When you activate the Command Center do you have to notify all the Satellites listed on a hospital's license?
Monday, March 7, 2011
Thursday, March 3, 2011
Generator Annual Maintenance (PM)
I recently received the question - "Is there a requirement for generator annual PM?
The short answer is yes, but knowing what to do requires knowing what each generator's manufacturer recommends.
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 www.nfpa.org.
etc.
The short answer is yes, but knowing what to do requires knowing what each generator's manufacturer recommends.
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 www.nfpa.org.
NFPA 99 references NFPA 110, and it’s all based upon manufacturer’s recommendations as far as NFPA 110 is concerned. Every emergency generator manufacturer that I am aware of recommends annual maintenance in the O&M manual.
From NFPA 99-1999:
3-4.4 Administration (Type 1 EES).
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and
Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set
or other alternate power source and associated equipment,
including all appurtenant parts, shall be so maintained as
to be capable of supplying service within the shortest time
practicable and within the 10-second interval specified in
3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in ac-
cordance with NFPA 110, Standard for Emergency and Standby
Power Systems, Chapter 6.
From NFPA 110-1999:
Chapter 6 Routine Maintenance and
Operational Testing
6-1 General.
6-1.1* The routine maintenance and operational testing program
shall be based on the manufacturer’s recommendations,
instruction manuals, and the minimum requirements of this
chapter and the authority having jurisdiction.
6-1.2 Consideration shall be given to temporarily providing a
portable or alternate source whenever the emergency generator
is out of service.
AND …
6-3 Maintenance and Operational Testing.
6-3.1* The EPSS shall be maintained to ensure to a reasonable
degree that the system is capable of supplying service
within the time specified for the type and for the time duration
specified for the class.
6-3.2 A routine maintenance and operational testing program
shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the
operational reliability of the system.
6-3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.
6-3.4 A written record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained on the premises.
The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended
by the manufacturer
6-3.5* Transfer switches shall be subjected to a maintenance
program including connections, inspection or testing for evidence
of overheating and excessive contact erosion, removal
of dust and dirt, and replacement of contacts when required.
6-3.6* Storage batteries, including electrolyte levels, used in
connection with Level 1 and Level 2 systems shall be inspected
at intervals of not more than 7 days and shall be maintained in
full compliance with manufacturer’s specifications. Defective
batteries shall be repaired or replaced immediately upon discovery
of defects.
If you do not have your generator set manufacturer's O&M manual, and cannot obtain it from the manufacturer's local office, service representative, factory, or website, you could use the generic recommendations in the NFPA 110 Annex. In that case I suggest you go with the NFPA 110-2010 Annex, since those recommendations are more updated than the 1999 edition. But the first source should always be the generator manufacturer.
There is similar (and some updated) wording in a more recent edition of NFPA 110, but the chapter numbering changed.
From NFPA 110-2010:
Chapter 8 Routine Maintenance and
Operational Testing
8.1* General.
8.1.1 The routine maintenance and operational testing program
shall be based on all of the following:
(1) Manufacturer’s recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.1.2 Consideration shall be given to temporarily providing a
portable or alternate source whenever the emergency generator is out of service.
Finally, don't forget TJC’s latest EC.02.05.01, EP3 and EP4.
Hand Sanitizers near Electrical Outlets and Switches
How far should a Hand Sanitizer dispenser be from electrical outlets and switches?
Wednesday, March 2, 2011
Exit Verbiage
A hospital has a sign posted that says “Not An Exit”, but the standard actually reads that “No Exit” should be posted. Will this be an issue?
Tuesday, March 1, 2011
Monday, February 28, 2011
Cheat Sheets During Surveys
What is TJC's position on staff using written prompts or "cheat sheets" during a survey when responding to surveyor questions about PASS, RACE, and other emergency procedures?
Thursday, February 24, 2011
Friday, February 18, 2011
Generator Weekly Inspection Tip
Here is a quick tip for a useful and proactive task to do during your generator weekly inspections. How often do you see evidence of leakage beneath your generator sets - either fuel oil, lube oil, or cooling water? Make sure to note the presence of that oil, and then clean it up (remove it) so that the slab under the generator set is clean. That way if leakage is observed during future weekly inspections you will know that you have an active leak that must be dealt with proactively to avoid costly future problems and potential generator failures.
SEPSS testing and UPS’s
There is often confusion about whether the EC.02.05.07 EP3 SEPSS testing requirements apply to the ubiquitous hospital UPS’s that are powered by the emergency power “branches” (life safety branch, critical branch, and equipment system.)
The short answer is that a UPS that gets its power from an EPSS (Emergency Power Supply System) is not a SEPSS. Therefore SEPSS testing requirements do not apply to such UPS’s. Be careful though, you still need to maintain and test any of your non-SEPSS UPS’s that are critical for operations during a power failure in accordance with Note 1 of EC.02.05.07, EP3.
The short answer is that a UPS that gets its power from an EPSS (Emergency Power Supply System) is not a SEPSS. Therefore SEPSS testing requirements do not apply to such UPS’s. Be careful though, you still need to maintain and test any of your non-SEPSS UPS’s that are critical for operations during a power failure in accordance with Note 1 of EC.02.05.07, EP3.
Tuesday, February 15, 2011
CMS Occupancy Classifications
Pending CMS Revision to S&C Letter on Occupancy Classifications
On December 17, 2010, CMS issued a Survey and Certification letter updating its occupancy classifications to ensure alignment with the 2000 edition of NFPA 101: Life Safety Code. As a result of the content of this update-S&C 11-05-LSC-ASHE has been receiving numerous telephone calls, e-mails, and traffic on the LISTSERV® about the potential impact this "clarification" could have on our members' clinics and medical office buildings.
On December 17, 2010, CMS issued a Survey and Certification letter updating its occupancy classifications to ensure alignment with the 2000 edition of NFPA 101: Life Safety Code. As a result of the content of this update-S&C 11-05-LSC-ASHE has been receiving numerous telephone calls, e-mails, and traffic on the LISTSERV® about the potential impact this "clarification" could have on our members' clinics and medical office buildings.
Thursday, February 3, 2011
Compliance News: Risk of Suicides in Hospital ER and Inpatient Units
By Dean Samet, CHSP
The Joint Commission issued a Sentinel Event Alert in its warning of the increased number of reported non-psychiatric patients committing suicide in hospital emergency rooms/departments and medical/surgical inpatient units. Suicide has ranked in the top five most frequently reported events to The Joint Commission in the past 15 years and ranks number 11 by the Centers for Disease Control and Prevention (CDC) as a leading cause of death in the nation.
The Joint Commission issued a Sentinel Event Alert in its warning of the increased number of reported non-psychiatric patients committing suicide in hospital emergency rooms/departments and medical/surgical inpatient units. Suicide has ranked in the top five most frequently reported events to The Joint Commission in the past 15 years and ranks number 11 by the Centers for Disease Control and Prevention (CDC) as a leading cause of death in the nation.
Compliance News: Environment of Care Time Notations
By Dean Samet, CHSP
The Joint Commission has a number of time notations designated in the Environment of Care standards’ elements of performance for its expectations when certain inspections, tests, tasks, functions, events, or drills are to occur. TJC recognizes that it will not always be possible to meet the exact time frames cited in their EPs. Therefore, as delineated in the November 2010 Environment of Care News article Time Defined, TJC has provided the following definitions which include some leeway and allowable deviation.
The Joint Commission has a number of time notations designated in the Environment of Care standards’ elements of performance for its expectations when certain inspections, tests, tasks, functions, events, or drills are to occur. TJC recognizes that it will not always be possible to meet the exact time frames cited in their EPs. Therefore, as delineated in the November 2010 Environment of Care News article Time Defined, TJC has provided the following definitions which include some leeway and allowable deviation.
Compliance News: Manufacturer's Maintenance Recommendations - Alternatives Accepted by CMS
By Dean Samet, CHSP
The Joint Commission accredited hospitals, critical access hospitals, and ambulatory care programs can breathe a sigh of relief. As reported in the December 2010 The Joint Commission Perspectives®, TJC engaged the Centers for Medicare & Medicaid Services (CMS) in a collaborative exchange to explain its viewpoint on why it is important to allow health care organizations to continue to employ TJC standards’ three criteria for scheduled maintenance activities for medical equipment and for utility systems.
The criteria consist of manufacturer’s recommendations, risk levels associated with the equipment, as well as hospital experience (see applicable TJC standards and elements of performance below along with yet to be revised CMS Interpretive Guidelines). According to the Perspectives article, CMS agreed!
The Joint Commission accredited hospitals, critical access hospitals, and ambulatory care programs can breathe a sigh of relief. As reported in the December 2010 The Joint Commission Perspectives®, TJC engaged the Centers for Medicare & Medicaid Services (CMS) in a collaborative exchange to explain its viewpoint on why it is important to allow health care organizations to continue to employ TJC standards’ three criteria for scheduled maintenance activities for medical equipment and for utility systems.
The criteria consist of manufacturer’s recommendations, risk levels associated with the equipment, as well as hospital experience (see applicable TJC standards and elements of performance below along with yet to be revised CMS Interpretive Guidelines). According to the Perspectives article, CMS agreed!
Compliance News: TJC News Brief on Shortened Survey Time Frame
By Dean Samet, CHSP
The Joint Commission announced in the November 17, 2010 Joint Commission Online that effective Jan. 1, 2011, full survey time frames will change from 39 to 36 months (see note below) for all accreditation programs (except the laboratory accreditation program). TJC will conduct an organization’s full survey within 36 months instead of 39 months after its previous full survey primarily to maintain consistency in the timing of the survey window with the Centers for Medicare & Medicaid Services (CMS).
Note: Previously, per the 2010 Hospital Accreditation Standards manual, The Accreditation Process chapter, section Duration of Accreditation Award, “An accreditation award is continuous until the organization has its next full survey, which will be between 18-39 months after its previous full survey, unless accreditation is revoked for cause or as otherwise outlined in this chapter.” In the same chapter under the Duration of the Accreditation Decision, “An organization’s previous accreditation decision remains in effect until a decision is made either to accredit or to preliminarily deny accreditation to the organization.”
The Joint Commission announced in the November 17, 2010 Joint Commission Online that effective Jan. 1, 2011, full survey time frames will change from 39 to 36 months (see note below) for all accreditation programs (except the laboratory accreditation program). TJC will conduct an organization’s full survey within 36 months instead of 39 months after its previous full survey primarily to maintain consistency in the timing of the survey window with the Centers for Medicare & Medicaid Services (CMS).
Note: Previously, per the 2010 Hospital Accreditation Standards manual, The Accreditation Process chapter, section Duration of Accreditation Award, “An accreditation award is continuous until the organization has its next full survey, which will be between 18-39 months after its previous full survey, unless accreditation is revoked for cause or as otherwise outlined in this chapter.” In the same chapter under the Duration of the Accreditation Decision, “An organization’s previous accreditation decision remains in effect until a decision is made either to accredit or to preliminarily deny accreditation to the organization.”
Tuesday, February 1, 2011
Current Technologies Are Vastly Different Than The Technologies In Place When Most Mechanical Engineers Started
By J. Patrick Banse, PE, LEED AP, Smith Seckman Reid Inc., Houston
When mechanical engineers are in school, few of them know exactly where their degree might take them. I was one of those engineers. Being exposed to many aspects of this fascinating engineering program, I was awed by the range of career choices—steam and power generation, automotive design, structures. However, only a few courses—thermodynamics, fluid dynamics, and heat transfer—prepared me for the area I ended up in, partially by choice but mostly by having mentors that instilled a passion in me that continues to guide me more than 35 years after graduation. The area of mechanical engineering I ended up in was HVAC, plumbing, and fire protection design in buildings, specifically healthcare, but that was after a few years of preliminaries and, as I found out, nothing like I learned in school.
Read entire article here: Current Technologies Are Vastly Different
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