GuideOne Risk Resources for Health Care
1111 Ashworth Road
W. Des Moines, IA 50265-3538



Life Safety Code

The National Fire Protection Association (NFPA) 101, Life Safety Code is the most widely used source for addressing minimum building design, construction and operation, as well as maintenance requirements necessary to protect building occupants from danger caused by fire, smoke and toxic fumes.

The following life safety controls are important to have in place concerning the safety of your residents, staff and visitors within your healthcare facility. It's recommended that you keep a log and record all inspections, training and follow-up actions, such as repairs and replacements.

Fire Walls

  • All penetrations in fire-rated walls should be sealed with fire-rated materials that are Underwriters Laboratories (UL) listed or Factory Mutual (FM) approved. Sealing penetrations reduces the possibility of smoke spreading throughout your building.


  • Exits should be free of all obstructions to allow for full use in the case of fire or other emergency. No furnishings, decorations or other objects shall obstruct an exit.
  • The discharge area outside of the building should be a hard surface and should not be blocked by snow or any other obstacle.
  • Illuminated exit signs should be in place.


  • Regularly check doors equipped with self-closing hardware to ensure they function properly.
  • Doors should not be obstructed, blocked or held open in any manner, for example, with the use of a door stop.
  • Hazardous areas, such as electrical and mechanical rooms should have doors that are self-closing.

Vertical Openings

  • All stairways, elevator shafts, ventilation shafts and other vertical openings, including trash and laundry chutes that open directly onto any corridor should be sealed by fire-resistive construction, including a fire door with a self-closing device and positive latching hardware.
  • Areas under stairs should not be utilized for storage.


  • Maintain a minimum distance of 36 inches from any combustible materials and electrical panels.

Emergency Lighting and Exit Signs

  • Regular maintenance and testing of emergency lighting and exit signs are important to ensure they operate in an emergency situation. Log results accordingly.
  • Battery operated exit and emergency lighting units should be tested every 30 days for a minimum of 30 seconds.
  • Annually, battery operated emergency exit signs and lighting units should be tested for a minimum of 90 minutes. The exit discharge must have an emergency light that lasts at least 90 minutes.
  • All bulbs must be operational.

Portable Fire Extinguishers

  • Monthly, visual inspection of fire extinguishers must be completed and logged.
  • An annual inspection of fire extinguishers must be completed by a certified contractor.
  • Fire extinguishers should be properly mounted to the wall and easily accessible.

Kitchen Hood Fire Suppression System

  • The hood, ventilation system and fire suppression system should be professionally installed in accordance with the NFPA Standard 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.
  • Kitchen staff must be adequately trained on the proper operation of the hood fire suppression system. Keep records of this training.
  • Servicing of the fire suppression system must be completed every six months by a certified contractor. They should inspect and clean the hood, which includes all the exhaust ventilation ductwork and fans.

Automatic Sprinkler System

  • Regular maintenance is important to ensure proper operation in a fire emergency. Annually, the fire sprinkler system should be serviced by a licensed contractor. Quarterly, the fire sprinkler system should be maintained by your staff and recorded.
  • Maintain no fewer than six spare sprinkler heads on the premises. These sprinklers should correspond to the types and temperature ratings of the sprinklers on the property. Also, keep a sprinkler wrench in the cabinet for sprinkler removal and installation.
  • Maintain an 18 inch vertical clearance between items being stored and any sprinkler heads. This would include materials placed on shelves in closets, storage rooms and resident rooms.
  • Make certain that nothing is hanging from sprinkler heads or piping, such as clothes on hangers.

Fire Alarm System

  • A complete fire alarm system test and servicing must be performed by a licensed contractor on an annual basis and recorded.
  • Upon activation of the alarm, determine that smoke and fire doors close properly, off premises notification devices are functioning correctly and smoke dampers close.

Smoke Detectors

  • Smoke detectors should be tested and recorded at least annually to ensure that each detector is functioning correctly.

By confirming the items mentioned above are in place at your facility, you are providing safety from the effects of fire and smoke to your residents/tenants, visitors and staff. This list is not all inclusive of requirements of the Life Safety Code. Please visit the following websites for additional information:

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