Life Safety Inspections at Offsite Locations

Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher inspections required? We have several off-site laboratories and other services in buildings that we do not own.

A: Yes… you must maintain all of the features of Life Safety at the offsite locations, even those that you do not own; the same as you would at the main hospital. Just because you do not own the fire extinguishers, fire alarm system, sprinkler system, fire dampers, exit signs, generator, elevators, medical gas systems, and fire doors does not give you a pass on not properly maintaining them. I understand that landlords rarely conduct the same level of testing and inspection of their building’s fire safety features as you would at the hospital, but the rules for testing and inspection apply evenly across all facilities where you have staff and patients, regardless who owns it. Your survey team may not always ask to see the documentation for testing and inspecting these systems at the offsite locations, but it is a requirement found in the core chapters and occupancy chapters of the Life Safety Code.

Brad Keyes
Brad Keyes, CHSP

Brad is a former advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor. He guides clients through  organizational assessment; management training; ongoing coaching of task groups; and extensive one-on-one coaching of facility leaders. He analyzes and develops leadership effectiveness and efficiency in work processes, focusing on assessing an organization’s preparedness for a survey, evaluating processes in achieving preparedness, and guiding organizations toward compliance. 

As a presenter at national seminars, regional conferences, and audio conferences, Brad teaches the Keyes Life Safety Boot Camp series to various groups and organizations. He is the author or co-author of many HCPro books, including the best-selling  Analyzing the Hospital Life Safety Survey, now in its 3rd edition. Brad has also authored a variety of articles in numerous publications addressing features of life safety and fire protection, as well as white papers and articles on the Building Maintenance Program. Currently serving as the contributing editor of the monthly HCPro newsletter Healthcare Life Safety Compliance  gives Brad further insight into the industry’s trends and best practices.