It is imperative that the master fire alarm control panel be adequately protected to ensure the integrity of the fire alarm system. The 2009 Hospital Accreditation Standards of The Joint Commission mandate in LS.02.01.34 Element of Performance 2, “The master fire alarm panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and ¾-hour fire-rated doors) that is continuously occupied or in an area with a smoke detector.” Health care occupancies unlike other occupancies practice a defend-in-place concept whereas other occupants of other occupancy classifications evacuate upon activation of the fire alarm system. Since health care occupants remain in the building, persons assigned to monitor the master fire alarm panel (where applicable) must remain at the panel to acknowledge all alarms received. Therefore, the area must be enclosed with one-hour fire-rated walls and ¾-hour fire-rated doors. Where off-site monitoring is provided for the organization and no staff is assigned alarm monitoring duties, the master fire alarm control panel must be protected by a smoke detector and the additional fire-rated walls and doors are not required.
Wednesday, July 29, 2009
Compliance News: Fire Watch for Scheduled and Unscheduled “Out of Service” Fire Alarm or Sprinkler System
By Dean H. Samet, CHSP
In a June 2009 The Joint Commission Perspectives® article titled “Conducting the Fire Watch of Standard LS.01.02.01,” TJC clarified when a “fire watch” is required during both scheduled and unscheduled outages.
Background: Standard LS.01.02.01, EP1 states, “The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is ‘out of service’ more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. (For full text and any exceptions, refer to NFPA 101®-2000: 9.6.1.8 and 9.7.6.1).” See also Life Safety Code® Annex A.9.6.1.8 and A.9.7.6. At a minimum, TJC expects the organization to:
• Notify the fire department, fire marshal, or other appropriate emergency response group, and document when that notification occurs; and
• Conduct rounds of the area(s) affected by the outage, and document those rounds.
It is mandated that the fire watch be enforced until the fire alarm or sprinkler system has been returned to service, is stable, and is fully functioning.
Fire Watch Defined: Per the NFPA 101®-2000: Annex A.9.6.1.8, “A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.” The Health Care Interpretations Task Force (see NFPA website for HITF info) agreed in 1998 that the clinical staff in an area affected by a fire alarm or sprinkler system impairment could be used to satisfy the requirements for a fire watch, provided there would be adequate staffing to continuously patrol the affected area(s), and staff would have the means to make proper notification to building occupants in the event of a fire.
Per the aforementioned Perspectives article, a “scheduled activity” (planned) would be an event known to and under the control of the organization’s staff, e.g., a new installation or servicing or upgrading an existing fire alarm or sprinkler system. All other outages would typically be considered “unscheduled activities” (unplanned).
A table is provided in the June 2009 The Joint Commission Perspectives article defining “Out of Service” responsibilities, showing different service situations, whether a fire watch is required, and whether an interim life safety measure (ILSM) evaluation is required. It is intended only to provide guidance regarding the phrase “out of service.” Organizations still need to assess each outage or activity to determine the need for a fire watch and if ILSM procedures should be implemented per their written ILSM policies.
Out of Service Situations:
• Putting a shield over one smoke detector to prevent dust/false alarms for more than four hours - No fire watch required; ILSM evaluation recommended.
• Covering all smoke detectors during a “controlled” event, such as only during the time the contractors are working in an affected area, although after hours, the entire area is fully operational - No fire watch required; ILSM evaluation required.
• Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than four hours as part of a:
1. “Scheduled” event, e.g., working on, servicing, or upgrading the fire alarm or sprinkler system - Fire watch not required in all cases; ILSM evaluation required with emphasis on occupant notification.
2. “Unscheduled” event, e.g., shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than four hours in response to a system failure - Fire watch required; ILSM evaluation required.
Further clarification was provided recently by TJC’s senior engineer, George Mills, at a June 2009 NFPA conference in Chicago where George talked about “planned” vs. “unplanned” outages of the fire alarm or sprinkler system. He said that if the outage was planned and only covered one alarm zone at a time, a fire watch would probably not be needed. However, if the outage was not planned and resulted from an indeterminate cause, then it would be a good idea to set up a fire watch and appropriate ILSMs. George also suggested that your ILSM policy not be overly restrictive and be matched to the hazard(s) being addressed.
In order to ensure as safe an environment as possible during any potential outages of the fire alarm system or automatic sprinkler system, whether scheduled or unscheduled, planned or unplanned, it is imperative that the above listed criteria be followed. Failure to do so could result in an adverse accreditation decision of either Conditional Accreditation or Preliminary Denial of Accreditation per the 2009 “criticality model” of scoring and Accreditation Decision Rules.
For questions about conducting a fire watch, you may contact The Joint Commission’s Standards Interpretation Group (SIG) at 630-792-5900 or on-line at SIGInquiries@jointcommission.org.
Compliance News: Novel Influenza A (H1N1): Swine Flu and You
By Dean H. Samet, CHSP
On June 11, 2009, the World Health Organization signaled that a global pandemic of novel influenza A (H1N1) was underway by raising the worldwide pandemic alert to Phase 6 as a reflection of the spread of this virus, not the severity of illness caused by the virus. Most of us have been informed and warned about this new so-called “swine flu” virus first detected in people in the United States in April of 2009. The Centers for Disease Control and Prevention (CDC) has determined that this now named novel influenza A (H1N1) flu virus is contagious and spreading from person to person the same way regular seasonal influenza viruses spread - primarily by the coughing and sneezing of those infected with the virus. What can you do to stay healthy?
If you have what feels like seasonal flu symptoms, e.g., fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, possibly diarrhea, and vomiting, you might be infected with the H1N1 virus. The CDC suggests:
• Stay informed via the CDC website (www.cdc.gov/h1n1flu).
• Cover your nose and mouth with a tissue when you cough or sneeze. Then throw the tissue in the trash after you use it.
• Wash your hands often with soap and water for 15 to 20 seconds, especially after you cough or
sneeze.
• Use alcohol-based hand cleansers or disposable hand wipes.
• Avoid touching your eyes, nose or mouth. You may have touched something with flu viruses on it. Germs spread that way.
• Try to avoid close contact with sick people.
• Stay home if you get sick except to seek medical care. The CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.
• If you have severe illness or you are at high risk for flu complications, contact your health care
provider or seek medical care.
• Stay home if you are sick for seven days after your symptoms begin or until you have been
symptom-free for 24 hours, whichever is longer.
• Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.
• Call 1-800-CDC-INFO for more information.
Furthermore, the CDC recommends urgent medical attention for children experiencing the following emergency warning signs:
• Fast breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough
In adults, emergency warning signs that need urgent medical attention include:
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough
The United States continues to report the largest number of novel H1N1 cases of any country worldwide. According to the CDC, as of July 17, 2009 there have been 40,617 reported cases of H1N1 flu infection in all 50 states, including the District of Columbia, and American Samoa, Guam, Puerto Rico, and the US Virgin Islands, and 263 deaths as a result of illness associated with this virus. A July 6th World Health Organization (WHO) update showed 94,512 confirmed cases in 122 countries with 429 deaths. The good news is that most people who have become ill have recovered without requiring medical treatment.
CDC anticipates that there will be more cases in the United States over the summer and into the fall and winter this year. By following the above-listed CDC suggestions and everyday actions, you can help prevent the spread of germs that cause respiratory illness like the H1N1 flu virus and that will permit you, your family, fellow workers, and those around you to stay healthy!
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