Entries by BKeyes

Fire Hose Removal

Q: We have an email confirmation from the State Fire Marshal that approves of our removal of the occupant-use fire hoses in our hospital. What exactly do we have to do with this email?  Do we have to let any other AHJ know? A: Depending on your accreditation organization (AO), you may have to ask more »

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor 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 Compliance One. Date: more »

Occupational Therapy Kitchens

Q: Do occupational therapy kitchens need to meet NFPA 96 standards? This unit will be a new build and will fall under business occupancy requirements, but the Life Safety Code for new business occupancies refers me back to 9.2.3, which refers me to NFPA 96. A: Is the cooking equipment really ‘commercial cooking equipment’? For more »

Smoke Dampers in Smoke Partitions?

Q: When comparing smoke dampers in smoke barriers vs smoke partitions, section 8.5.5.2 requires smoke dampers (with exemptions) for penetrations by ducts or air-transfer openings in a smoke barrier. Section 8.4.6.2 (smoke dampers in smoke partitions) only indicates air-transfer openings as required to have smoke dampers, with no mention of ducted openings, which we interpret more »

Strange Observations -Disabled Latches

Continuing in a series of strange things that I have seen while consulting at hospitals… Boy… I bet you’ve never had this problem at your facility, eh? [Sarcasm] This is why you need to do frequent rounds (i.e. weekly, if needed) to spot these trends and nip it in the bud. Healthcare staff will frequently more »

Marked Fire/Smoke Doors

Q: We are reviewing fire policy, and are wondering if it is a Life Safety Code requirement to have fire and smoke barrier doors labeled as such? By this I mean a sign or sticker on the face of the door stating: “smoke barrier” or “fire barrier”? A: No… there is no Life Safety Code more »

Compliance One Presents Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor 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 Compliance One. Date: more »

Offsite Locations

Q: For clinics that are in a facility classified as business occupancy, is an ICRA required? A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations that are considered hospital departments even if it is not classified as healthcare occupancy. For example, if a hospital has an offsite therapy unit in more »

Smoke Dampers in Corridor Walls?

Q: In regards to suite separations, section 18.2.5.7.1.2 of 2012 LSC requires walls separating suites to meet requirements for corridor walls, which have to be constructed to limit transfer of smoke. There don’t seem to be any requirements for smoke dampers in air transfer openings or duct penetrations through corridor walls – is this correct? more »

Strange Observations – Ceiling Gaps

Continuing in a series of strange things that I have seen while consulting at hospitals… Ceilings that contain smoke detectors and/or sprinkler heads have to resist the passage of smoke. For ceilings that are constructed with acoustical tile and grid assembly, this can be challenging in electrical rooms, or IT rooms where there are a more »