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.