Entries by BKeyes

Protection of Medical Records from Sprinkler Water

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 says we have to protect the medical records from water if the sprinkler system were to activate. I don’t see this requirement in the Life more »

Travel Distance to Fire Extinguisher on a Helipad

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 418 (1995 edition) addresses the classification of fire extinguishers for helipads, Table 5-1 lists the size according to the length of the helicopter, including the more »

Alcohol 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 Safety Code. I have a VP who doesn’t think it is allowed and I would like to show him where it is permitted. A: Actually, more »

Joint Compound on Fire Rated Walls

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 other penetrations but a surveyor said it was not an approved fire rated sealant, and cannot be used. This hardly makes sense as the whole more »

Storage Room Options

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 to a patient room to make it a real storeroom? A: Yes, I am in favor of re-classifying a patient room as a storage room, more »

New Day Care Occupancy Sprinklers

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 wellness center by a 2 hr fire wall.   The addition will be primarily open floor plan–non sleeping—day care.   Egresses meet code amount and distances.  It more »

No Smoking Signs on Patient Rooms

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 Smoking signs on the door frame for every patient that is currently being administered oxygen. A: Section ( for new construction) of the LSC more »

Sterile Scalpel Storage

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 the Joint Commission website and in their standards but cannot find anything that would relate to this question.  I even looked up on OSHA but more »

Fire Alarm Transmission Times

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 transmit an alarm to the monitoring company, and we are concerned this is too long. A: Section 19.3.4 (18.3.4 for new construction) of the LSC more »

Standpipe Waterflow Test

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 not aware of this, and cannot find this requirement in the Life Safety Code (LSC). Are we required to have a minimum of 500 GPM more »