Damaged Sprinklers

NFPA 101®, Life Safety Code®, 2000 edition mandates in Section 9.7.5 that “All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested and maintained  in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems” [1998 edition]. Section 2-2.1.1 of NFPA 25 states, “Sprinklers shall be inspected from the floor level annually. 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 shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” A damaged sprinkler (pictured) can have a detrimental effect on the performance of sprinklers by affecting water distribution pattern, or rendering the sprinkler ineffectual. In its new Life Safety Chapter (which will take effect January 1, 2009), The Joint Commission has a relative requirement in standard LS.02.01.35, Element of Performance No. 5, which states, “Sprinkler heads are not damaged and are free of corrosion, foreign materials and paint.”

Transformers

What  installation requirements affect transformers in healthcare occupancies?

Privacy Curtain Requirements

What kind of requirements are there for privacy and cubicle curtains?

Eliminating Immediate Threat to Life Situation Time Limit

Is there a time limit to eliminate an “immediate threat to life” situation for all TJC accreditation programs?

ILSMs - Emergency Management

Should emergency management scenarios include ILSM plans?

Sleep Lab

What is the occupancy classification for a sleep lab?

Seismic Design Category C

Does the code say that if you are in a Seismic Design Category C, you have to have 96 hours of fuel supply on site?

Backup Fuel to Hospital Boilers

Does The Joint Commission have a requirement for providing backup fuel to hospital boilers?  (e.g. Natural gas boiler with fuel oil backup.)

USP-NF Chapter 797

We have a Pharmacy area that is not compliant with the Chapter 797 ruling in the mixing room that will be renovated in the next year but not before our survey, is this something that would fall under the EOC Guidelines?  

Post-op Infection Control

Are there any Joint Commission requirements or standards that restrict a surgical scrub technician or circulating nurse from helping with the turnover and cleaning of a surgical room between cases?

Generator testing - dynamic vs. static loads

TJC Standard EC.02.05.07, EP5 requires annual load testing under certain conditions.  Specifically the EP states "The emergency generator [20 to 40 day] tests are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers’ exhaust gas temperature.  If the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07 EP 4 then they must test each emergency generator once every 12 months using supplemental (dynamic or static) loads of: 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours."

Hospitals often want to know what the difference is between dynamic loads and static loads.  Simply put, dynamic loads are the hospital emergency power loads that are connected to the transfer devices - motors, lights, receptacle loads, and the like.  Static loads, on the other hand, are load banks.

NFPA 110 does not use this terminology.  The related paragraph from NFPA 110 only refers to "supplemental loads."

Readers may also want to refer to my separate blog entry discussing the "not less than" terminology found in the latest version of NFPA 110.

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: PFI Extension Requests

By Dean Samet, CHSP

The Joint Commission allows organizations to exceed their electronic Statement of Conditions™ (eSOC) Plan for Improvement (PFI) “projected completion date” by up to six months on previously accepted or original PFIs without any penalty. However, once that PFI has been accepted by TJC, the organization can further request a one-time extension when it appears that they are going to exceed their projected completion date(s).

The following information is required to be provided:

• Original and proposed projected completion date(s)
• Brief description of the deficiency or deficiencies
• Reason(s) for the extension request
• Confirmation that the extended PFI will be given a high priority for completion

Compliance News: Continuous TJC Compliance - An Uphill Battle

By Dean Samet, CHSP





Continuous compliance with The Joint Commission standards helps accredited organizations maintain safe and functional environments for patients, visitors and staff and maintain/improve safe, quality patient care.

What are the possible ramifications of not being continuously prepared and ready for survey, and what difficulties lay therein?

1. Loss of accreditation resulting in loss of deemed status
2. Loss of Medicare reimbursements due to loss of accreditation
3. Potential reduction in staff, services, quality of patient care, and a less safe environment due to loss of Medicare reimbursements
4. Cessation of services or possible closure of hospital due to loss of Medicare reimbursements

Compliance News: CMS Life Safety Code® Waivers

By Dean Samet, CHSP






There are times when certain provisions of the NFPA 101® Life Safety Code® might not be met. The Centers for Medicare & Medicaid Services has a “waiver” process per 42 CFR 483.70(a) (2) specifying that a waiver may be granted where it would not adversely affect resident health and safety (while a reasonable degree of fire safety is being provided) and it would impose an “unreasonable hardship” on the facility to meet specific LSC provisions. When it is not readily practical for a health care facility to comply fully with all of the specific requirements of the LSC, the fire authorities having jurisdiction (AHJs) may evaluate the degree of enforcement necessary to provide a reasonable measure of safety and an equivalent degree of protection.

The NFPA 101 is the code for safety to life from fire in buildings and structures. The basic requirement for facilities participating in the Medicare and Medicaid programs is compliance with the 2000 edition of the LSC. This edition is also referenced by the various hospital-accrediting bodies granted deeming authority and recognized by CMS such as The Joint Commission (TJC), American Osteopathic Association (AOA), and Det Norske Veritas Healthcare (DNVHC), as well as many local and state fire marshals across the country.

Generator Testing

If during the monthly emergency generator test a critical procedure interrupts the testing of the automatic transfer switches and some of them do not get tested at that time, must the untested switches be tested prior to the next scheduled monthly generator test?