By Robert Trotter, CBO, CFM
The Joint Commission’s 2010 Hospital Accreditation Standards for the Environment of Care describes requirements for the main drain tests on sprinkler and standpipe systems. EC.02.03.05 Element of Performance 9 states, “For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The completion date of the tests is documented.” For additional information refer to the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Although The Joint Commission requires an annual test, NFPA 25 requires this test to be conducted quarterly. Section 9-2.6 states, “A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.”
Note: The test for standpipe systems should be done at the low point drain for each standpipe or the main drain test connection where the supply main enters the building.
Thursday, July 29, 2010
Compliance News: New and Existing Elevators
By Robert Trotter, CBO, CFM
According to the 2000 edition of NFPA 101®, Life Safety Code® elevators in all occupancies must comply with Section 9.4 which addresses general requirements, code compliance, fire fighters’ service, number of cars, elevator machine rooms, elevator testing, and openings. The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety have specific Elements of Performance for new and existing healthcare occupancies and ambulatory healthcare occupancies. LS.02.01.50 EP 4 and LS.03.01.50 EP 1 require new elevators to be equipped with the following:
• Fire fighters’ service key recall
• Smoke detector automatic recall
• Fire fighters’ service emergency in-car key operation
• Machine room smoke detectors
• Elevator lobby smoke detectors
Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of fire fighters shall also meet these requirements.
According to the 2000 edition of NFPA 101®, Life Safety Code® elevators in all occupancies must comply with Section 9.4 which addresses general requirements, code compliance, fire fighters’ service, number of cars, elevator machine rooms, elevator testing, and openings. The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety have specific Elements of Performance for new and existing healthcare occupancies and ambulatory healthcare occupancies. LS.02.01.50 EP 4 and LS.03.01.50 EP 1 require new elevators to be equipped with the following:
• Fire fighters’ service key recall
• Smoke detector automatic recall
• Fire fighters’ service emergency in-car key operation
• Machine room smoke detectors
• Elevator lobby smoke detectors
Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of fire fighters shall also meet these requirements.
Compliance News: Relative Humidity Levels in Operating Rooms Reduced
By Dean Samet, CHSP
The American Society for Healthcare Engineering (ASHE) announced in May 2010 that effective the end of June 2010 the requirement for relative humidity levels in operating rooms has been reduced to a minimum of 20%. The new design range for ORs and short-term patient treatment stay areas is now 20-60% relative humidity (RH).
The above changes are a result of actions taken by the ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities Standing Committee and were approved as issued in ASHRAE Standard 170, Addendum “d.” ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 has been incorporated into The Facility Guidelines Institute’s 2010 edition of Guidelines for Design and Construction of Healthcare Facilities. According to ASHE, the publication of Addendum (d) “stresses the aspects of relative humidity in operating rooms in terms of clinical outcomes, comfort, and engineering concepts.”
The American Society for Healthcare Engineering (ASHE) announced in May 2010 that effective the end of June 2010 the requirement for relative humidity levels in operating rooms has been reduced to a minimum of 20%. The new design range for ORs and short-term patient treatment stay areas is now 20-60% relative humidity (RH).
The above changes are a result of actions taken by the ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities Standing Committee and were approved as issued in ASHRAE Standard 170, Addendum “d.” ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 has been incorporated into The Facility Guidelines Institute’s 2010 edition of Guidelines for Design and Construction of Healthcare Facilities. According to ASHE, the publication of Addendum (d) “stresses the aspects of relative humidity in operating rooms in terms of clinical outcomes, comfort, and engineering concepts.”
Compliance News: Polyurethane Expanding Foam
By Robert Trotter, CBO, CFM
The use of polyurethane expanding foam is expressly not permitted by The Joint Commission for sealing penetrations in fire-rated walls and floors. According to the 2010 Hospital Accreditation Standards LS.02.01.10 Element of Performance 9, "The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material." The Joint Commission included this specific note, "Polyurethane expanding foam is not an acceptable fire-rated material for this purpose." According to the 2000 edition of NFPA 101®, Life Safety Code® section 8.2.3.2.4.2 requires the space between the penetrating item and the fire barrier to be filled with a material that is capable of maintaining the fire resistance rating of the fire barrier or it must be protected by an approved device that is designed for the specific purpose.
The use of polyurethane expanding foam is expressly not permitted by The Joint Commission for sealing penetrations in fire-rated walls and floors. According to the 2010 Hospital Accreditation Standards LS.02.01.10 Element of Performance 9, "The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material." The Joint Commission included this specific note, "Polyurethane expanding foam is not an acceptable fire-rated material for this purpose." According to the 2000 edition of NFPA 101®, Life Safety Code® section 8.2.3.2.4.2 requires the space between the penetrating item and the fire barrier to be filled with a material that is capable of maintaining the fire resistance rating of the fire barrier or it must be protected by an approved device that is designed for the specific purpose.
Compliance News: Electrical Arc Flash Safety: How close is too close?
By David Stymiest, PE, FASHE, CHFM, GBE
NFPA 70E® defines a series of boundaries related to electrical safety near energized equipment. These boundaries can be based on the voltage; the available short-circuit current and the predicted fault duration. The definitions are not repeated here, but the following considerations are useful to gain an overview of the issues involved.
• Flash Protection Boundary – an imaginary boundary within which there is the potential for a second-degree burn injury. Fire resistive protection (also called PPE) is required. This is the first item that must be determined by an arc flash hazard analysis.
NFPA 70E® defines a series of boundaries related to electrical safety near energized equipment. These boundaries can be based on the voltage; the available short-circuit current and the predicted fault duration. The definitions are not repeated here, but the following considerations are useful to gain an overview of the issues involved.
• Flash Protection Boundary – an imaginary boundary within which there is the potential for a second-degree burn injury. Fire resistive protection (also called PPE) is required. This is the first item that must be determined by an arc flash hazard analysis.
Compliance News: CMS Corridor Obstructions Stance Revised
By Dean Samet, CHSP
In a May 14, 2010 Centers for Medicare & Medicaid Services memorandum, Ref: S&C-10-18-LSC, CMS announced changes to previous policies regarding the use of corridor wall-mounted computer touch screens in healthcare facilities.
In a May 14, 2010 Centers for Medicare & Medicaid Services memorandum, Ref: S&C-10-18-LSC, CMS announced changes to previous policies regarding the use of corridor wall-mounted computer touch screens in healthcare facilities.
CMS is now allowing certain wall-mounted technologies and other items to be wall-mounted in corridors as long as they don’t project out more than six inches from the corridor wall or conflict with other sections of the National Fire Protection Association’s Life Safety Code®.
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