Part 1 appeared in the September/October 2009 issue of Compliance News.
The management plans, policies and procedures for renovations or expansions on an existing campus should reflect the impacts of the project on the existing facility. These impacts can include changes to facilities and areas, changes to infrastructure equipment and systems, new operational and infrastructure-related processes, and department locations or relocations.
Risk assessments may be required for safety, security, fire, and where the facility intends to permit patient smoking. Additional risk assessments may be done for input to the Emergency Operations Plan (EOP) and hazard vulnerability analysis (HVA), as well as hazardous chemicals, hazardous energy sources (including radiation, lasers, batteries), hazardous medications, hazardous gases and vapors, and radioactive materials. Other types of risk assessments apply to Life Safety Code™ deficiencies and Interim Life Safety Measure (ILSM) documentation, preconstruction risk assessments (PRA), and infection control risk assessments (ICRA).
Some of these risk assessments might be used to establish written inventories in the following areas as subsets based upon risk:
• Hazardous materials and waste
• Medical equipment (evaluation prior to initial use)
• Operating components of utility systems (evaluation of new component types prior to initial use)
Many of the systems and equipment, including life safety building features or components, must be commissioned and/or tested prior to initial use. It is not practical to list all of these item types here. Presumably project record documentation that includes all of the information required by the AHJ would be acceptable as long as it is available during survey.
The Project Record Documentation can be helpful in providing the complete list of components for ongoing testing provided that it is available early enough to be useful. The following systems and components require ongoing testing, and there would have to be policies, procedures, schedules, requirements, and forms that detail this testing:
• Fire safety equipment, fire safety building features, fire alarm, fire protection and sprinklers, fire extinguishers and extinguishing systems
• Smoke and fire dampers, air handling unit shutdown, elevator recall, etc.
• Door operation, exit door and corridor door resistance
• Medical equipment on the inventory
• Operating components of utility systems on the inventory
• Emergency power, medical gas, and vacuum systems and equipment
• Pathogenic biological agents in cooling towers, hot water and cold water systems
• Temporary systems required for ILSM
Project testing and certification reports would have to be on file and easily accessible during unannounced surveys. Types of project-related testing and certification reports could include, but are not limited to, the following:
• Contractor documentation and commissioning (Cx) agent documentation
• Documentation of typical AHJ inspections and approvals: Local, State, NRC, DOT, FAA, etc.
• Helipads and separator tank, elevators, fuel tanks, pressure vessels, fire protection water systems, lightning protection systems
• Building automation or building management system
• Low voltage systems, both medical and otherwise
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