Fire sprinkler valves controlling connections to water supplies and to supply pipes to sprinklers in new and existing health care occupancies are required by NFPA 101®, Life Safety Code® to be electrically supervised. Any valve that controls automatic sprinklers in the entire building or portions of the building, sectional and floor control valves, OS&Y valves (as pictured) located within the building or building exterior, and post indicating valves located outside on the property are included in the requirement. Electrically supervised means supervisory signals must sound and be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility to indicate a condition that would impair the satisfactory operation of the sprinkler system. A chain and/or padlock are not acceptable means of valve supervision. The Joint Commission verifies these requirements through the 2010 Hospital Accreditation Standards for Life Safety. LS.02.01.35 Element of Performance 5 states, “The fire alarm system monitors approved automatic sprinkler system components.”
Friday, January 29, 2010
Compliance News: Stairway Doors Held Open
By Robert Trotter, CBO, CFM
Stairway doors are an integral part of the egress system and they protect openings of vertical enclosures. The Joint Commission mandates specific requirements when stairway doors are held open (as pictured). In accordance with the 2010 Hospital Accreditation Standards for Life Safety, hospitals must maintain the integrity of the means of egress.
Regarding health care occupancies, LS.02.01.20 Element of Performance number 9 states, “When stairway doors are held and the sprinkler or fire alarms system activates the release of one door in a stairway, all doors serving that stairway close.” This requirement is also found in the 2000 edition of NFPA 101®, Life Safety Code® 18/19.2.2.2.7.
Likewise for ambulatory health care occupancies LS.03.01.20 Element of Performance number 5 states, “When stairway doors are held and the sprinkler or fire alarms system activates the release of one door in a stairway, all doors serving that stairway close.” This requirement is also found in the 2000 edition of NFPA 101®, Life Safety Code® 20/21.2.2.4.
Compliance News: Emergency Instructions for Occupants
By Robert Trotter, CBO, CFM
Most people are familiar with evacuation plans and fire safety information located on hotel room doors. This information is not required in hospitals under normal conditions; however, they must protect occupants during periods when NFPA 101®, Life Safety Code® is not met or during periods of construction. One of the administrative activities prescribed for Interim Life Safety Measures as required by the 2010 Hospital Accreditation Standards for Life Safety is LS.01.02.01 which states, “The hospital posts signage identifying the location of alternate exits to everyone affected.”
While there are no prescriptive requirements for the arrangement or information provided on the signs, here are a few suggestions to consider:
Compliance News: Re-entry from the Stair Enclosure
By Robert Trotter, CBO, CFM
The stair enclosure in a facility is an essential component of the means of egress. It serves as a primary way of protecting occupants during their egress from the building. Under certain circumstances, health care organizations have the need to secure stair doors from re-entry to the interior of the building. Where this need exists you should consider the applicable re-entry provisions found in the 2000 edition of NFPA 101®, Life Safety Code®.
Compliance News: 2010 TJC Accreditation Decision Changes
By Dean Samet, CHSP
The Joint Commission has made additions to their 2010 Conditional Accreditation decision rules. Unchanged is where Conditional Accreditation will still result when a health care organization fails to resolve the requirements of a Provisional Accreditation status, or was in substantial noncompliance with applicable TJC standards. As always, the organization must remedy the identified problem area(s) through an Evidence of Standards Compliance (ESC) submission and subsequently undergo an on-site follow-up survey.
New for 2010, “Conditional Accreditation may result when an organization fails to meet requirements for the timely submission of data and information to The Joint Commission; or survey findings demonstrate systematic patterns, trends or repeat findings from previous surveys; or there is credible evidence indicating that possible fraud or abuse has occurred at a health care organization.” (Refer to The Joint Commission Online August 5, 2009.) The new language related to survey findings has been made to bring the decision in line with TJC’s Standards Improvement Initiative (SII). The new wording related to possible fraud or abuse has been created to meet Centers for Medicare and Medicaid Services (CMS) requirements.
Also new for 2010 and related to TJC’s application to CMS for continued hospital-deeming authority, TJC has adopted a new type of follow-up survey called “Medicare Condition-Level Deficiency Follow-Up Survey.” This new survey will be required after an organization has one or more Medicare Conditions of Participation (CoPs) assessed by CMS as a “Condition-Level Deficiency.” This new regulation requires that an organization remedy the identified CoPs and then undergo an on-site follow-up survey by TJC. This follow-up survey is in addition to the above mentioned TJC Conditional Accreditation decision rules.
Compliance News: Transitioning from Construction to Survey-Ready Compliance - Part 3
By David Stymiest, PE, FASHE, CHFM
Part 1 appeared in the September/October 2009 issue of Compliance News.
Part 2 appeared in the November/December 2009 issue of Compliance News.
Schedules (policies and procedures, forms, lists, etc.) would have to be established for the following types of items (listing is not all-inclusive):
• Fire drills, safety rounds, safety monitoring and security monitoring of EC
• Ongoing testing, inspections and maintenance
• Inspections of all ‘previous’ Building Maintenance Plan (BMP) components – (smoke and corridor walls; fire, smoke and corridor doors; exit signs and egress lights, trash and linen chutes, grease producing devices, and means of egress free of blockage such as ice and snow)
• Inspections of fire walls
• Inspections of fire and smoke dampers, including the special one-year inspection
• Fire alarm systems, devices and equipment; fire protection systems, devices and equipment; fire extinguishers
• Eyewash stations
• Emergency power, medical gas and vacuum, and other systems
Labeling would be expected for hazardous materials and waste, utility system controls to facilitate partial or complete emergency shutdowns, medical gas and vacuum system valves, both permanent and temporary signage, and maps if they are used. Standard labels may not meet all of the AHJ requirements.
Project record documentation that meets the AHJ requirements for mapping of utility systems would be acceptable if it is available during survey. The utility systems include normal and emergency power, steam, chilled water, domestic water, sanitary piping, fire protection, medical gas and vacuum, fire alarm and emergency communications, telecom, and any other systems included in the Utility Systems Management Plan scope.
Utility maintenance documentation is required to be accessible during survey. This includes documentation generated both internally and by outside services. The organization needs to have processes (and contract provisions) to obtain, store and access all such documentation during both equipment failures and unannounced surveys. The decision process for the types of maintenance (preventive, predictive, reliability-centered, corrective, or metered) to be performed on all new equipment should also be documented and available during survey.
Similar requirements apply to maintenance documentation for other types of equipment, including equipment serviced by both internal biomedical engineering departments and external service organizations.
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