May 26, 2014
Q&ABusiness OccupanciesILSM

Q: Are Interim Life Safety Measures (ILSMs) required in Business Occupancies due to construction or life safety code deficiencies? Do we have to conduct a fire watch in Business Occupancies? …

Brad Keyes, CHSP | May 19, 2014
Q&APower Strips

Q: I read the June, 2012 article in HLSC about power strips in healthcare facilities and we have been hesitant to use power strips in patient care areas because the …

Brad Keyes, CHSP | May 12, 2014
Mechanical RoomsQ&AElectrical RoomsGeneratorsFire Barrier

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We …

Brad Keyes, CHSP | May 5, 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&AAmbulatory Care OccupancyFire & Smoke Dampers

Q: Our facility is a freestanding ambulatory surgical center and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story …

Brad Keyes, CHSP | Apr 21, 2014
Q&ADoor LocksStairwells

Q: During a recent survey, the surveyor said a card reader on the stairwell door cannot be located on an adjacent wall or door frame, but it must be an …

Brad Keyes, CHSP | Apr 14, 2014
Q&AAmbulatory Care OccupancySmoke Compartment

Q: We are a freestanding ambulatory surgical center (ASC) and we only perform gastrointestinal (GI) procedures, not surgery. We lease a suite on the ground level in a 3 story …

Brad Keyes, CHSP | Apr 7, 2014
Q&ADoor LocksSoiled Utility Room

Q: Where is the reference in the Life Safety Code that requires the doors to housekeeping or soiled utility rooms to be locked? I have a Risk Management director that …

Brad Keyes, CHSP | Mar 31, 2014
Q&ASprinklers

Q: How many spare sprinkler heads are we supposed to have in stock at our facility? We had an inspection recently, and the fire marshal said we did not have …

Brad Keyes, CHSP | Mar 24, 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
Q&AVentilationCeilings (Life Safety Code)

Q: We have decorative wood panels in our cafeteria ceiling which do not provide a seal to limit the passage of smoke. In fact, there are wide gaps between the …

Brad Keyes, CHSP | Mar 10, 2014
Q&AFire AlarmConstruction

Q: Are we required to install fire alarm occupant notification devices and manual pull stations in construction areas? I couldn’t find anything in NFPA 72 or the Life Safety Code …

Brad Keyes, CHSP | Mar 3, 2014
Q&ACorridorsCurtains

Q: The health care facility where I work needs additional privacy on the nursing floor from the rest of the building. I would like to know if we could mount …

Brad Keyes, CHSP | Feb 24, 2014
Q&AArticleStairwells

Q: Can evacuation chairs be installed in stairwells? A: The answer is… maybe yes and maybe no. Sorry, that’s not a direct answer, so please allow me to explain. Section …

Brad Keyes, CHSP | Feb 17, 2014
Q&AFire AlarmTesting (Life Safety Code)

Q: What are the testing frequencies for fire alarm panel batteries and where do you find this requirement? A: The testing frequencies for batteries for fire alarm control panels (including …

Brad Keyes, CHSP | Feb 10, 2014
Q&AGas ManifoldsMedical Gas

Q: We have a situation in our Lab where they would like to purchase another incubator that requires additional CO2 gas. The problem is that we do not have a …

Brad Keyes, CHSP | Feb 3, 2014
Q&AGeneratorsFire Barrier

Q: Do emergency power generators have to be located in a room by themselves? We have a generator that is located in a mechanical room which is shared with an …

Brad Keyes, CHSP | Jan 27, 2014
Q&ACeilings (Fire Suppression Systems)Sprinklers

Q: I have a reception area that has a sprinkler head in the middle of a 2'x2' ceiling tile and less than twelve inches from this sprinkler head the interior …

Brad Keyes, CHSP | Jan 20, 2014
Q&ABusiness OccupanciesSprinklers

Q: We are designing a retrofit for a dental office in an existing business occupancy building without a fire sprinkler system. The space we are remodeling was formerly a doctor's …

Brad Keyes, CHSP | Jan 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
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&AAmbulatory Care OccupancyWallsOccupancies

Q: Do different occupancies have to be separated by fire-rated barriers both horizontally as well as vertically? We are considering installing a dialysis unit on the second floor of a …

Brad Keyes, CHSP | Dec 23, 2013
Signs (Fire Suppression Systems)Q&AFire Extinguishers

Q: During a recent survey we were almost cited because one of the fire extinguisher signs was on the front of the fire extinguisher cabinet and the rest were above …

Brad Keyes, CHSP | Dec 16, 2013
Storage (Life Safety Code)Q&AConstruction

Q: We are renovating one of our patient sleeping suites in an existing area. Would it be permissible to stage construction materials (some of which will be combustible) in one …

Brad Keyes, CHSP | Nov 25, 2013
Q&AHazardous AreasTrash Receptacles

Q: We just completed a renovation of our cafeteria dining area and as part of the project an 8 container trash cabinet was built and installed in a separated area …

Brad Keyes, CHSP | Nov 4, 2013
Q&ASprinklers

Q: We have an electrical room that is not protected with sprinklers and the old-timers here say the building department would not permit sprinklers in this room when the hospital …

Brad Keyes, CHSP | Oct 28, 2013
Q&AOxygen Cylinders

Q: I came across a bunch of wheelchairs folded up in an equipment storage room. Each had an oxygen cylinder attached. Are these cylinders included in the tally for aggregate …

Brad Keyes, CHSP | Oct 21, 2013
Q&AClean LinenHazardous AreasOxygen Cylinders

Q: Are oxygen cylinder tanks (in holders) allowed to be stored in alcoves in corridors? Also, what about clean linen carts? I am told that our accreditation organization allows this, …

Brad Keyes, CHSP | Oct 14, 2013
Q&AFire AlarmOn Call Sleeping Rooms

Q: We have a physician on-call sleeping room inside our labor and delivery unit. A surveyor told us that we need audible smoke alarms in each on-call sleeping room. We …

Brad Keyes, CHSP | Oct 7, 2013
Q&ADomestic Water

Q: Two different state authorities are telling me conflicting information concerning the maximum temperature for domestic hot water. The first one is telling me the hot water cannot exceed 100°F …

Brad Keyes, CHSP | Sep 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&ATesting (Life Safety Code)Sprinklers

Q: What is the required inspection frequency on sprinkler systems for a building classified as business occupancy? Is it less than what would be required for the main hospital? A: …

Brad Keyes, CHSP | Sep 16, 2013
Hazardous WasteQ&AHand Wipes

Q: What is the proper method to store and dispose of waste alcohol prep pads? Are they considered hazardous waste? A: The quantities of liquid alcohol in the preps would …

Brad Keyes, CHSP | Sep 9, 2013
Q&AWet Locations

Q: How are ‘wet locations’ defined in the NFPA codes and standards? We are not clear if we have any ‘wet locations’ in our hospital. A: You probably do, based …

Brad Keyes, CHSP | Sep 2, 2013
Q&ATesting (Fire Detection Systems)Technician (Fire Detection Systems)

Q: We recently found out that our own maintenance staff is not qualified to service our fire alarm system. What other systems or items in the hospital requires our own …

Brad Keyes, CHSP | Aug 26, 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
Q&ASmoke Dampers

Q: What is the amount of air delivery (in CFM) that an air handler needs to have before it is required to have a smoke damper on the discharge of …

Brad Keyes, CHSP | Aug 12, 2013
Q&AMedical Gas

Q: I came across a medical gas shutoff valve that was located behind an access panel in a small storage closet in a surgery department. The closet was packed and …

Brad Keyes, CHSP | Aug 4, 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&AFire Alarm

Q: What is the spacing requirement for fire alarm occupant notification devices? A: The spacing requirements are not listed in a specific distance, but they are listed by their decibel …

Brad Keyes, CHSP | Jun 24, 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
Q&ATesting (Fire Suppression Systems)Sprinklers

Q: Where is the main drain test supposed to be conducted? Is it supposed to be at the sprinkler riser or low point drain? A: According to NFPA 25 Inspection, …

Brad Keyes, CHSP | Jun 10, 2013
Q&AParking GarageFire Extinguishers

Q: Are we required to have portable fire extinguishers in our parking garages? A: No. The placement of portable fire extinguishers is dependent on the requirements for that particular occupancy …

Brad Keyes, CHSP | Jun 3, 2013
Q&AEvacuation (Life Safety Code)DrawingsMaps

Q: We had a question as to whether or not we are required to have posted emergency evacuation route signage posted throughout the hospital and clinical buildings. Given the fact …

Brad Keyes, CHSP | May 27, 2013
Q&AFire BarrierWalls

Q: Are fire rated walls the same thing as fire rated barrier? And are smoke compartment barriers actually fire rated walls? A: As it has been explained to me, a …

Brad Keyes, CHSP | May 20, 2013
Q&AAmbulatory Care OccupancySprinklers

Q: We are in the process of renovating an existing two story office building where a dialysis unit will be located on the lower level. According to our state requirements, …

Brad Keyes, CHSP | May 13, 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
Q&AFireplaces

Q: Are gas-fired ventless fire places permitted in nursing homes? A: I would say they are not permitted, but it has a lot to do whether or not the gas …

Brad Keyes, CHSP | Apr 29, 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
Q&AAmbulatory Care OccupancyBusiness OccupanciesOccupancies

Q: We discovered our offsite free standing Dialysis center is in a building that is classified as Business Occupancy, but we were recently told by a consultant that the building …

Brad Keyes, CHSP | Apr 15, 2013
Q&ASprinklers

Q: Our project team has to do a domestic water shutdown for about 12 hours and unfortunately the water they want to shut down serves water-cooled refrigeration units in the …

Brad Keyes, CHSP | Apr 8, 2013
Q&AFire AlarmSprinklers

Q: The 2008 edition of NFPA 25 allows vane-style waterflow switches to be tested semi-annually, but during a recent survey, the surveyor cited us for not testing them on a …

Brad Keyes, CHSP | Apr 1, 2013
Q&ATesting (Generators)Generators

Q: Is it allowed to combine the 3-year 4-hour generator load test along with the annual 2-hour load test? Our generator test company plans on running the generator at 50% …

Brad Keyes, CHSP | Mar 25, 2013
Q&AMedical Gas

Q: What is the distance needed to prevent obstructing medical gas shut-off valves? Is it just not having anything directly in front of the valve itself - or does it have …

Brad Keyes, CHSP | Mar 21, 2013
Q&AFire PumpTesting (Fire Suppression Systems)

Q: My sprinkler testing contractor is questioning the requirement that fire pumps are to be flow-tested annually at 150% load on emergency power. It's the emergency power requirement in question …

Brad Keyes, CHSP | Mar 18, 2013
Q&ASmoke Compartment

Q: Are smoke compartment barriers considered to be fire rated barriers? The architect that we have doing our drawings wants to call the smoke compartment barrier walls “1-hour smoke/fire barrier”, …

Brad Keyes, CHSP | Mar 14, 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&ADecorations

Q: Our corporate office has informed us that we need to remove all artificial plants from the hospital if they do not have a fire rating label attached to the …

Brad Keyes, CHSP | Mar 7, 2013
Storage (Life Safety Code)Q&AHazardous AreasPatient RoomsILSM

Q: We have a short-term project where we need to find some space to store equipment until they are installed. The equipment is electronic and needs to remain in their …

Brad Keyes, CHSP | Mar 4, 2013
SuitesQ&AEquivalencies

Q: Can an FSES equivalency be written for an oversized ER suite? Our ER was constructed in 2005 and the designer made it 13,450 square feet, which is more than …

Brad Keyes, CHSP | Feb 28, 2013
Q&AHand Wipes

Q: What are your thoughts on the flammability of disinfectant hand wipes? One of our VPs raised the question, noting that the wipes burn pretty well. Are these wipes a …

Brad Keyes, CHSP | Feb 25, 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
Q&AFire AlarmFire Pump

Q: Are “fire pump running” and “fire pump power loss” switches which are connected to the hospital fire alarm system considered to be supervisory signal devices? I say they aren’t …

Brad Keyes, CHSP | Feb 18, 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&AOxygen CylindersGas Cylinders

Q: Several of our department have stretchers with onboard E-size oxygen cylinders. Can these be considered "in use" and not count against the smoke compartment's 300 cubic feet limit? Also, …

Brad Keyes, CHSP | Feb 7, 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&ADoor Locks

Q: In a Psychiatric hospital emergency room, are patient holding rooms allowed to have dead bolts on the corridor side with no thumb latch on the inside of the room? …

Brad Keyes, CHSP | Jan 31, 2013
Storage (Life Safety Code)Q&AAmbulatory Care Occupancy

Q: We have an ambulatory healthcare occupancy which has clean supply and soiled linen rooms. Since these rooms are considered storage with combustibles, the Life Safety Code (LSC) views them …

Brad Keyes, CHSP | Jan 28, 2013
Q&A

Q: We have a large computer center that has a halon system in the room. They know in a sprinkled area that they must keep items 18" below the sprinkler but is that …

Brad Keyes, CHSP | Nov 26, 2012
SuitesQ&ACorridors

Q: During a recent survey, we were cited for not maintaining at least 36 inches of clear width in our suites for exiting purposes. I thought one of the advantages …

Brad Keyes, CHSP | Nov 19, 2012
Q&AHazardous AreasTrash Receptacles

Q: During a recent survey, the surveyor noted that we had two 64 gallon capacity containers which we use for document shredding, sitting side-by-side in the laboratory work room. He …

Brad Keyes, CHSP | Nov 12, 2012
Q&AFire Alarm

Q: We recently had an inspection and we were cited for not having a smoke detector in the on-call sleeping room for physicians which is located on our Labor & …

Brad Keyes, CHSP | Nov 5, 2012
Q&ASmoke Dampers

[This week's Q&A came from the 49th Annual Conference and Exhibition of the American Society for Healthcare Engineering (ASHE), held in San Antonio, TX, last July, and how it applies …

Brad Keyes, CHSP | Oct 29, 2012
Q&ASmoke Dampers

[This week's Q&A came from the 49th Annual Conference and Exhibition of the American Society for Healthcare Engineering (ASHE), held in San Antonio, TX, last July, and how it applies to …

Brad Keyes, CHSP | Oct 22, 2012
Q&AGeneratorsTesting (Life Safety Code)

Q: During a recent survey, the inspector cited us for not exercising our circuit breakers downstream of our generator. Does the LSC require annual exercising of all circuit breakers between …

Brad Keyes, CHSP | Oct 15, 2012
Storage (Life Safety Code)Q&ABusiness Occupancies

Q: We have a new facility which has recently opened, and it is a physician’s office/business occupancy. There is a medical record storage room which contains combustible files which we …

Brad Keyes, CHSP | Oct 8, 2012
Q&ACorridorsLSC

Q: Our Risk Management Department has conducted an assessment of our waiting areas in our hospital. They are stating that staff should be able to see all patrons who are …

Brad Keyes, CHSP | Oct 1, 2012
Q&AChutes (Life Safety Code)

Q: Do linen chute doors have to be locked? Our risk manager says they are required to be locked, but I don’t see anything in the LSC that says that …

Brad Keyes, CHSP | Sep 24, 2012
SuitesStorage (Life Safety Code)Q&A

Q: Can we install shelving along the walls within a patient sleeping suite? This shelving would not be limited to a supply room, but would be permanently affixed to the …

Brad Keyes, CHSP | Sep 17, 2012
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
Q&AEmergency Lights (Life Safety Code)

Q: Are battery powered emergency lights required in business occupancies? We have a small clinic that does not have battery powered emergency lights (or battery powered “Exit’ signs for that …

Brad Keyes, CHSP | Aug 20, 2012
Mechanical RoomsQ&A

Q: We have equipment rooms on the top floor of our hospital that contain mechanical equipment, but no boilers or generators. Are these equipment rooms required to be protected with …

Brad Keyes, CHSP | Aug 13, 2012
Q&AElectrical Rooms

Q: In a recent posting a question was raised about storage in a mechanical room. What about storage in an electrical room? Is it permitted? A: In some cases storage …

Brad Keyes, CHSP | Aug 6, 2012
Storage (Life Safety Code)Q&A

Q: Our medical supply room contains combustibles, and is larger than 100 square feet. It does not have a door and the room opens onto the corridor, behind our nurse …

Brad Keyes, CHSP | Jul 29, 2012
Mechanical RoomsQ&A

Q: I have a storage question for you that relates to storing beds and other hospital equipment in our mechanical rooms. Is this allowed or would I be cited for …

Brad Keyes, CHSP | Jul 22, 2012
Q&AFire Extinguishers

Q: Is the hospital responsible for the fire extinguishers supplied by the contractors while they are performing work in our hospital? We had a surveyor cite us for not performing …

Brad Keyes, CHSP | Jul 15, 2012
Q&AHazardous Areas

Q: Is the main kitchen in a hospital considered a hazardous area? I’m referring to the main kitchen where all the food is prepared for the hospital, not the kitchenettes …

Brad Keyes, CHSP | Jul 8, 2012
Q&A

Q: Our entire hospital is protected with automatic sprinklers. Do the contents and furnishings in our patient rooms need to meet a flame spread standard? A: The answer to this …

Brad Keyes, CHSP | Jul 1, 2012
Mechanical RoomsQ&A

Q: Is it prohibited to store items in a mechanical equipment room? We have different opinions at our hospital as to what is allowed and what is not allowed. Do …

Brad Keyes, CHSP | Jun 24, 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&AMedical Air

Q: I have a compressor that delivers medical air for our patients and want to know what the requirements are for the alarm system for the air dryers. Where do …

Brad Keyes, CHSP | Jun 10, 2012
Q&AMedical Air

Q: Is it a requirement to keep access to the medical gas alarm panel clear in a similar manner that access to medical gas shutoff valves must remain clear? These …

Brad Keyes, CHSP | Jun 3, 2012
Q&AElectrical Rooms

Q: I had a state inspector tell me that communication wires and cable in our hospital are not permitted to be tied to conduit containing electrical wires. Is this true? …

Brad Keyes, CHSP | May 28, 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&AAlcohol Based Hand Rub Dispensers

Q: What is the actual spacing requirement for alcohol based hand-rub (ABHR) dispensers from electrical sources such as light switches in the hospital? I have heard it must be 4 …

Brad Keyes, CHSP | May 14, 2012
Q&ASprinklers

Q: We are about to install a new shelving system into a room that is protected with automatic sprinklers. I know we are supposed to maintain 18 inches clearance underneath …

Brad Keyes, CHSP | May 7, 2012
Q&ATravel Distances

Q: How do you calculate the Common Path of Travel and/or Total Travel Distance for a multi tenant suite when the space planning for the individual rooms has not been …

Brad Keyes, CHSP | Apr 30, 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&AElevators

Q: We are putting in fire recall on our elevators. Now the elevator people are telling us that due to the age of some of our elevators they can only …

Brad Keyes, CHSP | Apr 9, 2012
Q&AGas Cylinders

Q: We have a contractual Dialysis Unit on the 2nd Floor of our Medical Office Building which consists mainly of one large open room. Very often in the treatment area …

Brad Keyes, CHSP | Apr 1, 2012
Q&AGas Cylinders

Q: At our hospital, we have differing opinions concerning the proper method to restrain compressed gas cylinders. Would you please provide us the code reference regarding the correct method to …

Brad Keyes, CHSP | Mar 18, 2012
Q&AFire Alarm

Q: We have an outpatient clinic which is a business occupancy and provides ancillary services like physical therapy and radiology, and there are no fire alarm pull stations in the …

Brad Keyes, CHSP | Mar 11, 2012
Q&AFire Pump

Q: We recently replaced our old fire pump with a brand new unit that is up to date with the current requirements of NFPA 20 Standard for the Installation of …

Brad Keyes, CHSP | Mar 4, 2012
Q&AFire Extinguishers

Q: Is there any formal requirement to have a “contract” with a fire extinguisher company for extinguisher maintenance? I have a copy of their credentials but recently was I lead …

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

Q: In regards to stairwell signage, when you have restrictive access back into the building from a stairwell in accordance with section 7.2.1.5.2 of the NFPA 101 Life Safety Code, …

Brad Keyes, CHSP | Feb 1, 2012
Q&ADoor Locks

Q: Are dead-bolt locks permitted on patient room doors, to keep unauthorized people from entering the rooms? We have dead-bolt locks on the patient room doors in our behavioral health …

Brad Keyes, CHSP | Feb 1, 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&ATrash Receptacles

Q: We have these big recycling containers mounted on wheels all over the hospital, which must have a capacity of 50 gallons each, at least. Does this container need to be …

Brad Keyes, CHSP | Jan 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
Mechanical RoomsQ&A

Q: We have a mechanical room in our hospital whose entrance door opens into the top of an exit stairwell. I was informed by a consultant that this arrangement is …

Brad Keyes, CHSP | Dec 6, 2011
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&AHazardous Areas

Q: Does the kitchen in a nursing home have to be considered as a hazardous room? I don’t see where the LSC defines the kitchen as a hazardous room, but …

Brad Keyes, CHSP | Dec 1, 2011
Q&AShelves

Q: Are we required to have solid bottom shelves in all areas where we have items stored, including on carts? Does this requirement extend to all stored items? A: It …

Brad Keyes, CHSP | Dec 1, 2011
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&ASprinklers

Q: I’ve read that installing sprinklers in our existing hospital, even when they are not required such as a renovation project, provides us with exceptions to the LSC. If we …

Brad Keyes, CHSP | Nov 1, 2011
Q&AFire & Smoke Dampers

Q: During a recent survey, we were cited by the surveyor for a 6 inch round duct that did not have a smoke damper installed where it penetrated a smoke …

Brad Keyes, CHSP | Nov 1, 2011
Q&AFire AlarmConstruction

Q: Our projects team currently disables our fire alarm control panel each morning during periods of construction and restores the panel each evening. They do this to prevent unwanted fire …

Brad Keyes, CHSP | Nov 1, 2011
Q&AHazardous Areas

Q: Do employee locker rooms automatically have to be considered a hazardous area? If they are protected with sprinklers, does this change the situation? A: No, employee locker rooms are …

Brad Keyes, CHSP | Oct 1, 2011
Q&AAlcohol Based Hand Rub Dispensers

Q: During a recent survey, the surveyor told us that we could not have Alcohol Based Hand Rub (ABHR) dispensers over carpeting in areas of the hospital that do not …

Brad Keyes, CHSP | Oct 1, 2011
Q&ABulletin Boards

Q: What is the requirement for bulletin boards in exit corridors? I heard from another hospital that bulletin boards greater than 4 square feet must be protected with glass. Is …

Brad Keyes, CHSP | Oct 1, 2011
Q&ATrash Receptacles

Q: Are waste container required to be fire retardant in hospitals? What about long term care facilities? A: No, they are not. At one time, the Life Safety Code® (LSC) …

Brad Keyes, CHSP | Oct 1, 2011
Q&AFire Extinguishers

Hazard Classification Hazard Type Minimum Fire Extinguisher Rating Travel Distance Class A Low 2-A 75 ft Class A Moderate 2-A 75 ft Class A High 4-A 75 ft Class B …

Brad Keyes, CHSP | Sep 1, 2011
Q&AFire Pump

Q: What is the requirement for water flow testing fire pumps under emergency power? I have heard some hospitals are being cited for not doing this, but a surveyor once …

Brad Keyes, CHSP | Sep 1, 2011
Q&AGenerators

Q: The AHJs who inspect my hospital require that I conduct a three-year, four-hour load test, which we do simultaneously with our annual load bank test. One AHJ says this …

Brad Keyes, CHSP | Sep 1, 2011
Q&AFire Extinguishers

Q: Can you direct me to the standard that states we must have a CO2 fire extinguisher in the operating rooms of our surgery department? Our operations chief insists a …

Brad Keyes, CHSP | Sep 1, 2011
Storage (Life Safety Code)Q&AHazardous Areas

Q: We are looking at purchasing a medical practice with a business occupancy rated office, which is not sprinkled. They are using a room on the second floor as a …

Brad Keyes, CHSP | Aug 1, 2011
Q&AFire Watch

Q: Do you know of any guidelines for the amount of time you have to conduct a fire watch during an Interim Life Safety Measures (ILSM) operation? Does it have …

Brad Keyes, CHSP | Aug 1, 2011
Q&AFire Alarm

Q: Is there a minimum reaction time for an air handler to respond to a duct detector activation? We had a consultant say that we had to record documentation that …

Brad Keyes, CHSP | Aug 1, 2011
Q&AAlcohol Based Hand Rub Dispensers

Q: Brad- Are alcohol based hand-rub (ABHR) dispensers permitted in corridor of business occupancies? A: The LSC is very silent about alcohol based hand rub (ABHR) dispensers in a business …

Brad Keyes, CHSP | Jul 1, 2011
Q&AChutes (Life Safety Code)

Q: Can you please direct me to where it says we have to have locks on our linen and waste chutes? What is the requirement and where does it come …

Brad Keyes, CHSP | Jul 1, 2011
Q&AElevators

Q: We have all seen the signs “In case of fire, do not use elevators.” This to me suggests when the fire alarm sounds no one is to use the …

Brad Keyes, CHSP | Jul 1, 2011
Q&ADoor Locks

Q: I was recently informed by a contractor the magnetic locks that we use to lock our ER department doors are not allowed to be connected to our emergency generator …

Brad Keyes, CHSP | Jun 1, 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&AChutes (Life Safety Code)

Q: We have an existing 24-inch diameter chute throughout our building that is designed for housekeepers to shake out the dry dust mops into the chute. A ventilation fan takes …

Brad Keyes, CHSP | Jun 1, 2011
Q&AFire Extinguishers

Q: Can you tell me if there is a requirement for the operating rooms to have a CO2 fire extinguisher inside the rooms themselves? Our hospital received a citation by …

Brad Keyes, CHSP | May 1, 2011
Q&AExitsConstructionStairwells

Q: We have a stairwell in our hospital that extends from the 8th floor to the 1st floor, where there is a door that discharges the occupants to the outdoors …

Brad Keyes, CHSP | May 1, 2011
Q&AElectrical RoomsSprinklers

Q: I was recently informed by an architect that an electrical equipment room does not need to be sprinkled if it has a two-hour fire resistant separation. Have you heard …

Brad Keyes, CHSP | May 1, 2011
Mechanical RoomsQ&A

Q: We have a penthouse mechanical room on top of our hospital that has a vertical shaft used for pipes, conduits and HVAC ductwork which is open to the mechanical …

Brad Keyes, CHSP | Apr 1, 2011
Cooking AppliancesQ&A

Q: We have portable little butane one burner stoves that dietary likes to use to cook one pan of something in the server area, but they also use it to …

Brad Keyes, CHSP | Apr 1, 2011
Q&ASprinklers

Q: We have exposed sprinkler heads in our hospital, and the design rings around the sprinkler heads occasionally fall off and disappear. One of our sprinkler contractors said those rings …

Brad Keyes, CHSP | Apr 1, 2011
Q&AVentilation

Q: Is there a Life Safety Code regulation stating the need for 100% outside air for the lab HVAC system or where could I find the requirements that regulate this …

Brad Keyes, CHSP | Mar 1, 2011
Q&ASprinklers

Q: How close can a sprinkler head be located to a wall mounted cabinet? I have some cabinets that were added after the sprinkler heads were installed, and the heads …

Brad Keyes, CHSP | Mar 1, 2011
Q&ASprinklers

Q: NFPA 13 (1999 edition) section 5-3.1.5.2 states whenever standard response sprinklers are changed to quick response type, then all of the sprinklers have to be changed in the that …

Brad Keyes, CHSP | Mar 1, 2011
Q&AConstructionFire BarrierWalls

Q: I read with interest the article Understanding the Importance of Construction Types in the February, 2011 issue of HLSC. The article said a 2-hour fire resistance horizontal barrier is …

Brad Keyes, CHSP | Mar 1, 2011
Q&AFire Alarm

Q: Are fire alarm notification appliances required to have annual sound level measurement testing? We had a consultant tell us that we are supposed to conduct the sound level testing …

Brad Keyes, CHSP | Feb 1, 2011
SuitesQ&AHazardous Areas

Q: Can the entire patient sleeping suite of rooms, such as an ICU, be considered a hazardous room? This would allow us to store supplies in the common area of …

Brad Keyes, CHSP | Feb 1, 2011
Storage (Life Safety Code)Q&AHazardous Areas

Q: During a recent mock survey it was mentioned that cardboard boxes are not allowed in clean storage rooms because they are combustible. Many of the supplies that we have …

Brad Keyes, CHSP | Feb 1, 2011
Q&ABulletin Boards

Q: What are the limitations to bulletin boards that have paper tacked to them, in exit corridors in a hospital? Do they have to be behind glass doors? A: No, …

Brad Keyes, CHSP | Feb 1, 2011
Q&ABridge Between Buildings (Life Safety Code)

Q: We have a new 12 story patient tower that is built next to our original 4 story hospital. On the 4th floor there is a bridge that spans across the …

Brad Keyes, CHSP | Jan 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&AAlcohol Based Hand Rub Dispensers

Q: Is there a rule about how far apart hand sanitizers should be? One of my directors wants to put one just inside a patient room and outside in the …

Brad Keyes, CHSP | Jan 1, 2011
Q&ASmoke Compartment

Q: In 1970, our smoke compartment barriers were originally constructed to 1-hour fire ratings, but I see that the Life Safety Code allows existing smoke compartment barriers to be only …

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

Q: I read an article were an interruption gate is required in a stairwell to prevent people from traveling past the floor where they should exit. Is this a requirement …

Brad Keyes, CHSP | Dec 1, 2010
Q&AElectrical RoomsWalls

Q: Are electrical equipment rooms required to be fire rated? We have a dry-type transformer in an utility room on one of our nursing units and wanted to know if …

Brad Keyes, CHSP | Dec 1, 2010
Q&AElectrical RoomsSprinklers

Q: Do all electrical rooms have to have automatic sprinklers installed in them? Our electrician tells us there are exceptions to installing sprinklers in an electrical room even when the …

Brad Keyes, CHSP | Dec 1, 2010
Q&ASprinklers

Q: We have open concrete beam floor construction in our hospital, and the depth of the beams are14 inches below the deck, and they are spaced 70 inches center-to-center. The …

Brad Keyes, CHSP | Dec 1, 2010
Q&AExits

Q: Are hard-surface sidewalks, such as concrete, required between the exit door and the public way in order to qualify as an exit discharge? I was told that we need …

Brad Keyes, CHSP | Dec 1, 2010
Q&ATrash Receptacles

Q: In a business occupancy (physician medical office) can waste receptacles that are used for exam room waste paper be made of plastic, or do they have to be fire …

Brad Keyes, CHSP | Nov 1, 2010
Q&AGenerators

Q: Are we required to replace the batteries that start our emergency generators every two years? Our generator service contractor told us that the code requires us to replace the …

Brad Keyes, CHSP | Nov 1, 2010
Q&ABulletin Boards

Q: What, if any, are the limits on bulletin boards in a means of egress corridor? I have managers who want to place large quantities of paper on their bulletin …

Brad Keyes, CHSP | Nov 1, 2010
Q&APortable Space Heaters

Q: We have a contractor who wants to use a propane gas-fired portable heater to warm an unoccupied space that is currently under renovation in the hospital. The central heating …

Brad Keyes, CHSP | Nov 1, 2010
Q&ATransformer

Q: What are the limitations to installing a 112 kVA dry-type transformer in a soiled utility room? Our local building inspector wants a shield around the transformer separating it from …

Brad Keyes, CHSP | Oct 1, 2010
Q&AElevators

Q: Do we need to test our elevator recall system once a month? I don’t see where this is required in the Life Safety Code (LSC). We test our elevator …

Brad Keyes, CHSP | Oct 1, 2010
Q&ACurtains

Q: Our hospital is fully protected with automatic sprinklers. Our cubicle curtains have an open mesh at the top to prevent water discharged from a sprinkler head from being obstructed …

Brad Keyes, CHSP | Oct 1, 2010
Q&AGas Cylinders

Q: Our gas storage room has little mini-helium tanks which are full and under pressure. Are these tanks required to be restrained in the same way that the larger ‘E’ …

Brad Keyes, CHSP | Oct 1, 2010
Q&ASprinklers

Q: During a recent survey, an inspector cited us for not having the escutcheon (trim) plates around all of our sprinkler heads. I always thought these plates were for decorative …

Brad Keyes, CHSP | Sep 1, 2010
Q&AILSM

Q: What ILSM's apply to occupancies other than healthcare? For example, if a fire alarm/sprinkler system is out of service for more than 4 hours in a 24 hour period in …

Brad Keyes, CHSP | Sep 1, 2010
Q&AFire Watch

Q: What is actually required in order to perform a Fire Watch when the fire alarm system is inoperative? How often should a Fire Watch be performed? A: The Life …

Brad Keyes, CHSP | Sep 1, 2010
Q&ALiquid Oxygen

Q: We are aware of the NFPA 99 requirements to separate the transfilling operation of liquid oxygen from our patient care areas with a 1-hour fire rated room with noncombustible …

Brad Keyes, CHSP | Aug 1, 2010
Q&ASprinklers

Q: Like many older hospitals, we have areas with a mix of quick response sprinkler heads and standard response sprinkler heads. Are we required to go back and make them …

Brad Keyes, CHSP | Aug 1, 2010
Q&AConstruction

Q: Our project team insists on using non-combustible plastic sheeting for temporary barriers between construction areas and occupied areas of our hospital. Is this acceptable according to the Life Safety …

Brad Keyes, CHSP | Aug 1, 2010
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&ADoor Locks

Q: During a recent inspection, the surveyor cited our hospital for having dead-bolt locks on our patient room doors. None of the doors were locked at the time of the …

Brad Keyes, CHSP | Jul 1, 2010
Q&AHazardous Areas

Q: Is it acceptable for a 20 minute fire door to be used for a hazardous room in a new construction of a hospital? I'm looking at the Life Safety …

Brad Keyes, CHSP | Jul 1, 2010
Q&AGenerators

Q: We are completing a project that includes a new generator for our hospital. The installing contractor will conduct a 2-hour load test as part of his commissioning. My question …

Brad Keyes, CHSP | Jul 1, 2010
Q&ADoor Locks

Q: What is the LSC stance on card swipe systems to access doors? We were told by a city inspector that we could not install access control locks because we …

Brad Keyes, CHSP | Jun 1, 2010
Q&AMedical Air

Q: Is it allowable to use clean compressed medical air to blow off equipment in central sterile? Currently, we use compressed air from our medical air distribution system to dry …

Brad Keyes, CHSP | Jun 1, 2010
Q&ASprinklers

Q: Is an elevator equipment room required to be sprinklered in a hospital? A consultant recently told us that NFPA 13 requires us to install sprinklers inside our elevator equipment …

Brad Keyes, CHSP | Jun 1, 2010
Q&ADoor Locks

Q: We have multiple paths of egress from an area used by our Bio-Med staff, and for security reasons we lock the doors to and from this area. This is …

Brad Keyes, CHSP | May 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
SuitesQ&A

Q: We want to relocate a smoke compartment barrier to the entrance of our OR Surgery, in order to make the OR Surgery a suite of room. Do you see …

Brad Keyes, CHSP | May 1, 2010
Q&AStairwells

Q: In my hospital, I have an exit stairwell that does not discharge to the outside of the building, but rather it terminates in a corridor inside the building. Is …

Brad Keyes, CHSP | Apr 1, 2010
Q&ASoiled Utility Room

Q: We plan to take an existing small closet and make it into a new soiled linen room. It measures approximately 35 square feet and I plan to construct this …

Brad Keyes, CHSP | Apr 1, 2010
Q&AFire Alarm

Q: We have our Code Blue medical emergency system tied into the hospital’s fire alarm system and the control panel is located next to the telephone operators. They will then …

Brad Keyes, CHSP | Apr 1, 2010
Q&AGas Manifolds

Q: I am aware that medical gas manifold systems have to meet the regulations of NFPA 99-1999 (NFPA 99-2005 for Joint Commission and CMS compliance), and there are specific requirements …

Brad Keyes, CHSP | Mar 1, 2010
Q&AExit Signs

Q: We have a physicians' office building in an existing business occupancy, which has two remotely located exits. Exits paths are clearly marked with lit exit signs and the egress …

Brad Keyes, CHSP | Mar 1, 2010
Cooking AppliancesQ&A

Q: Are toasters, toaster ovens, microwave ovens and coffee makers prohibited in a staff lounge? We have nursing units that want these appliances in their staff lounge but we want …

Brad Keyes, CHSP | Mar 1, 2010
Q&ASprinklers

Q: Have you ever heard of patient files on shelves needing to be covered with a sheet of plastic to protect it from the sprinkler system? My VP of Accreditation …

Brad Keyes, CHSP | Mar 1, 2010
Q&AFire Extinguishers

Q: Is there a maximum distance that a fire extinguisher needs to be located from a helipad? Where would I find the fire extinguisher requirements for a helipad? A: NFPA …

Brad Keyes, CHSP | Feb 1, 2010
Q&AAlcohol Based Hand Rub Dispensers

Q: I know that Joint Commission permits alcohol based hand-rub (ABHR) dispensers in the corridors of hospitals, but I do not see where it is permitted according to the Life …

Brad Keyes, CHSP | Feb 1, 2010
Q&AWalls

Q: Is joint compound acceptable to use to seal penetrations through a fire rated barrier made with gypsum wall board? We used the joint compound to seal around conduits and …

Brad Keyes, CHSP | Feb 1, 2010
Storage (Life Safety Code)Q&A

Q: Are you really in favor of re-classifying patient rooms for floor storage? I thought that was dicey business. Aren't there a lot of things that need to be done …

Brad Keyes, CHSP | Jan 1, 2010
Q&ASprinklers

Q: I have an unattached building that houses a cardiac rehab/wellness center with office space. We are converting 4900 sq ft into a day care. It is separated from the …

Brad Keyes, CHSP | Jan 1, 2010
Q&ASmoking

Q. Is there a Life Safety Code requirement to post “No Smoking” signs on patient room doors where oxygen is being administered? Our Respiratory Care department insists on posting No …

Brad Keyes, CHSP | Dec 1, 2009
Storage (Life Safety Code)Q&A

Q: Does the Life Safety Code specify if we have to lock up our sterile scalpels in the same way that our syringes are locked? I have looked everywhere on …

Brad Keyes, CHSP | Dec 1, 2009
Q&AFire Alarm

Q: What is the requirement in time that a fire alarm needs to be transmitted to the fire department? Our fire alarm communication automatic dialer takes nearly 3 minutes to …

Brad Keyes, CHSP | Dec 1, 2009
Q&ASprinklers

Q: During a recent inspection, our fire marshal said the 5-year standpipe water-flow test is required to have at least 500 gallons per minute (GPM) at the roof. We are …

Brad Keyes, CHSP | Dec 1, 2009