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Inspection & Maintenance (Life Safety Code)Joint CommissionTesting (Generators)Testing (Facilities Management)Testing (Fire Suppression Systems)Testing (Life Safety Code)AccreditationTesting (Fire Detection Systems)CMSTesting (Medical Gas)Testing (Accreditation/Certification)Fire Drills

Q: Has there been an update to the definition of time by TJC/CMS? I'm looking at quarterly fire drills right now, but any changes/clarification on the definition for all intervals …

Brad Keyes, CHSP | Apr 15, 2020
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
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 States "Where required by Chapters 11 through 43, the following door …

Brad Keyes, CHSP | Sep 20, 2017
Smoke BarrierQ&ATesting (Life Safety Code)Doors

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

Brad Keyes, CHSP | Aug 23, 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 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&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&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&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
Life Safety CodeArticleTesting (Life Safety Code)Documentation (Life Safety Code)

My recent series of articles on Documentation created quite a bit of response. One individual had this question: "What is your opinion of documentation being kept electronically rather than in …

Brad Keyes, CHSP | Jul 17, 2014
Life Safety CodeArticleTesting (Life Safety Code)Smoke Dampers

What do we do with smoke dampers now that the hospital is fully protected with sprinklers? That question is asked many times by facility managers who are looking to cut …

Brad Keyes, CHSP | Jul 3, 2014
Life Safety CodeArticleFire/Smoke DampersTesting (Life Safety Code)

Many of you may be familiar with the Joint Commission's standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose …

Brad Keyes, CHSP | Jun 5, 2014
Fire AlarmLife Safety CodeArticleTesting (Life Safety Code)Documentation (Fire Detection Systems)

Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings …

Brad Keyes, CHSP | May 15, 2014
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
Life Safety CodeGeneratorsArticleTesting (Life Safety Code)

As mentioned in last week's posting, The Joint Commission announced changes to their standards that takes affect January 1, 2014. We discussed already the change they are making with time …

Brad Keyes, CHSP | Nov 7, 2013
Life Safety CodeArticleTesting (Life Safety Code)Accreditation

Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define …

Brad Keyes, CHSP | Oct 31, 2013
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
Life Safety CodeElevatorsArticleTesting (Life Safety Code)

One of the requirements that CMS and Joint Commission surveyors is requesting from hospitals and nursing homes is documentation that the elevators have been tested for 'Recall'. Elevator recall is a test …

Brad Keyes, CHSP | May 16, 2013
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

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