Apr 05 2018

Strange Observations – Part 20

Category: BlogBKeyes @ 12:00 am

Continuing in a series of strange things I have seen while consulting at hospitals…

Did you know that you cannot make home-made devices and connect them to the fire alarm system?

That includes magnetic door hold-open devices. This picture shows a threaded rod installed to extend the MHO target to allow the door to remain less than fully open.

The threaded rod is not UL listed for use on the fire alarm system.


Apr 04 2018

Sprinkler System Pressure Gauges

Category: BlogBKeyes @ 12:00 am

Q: My question has to do with the pressure gauges for our fire sprinkler system. We just had some out of date pressure gauges replaced by a new sprinkler contractor. They removed the 3 1/2 inch gauges and replaced them with 2 inch gauges. Upon further inspection I noticed that the gauges had no UL or FM listing. They have on the back a CRN aka Canadian Registration Number. Can this type of gauge be used?

A: The Canadian Registration Number (CRN) is a number issued by each province or territory of Canada for the design of a boiler, pressure vessel or fitting. The CRN identifies the design has been accepted and registered for use in that province or territory. You are in Florida, so there is no requirement in the USA for a CRN. According to NFPA 13-2010, the standard on the installation of sprinkler systems, section says the pressure gauges must be listed and must have a maximum limit not less than twice the normal system working pressure at the point where installed. It is apparent that the Canadian Registration Number is not the same as a listing from an independent testing laboratory, so I would say the gauges that were installed at your facility would not be acceptable.

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Apr 03 2018

Lawmakers Want More Oversight on AOs

Category: BlogBKeyes @ 12:00 am

In a letter to CMS Administrator Seema Verma, the committee on Energy and Commerce is asking for what could be reams of information from the agency about patient harm and incidents of misconduct at acute care hospitals. The committee has also asked for similar information from each of the four hospital accrediting organizations (AOs).

The committee was particularly concerned about information in a report to Congress published last summer that indicated AOs “conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by [CMS] State Survey Agencies no later than 60 days following the AO survey.”

“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the accrediting organization survey process,” wrote the committee leaders.

Noting that the Department of Health and Human Services, through CMS, must provide oversight of accrediting organizations, including CMS’ own survey agencies, “the Committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” read the letter to Verma.

You can view a copy of this letter at this link: https://energycommerce.house.gov/wp-content/uploads/2018/03/20180309CMS.pdf

In 2017, approximately 67% of the surveys performed by HFAP and The Joint Commission received a Condition Level Deficiency in the Life Safety or Environment of Care chapters. This percentage of Condition Level Findings was up in 2017 compared to 2016. How much more does the committee expect the AOs to cite Condition Level Findings?

What does all of this mean for the future…? From my point of view, I believe you will see CMS tighten their reigns on the hospital AOs such as Joint Commission, HFAP, DNV-GL and CIHQ…. especially on issues of Life Safety, Environment of Care, and Emergency Management. The reason for this is based on the high disparity rates that most of the AOs have when compared to state agency validation surveys in the area of Life Safety.

Many observers have said that the method CMS uses to compare the efficiency of findings between the AOs and the state agencies is unfair based on the state agencies allowed to have more LS surveyors for more days on their surveys than the AOs.

I also claim that not all surveyors are the same: Most AOs hire current or former hospital facility managers who are operation minded. So they will focus on Life Safety issues pertaining to operations, such as corridor clutter, obstructions to doors and medical gas valves, etc. On the contrary, most state agencies surveying on behalf of CMS hire architects and engineers as LS surveyors, who focus on design issues (such as construction type and egress capacity) and mechanical systems (such as fire alarm systems and sprinkler systems).

Just because the surveyors have different backgrounds does not make them right or wrong: But it does make them different. So naturally, state agency surveyors will gravitate to cite deficiencies that are more along their specialty. And AO surveyors will do likewise. There will always be a disparity when the survey teams are different. To prove that point, the high disparity rate of AO findings compared to state agencies findings, is just as high when you make the comparison the opposite way: When you compare state agency findings to AO findings. The point is…. it is normal to have a high disparity rate when there are so many variables in the mix.

I don’t see this ever being fixed in my lifetime… The people in power seem to be too stubborn to acknowledge this issue and take appropriate action to resolve it. In the mean-time, I foresee CMS cracking down even harder on the AOs to cite even more findings, which will result in tougher Life Safety surveys.


Apr 02 2018

4-Inch Corridor Projection

Category: BlogBKeyes @ 12:00 am

Q: With the adoption of the new 2012 Life Safety Code by CMS, we had a discussion about projections from the corridor wall. Since the LSC only allows projections to be 4 inches, the question that came up was in regards to fire extinguishers mounted to the wall and not recessed as they project out from the wall about 7 inches. Will we be required to recess them or will they be allowed? The same question was raised about wall mounted telephones?

A: Actually, the 2012 LSC allows a 6-inch projection into the corridor [see], but CMS’ Final Rule published May 4, 2016 said they will enforce the more restrictive 4-inch maximum projection into the corridor, based on the Americans with Disabilities Act (ADA). For all healthcare facilities that receive Medicare & Medicaid funds, they must comply with CMS’ exception to the 2012 LSC.

To answer your question, there are no exceptions to the 4-inch maximum projection rule. So, anything projecting more than 4 inches into the corridor, including fire extinguishers and telephones, would likely be cited by a surveyor or inspector.

I read a survey report just the other day where the surveyor cited the hospital for having an ABHR dispenser that projected into the corridor by 4 1/4 inches. So, AHJs are citing anything that projects more than 4-inches into the corridor, including fire extinguishers.

This may be a good opportunity to consider oval-shaped fire extinguishers that do not project more than 4 inches into the corridor. Take a look at these compliant fire extinguishers from Oval brand: http://ovalfireproducts.com/


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Mar 31 2018

Strange Observations – Part 19

Category: BlogBKeyes @ 7:31 am

Continuing in a series of strange things that I have seen when consulting at hospitals…

Ceilings that have smoke or heat detectors mounted on them, and ceilings that have sprinkler heads have to provide a monolith barrier that resists the passage of smoke and heat. When ever there are gaps in the ceiling, or cracks wider than 1/8-inch, then that allows heat and smoke to travel to the space above, which impairs the function of the detectors or sprinkler heads.

This picture provides a two-fer: 1) The sprinkler head is missing its escutcheon cover plate, and; 2) This is apparently taken in an IT room. All of the blue data cable is creating a difficult opening to seal properly.

I’m an advocate to remove the ceilings in IT rooms so there are no ceiling tiles to have to seal. Just remount the lights to be suspended from the deck and turn up the sprinklers to within 12 inches of the deck (and use upright sprinkler heads).

Mar 30 2018

Fire Alarm Pull Stations

Category: BlogBKeyes @ 12:00 am

Q: I have a question regarding fire alarm manual pull stations. In our multi-level long term health care facility, we added a new building onto the existing building. At the point where the old building and the new addition connect, there is a 2-hour fire-rated barrier with fire-rated doors that are held-open with magnets. Do we need pull stations within 5-feet of those doors? Both buildings are fully sprinkled and both have a fire alarm system. My reading of the code says that they would have to have pull stations on either side of the building separation wall door assemblies as one should be able to pull a pull station while in the act of leaving one building and going into another. Am I correct?

A: I’m not sure I agree with you, but let’s think this through…. NFPA 72 (2010 edition) section 17.14.6 discusses the location and spacing of fire alarm pull stations. In this section it says pull stations must be located within 5 feet of the exit doorway opening at each floor. So, if the 2-hour separation between the two buildings is in fact a horizontal exit, then I would agree with you that pull stations would have to be mounted within 5 feet of the exit, on both sides of the 2-hour wall. However, if the 2-hour separation between the two buildings is not classified as a horizontal exit, and it is simply a building separation, then I do not see where the standard requires a pull station.

You may ask what is the difference between a building separation and a horizontal exit if they are both 2-hour fire rated, and the answer is a new horizontal exit does not allow any HVAC duct to penetrate the barrier, unless the building on both sides of the barrier is fully protected with automatic sprinklers. Other than that, there really isn’t much difference, other than the name applied to the barrier by the designing architect.

I can see your point that it appears you are ‘exiting’ one building and entering another at this barrier, and a pull station would be required. But if it is not a designated horizontal exit, I think that should be sufficient for an AHJ to not require a pull station. But, what is the cost of adding pull stations at this barrier even if the standard does not require them? If you feel more comfortable, go ahead and add them.

Other pull station location requirements in the standard says the travel distance to the nearest pull station cannot exceed 200 feet, and if you have a group opening (office cubicles) over 40 feet wide, then you need pull stations on each side of the openings. Also, section 18/ in the 2012 edition of the Life Safety Code says a pull station may be mounted at the nurse station in patient sleeping areas in lieu of being mounted within 5 feet of an exit, provided the nurse station is continuously attended by staff, and the 200 foot travel distance is maintained.

So, the conclusion is… go ahead and mount pull stations at the building separation if it makes you more comfortable, but I’m not sure it is needed. I recommend that you consult with your local and state authorities to gain their interpretation.

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Mar 28 2018

Sleep Labs

Category: BlogBKeyes @ 12:00 am

Q: Are sleep labs considered healthcare occupancies or business occupancies? I have a fire marshal who says it has to be a healthcare occupancy.

 A: These types of things are interpretations. There is not a firm paragraph in the Life Safety Code that says “Sleep labs are business occupancies”. But, if you (or the AHJ) examines the different definitions of occupancies in the Life Safety Code, then one draws the conclusion that it is a business occupancy. For example:

Healthcare occupancy consideration:

“A healthcare occupancy is used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants control.” ( of the 2012 LSC)

“The healthcare facilities regulated by this chapter shall be those that provide sleeping accommodations for their occupants and are occupied by persons who are mostly incapable of self-preservation because of age, because of physical or mental disability, or because of security measures not under the occupants control.” (

So, let’s examine how a sleep Lab meets this criteria:

  • A patient in a sleep lab is not an inpatient of the facility;
  • A patient in a sleep lab is not being provided medical care, or other treatment. The sleep lab is monitoring the patient… not providing care.
  • A patient in a sleep lab is fully capable of self-preservation.
  • The sleep lab does provide sleeping accommodations, but that alone does not make it a healthcare occupancy because the patients are not inpatients, are not receiving care or treatment, and are not incapable of self-preservation. If just providing sleeping accommodations makes the sleep lab a healthcare occupancy, then all residential, hotels, dormitories and apartment facilities would have to be designated a healthcare occupancy.

Therefore… the conclusion is a sleep lab is not a healthcare occupancy. Now, a sleep lab may be located in a hospital that is a healthcare occupancy and that would be a mixed occupancy situation. But if the sleep lab is located offsite from the hospital, it does not have to be considered a healthcare occupancy.

 Ambulatory healthcare occupancy consideration:

  • “An occupancy used to provide services or treatment simultaneously to four or more patients (one or more patients per CMS) that provides, on an outpatient basis, one or more of the following:
  • Treatment for patients that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Emergency or urgent care for patients who, due to the nature of their injury or illness, are incapable of taking action for self-preservation under emergency conditions without the assistance of others.” (

While a patient in a sleep lab is an outpatient, that person is not receiving services or treatment that renders them incapable of self-preservation.

  • The sleep lab patient is not under anesthesia.
  • The sleep lab patient does not have an illness or injury that prevents them to take self-preservation action under emergency conditions without the assistance of others.
  • The sleep lab patient is not receiving emergency or urgent care.


Therefore, the conclusion is a sleep lab is not an ambulatory healthcare occupancy. To further this discussion… a sleep lab is not a hotel or dormitory, and is not a residential board & care occupancy. So, the conclusion is, a sleep lab is a business occupancy… not unlike your typical physician-office exam room. A patient in a sleep lab is being examined… not treated. That is how the Life Safety Code is interpreted. The challenge many facility managers have is convincing state or local AHJs that a sleep lab is a business occupancy. Once they see ‘sleeping accommodations’ and ‘healthcare’ they automatically want to lump it in with healthcare occupancy. If you have this situation, then you need to educate those AHJs so they understand that sleep labs are business occupancies.

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Mar 27 2018

Last Chance to Sign Up – Keyes Life Safety Boot Camp April 24 & 25, 2018

Category: BlogBKeyes @ 12:00 am

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination 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 24 & 25, 2018

Location: Embassy Suites Centennial Olympic Park, 267 Marietta St., Atlanta, GA 30313  404-223-2300

• 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; and former Joint Commission LS surveyor.

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

Cost: $889.00 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.

Embassy Suites at Centennial Olympic Park, 267 Marietta Street, Atlanta, GA 30313, phone (404) 223-2300

To receive special event hotel room pricing of $179/night, book your room prior to March 24 at: http://embassysuites.hilton.com/en/es/groups/personalized/A/ATLESES-KLS-20180423/index.jhtml

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on April 2. Go to https://www.eventbrite.com and search “Keyes Life Safety Boot Camp-Atlanta”

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or April 2, 2018

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:


Mar 26 2018

Locked Exit Doors From Psychiatric Unit

Category: BlogBKeyes @ 12:00 am

Q: I am a consultant and I have a 30% sprinklered high rise hospital with locked psychiatric units. The state authority made them unlock the stairwell doors under the 2000 LSC. The stairwell doors were locked with a key. With the 2012 LSC, can those doors have delayed egress installed for security of patients or does the entire building need to be sprinklered?  The smoke compartments into the stairs in question are sprinklered.

A: No… they cannot install delayed egress locks on any door in the building because section of the 2012 LSC requires the entire building to be either fully protected with sprinklers or smoke detectors. I’ve yet to find a hospital that is fully protected with smoke detectors, so it is a safe bet it is not. Since the building is not fully protected with sprinklers, then they cannot install delayed egress locks (, elevator lobby locks (, or specialized protective measure locks ( Their only recourse is to install clinical needs locks ( or access-control locks (, but access-control locks do not lock the door in the path of egress).


Did the state agency explain why they could not lock the stairwell exit doors via clinical needs locks ( Perhaps the hospital did not comply with all of the requirements found in, or perhaps it was a personal preference of the state inspector…

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Mar 23 2018

Interim Life Safety Measures

Category: BlogBKeyes @ 12:00 am

Q: At our hospital, we had numerous fire dampers that failed their 6-year test. What ILSM measures for that many dampers would you recommend putting in place?

A: You are correct in saying ILSM assessment needs to be made for deficient fire dampers. Many hospitals get into trouble over that and forget to do that, so I’m glad to hear that you are on top of that. What I see some of my clients do for defective fire dampers is to make an ILSM assessment that states “No compensating measures are required”. I would not recommend that, but it appears that will be accepted by some accreditation surveyors. I would recommend at the minimum “Staff Education” as a compensation measure for an ILSM assessment. Send a memo to the staff in the area of the defective fire damper instructing them in the case of a fire, the fire dampers may not operate correctly until you get them repaired. They should take into account the location of the defective fire dampers when determining which direction they will evacuate (if needed).


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