Generator Annual Load Test

Q: My client installed a generator in a Phase 1 project that does not and will not for some time be able to meet the requirements for the 30% load during the monthly test due to low current loading. As I understand it, in NFPA 110 allows you to do the monthly test as is and do a supplemental annual test yearly as outlined which would then meet the requirement for the monthly test. Is that the proper interpretation as the generator will not meet the 30% requirement until some unknown future date?

A: Yes… section of NFPA 110-2010 is the correct reference when any one of the monthly tests cannot meet the requirement for at least a 30% load. The annual test must be conducted within 12 months of the first monthly test that was incapable of meeting the 30% load requirement, and then no more than 12 months from the last annual load test.

Your client should continue to conduct the monthly load tests (not less than 20 days and not more than 40 days) with the available load. For the annual load test, a supplemental load (i.e. load bank) of not less than 50% of the nameplate kW rating for 30-minutes and a supplemental load of 75% of the nameplate kW rating for 60-minutes must be conducted, for a total test of 90 continuous minutes.

The cool-down period for the generator is not part of this 90-minute test.

Time Allowed for Repairs

Q: What are the time frames for repairing life safety deficiencies found during routine inspections? How much time would be allowed to repair emergency exit signs, or failed smoke detectors?

A: Well… if you’re talking about resolving a deficiency that was cited on a survey report, you have 60-days from the time you receive the report. This is actually a mandate from CMS under CFR 488.28(d). But CMS (and the accreditation organizations, or AO) understand if additional time is required, due to the need of obtaining approval from your governing body, or engaging in competitive bidding, as examples.

If you need more time and the deficiency is a LSC deficiency, then you have the option of requesting a Time-Limited Waiver, a Standard Waiver, or a FSES Equivalency. Each AO has their own instructions and procedures for you to follow when requesting one of these.

But if you conduct your own assessment and find certain items deficient, then you are not obligated to resolve the deficiency within the 60-day window. Most AOs will expect you to resolve the deficiency in a reasonable amount of time.

If all you need to do is install four new ‘Exit’ signs, then a month or so is reasonable. But a year would not be considered reasonable.  A failed smoke detector should not take more than a month or so, unless it is such a special item that delivery time is excessive.

Other than the 60-day window after a survey, I’ve never seen a set time-limit for life safety repairs. All of the AHJs I’ve worked with are willing to work with you. If you need extra time due to extenuating circumstances, they will be understanding.

Whatever is reasonable… Most AHJs will work with you on this, as long as the time-frame is reasonable.

Elevator Shaft Construction

Q: We have a hospital that was built in 2008. We believe there is an elevator construction issue. When they built the elevator shafts they put smoke detectors inside at the top but no sprinklers. On the three exterior sides of the shaft (non-door side) they have cinder block wall. On the interior wall (door side) they have some cinder block construction but they also have in sporadic places two pieces of plywood with glue creating a 2-hour fire rated wall. The other issue is in between the glue there are holes or air pockets. Is this acceptable to use plywood to create a 2-hour fire rated wall or does it have to be cinder block top to bottom? Our construction type is Type II (222) and the elevator shaft serves 8 stories.

A: No… it is not acceptable to use plywood as part of the construction of a 2-hour fire-rated wall. First of all, Type II buildings are not permitted to have combustible construction on their structural members. NFPA 220-2012, section 4.3.1 says Type I and Type II construction must be those types in which the fire walls, structural elements, walls, arches, floors, and roofs are of approved noncombustible or limited combustible materials. Plywood is combustible, even if it is fire-retardant. So, the plywood has to go, and must be replaced with non-combustible materials in order to complete the 2-hour fire rated elevator shaft. NFPA 13 does not require sprinklers in a non-combustible elevator shaft that does not use hydraulic fluids. Assuming it is a traction elevator (i.e. cables and pulleys), then the elevator shaft is not required to be sprinklered. But to answer your question, the plywood is a problem and should not be there.

Updated Forms Available

Just to keep you informed, I have updated one of the more popular forms on my website, and I have added two new forms.

The updated form is the Life Safety Documentation Requirement list and it has some corrections that I needed to make:

  • Incorrect reference to NFPA 12A on Halon system testing
  • Incorrect frequency to generator battery electrolyte level check; Changed from weekly to monthly

And I added a few more items to the list that are required to be tested/inspected, such as:

  • Replace lead-acid batteries used for starting generators, every 30-months
  • Non-stationary medical gas booms with flexible connectors must be leak tested every 18-months
  • GFCI receptacle testing – Monthly
  • Emergency shower test/inspection – Annual inspection; Weekly test
  • Emergency eyewash test/inspection – Annual inspection; Weekly test
  • Battery powered emergency lights – Monthly and Annual tests
  • Fire drills – Healthcare and Ambulatory healthcare and Business

Also included are two new forms:

  • Receptacle Testing Form – Annual
  • Sprinkler Inspection Form – Annual

The receptacle testing form is for non-hospital grade receptacles located near patient beds or in anesthesia administered locations. I had a client that had non-hospital grade receptacles in these areas and they decided to test them rather than change them out (go figure).

Also, the sprinkler inspection form is designed to inspect sprinklers on a room by room basis, which ensures all of the sprinklers are inspected.

These updated and new forms can by found on the “Tools” webpage and are free to all to download and use.


Q: We are renovating a smoke compartment in an existing health care building. There is no change of use or occupancy, should we apply the existing requirements for hazardous rooms? The building is fully sprinkler protected.

A: This is usually an issue where the Authority Having Jurisdiction (AHJ) would offer a decision. Since you are saying you are renovating a smoke compartment, this could mean different things. Are you just doing cosmetic changes like new wallpaper and new carpets? If so, then you do not have to meet new construction requirements. Or are you taking down ceilings, moving walls, and upgrading mechanicals? If it is the latter, then new construction requirements would need to be accomplished in accordance with Chapter 18. This includes making everything meet new construction requirements, including medical gas systems, nurse call systems, fire alarm systems, sprinkler systems, emergency power systems and HVAC pressure differential rates and air changes per hour.

I do not know which state you are in, but most states have a department that monitors hospital construction and they usually want plans and specifications of all renovations sent to them for review and approval prior to starting the renovation.

Chapter 43 is a new chapter for the 2012 Life Safety Code on building renovation. Section states newly constructed elements, components, and systems must comply with the requirements of the new construction occupancy chapter.

Un-Sprinklered High Rise Hospital

Q: I am a consultant and I have a client who has a new high rise hospital that is not fully sprinklered. The plans for this hospital were approved and stamped by the local building officials after 2003 and the building construction completed in 2010. Would the entire building have been required to be fully sprinklered when it was constructed?

A: I would say so. Depending on who they are accredited by, and what state they are in, they could be cited for not being 100% sprinklered, since the building design was approved after the 2000 Life Safety Code was adopted. For example, if they are Joint Commission accredited, Joint Commission had been adopting the new editions of the Life Safety Code soon after NFPA published them, up to and including the 2000 edition. So, that means since the 1991 edition of the Life Safety Code was the first edition to require all new construction healthcare occupancies to be fully protected with sprinklers, this building would have been required to be sprinklered if they were Joint Commission accredited. Also, most states adopt new versions of the LSC as they are published, so from a state viewpoint this building would likely have been required to be 100% sprinklered as well.

CMS adopted the 2000 edition of the LSC in March, 2003. Previously they were on the 1985 edition which did not require new construction to be protected with sprinklers. So, for CMS certified hospitals, the start date for new construction required to be sprinklered was March, 2003. For Joint Commission accredited hospitals, it would have been when they adopted the 1991 edition of the Life Safety Code. So, it is apparent someone did not get the word that a newly constructed high-rise hospital that had their design stamped by the local authorities after 2003, is required to be fully sprinklered.

Yep… that is a citation waiting to be written. Could even be a Condition Level Finding. Better advise them to get started in completing the sprinkler installation as soon as possible.

Life Safety Training

Q: I am a healthcare consultant working mostly with home health and hospice clients. I have recently picked up two facilities that are smaller hospitals and am utterly clueless when it comes to Life Safety Code issues. I, and another long-time nurse who is somewhat more familiar than I am with issues have been struggling with keeping up. Being that I am a nurse and do not know a damper valve from an air conditioning duct, is the learning curve too steep? Is there a book written for real people – like me – that walks through the required testing, the intervals at which stuff should be tested and how the testing should be documented? Finally, one hospital was cited for the lack of an inventory. Got any advice on how I can construct one and what needs to be on there? I am hoping you will be able to tell me that there is a three day seminar a non-mechanical nurse can attend and return from an expert on all things life safety. Any luck with that?

A: No… I’m sorry to say there is no magic 3-day seminar to provide a rookie with adequate training on the Life Safety Code to conduct an adequate assessment. The Life Safety Code is very complicated and convoluted and it would take years of day-to-day application to begin to understand the nuances of the code.

However, if you are interested, I would recommend the following resources:

  • Joint Commission Resources seminars on EC Base Camp and Life Safety Chapter training.
  • ASHE seminars on Life Safety Code
  • NFPA seminars on Life Safety Code
  • Keyes Life Safety Boot Camp

All of the above are excellent starts to begin your second career as a Life Safety consultant. But you would need to back it up with on-the-job training for years to begin to understand the code. For now, my recommendation is for you to sub-contract with a life safety expert consultant to perform a life safety assessment at your client’s hospital.

Elevator Recall Test

Q: How do I perform the elevator recall test?

A: If you have never performed an elevator recall test, I suggest you have your elevator maintenance company show you how it is done the first time, then you can continue to do it on a monthly test. But, in lieu of that, here is how a monthly elevator recall test is performed:

  1. Take a copy of the elevator recall key, insert it in the corridor keyed switch on the level best used by the responding fire department, and turn it to the “Test” position. This key should be available from the elevator service company.
  2. This will recall all the elevators in that bank to the floor that you are on. The elevator will ‘recall’ to that floor and open the doors. The controls inside the elevator will not respond and the elevator car will sit there waiting for someone to take control. The elevators will be “out of service” during this test, so plan on doing this test when it will least impact your operations.
  3. Remove the key from the recall corridor switch (leave the switch still in the “Test” position) and enter one of the elevator cars. Take the key and insert it in the keyed switched labeled “Fire Fighter Service”, and turn it to the “Test” position (It should say “Test”, but if not, turn the switch anyway). Now you have manual control on the elevator buttons inside the car.
  4. Push a button to another floor, holding it until the doors closed. The elevator will travel to that floor, but the doors will not open. If you push the “Door Open” button, then the doors will open, and stay that way until another floor button is pressed.
  5. While in the elevator car, test the function of the emergency telephone in the car.
  6. Return the elevator car to the recall floor, and test any other cars in that bank. Remove the key and go back to the corridor switch and return the switch to the normal setting.

That is a monthly recall test, which must be done each month to all elevators. You may find that the fire alarm system will become alerted during this test and before the elevators return to normal service you may have to reset the fire alarm system.

But check with your sate and local AHJs before conducting this test for the first time… There are some states that will only allow certified elevator technicians to perform this test.

Windows in Patient Sleeping Rooms

Q: In the 2000 edition of the Life Safety Code, under section 18.3.8 “Special Protection Features -Outside Window or Door”, they have requirements for windows or doors to the outside in patient sleeping rooms. However, in the 2012 edition of LSC, under section 18.3.8 “Special Protection Features (Reserved)”, it does not list any requirements for windows or doors to the outside in patient sleeping rooms. Does this mean that outside windows or doors are no longer required?

A: You have touched on an issue that is not often discussed. Yes, you are correct: The 2000 LSC did require a window or door to the outside in patient sleeping rooms. Up until the 1994 edition, the LSC required those windows and doors to operate, to allow venting during a fire emergency. In the 1994 edition, the LSC changed to stop requiring the windows to operate, but the requirement for the windows or doors remained. In the 2009 edition, the LSC deleted the requirement for windows or doors to the outside in patient sleeping rooms all-together, because the technical committee feels the total concept approach in section 18/ covers the issue of evacuation, and no longer requires such an opening.

However… that does not mean you can design new hospitals without windows in patient sleeping rooms. Many local building codes, and state agencies with authority over hospital construction, still require windows in patient sleeping rooms in hospitals. There is a psychological need for the patient to see the outside light of day in the recovery process. The problem is, the LSC does not deal in the psychological needs of patients… at least not on this issue.

I also reviewed the Final Rule that CMS issued last May when they adopted the new 2012 LSC. Sometimes, CMS will retain a requirement in an older version of the LSC even though the newer version no longer requires it. In this case though, CMS did not say anything about keeping the requirement for windows in patient sleeping rooms.

But I suggest you check with your state and local authorities to determine if they have any regulations on this issue.

Keyes Life Safety Boot Camp – Last Chance to Register

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 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: