Tuesday, July 31, 2012

Compliance News: Corridor Clutter Remains an Issue in Many Hospitals



By David Stymiest, PE, CHFM, FASHE


An article by TJC Director of Engineering George Mills in the August 2012 edition of EC News discussed at length the continuing issue of corridor clutter. This article is in the EC News “Clarifications and Expectations” column that is intended to increase accredited organizations’ awareness of the NFPA 101 Life Safety Code®.1 We recommend that you obtain and review this article and its follow-up article in the next issue of EC News.

Corridors need to be kept clear of clutter because of NFPA 101 Life Safety Code® requirements and also for ease of rapid patient movement in response to emergency conditions.

Crash carts and isolation carts may be stored in corridors while they are “in use” according to TJC. Crash carts must always be available and ready for use, so they are always “in use.” Isolation carts are in use as long as they are outside a patient room to which the patient for that cart has been assigned. An isolation cart outside a patient room is not in use after that patient has been discharged. If a hospital chooses to use door-hanging isolation cabinets rather than isolation carts, it is important to ensure that all NFPA 101 Life Safety Code® clear width requirements are maintained when the door is open. With the door closed the maximum six inch obstruction rule (reducing corridor width by not more than six inches) still applies even to that cabinet.

Compliance News: Weekly Generator Run Tests



By David Stymiest, PE, CHFM, FASHE



A question that I am commonly asked is whether weekly generator run tests are required. This question occurred almost a half dozen times at the recent ASHE Annual Conference.

NFPA 110 requires weekly Emergency Power Supply System (EPSS) inspections as stated in this excerpt from NFPA 110-2010 (The EPSS consists of the generators downstream to the transfer switch load terminals, inclusive):

“8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.”

However NFPA 110 does not require weekly emergency generator run tests. In fact NFPA 110 clarified this issue in the 2010 edition Annex as stated below:

Compliance News: Current Life Safety Plans



By David Stymiest, PE, CHFM, FASHE


In In his recent ASHE Annual Conference presentation, George Mills of TJC reminded attendees about the requirements for current LS plans. Much of this information is in a related February 2012 EC News article and is summarized below.


TJC Standard LS.01.01.01, EP 2, requires an organization to have a current Statement of Conditions™ (SOC™). EP2 is scoring category A with documentation required. In order to have a current SOC™ an organization must create and maintain an up-to-date and complete Basic Building Information (BBI). Since the BBI requires organizations to indicate the location of current LS drawings, not being able to supply those current LS drawings during a survey can result in a direct impact RFI against EP2.

TJC has stated that current LS drawings must address the following topics:

Tuesday, July 3, 2012

OR Temperature and Humidity Requirements


Has there been an update regarding temperature and humidity requirements for OR's or do we have to have a 35%-60% humidity range to be compliant with CMS? and not the 20%-60% range?