Compliance News: Holiday Decorations

Compliance News:  Holiday Decorations 

by Robert Trotter, BS, MCP and David Stymiest, PE, CHFM, CHSP, FASHE

Many of this newsletter’s readers are regularly confronted with questions concerning holiday decorations. The Joint Commission’s 2012 Hospital Accreditation Standards, Standard LS.02.01.70 EP-1 states: “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)”

In NFPA 101-2000®, paragraph 18/19.7.5.4 states “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

Compliance News: ECRI Institute Lists 2013's Top 10 Health Technology Hazards

Compliance News:  ECRI Institute Lists 2013's Top 10 Health Technology Hazards 

by David Stymiest, PE, CHFM, CHSP, FASHE

The ECRI Institute recently published a 25-page special report entitled “ECRI Institute 2013 Top 10 Health Technology Hazards” – available at www.ecri.org/2013hazards. In its introduction, ECRI encourages facilities to use the list of generic hazards as a “starting point for patient safety discussions and for setting their health technology safety priorities.” This report is comprehensive with a multitude of useful recommendations along with exhaustive lists of further reference publications. We recommend that our readers use the link above to acquire their own copies of the ECRI publication for review and possible action.

ECRI stated that it considered a number of factors in determining which hazards actually made it to the top 10 list, including potential for harm, frequency/likelihood of the hazard, how widespread is the hazard, whether the problem is difficult to recognize or challenging to rectify, and whether the hazard has a high profile in the media.

Compliance News: ASHE Publishes New Management Monograph "Managing Hospital Electrical Shutdowns"

Compliance News:  ASHE Publishes New Management Monograph "Managing Hospital Electrical Shutdowns" 

by David Stymiest, PE, CHFM, CHSP, FASHE 

ASHE recently published a new management monograph that provides guidance for managing safe electrical shutdowns. It is available free of charge as a downloaded protected PDF to all ASHE members at :

http://www.ashe.org/resources/management_monographs/mg2012stymiest.html.

Hard copies are also available to both ASHE members and non-members in the ASHE Online Store as ASHE catalog # 055978.

This 55-page monograph covers the following major topics in depth:

• Why electrical shutdowns should be planned
• Things to consider before planning a shutdown
• Planning a shutdown
• Electrical system considerations during a shutdown
• After the shutdown
• Planning for future shutdowns
• Numerous appendices with samples and templates to assist hospitals in their shutdown management activities

Our Compliance News readers are welcome to submit comments, suggestions and questions by email to: DStymiest@ssr-inc.com.

Compliance News: TJC Provides More Corridor Clutter Guidance

Compliance News:  TJC Provides More Corridor Clutter Guidance 

by David Stymiest, PE, CHFM, CHSP, FASHE 

  

TJC continued providing corridor clutter clarifications and expectations in the September 2012 edition of The Joint Commission Perspectives®, which is TJC’s official newsletter. In this issue TJC Department of Engineering Director George Mills followed up on his August 2012 column by addressing several additional issues including latching patient room doors, corridor walls, corridors and air supply, corridor projections. He also provided additional guidance related to the CMS waiver policy regarding certain provisions of the 2012 Life Safety Code.

Mr. Mills discussed the differences between the required patient room door latches and the self-closing or automatic closing devices that are not required for patient room doors. He discussed TJC’s expectation that accredited organizations are required to have in their fire response plans a process to ensure that patient room doors close and latch in a fire emergency. Because this requirement must be in the facility fire response plan, staff are accountable for checking patient room doors and closing the open ones during both fire drills and non-drill fire events.

Compliance News: NFPA 110-2013 Edition Addresses Generator Fuel Oil Management

By David L. Stymiest, PE, CHFM, CHSP, FASHE



The 2013 edition of NFPA 110 was recently released by the NFPA Standards Council. Chief among the changes in this edition were several changes, including informational Annex recommendations, intended to improve emergency power supply system (EPSS) reliability through better fuel oil management processes. The excerpts below are only partial excerpts, and readers should review the full text of the updated standard, which is available at www.nfpa.org/110. In the discussion below, note that all Annex language is not mandatory, rather it is advisory only and contains recommendations for user consideration.

Paragraph 7.9.1.3 was modified to stipulate that “tanks shall be sized so that the fuel is consumed within the storage life, or provisions shall be made to remediate fuel that is stale or contaminated or to replace stale or contaminated fuel with clean fuel.” Although these are not in NFPA 110, some popular remediation techniques incorporate filtering of the stored fuel through a series of water separators and media filters, periodic centrifuge cleaning/polishing with high pressure tank agitation and/or mechanical tank cleaning with auxiliary filtration.

RISK + REWARD 

Assessing the need for electrical system shutdowns

By David L. Stymiest, P.E., CHFM, FASHE

Citing concerns for worker safety, tighter insurance requirements and Occupational Safety and Health Administration enforcement actions, most electrical contractors and electrical service companies now do their work in accordance with the National Fire Protection Association (NFPA) 70E, Standard for Electrical Safety in the Workplace.

They are no longer willing to maintain or to modify "hot," or energized, electrical equipment. Consequently, increasing numbers of hospitals have been undertaking the field investigations and electrical system studies necessary for applying those ubiquitous arc flash labels on electrical equipment. What's more, new maintenance requirements have increased the urgency of this process.

Read the entire article at HFM Magazine

Assessing the need for hospital electrical system shutdowns

Risk + Reward - Assessing the need for electrical system shutdowns

By David L. Stymiest, P.E., CHFM, FASHE

Consider conducting Shutdown Risk Assessments

This article first appeared in the August 2012 issue of HFM magazine.

NFPA disclaimer: Although the author is chairman of the NFPA tech­nical committee on emergency power supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this article are purely those of the author and shall not be considered the official position of NFPA or any of its technical committees, and shall not be considered to be, nor be relied upon as, a formal interpretation of the discussed standards.

Citing concerns for worker safety, tighter insurance requirements and Occupational Safety and Health Administration enforcement actions, most electrical contractors and electrical service companies now do their work in accordance with the National Fire Protection Association (NFPA) 70E, Standard for Electrical Safety in the Workplace.

They are no longer willing to maintain or to modify "hot," or energized, electrical equipment. Consequently, increasing numbers of hospitals have been undertaking the field investigations and electrical system studies necessary for applying those ubiquitous arc flash labels on electrical equipment. What's more, new maintenance requirements have increased the urgency of this process.

Click here to read more 

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:

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?

Maintenance Free Emergency Generator Starting Batteries

Am I permitted to use maintenance free generator starting batteries?

Generator O&M Manuals and Generator Logs

Question: What are the requirements for my generator O&M manuals and my generator logs?

NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at http://www.nfpa.org/.

The following excerpts are from NFPA 110-1999 (the edition presently imposed by CMS and TJC):  NOTE paragraph 6-2.2 on instruction manuals and paragraph 6-3.4 on the logs:

Compliance News: CMS Will Consider 2012 Life Safety Code in Notice-and Comment Rulemaking Process

By David L. Stymiest, PE, CHFM, FASHE





Last year CMS requested public comments about whether it should adopt the 2012 Life Safety Code® instead of the currently required 2000 edition. In its recently-issued final rule regarding revisions to the Conditions of Participation, CMS also addressed those public comments.

In response to the public comments that it received, CMS stated “We appreciate commenters’ suggestions regarding the LSC regulations set out under our ‘Physical environment’ CoP at §482.41. Suggestions received were outside the scope of this final rule and will be considered through separate notice-and-comment rulemaking in a LSC omnibus rule, targeted for publication in the near future.”

The discussion and response are on pages 113-114 of Final Rule CMS-3244-F, RIN 0938-AQ89, entitled “Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation.” This document is available from CMS at http://www.ofr.gov/OFRUpload/OFRData/2012-11548_PI.pdf.

Compliance News: Discharge from Exits

By Robert Trotter, CBO, CFM - Koffel Associates





The Life Safety Code® mandates that exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with a safe access to a public way. However, this requirement does not apply to rooftop exit discharge where approved by the authority having jurisdiction. Exits are permitted to discharge to roofs or other sections of the building or an adjoining building where the following criteria are met:

(1) The roof construction has a fire resistance rating not less than that required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof.

Compliance News: Hazardous Areas - Laundry Rooms

By Robert Trotter, CBO, CFM - Koffel Associates





According to the Life Safety Code® central/bulk laundries larger than 100-SF in health care occupancies are considered hazardous areas. There are two principle considerations when determining the required level of protection. First, you have to determine if the hazardous area is located in a new or existing health care occupancy. Secondly, you should know the applicable requirements at the time of construction. In other words, if a hazardous area required one-hour fire resistance rated separation at the time of construction, the fire barrier is not permitted to be downgraded to less than what was required for new construction.


Laundries in new health care occupancies must be protected by sprinklers and safeguarded by a fire barrier having a one-hour fire resistance rating. Laundries in existing health care occupancies must be safeguarded by a fire barrier having a one-hour fire resistance rating or it must be provided with an automatic extinguishing system. Existing isolated hazardous areas may have sprinkler piping serving not more than six sprinklers connected directly to a domestic water supply system under certain conditions. Where the sprinkler option is used, the hazardous area must be separated from other spaces by smoke-resisting partitions and doors. Regardless of the new or existing provisions doors must be self-closing or automatic-closing. Doors in fire barriers must be provided with positive latching hardware.

Compliance News: OSHA Revises Hazard Communication Standard

By David L. Stymiest, PE, CHFM, FASHE




In its March 20, 2012 press release and conference call, OSHA announced revisions to its Hazard Communication Standard to align it with the United Nations’ global chemical labeling system, known as the Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. OSHA stated that this change is intended to improve understanding and “will improve the quality, consistency and clarity of hazard information that workers receive, making it safer for workers to do their jobs and easier for employers to stay competitive in the global marketplace.”

According to OSHA, the standard will classify chemicals according to their health and physical hazards, and establish consistent labels and safety data sheets for all chemicals both made in the USA and imported from abroad.


Employers have until December 2013 to train employees to the new requirements. The new standard, informally known as HazCom 2012, will be fully implemented by 2016. OSHA noted that during the transition period to the effective completion dates noted in the standard, chemical manufacturers, importers, distributors and employers may comply with either 29 Code of Federal Regulations 1910.1200 (the final standard), the current standard or both.

How to obtain more information:

OSHA’s press release is available at:
http://www.dol.gov/opa/media/press/osha/OSHA20120280.htm

The voluminous final rule revising the standard is available at: http://s.dol.gov/P1
(That URL also contains links to an MP3 (audio) file of the conference call as well as further related information.)

The GHS is available from OSHA at: http://www.osha.gov/dsg/hazcom/ghs.html

A list of OSHA’s FAQ’s and responses is available at: http://www.osha.gov/dsg/hazcom/hazcom-faq.html

NFPA 110 and 111 Versions

What version of NFPA 110 and 111 should we be using as a regulatory reference? 

Choosing an Emergency Power Test Time

Many hospitals conduct their emergency power supply system (EPSS) tests at the start of the day, such as just before the first shift commences.  This is when most of the operating rooms are not yet occupied for the day.

Another option is in the afternoon, either immediately after lunch or later that afternoon.  Testing at the end of the lunch period, however, may conflict with the hospital's patient focus.  This early afternoon test may be problematic due to the hospital's concern about avoiding elevator recalls when there is a high visitor population riding the elevators. 

Some hospitals schedule EPSS testing for the third shift, or nighttime.  This approach can minimize the impact of the testing on daytime hospital operations, but may become problematic when equipment failures occur during the test and the full daytime shift complement of operations and maintenance personnel are not yet on duty to deal with the failure expeditiously.

For additional discussion, including a detailed discussion of the common effects of monthly EPSS testing in hospitals, refer to my 2009 ASHE Management Monograph “Managing Hospital Emergency Power Systems – Testing, Operation, Maintenance and Power Failure Planning” that can be obtained directly from ASHE at http://www.ashe.org/resources/management_monographs/mg2009stymiest.html.  

IMPORTANT NFPA DISCLAIMER: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at http://www.nfpa.org/.

Compliance News: CMS Eases Hospital Corridor Clutter Waiver Process

By David Stymiest, PE, CHFM, FASHE


CMS issued new Survey and Clarification Memo # S&C-12-21-LSC, which applies to both hospitals and nursing homes, on March 9, 2012. CMS is easing its process for obtaining waivers in order to take advantage of four provisions in the NFPA 101 Life Safety Code© 2012 edition. CMS will now “allow providers to implement these four changes by considering waivers of the current LSC requirements found in the 2000 edition of the LSC without showing ‘unreasonable hardship’.” The four 2012 Life Safety Code© portions referenced by CMS are 18/19.2.3.4 under Capacity of Means of Egress; 18/19.3.2.5.2, 18/19.3.2.5.3, 18/19.3.2.5.4 and sections 18/19.3.2.5.5 under Cooking Facilities; 18/19.5.2.3(2), (3) and (4) under Heating, Ventilating, and Air Conditioning; and 18/19.7.5.6 under Furnishings, Mattresses, and Decorations. CMS stated “Due to the complex nature of some of the requirements, each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.”

ASHE members should have already received both an ASHE Advocacy Alert and Issue Brief regarding this topic. Since CMS waivers are issued after adverse findings during validation surveys, our recommendation is that organizations stay tuned and follow the development of this issue. As of this writing The Joint Commission has not commented publically.

Compliance News: The NFPA 110 Installation Acceptance Test

By David Stymiest, PE, CHFM, FASHE





Many hospitals are installing new or replacement emergency power systems. NFPA 110 requires a special testing sequence before the system may be used. 

Although the NFPA 110-2005 edition is referenced by the 2010 FGI Guidelines for Design and Construction of Healthcare Facilities, readers should review the updated and considerably improved Installation Acceptance Test in Section 7.13 of NFPA 110-2010 (www.nfpa.org/110). The 2010 update was rewritten to clarify the intent of the testing. If a project team is considering deviating from verbatim NFPA 110 requirements because of facility-specific differences, all necessary authority having jurisdiction (AHJ) approvals should be obtained.

Some of the major requirements of the NFPA 110-2010 Installation Acceptance Test include:

Transfer Switch Location Battery Lighting

QUESTION:  Where is the requirement for battery lights at transfer switch locations?  When did that requirement first appear?

Maintenance Repair Shop

Why do Maintenance repair shops need sprinkler systems?

Cooking Appliances

Do we need approval or an inspection to move our cooking appliances?

Penetrations in 2-HR Fire Barriers

What does a penetration in a 2-hour fire barrier have to be sealed with in order to maintain fire resistance?

Mural Painted Exit Access Doors

Life Safety Tip from Bob Trotter, CBO, CFM, MCP

Mural Painted Exit Access Doors

Be careful about where painted murals are located.  Exit access and exit doors with painted murals for decorative effect are not acceptable, as casual occupants might not be aware of such means of egress even though it is visible. The 2000 edition of NFPA 101^®, Life Safety Code^® 7.5.2.2 states “Exit access and exit doors shall be designed and arranged to be clearly recognizable”.

Improper Exit Arrangement

Life Safety Tip from Bob Trotter, CBO, CFM, MCP

Improper Exit Arrangement

If a temporary partition is installed to separate an area undergoing construction, repair, or improvement operations, alternate EXITS need to be identified. According to LS.01.02.01 Element of Performance 2 of the 2012 Hospital Accreditation Standards “The hospital posts signage identifying the location of alternate exits to everyone affected”. The appropriate action for this scenario would be to cover or remove the EXIT sign and post the (floor plan) signage indicating the location(s) of alternate EXITS.

Separation of E-Cylinders

Is there a standard that notes that full e-cylinders need to be separated from empty cylinders?  

In Case of Fire, Resolve to Make a Plan in 2012

"In Case of Fire, Resolve to Make a Plan in 2012" 

This article first appeared in the February 2012 issue of Nashville Medical News.

By Robert Trotter, CBO, CFM, MCP


In a February 2009 report, the National Fire Protection Association (NFPA) identified that during 2003-2006, municipal fire departments responded to an estimated 3,750 structure fires in medical, mental health, and substance abuse facilities, annually. These fires resulted in one civilian death, 57 civilian injuries, and $26.9 million in direct property damage. While no amount of money can account for the loss of a loved one, the United States Consumer Product Safety Commission (CPSC) assigns a statistical value per life of $5 million; and according to its Injury Cost Model, the estimated cost of a fire-related injury is about $56,000 per incident. Therefore, the average total estimated cost of these healthcare facility fires was $34.2 million.

Every well-managed healthcare organization should have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.


To read the entire article, please click here.

Temporary Electrical Wiring

Life Safety Tip from Bob Trotter, BS, MCP

Temporary Electrical Wiring
  
According to NFPA 70, National Electrical Code, 1999 edition temporary wiring is defined as “Approved wiring for power and lighting during a period of construction, remodeling, maintenance, repair, or demolition, and decorative lighting, carnival power and lighting, and similar purposes”. The NEC requires temporary wiring to be removed immediately upon completion of construction or purpose for which the wiring was installed.

Continuous Compliance - Maintaining a constant state of regulatory readiness

Continuous compliance - Maintaining a constant state of regulatory readiness

This article first appeared in the May 2011 issue of HFM Magazine.

By David L. Stymiest, P.E., CHFM, FASHE

Continuous compliance also has been called continuous survey readiness. It involves proactively maintaining a safe health care environment conducive to high-quality patient care. It essentially means having staff at all levels doing the right things for the right reasons because they understand those reasons.


Just about all accrediting agencies conduct unannounced surveys or inspections. Even when organizations think they know approximately when the next unannounced survey is due, there is the potential for random unannounced surveys or a for-cause survey. Thus, continuous survey readiness is crucial. Ongoing training and thorough staff involvement in compliance activities are essential because key managers might be unavailable when the surveyors arrive.


To read the entire article, please click here

Daily checks on Airborne Infectious Isolation (AII) rooms

CDC is often listed as the source of guidelines for daily checks on Airborne Infectious Isolation (AII) rooms.

The document with the CDC guidelines is "Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17)" and is at the following link: 

http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

If you go to the CDC website and download the linked document, you will see the following wording in the right column on page 19 (PDF) or 17 (DOCUMENT PAGE #):

"Settings with AII Rooms

Health-care personnel settings with AII rooms should

• keep doors to AII rooms closed except when patients,

HCWs, or others must enter or exit the room (118);

• maintain enough AII rooms to provide airborne precautions

of all patients who have suspected or confirmed TB

disease. Estimate the number of AII rooms needed based

on the results of the risk assessment for the setting;

• monitor and record direction of airflow (i.e., negative pressure)

in the room on a daily basis, while the room is being

used for TB airborne precautions. Record results in an

electronic or readily retrievable document;"

Continuation not inserted here.  Refer to the referenced document for all guidelines.

 

Styrofoam Sound Barrier

Life Safety Tip from Bob Trotter, BS, MCP

Styrofoam Sound Barrier

The Styrofoam™ sheets applied to the walls of this mechanical room being use as a sound barrier must meet the interior wall and ceiling finish requirements of the 2000 edition of NFPA 101^®, Life Safety Code^®. For Health Care Occupancies Section 19.3.3.2 states the following: 

19.3.3.2  Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows: (1)   Existing materials — Class A or Class B. 

Exception:  In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6. 

It is expected that this type exposed product for this application will not meet the interior finish requirements.

Conflicting Exit Signs

Life Safety Tip from Bob Trotter, BS, MCP

Conflicting Exit Signs

This scenario exists at the bottom of an EXIT stair enclosure. The original EXIT sign did not indicate the direction of egress travel. Therefore the more modern EXIT sign was installed with the left Chevron indicating the direction of egress travel. However, the original sign should have been removed to eliminate the conflict that could pose risk to life safety.

Locker Rooms

Is a Locker Room considered a suite?

Smooth Start: Ensuring Emergency Power System Performance

Smooth Start
Ensuring emergency power system performance

This article first appeared in the February 2012 issue of HFM Magazine.

By David L. Stymiest, P.E., FASHE, CHFM

Like all other mission-critical systems, emergency power systems should be commissioned to attain the necessary operational reliability.

Emergency power system commissioning (Cx) can be considered a documented quality assurance program that finds and resolves potential emergency power system-related problems before patients are admitted and procedures are performed.

Emergency power system Cx is not the same as doing walk-throughs of the emergency power system and creating punch lists. Punch lists simply report what their preparers observed to be incorrect; whereas the Cx process can document that the installed equipment and systems are correct.

Click here to go to the article at the HFM Magazine website.

Fold-down Charting Stations in Corridors

What is The Joint Commission’s position on the use of springloaded, fold-down charting stations installed in corridors outside patient rooms? Are these a violation of the NFPA Life Safety Code, Section 7.1.10?

Preconstruction Risk Assessment

Is a preconstruction risk assessment required for every planned project? If not, how extensive must the construction project be before this is required? Does this apply to hospitals only, to ambulatory health care, or to other categories?

Life Safety Drawings

During a recent survey, a surveyor asked for our current LS drawings. We were unable to provide them, and the surveyor gave us a Requirement for Improvement (RFI), stating that we did not have a current Statement of Conditions (SOC). What is the link between current LS drawings and the SOC? What is required in a current set of LS drawings?

Emergency Lighting in Anesthetizing Locations

Does my organization need emergency lighting in anesthetizing locations? If so, where is this discussed?

Alcohol-based Hand Rub Volume

When calculating the volume of alcohol-based hand rub (ABHR) permitted in a single smoke compartment, do I need to include the amount in patient room dispensers?

CMS Recognizes Joint Commission Critical Access Hospital Accreditation

The Centers for Medicare & Medicaid Services (CMS) has again granted The Joint Commission deeming authority for the accreditation of critical access hospitals. The designation is effective November 21, 2011, through November 21, 2017, and means that critical access hospitals accredited by The Joint Commission may request to be “deemed” as meeting Medicare and Medicaid certification requirements.


From February 2012 EC News

New Joint Commission Partner Offers ISO Certification Option

The Joint Commission announced a new partnership with SGS Group that offers hospitals and critical access hospitals in the United States the option of pursuing both accreditation and certification with various International Organization for Standardization (ISO) and industry best-practice standards. Hospitals can select from a menu of certifications and tests, including ISO 9001 (quality management system), ISO 14001 (environmental management), ISO 27001 (information security), OHSAS 18001 (occupational health and safety), ISO 17025 (testing and calibration laboratories), and food safety testing and certification.


From February 2012 EC News

Joint Commission Issues Sentinel Event Alert on Health Care Worker Fatigue

The Joint Commission has issued a new Sentinel Event Alert: “Health care worker fatigue and patient safety.” The Alert urges greater attention to preventing fatigue among health care workers and suggests specific actions health care organizations can take to mitigate the risks. The Joint Commission Journal on Quality and Patient Safety reported that health care professionals who work long hours are at increased risk of injuring themselves on the job. The Alert is available on The Joint Commission website, at http://www.jointcommission.org/sea_issue_48.


From February 2012 EC News

Mesh Cubicle Curtains

What is the mesh requirement for cubicle curtains in hospitals?

Sprinkler Distance from Wall

What is the allowable distance a sprinkler head can be installed to a wall?

Negative/Positive Air Pressure Testing

What are the requirements for testing for negative and or positive pressure in rooms, like isolation and OR's, and how often should it be tested?

Compliance News: Floor Level at Exit Doors

By Robert Trotter, CBO, CFM

According to the Life Safety Code® the elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 inch. The elevation must be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways may not exceed 1/2 inch in height. Raised thresholds and floor level changes in excess of 1/4 inch at doorways are to be bevelled with a slope not steeper than 1 in 2. However, in existing buildings where the door discharges to the outside or to an exterior balcony or exterior exit access, the floor level outside the door is permitted to be one step lower than the inside, but may not be in excess of 8 inches lower.

Compliance News: Loaded or Corroded Sprinklers

By Robert Trotter, CBO, CFM




The Life Safety Code® mandates that all automatic sprinkler and standpipe systems required by this Code must be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Section 2-2.1.1 of the 1998 edition states “Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler must be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” The Appendix says that the conditions described above can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual.

Compliance News: CMS Hospital Equipment Maintenance Requirements Clarified

By Dean Samet, CHSP



Hospitals are expected to maintain equipment inventories and documentation of their maintenance activities. Federal or state laws and regulations may require that equipment maintenance activities be performed in accordance with the manufacturer’s recommendations, or may establish other maintenance requirements. In such instances, hospitals must be in compliance with the most stringent maintenance requirements mandated. Absent such mandated requirements, the Centers for Medicare & Medicaid Services (CMS) is allowing hospitals to follow one of the following: The manufacturer’s recommended maintenance schedule; to schedule more frequent maintenance than the manufacturer recommends; or, in some cases of non-critical equipment, to schedule less frequent equipment maintenance than the manufacturer calls for.

Compliance News: Influenza Vaccination Standard Revised by TJC

By Dean Samet, CHSP




In their December 2011 edition of The Joint Commission Perspectives, TJC announced their Infection Prevention and Control (IC) Standard IC.02.04.01 would be revised, strengthened, and extended to all TJC accreditation programs in which the standard is not currently applicable. The revised IC changes for hospital, critical access hospital, and long term care accreditation programs will be effective July 1, 2012. The revised IC changes for ambulatory care, behavioral health care, home care, laboratory, office-based surgery, and Medicare/Medicaid certification-based long term care accreditation programs will be implemented in a phased approach commencing July 1, 2012.


Revised Standard IC.02.04.01 elements of performance (EPs) will require accredited organizations to:

Compliance News: Alcohol-Based Hand-Rub Dispenser Placement

By Robert Trotter, CBO, CFM




Health care organizations should already be familiar with the current code-based requirements of NFPA 101®, Life Safety Code® and The Joint Commission (TJC) regarding the placement of Alcohol-Based Hand-Rub (ABHR) Dispensers. TJC is now allowing ABHR dispensers to be placed according to the requirements of the 2009 and 2012 editions of NFPA 101®,Life Safety Code®. The primary change from previous TJC requirements is the reduction of the minimum measurements from the ignition source to the dispenser. LSC Sections 18/19.3.2.6 (7) state: Dispensers shall not be installed in the following locations: 

• Above an ignition source within 1 inch (25 mm) horizontal distance from each side of the ignition source.
• To the side of an ignition source within a 1 inch (25 mm) horizontal distance from the ignition source.
• Beneath an ignition source within a 1 inch (25 mm) vertical distance from the ignition source.

For ignition sources such as duplex receptacles and light switches the measurements are taken from the side edges of the ignition source coverplate as depicted in the diagram.

Oxygen Storage

If storage under 300 cubic feet can be “open to the corridor” is there still a requirement to install a sign if the oxygen is stored in an enclosure versus being stored open to the corridor?  Would this be considered a Life Safety or an Environment of Care issue?

Blocked Exit Passageway

Our nursing department is conducting training and we need to have various types of equipment lined up along the corridor during that time for training.  Is there a way this setup could be legally permitted for a week or two?

Surgery Fire Plans

Our director of surgery is wanting to create their own plan.  Is it common for a facility to have a fire plan specific for surgery? 

Limiting Access to Clinical Lab

What standard requires organizations to limit access to the clinical lab area to authorized personnel only?

Recyclable Paper Containers

We keep large receptacles for recyclable paper in our nursing stations. The dimensions of the receptacles are approximately 18'' x 18'' x 36''. Is recycled paper considered to be “waste” by the Joint Commission? Is it okay to keep these receptacles in the hallway of a nursing unit?

Corridors in Suites

Are there any TJC requirements for the width of corridors within a suite?

Ceilings and Grab Bars

Our hospital received a supplemental recommendation for EC.1.10 in our psychiatric unit. The reference was to the potential for hanging oneself from grab bars and ceilings. The bathrooms have hard ceilings, but the patient rooms do not. I see that there is a requirement in the 2001 AIA Guidelines for Design and Construction for tamper resistant ceilings. Would clips of the tiles suffice? Also, no mention is made of grab bars.

Equipment Scheduled Maintenance

What is equipment scheduled maintenance based on?

AIA Guidelines for TJC

What year of AIA Guidelines does The Joint Commission follow?  If we are renovating a critical access hospital that will follow state rules and regulations, do we have to follow TJC?

Testing Hospital-Owned Fire Hydrants

We have on-campus exterior fire hydrants owned by the hospital.  Do they need to be tested?  

Written Management Plans

How many written management plans does The Joint Commission require?

Mixed Occupancies

Can a hospital have several classifications of types of care in the same building?

ABHR Placement

Has TJC adopted the NFPA 101, 2009 requirements for placing ABHR dispensers with the 1-inch in lieu of 6-inch spacing from ignition sources? 

CMS Corridor Door Gap Requirements

What does CMS say about the gap between the door and the door frame for a corridor door?