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.

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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: