Fire Drill Announcements

If we make an announcement prior to activating the fire alarm system for a fire drill, is that considered an announced or unannounced fire drill?

Data Room Suppression System

A hospital has a data room suppression system that is not sprinklered, but the rest of the facility is sprinklered.  Would TJC still consider the hospital to be fully sprinklered?

Refrigerator Temperature

What are some general concerns regarding refrigerator temperature and monitoring?

Fire Drills

We have several buildings where outpatient behavioral health care, administrative, and business activities are conducted.  We rarely achieve the one-minute standard we have set for total egress of the buildings to the designated assembly areas.  What is the NFPA code requirement for the drill execution, or are we to use the drill execution time set by the local municipality?

Suicide Prevention Structural Precautions for Behavioral Health

We have an inpatient behavioral medicine unit that is made up of two separate areas. One side is a locked high-risk unit, and the other side is a voluntary unit.  Is the voluntary unit required to have the same suicide prevention structural precautions that we have in the locked unit?

Utility Room Doors

A nearby hospital recently told us that they were advised to lock their clean and dirty utility rooms. We hadn’t heard this expectation before and can’t find it in the standards. Is it indeed a requirement to lock clean and dirty utility rooms?

Evacuation Maps

Are evacuation maps required to be posted in health care organizations? If so, where? And how many are needed?

Fire Extinguisher Inspection

Do all portable Fire Extinguishers require monthly inspections or only those that are classified as a healthcare occupancy?  

Isolation Rooms

What is the required testing frequency for TB Isolation Rooms?

Medical Gas System Inspection

What is the definition of a med gas flexible hose and flexible connection related to routine system inspections?   

Electrical Outlet Marking

Is circuit labeling required on all electrical outlets, or just emergency power?  And is this required in the entire facility or just patient care areas?  Where is the code reference?

Emergency Plans

Does DNV differ from TJC with regard to having a 96 hour Emergency Operation Plan in place?

Life Safety Essentials: Reasons Why Sprinklers Fail to Operate

Learning Objective: To identify possible causes of non-functioning sprinklers.
 

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

Automatic fire sprinkler systems are the most widely recognized fire protection feature for building protection and life safety. Sprinklers have been in existence since 1874 and today all new health care occupancies are required to be sprinklered. The reasons sprinklers fail to operate can easily be controlled procedurally, which will also ensure proper inspection, testing and maintenance. 

According to a 2009 report Experience with Sprinklers and other Automatic Fire Extinguishing Equipment, John R. Hall, Jr. of the National Fire Protection Association categorized five reasons why sprinklers fail to operate. The chart seen here identifies those reasons and compares health care occupancies to all structures. While it is recognized that there are times when sprinklers are shut down (such as during construction), limiting the affected area and firewatch may be helpful to reduce the statistic for when the system is shut off before the fire.  Lack of maintenance is one of the easiest categories to get under control. To reduce risks, liability, and responsibility for contributing to property damage and the cause of death and injury proper maintenance is essential. 

Inappropriate systems for a fire generally come into consideration when something changes, like using a room designed for light hazard operations for large storage of combustibles. In health care, manual intervention defeating the system is the leading cause of sprinkler failures. Health care managers must keep an accurate and continuous account of the status of systems and be on alert for inoperable systems. Damaged components may include valves, piping and sprinkler heads - all of which may affect water reaching the hazard or affect the distribution pattern.

Hazard Vulnerability Analysis

Does the Joint Commission have a prescribed template for performing a hazard vulnerability analysis (HVA)? 

Tamper-Resistant Electrical Receptacles

What are the requirements for tamper-resistant electrical receptacles? I was told to install these in all waiting areas or anywhere there may be children.  This is not a pediatric hospital, and we do not have a pediatric unit. If I do need to install them, can I use a cover that has a slide system and is called a child-resistant cover? 

Major Vs. Minor Renovations

What qualifies a renovation as major, and therefore necessary to classify it as New Healthcare?

Testing Frequency Flexibility

If the required time frames can't be met to complete a task or function as specified in TJC's 2010 Hospital Accreditation Standards, what kind of leeway is there in completing them?

Immediate Threat to Health or Safety

What triggers an “Immediate Threat to Health or Safety” condition in the environment of care?

Chute Discharge Doors

Is it the intent that the chute discharge door that opens into the chute discharge room be a listed self-closing fire door assembly with a minimum 1-hour rating?