Dec 05 2016

Keyes Life Safety Boot Camp – April 3 & 4, 2017

Category: BlogBKeyes @ 12:00 am

keyes_logo_lg_nobackUnderstand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: April 3 & 4, 2017

Location: Hilton Garden Inn, 45 Lockwood Drive, Charleston, SC (843) 637-4074

• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Challenges in Implementing the New Requirements of the 2012 LSC • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $879.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion / AIA CEU’s pending.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 843-637-4074

Register: Online at and search “Keyes Life Safety Boot Camp” or go to:

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or March 6, 2017

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:





Tags: ,

Dec 03 2016

A New Form Has Been Posted on Changes With the 2012 LSC

Category: BlogBKeyes @ 12:00 am

Hello all…

This fall has been a very busy time for me. I am thankful that I completed my task of reading all 651 pages of the new CMS Final Rule on Emergency Management standards that will become effective November 15, 2017. I re-wrote the HFAP EM chapter to align with the new requirements and it will soon be sent to CMS for review and approval.

But what I wanted to bring to your attention is I have posted a new document under “Tools” on this website that explains most of the changes that healthcare facilities need to know in regards with the new 2012 LSC. Click on “Tools”, then go to the bottom of the page and click on “Changes the New 2012 Life Safety Code Will Bring”, and open the document called “Changes to the Life Safety Code that the 2012 Edition Will Bring”.

I hope you will find this helpful. If you like it, pass it on to someone who you feel could benefit from it.


Brad Keyes, CHSP


Oct 11 2016

Save The Date…. Another Keyes Life Safety Boot Camp!

Category: BlogBKeyes @ 12:00 am

Web 2April 3 & 4, 2017 is the date of the next Keyes Life Safety Boot Camp, to be held in Charleston, SC.

  • This two-day boot camp on the 2012 Life Safety Code is designed for healthcare organizations that want to:
  • Understand practical applications of the Life Safety Code
  • Learn from actual Life Safety surveyors on what to prepare for during surveys
  • Recognize how the new 2012 Life Safety Code will impact your organization
  • Appreciate key requirements of the 2012 Life Safety Code as they apply to health care facilities and related occupancies

Who should attend:

  • Facility managers
  • Safety officers
  • Chief operating officers
  • Accreditation coordinators
  • Architects / Engineers
  • Consultants
  • AHJs

Watch for further announcements on information to register.

This boot camp is co-presented by Brad Keyes (Keyes Life Safety Compliance, LLC) and Alise Howlett (Codenity, LLC), and is sponsored by:




Tags: , ,

Sep 22 2016

Oops! Brad Made a Mistake…

Category: BlogBKeyes @ 12:00 am

I need to apologize to you, as I made an error in an earlier post where I stated the expected dates for the new testing/inspection requirements of the new 2012 Life Safety Code.

Previously, I said healthcare organizations needed to get their first quarterly, annual, 3-year, and 5-year test/inspection completed by November 1, 2016, which is the date CMS said the requirements of the new 2012 LSC will be enforced.

That wasn’t quite true… I received an email from a friend who also is a reader of my blog and said that is not what Joint Commission said at the annual ASHE conference. So, I contacted CMS directly in Baltimore, and communicated with the people who make these interpretations, and they told me this:

Although CMS will begin surveying to the new 2012 LSC on November 1, 2016, the regulation still requires the facility to be in compliance with the 2012 LSC and the 2012 NFPA 99 as of July 5, 2016.

Therefore, when CMS begins to survey on November 1, 2016, the healthcare facility should be able to verify compliance with any new daily, weekly, or quarterly requirements as it has been over 3 months since July 5th. But a facility would not yet be required to meet the new annual, 3-year, or 5-year requirements.

The email from CMS went on to explain that the first annual test/inspection activity that is a new requirement of the 2012 LSC is due July 5, 2017. Similarly, the first 3-year activity is due July 5, 2019, and the first 5-year is due July 5, 2021.

Just as a refresher, here is a list of the new testing/inspecting requirements of the 2012 LSC and the 2012 NFPA 99:

  • Quarterly main drain test on one system riser downstream of the backflow preventer where the sole water supply to the sprinkler system is through a backflow preventer;
  • Quarterly inspection of fire hose valves;
  • Annual test/inspection of all fire-rated door assemblies;
  • Annual test of the 2.5 inch fire hose valves;
  • 18-month test of non-stationary medical gas booms and articulating assemblies using flexible connectors for medical gas outlets;
  • 3-year test of the 1.5 inch fire hose valves;
  • 5-year internal inspection of sprinkler pipe.

So… according to the information provided by CMS, when they begin surveying to the 2012 LSC on November 1, 2016, you need to have your first quarterly main drain test conducted and your first quarterly inspection of fire hose valves. However, the annual, 18-month, 3-year, and 5-year new requirements are not due until their respective anniversary from the July 5, 2016 effective date.

I apologize for this miscommunication…. And I’m glad my friend took the time to point that out to me.

Tags: ,

Sep 19 2016

A Reader Questions Brad’s Comment…

Category: BlogBKeyes @ 12:00 am

I had a reader question one of my postings on this blog, that I thought you might be interested in reading…

Oxygen Cylinder Storage

The reader wanted to know if the yellow fire cabinets could be used to store oxygen cylinders in lieu of storing them in a designated room, when the accumulative quantity per smoke compartment reaches the 300 cubic feet mark. I said no, according to NFPA 99-2012, section requires an enclosed interior space of non-combustible or limited-combustible construction.

The reader said “I contacted my accreditation organization’s standards interpretation group and asked them the question, and they said it was all-right to store the O2 cylinders in the yellow fire cabinets because they meet the definition of 1/2 hour fire rating.”

A check with one of the manufacturers of the yellow fire cabinets says their cabinets are NOT UL rated for 1/2 hour fire rating. They stated there is not any approved test parameters for the cabinet’s fire rating to be verified with the gypsum material installed in the cabinet’s wall cavity.

To be safe, it is best to not use the yellow fire cabinets for storage of O2 cylinders unless you know for sure the cabinet carries a UL (or similar) test laboratory fire rating of at least 1/2 hour.


Sep 15 2016

Comments and Observations in the CMS EM Final Rule – Part 1

Category: BlogBKeyes @ 12:00 am

I have started to review the new CMS Final Rule on Emergency Preparedness. Here are some of the highlights, along with my comments…

Comments and Observations in the CMS EM Final Rule

1) CMS says there are three key essential requirements for maintaining access to healthcare services during emergencies:

  • Safeguarding human resources
  • Maintaining business continuity
  • Protecting physical resources

2) CMS has identified four core elements that are central to emergency preparedness program:

  • Risk assessment and emergency planning: CMS requires all facilities to perform a risk assessment that uses an “all hazards” approach prior to establishing an emergency plan. (NOTE: This is the HVA currently required)
  • Policies and procedures: CMS requires the facility to develop and implement policies and procedures that support the execution of the emergency plan.
  • Communication plan: CMS is requiring the facility to develop and maintain an emergency preparedness communication plan.
  • Training and testing: CMS is requiring the facility to develop and maintain an emergency preparedness training and testing program. (NOTE: This applies to all staff and must include annual refresher training).

3) CMS states in their Final Rule that “Currently, in the event of a disaster, healthcare facilities across the nation will not have the necessary planning and preparation in place to adequately protect the health and safety of the patients. In addition, we believe that the current regulatory patchwork of federal, state, and local laws and guidelines, combined with various accrediting organizations’ emergency preparedness standards, falls short of what is needed for healthcare facilities to be adequately prepared for a disaster.” (OUCH! CMS is saying The Joint Commission’s EM standards and HFAP’s EM standards are inadequate and ‘falls short’ for healthcare facilities to be adequately prepared for a disaster. I don’t agree with that comment.)

4) CMS defines an “emergency” or a “disaster” as an event that can affect the facility internally as well as the overall target population or the community at large. Emergencies can be internal, man-made, or natural events, and can be small or large events.

5) CMS states that their new emergency preparedness requirements focus on continuity of operations, not recovery of operations. Facilities may choose to include recovery of operations planning in their emergency preparedness plan, but they have not made recovery of operations planning a requirement.

6) CMS states facilities are required to track the location of patients and staff in the facility’s care during the emergency.

7) CMS says individual physicians are not required, but are encouraged, to develop and maintain emergency preparedness plans. In addition, physicians that are employed by the facility and all new and existing staff must participate in emergency preparedness training and testing. CMS has not mandated a specific role for physicians during an emergency or disaster event, but they expect facilities to delineate responsibilities for all of their facility’s workers in the emergency preparedness plans and to determine the appropriate level of training for each professional role.

8) Based on a response they received during the public comment period, CMS has changed their proposed rule to allow integrated health systems to have a coordinated emergency preparedness program. CMS revised their proposed requirements by adding a separate standard to the CoPs and CfCs. This separate standard will allow any separately certified healthcare facility that operates within a healthcare system to elect to be a part of the healthcare system’s unified emergency preparedness program.


Tags: ,

Sep 09 2016

CMS Announces New Rule on Emergency Management

Category: BlogBKeyes @ 12:00 am

Well… here it is. CMS has announced that they will publish their Final Rule on the new standards for Emergency Management. It appears the new rule will not be published in the Federal Register until September 16, 2016, which is a week away, but take time now to read their press release below… and start learning all the changes you will need to know.

According to the press release, the new rule becomes effective 60 days after it is published in the Federal Register, which would be November 15, 2016. But it also says the new requirements will not be enforced until November, 2017, so the healthcare organizations and the AOs have a year to get ready for these changes.

CMS News


Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries

CMS finalizes rule to bolster emergency preparedness of certain facilities participating in Medicare and Medicaid

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.

Over the past several years, and most recently in Louisiana, a number of natural and man-made disasters have put the health and safety of Medicare and Medicaid beneficiaries – and the public at large – at risk. These new requirements will require certain participating providers and suppliers to plan for disasters and coordinate with federal, state tribal, regional, and local emergency preparedness systems to ensure that facilities are adequately prepared to meet the needs of their patients during disasters and emergency situations.

“Situations like the recent flooding in Baton Rouge, Louisiana, remind us that in the event of an emergency, the first priority of health care providers and suppliers is to protect the health and safety of their patients,” said CMS Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., MSc. “Preparation, planning, and one comprehensive approach for emergency preparedness is key. One life lost is one too many.”

“As people with medical needs are cared for in increasingly diverse settings, disaster preparedness is not only a responsibility of hospitals, but of many other providers and suppliers of healthcare services. Whether it’s trauma care or long-term nursing care or a home health service, patients’ needs for health care don’t stop when disasters strike; in fact their needs often increase  in the immediate aftermath of a disaster,” said Dr. Nicole Lurie, HHS assistant secretary for preparedness and response. “All parts of the healthcare system must be able to keep providing care through a disaster, both to save lives and to ensure that people can continue to function in their usual setting. Disasters tend to stress the entire health care system, and that’s not good for anyone.”

After reviewing the current Medicare emergency preparedness regulations for both providers and suppliers, CMS found that regulatory requirements were not comprehensive enough to address the complexities of emergency preparedness. For example, the requirements did not address the need for: (1) communication to coordinate with other systems of care within cities or states; (2) contingency planning; and (3) training of personnel. CMS proposed policies to address these gaps in the proposed rule, which was open to stakeholder comments.

After careful consideration of stakeholder comments on the proposed rule, this final rule requires Medicare and Medicaid participating providers and suppliers to meet the following four common and well known industry best practice standards.

1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.

2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.

3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.

4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

These standards are adjusted to reflect the characteristics of each type of provider and supplier. For example:

  • Outpatient providers and suppliers such as Ambulatory Surgical Centers and End-Stage Renal Disease Facilities will not be required to have policies and procedures for provision of subsistence needs.
  • Hospitals, Critical Access Hospitals, and Long Term Care facilities will be required to install and maintain emergency and standby power systems based on their emergency plan.

In response to comments, CMS made changes in several areas of the final rule, including removing the requirement for additional hours of generator testing, flexibility to choose the type of exercise a facility conducts for its second annual testing requirement, and allowing a separately certified facility within a healthcare system to take part in the system’s unified emergency preparedness program.

The final rule also includes a number of local and national resources related to emergency preparedness, including helpful reports, toolkits, and samples. Additionally, health care providers and suppliers can choose to participate in their local healthcare coalitions, which provide an opportunity to share resources and expertise in developing an emergency plan and also can provide support during an emergency.

These regulations are effective 60 days after publication in the Federal Register. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date.

For more information please see a blog by Dr. Lurie, HHS assistant secretary for preparedness and response, and the CMS Survey & Certification – Emergency Preparedness webpage.


Tags: ,

Aug 04 2016

How the Changes to the SOC Process Will Affect Life Safety Compliance

Category: BlogBKeyes @ 12:00 am

On July 13, 2016, The Joint Commission issued the following statement:

 “Effective Aug. 1, 2016, changes will become effective to the Statement of Conditions™ (SOC) process that will affect the survey of Life Safety (LS) chapter requirements. Following Aug. 1, 2016, the following changes to survey will occur:

  1. The open Plan for Improvement (PFI) items will no longer be reviewed by the survey team.
  2. The open PFI will no longer be imported into the Final Report.
  3. All Life Safety (LS) chapter deficiencies identified during survey will become Requirements for Improvement (RFI) with a 60-day Evidence of Standards Compliance (ESC). For those deficiencies that require more than 60 days, a Time-Limited Waiver process is available.
  4. Only equivalency requests related to survey events will be reviewed.

The Joint Commission has had the SOC as part of its accreditation program since 1995. The SOC was originally created to allow organizations a process to develop a plan for improvement to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures (ILSM) to ensure patient safety. Initially, these self-identified actions were not documented during survey because the SOC already documented the deficiency. The Joint Commission also created the ILSM process to mitigate risk while resolving the deficiencies. This allowed the SOC process to be the method for organizations to create and submit their Plan for Improvement (PFI), with an amount of time to make the correction that the organization could manage, while still providing a safe environment. Occasionally, an organization would need additional time to complete the corrective action, and The Joint Commission granted extension requests. Many of these extension requests occurred during the six-month automatic extension period.      

CMS has identified required changes to the SOC process, including:  

  • No longer allowing the SOC to document self-identified deficiencies, instead, taking the self-identified deficiencies and converting those to RFIs by the surveyor 
  • No longer allowing more than 60 days for corrective actions unless approved by the CMS regional office
  • The surveyor citing all deficiencies replacing the extension request component with a Time Limited Waiver process, using the Survey-related Plan For Improvement (SPFI) process that will be managed and tracked by the CMS regional office
  • Managing the survey-related equivalency process, as defined by CMS, using Salesforce and the SOC to manage and track the CMS regional office action  
  • Removing the six-month automatic extension
  • No longer granting requested extensions
  • Joint Commission leadership, after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process. Post survey, the CMS Time Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies. All questions should go to The Joint Commission Department of Engineering at 630-792-5900.”


This is another sad event for patient safety caused by a federal agency that cannot see the positive that the SOC / PFI process had for healthcare organizations. This action by CMS is not a knee-jerk reaction that was not carefully considered; rather this decision by CMS to not allow the hospitals and ambulatory surgical centers to have a process of self-identification of Life Safety Code deficiencies and an incentive to be proactive has been long-coming for years.

Back in 2008 when Det Norske Veritas (DNV) Healthcare received deeming authority from CMS, the new accreditor wanted a system similar to the Statement of Conditions PFI list, but was told by CMS that they could not. Similarly, in 2012 HFAP applied for a system similar to the PFI list but was also denied by the federal agency.

In 2014 when CMS issued their proposed rule to adopt the 2012 Life Safety Code, the public responded with many comments. Quite a few commenters mentioned that CMS should keep the SOC/PFI system and allow all of the accreditation organizations a chance to utilize it.

When CMS issued their final rule on May 4, 2016, they made it very clear that there will not be any Plan For Improvement list in the way that Joint Commission was operating. That was the writing on the wall and it became clear that the major hospital accreditor would have to discontinue its use.

This is a very sad event, because now it is feared that many hospitals will no longer be proactive and self-identify their own Life Safety Code deficiencies because any incentive to do so (i.e. not citing the deficiency on the survey report) has been removed. CMS has struck harder and put a stop to hospital self-identifying the projected completion date, and now makes all LSC deficiencies cited during a survey to be resolved within 60 days of the end of the survey.

Since major LSC deficiencies cannot be resolved that quickly, CMS is now requiring the healthcare organizations to request a time-limited waiver through the accreditor. This is another example of CMS tightening their grip on the accreditation process. In this case, it reduces the level of safety for the patients. Where is the logic in that?

Tags: , ,

Jul 16 2016

Asked a Question Lately?

Category: BlogBKeyes @ 8:31 pm

If you tried to ask a question or send me a comment since July 5, 2016 via this website, you probably receive a notice that the email did not transmit properly. That is because of a failure in the security system, which has now been resolved.

Any questions or comments you wish to send should now reach me.

Thank you…


Jun 24 2016

FM Approval on Waste Containers

Category: BlogBKeyes @ 12:00 am

Q: In the fine print of the new 2012 Life Safety Code, under sections 18/ for containers used solely for recycling clean waste or for patient medical records awaiting destruction, the following is noted:

(4) Containers for combustibles shall be labeled and listed as meeting the requirements of FM Approval Standard 6921, Containers for Combustible Waste; however, such testing, listing, and labeling shall not be limited to FM Approvals.

My question is: Does this in reality become a hard burden to prove? Are other hospital facility managers unwilling to utilize the CMS waiver for this for fear that they will have difficulty proving compliance?

A: I have not heard of any facility manager not using the CMS categorical waiver based on the reluctance to be able to prove that the containers meet the requirements listed. It is a real possibility, but I can’t say I am aware of anyone with this concern.

It sounds like you must have checked your own containers to see if they comply with this FM Approval listing requirement. If so, I assume you found some that did not meet the requirements. I do know that some manufacturers do meet this requirement and therefore there are containers out there for clean recyclables and patient records waiting for shredding that do meet this requirement.

I would suggest you make it a condition with the shredding company to provide FM Approval listed containers if they continue to want your business.


Next Page »