By Robert Trotter, CBO, CFM
According to the 2000 edition of NFPA 101®, Life Safety Code®, “Experience indicates that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving towards exits that they can see…” However, the stoppage of egress travel such as an exit door locked with a padlock (as shown on a marked exit door in an industrial occupancy of a hospital) is potentially conducive to panic. Healthcare occupancies as well as business, industrial and storage occupancies are required to comply with the means of egress provisions for locks, latches and alarm devices for doors. Section 7.2.1.5.1 of the Life Safety Code® states, “Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.” It is also important that locks, if provided, “shall not require the use of a key, tool, or special knowledge or effort from the egress side.”
Saturday, May 29, 2010
Compliance News: Labeling Utility System Controls
By Robert Trotter, CBO, CFM
Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”
While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”
Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”
While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”
Compliance News: NFPA® Codes Available On-Line (Free)
By Pete Kendrick, CHFM, CPMM
Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.
First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”
Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.
First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”
Compliance News: Damaged Sprinkler Heads
By Robert Trotter, CBO, CFM
Damaged sprinkler heads 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. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.
Damaged sprinkler heads 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. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.
Compliance News: Electrical Arc Flash Safety: Why is it important?
By David Stymiest, PE, FASHE, CHFM, GBE
With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.
According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.
With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.
According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.
Compliance News: Measures of Success and Scoring Category Changes
By Dean Samet, CHSP
According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.
Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.
According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.
Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.
Saturday, May 1, 2010
Opening Day: Transitioning from Construction to Survey-Ready Operation
By David l. Stymiest, P.E., FASHE, CHFM (in Health Facilities Management)
Construction project turnover time is hectic. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and survey-ready compliance at occupancy can put a hospital at risk during an early survey.
Challenges and Limitations
There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.
Challenges and Limitations
There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.
Read entire article here: Opening Day
Monday, March 29, 2010
Compliance News: Minimum Clear Width for Doors
By Robert Trotter, CBO, CFM
Egress doors in existing healthcare occupancies should comply with the 2000 edition of NFPA 101®, Life Safety Code® section 19.2.3.5 which states, “The minimum clear width for doors in the means of egress from hospitals; nursing homes; limited care facilities; psychiatric hospital sleeping rooms; and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. wide.” There is an exception for existing 34-inch doors, and existing 28-inch corridor doors in facilities where the fire plans do not require evacuation by bed, gurney, or wheelchair. Excluding any of the four exceptions, egress doors in new healthcare occupancies must meet the requirements prescribed in 18.2.3.5. The minimum clear width for doors in the means of egress from sleeping rooms, diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, and nursery rooms in hospitals and nursing homes is 41.5 inches and 32 inches in psychiatric hospitals and limited care facilities.
Egress doors in existing healthcare occupancies should comply with the 2000 edition of NFPA 101®, Life Safety Code® section 19.2.3.5 which states, “The minimum clear width for doors in the means of egress from hospitals; nursing homes; limited care facilities; psychiatric hospital sleeping rooms; and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. wide.” There is an exception for existing 34-inch doors, and existing 28-inch corridor doors in facilities where the fire plans do not require evacuation by bed, gurney, or wheelchair. Excluding any of the four exceptions, egress doors in new healthcare occupancies must meet the requirements prescribed in 18.2.3.5. The minimum clear width for doors in the means of egress from sleeping rooms, diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, and nursery rooms in hospitals and nursing homes is 41.5 inches and 32 inches in psychiatric hospitals and limited care facilities.
Compliance News: Access to Electrical Switchboards
By Robert Trotter, CBO, CFM
Electrical wiring and equipment are required by NFPA 101®, Life Safety Code® to be in accordance with the 1999 edition of NFPA 70, National Electrical Code. While there are specific requirements for access to electrical switchboards, here is an overview of the requirements. Sufficient access and working space should be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The depth of the working space in the direction of access to live parts should not be less than 36 inches and the width of the working space in front of the electric equipment should be the width of the equipment or 30 inches, whichever is greater. The work space should be clear and extend from the grade, floor, or platform to the minimum height of six and one-half feet. The working space required by the NEC is not permitted to be used for storage (as pictured).
Electrical wiring and equipment are required by NFPA 101®, Life Safety Code® to be in accordance with the 1999 edition of NFPA 70, National Electrical Code. While there are specific requirements for access to electrical switchboards, here is an overview of the requirements. Sufficient access and working space should be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The depth of the working space in the direction of access to live parts should not be less than 36 inches and the width of the working space in front of the electric equipment should be the width of the equipment or 30 inches, whichever is greater. The work space should be clear and extend from the grade, floor, or platform to the minimum height of six and one-half feet. The working space required by the NEC is not permitted to be used for storage (as pictured).
Compliance News: Smoke Alarms in Doctors’ Sleeping Rooms
By Pete Kendrick, CHFM, CPMM
As part of the preparations for your next The Joint Commission survey, you may have decided to claim several occupancy classifications in accordance with NFPA 101® (2000 Edition) Sections 18/19.1.1.1.4 which state in part that, in the opinion of the governing body of the facility and the agency having jurisdiction, if patients or visitors are capable of self-preservation, sections of the building can comply with other occupancy chapters. Besides ambulatory, business, and assembly, what other occupancies need to be considered?
If you have doctors’ sleeping rooms, do you know if they are equipped with approved single-station smoke alarms? Such rooms are required to meet a small section of some other chapters you possibly aren’t familiar with. Open your NFPA 101® to Chapter 26, Lodging and Rooming Houses. You may not know it but you might actually be the proprietor of a rooming house. Look at 26.1.1.1, which states that, “This chapter applies to buildings that provide sleeping accommodations for a total of 16 or fewer persons on either a transient or permanent basis, with or without meals, but with separate cooking facilities for individual occupants…” Does this apply to your doctors’ sleeping rooms? Probably.
As part of the preparations for your next The Joint Commission survey, you may have decided to claim several occupancy classifications in accordance with NFPA 101® (2000 Edition) Sections 18/19.1.1.1.4 which state in part that, in the opinion of the governing body of the facility and the agency having jurisdiction, if patients or visitors are capable of self-preservation, sections of the building can comply with other occupancy chapters. Besides ambulatory, business, and assembly, what other occupancies need to be considered?
If you have doctors’ sleeping rooms, do you know if they are equipped with approved single-station smoke alarms? Such rooms are required to meet a small section of some other chapters you possibly aren’t familiar with. Open your NFPA 101® to Chapter 26, Lodging and Rooming Houses. You may not know it but you might actually be the proprietor of a rooming house. Look at 26.1.1.1, which states that, “This chapter applies to buildings that provide sleeping accommodations for a total of 16 or fewer persons on either a transient or permanent basis, with or without meals, but with separate cooking facilities for individual occupants…” Does this apply to your doctors’ sleeping rooms? Probably.
Compliance News: Maintaining Smoke Barriers
By Dean Samet, CHSP
Smoke barriers serve a very important purpose, especially in healthcare occupancies. During a fire, protection of patients and staff is of paramount concern. If possible, patients intimate with the fire should be moved to safety immediately. For others, “defending patients in place” is often the first step in a number of actions established to keep patients out of harm’s way from a fire and the products of combustion. If and when it is determined that patients must be evacuated to an area of safe refuge, it is typically horizontally, on the same floor level, through smoke barriers to an adjacent smoke compartment. If the fire escalates, patients may have to be relocated from that smoke compartment or floor and moved vertically via stairs or elevators (if possible and permitted).
Smoke barriers serve a very important purpose, especially in healthcare occupancies. During a fire, protection of patients and staff is of paramount concern. If possible, patients intimate with the fire should be moved to safety immediately. For others, “defending patients in place” is often the first step in a number of actions established to keep patients out of harm’s way from a fire and the products of combustion. If and when it is determined that patients must be evacuated to an area of safe refuge, it is typically horizontally, on the same floor level, through smoke barriers to an adjacent smoke compartment. If the fire escalates, patients may have to be relocated from that smoke compartment or floor and moved vertically via stairs or elevators (if possible and permitted).
Compliance News: Det Norske Veritas Healthcare (DNVHC) Hospital Accreditation
By Dean Samet, CHSP
Effective September 26, 2008, the Centers for Medicare & Medicaid Services (CMS) announced their decision to approve Det Norske Veritas Healthcare, Inc. (DNVHC) for recognition as a national accreditation organization for hospitals seeking to participate in the Medicare or Medicaid programs. This has provided another alternative for roughly 80% or more of the country’s hospitals that have looked primarily to The Joint Commission (TJC) for their hospital accreditation for over 50 years.
Accreditation by an accreditation organization is voluntary and is not required for Medicareparticipation. A hospital may opt for routine surveys by a state survey agency to determine whether it meets the Medicare requirements.
Effective September 26, 2008, the Centers for Medicare & Medicaid Services (CMS) announced their decision to approve Det Norske Veritas Healthcare, Inc. (DNVHC) for recognition as a national accreditation organization for hospitals seeking to participate in the Medicare or Medicaid programs. This has provided another alternative for roughly 80% or more of the country’s hospitals that have looked primarily to The Joint Commission (TJC) for their hospital accreditation for over 50 years.
Accreditation by an accreditation organization is voluntary and is not required for Medicareparticipation. A hospital may opt for routine surveys by a state survey agency to determine whether it meets the Medicare requirements.
Friday, January 29, 2010
Compliance News: Supervision of Fire Sprinkler Control Valves
By Robert Trotter, CBO, CFM
Fire sprinkler valves controlling connections to water supplies and to supply pipes to sprinklers in new and existing health care occupancies are required by NFPA 101®, Life Safety Code® to be electrically supervised. Any valve that controls automatic sprinklers in the entire building or portions of the building, sectional and floor control valves, OS&Y valves (as pictured) located within the building or building exterior, and post indicating valves located outside on the property are included in the requirement. Electrically supervised means supervisory signals must sound and be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility to indicate a condition that would impair the satisfactory operation of the sprinkler system. A chain and/or padlock are not acceptable means of valve supervision. The Joint Commission verifies these requirements through the 2010 Hospital Accreditation Standards for Life Safety. LS.02.01.35 Element of Performance 5 states, “The fire alarm system monitors approved automatic sprinkler system components.”
Compliance News: Stairway Doors Held Open
By Robert Trotter, CBO, CFM
Stairway doors are an integral part of the egress system and they protect openings of vertical enclosures. The Joint Commission mandates specific requirements when stairway doors are held open (as pictured). In accordance with the 2010 Hospital Accreditation Standards for Life Safety, hospitals must maintain the integrity of the means of egress.
Regarding health care occupancies, LS.02.01.20 Element of Performance number 9 states, “When stairway doors are held and the sprinkler or fire alarms system activates the release of one door in a stairway, all doors serving that stairway close.” This requirement is also found in the 2000 edition of NFPA 101®, Life Safety Code® 18/19.2.2.2.7.
Likewise for ambulatory health care occupancies LS.03.01.20 Element of Performance number 5 states, “When stairway doors are held and the sprinkler or fire alarms system activates the release of one door in a stairway, all doors serving that stairway close.” This requirement is also found in the 2000 edition of NFPA 101®, Life Safety Code® 20/21.2.2.4.
Compliance News: Emergency Instructions for Occupants
By Robert Trotter, CBO, CFM
Most people are familiar with evacuation plans and fire safety information located on hotel room doors. This information is not required in hospitals under normal conditions; however, they must protect occupants during periods when NFPA 101®, Life Safety Code® is not met or during periods of construction. One of the administrative activities prescribed for Interim Life Safety Measures as required by the 2010 Hospital Accreditation Standards for Life Safety is LS.01.02.01 which states, “The hospital posts signage identifying the location of alternate exits to everyone affected.”
While there are no prescriptive requirements for the arrangement or information provided on the signs, here are a few suggestions to consider:
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