Saturday, May 29, 2010

Compliance News: Locks on Doors in Means of Egress

By Robert Trotter, CBO, CFM


According to the 2000 edition of NFPA 101®, Life Safety Code®, “Experience indicates that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving towards exits that they can see…” However, the stoppage of egress travel such as an exit door locked with a padlock (as shown on a marked exit door in an industrial occupancy of a hospital) is potentially conducive to panic. Healthcare occupancies as well as business, industrial and storage occupancies are required to comply with the means of egress provisions for locks, latches and alarm devices for doors. Section 7.2.1.5.1 of the Life Safety Code® states, “Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.” It is also important that locks, if provided, “shall not require the use of a key, tool, or special knowledge or effort from the egress side.”

Compliance News: Labeling Utility System Controls

By Robert Trotter, CBO, CFM


Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”

While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”

Compliance News: NFPA® Codes Available On-Line (Free)

By Pete Kendrick, CHFM, CPMM


Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.

First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”


Compliance News: Damaged Sprinkler Heads

By Robert Trotter, CBO, CFM


Damaged sprinkler heads can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.

Compliance News: Electrical Arc Flash Safety: Why is it important?

By David Stymiest, PE, FASHE, CHFM, GBE


With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.

According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.


Compliance News: Measures of Success and Scoring Category Changes

By Dean Samet, CHSP


According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.

Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.


Saturday, May 1, 2010

Opening Day: Transitioning from Construction to Survey-Ready Operation

By David l. Stymiest, P.E., FASHE, CHFM (in Health Facilities Management)


Construction project turnover time is hectic. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and survey-ready compliance at occupancy can put a hospital at risk during an early survey.

Challenges and Limitations

There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.

Read entire article here: Opening Day