Jan 30 2018

Category: Blogcreekside @ 10:21 am
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May 22 2018

Hospital-Grade Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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Q: All of our receptacles in patient care rooms are hospital grade and therefore do not have to be tested annually, correct? What I don’t understand is section 6.3.4.1.2 of NFPA 99-2012, which states additional testing of hospital-grade receptacles in patient rooms shall be performed at intervals defined by document performance data. What is document performance data? How do I determine my testing intervals by document performance data?

A: You are correct: Hospital-grade receptacles are not required to be tested annually, but they are required to be tested at intervals determined by the healthcare facility. This is what the NFPA 99-2012 Handbook says about maintenance and testing of electrical receptacles under section 6.3.4.1 of NFPA 99-2012:

NFPA 99 prescribes no time between test intervals for hospital-grade receptacles. Hospital facility managers are permitted to determine appropriate test intervals for hospital-grade receptacles based on ‘documented performance data’. However, this paragraph requires that all non-hospital-grade receptacles within patient bed locations and anesthetizing locations must be tested at least every 12-months. This immediately raises the following question” “What is documented performance data?” There are two possible kinds of data that could meet this requirement. First, the manufacturer could provide data of this sort. Second, experiential data from other hospitals that have used similar devices and documented their failure rates could provide the kind of indication needed for appropriate testing intervals.

So, section 6.3.4.1.2 of NFPA 99-2012 does say additional testing of hospital-grade receptacles in patient care rooms shall be performed at intervals defined by the hospital using information that provides evidence that supports the testing interval decision. This information may come from the manufacturer, or it may come from your own experiences in testing these receptacles. According to NFPA 99-2012, you do not have to test hospital-grade receptacles annually that are located in patient rooms and anesthetizing locations, but you do have to determine what the testing frequency of these receptacles will be based ‘documented performance data’.

The testing requirements that you will need to do is found in NFPA 99-2012, section 6.3.3.2, and is summarized here:

  • The physical integrity of each receptacle shall be confirmed by visual inspection
  • The continuity of the grounding circuit in each electrical receptacle shall be verified
  • The correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed
  • The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less that 4 oz (115 g).

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May 21 2018

Fire Damper Testing Frequency for LTC Facilities

Category: BlogBKeyes @ 12:00 am
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Q: I work in a long-term care facility. It used to be that fire dampers had to be tested/inspected every four years, but I’ve heard that has changed with the new 2012 LSC. Now fire dampers are only required to be tested/inspected once every 6 years. I am perplexed because I cannot seem to locate where in the LSC it is written. Can you please tell me where it is written that we can now test fire dampers once every 6 years?

A: You seem to have it backwards. Section 8.3.3.1 of the 2012 Life Safety Code requires compliance with NFPA 80 for all openings (i.e. doors, ductwork, windows, etc.) in fire-rated barriers. Section 19.4.1.1 of NFPA 80-2010 says fire dampers in hospitals are required to be tested and inspected every 6 years; for all other facilities the test and inspection frequency is every 4 years.

Since Long-Term Care facilities are not hospitals, you would be required to test and inspect your fire dampers once every 4 years. The same holds true for smoke dampers.

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May 18 2018

Fire Alarm System Communication

Category: BlogBKeyes @ 12:00 am
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The answer to this question was provided by my good friend Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL

Q: With the impending discontinuation of the hard copper (POTS) phone lines, and in fact many municipalities already no longer have hard copper pairs from end user to the Central Office, are we, or will we be, in violation of the NFPA code for the primary DACT connection to the CO? Our fire alarm system company is telling us we must upgrade to another form of communication; however we have an IP based phone system in all buildings and the fire alarm company documentation indicates that IP based technology is acceptable, can I simply designate two analog phone lines from our system to the DACT, eliminating the POTS connection?

A: Per NFPA 72 (2010) Chap. 26.6.3.2, Patrick would be code compliant if he continues to use phone lines for a central station connection.  However, if the vendor is saying he must upgrade, it sounds like they’re discontinuing DACT monitoring.  He should verify that with the vendor.  Most central stations have DACT, radio and cellular receivers, but some are discontinuing DACT receiving for the reasons Patrick stated.  If he’s connected to a central station that’s dropping it, he may be able to find a new central station that still has it.  If he’s directly connected to a fire department that’s dropping it, he can see if he’s allowed to use a central station for monitoring.  If they’re not dropping DACT monitoring, he can ride that horse until discontinued by the monitoring agency or the lines die, but I’d advise setting up a new method so he can control the costs before it becomes an emergency.

Switching to IP based phone lines would still use the existing DACT transmitter, but without getting too technical, it comes with a couple of conditions:

  1. There has to be a dial tone on the IP phone lines when the receiver is picked up (loop started).  If you have to dial a number to get a dial tone (ground started), you can’t use it.
  2. The DACT communication out of the fire panel must now be converted into IP packets at the source, then reassembled into digital signals at the receiver.  That means the central station must have an IP converter & the end user must install an IP converter that matches it.
  3. The power for the phone system must be backed up by the emergency generator.

Obviously, bullet #2 is where the costs comes in & it won’t be cheap.  It may seem like it shouldn’t be a big deal, but changing communication methods always involves new equipment.  The costs & legwork involved in staying with phone lines may be more than installing the upgrade, which is probably a radio.

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May 17 2018

Strange Observations – Part 26

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things that I have seen while consulting at hospitals…

Ah.. Portable electric heaters. A problem for nearly every hospital.

Staff gets cold and Facilities Management cannot adjust the HVAC system to keep everyone happy. So portable electric heaters brought from home start showing up.

You need to do frequent rounding of suspicious trouble spots (you know where they are) to make sure staff does not bring in portable heaters.


May 16 2018

Generator Fuel Testing

Category: BlogBKeyes @ 12:00 am
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Q: What are the guidelines on the diesel fuel test for the generator as far as having it treated or a sample sent off for testing?

A: The new 2012 Life Safety Code references the 2010 edition of NFPA 110, the standard for emergency and standby power systems. Section 8.3.8 of the NFPA 110-2010 requires the fuel for the generators to be tested annually for quality. According to more recent editions of NFPA 110, this test is to be conducted in accordance with ASTM D975, Standard Specification for Diesel Fuel Oils. You may purchase a copy of the standard direct for the ASTM website https://www.astm.org/Standards/D975.htm

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May 15 2018

Response to a Recent Post

Category: BlogBKeyes @ 12:00 am
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The following is a response I received from a reader after my posting on April 3, 2018 titled Lawmakers Want More Oversight on AOs. This reader put into words the feelings and emotions of hundreds (if not thousands) of concerned healthcare workers on the subject of over-regulation by the government.

Today’s message makes retirement look sweeter and sweeter. I love my job and for 35 years I have loved taking care of patients and staff from the Plant Ops seat. The last 5-10 years has been harder as the Code enforcement has gotten pickier and more involved in minutia. Your posting today is a virtual death knoll for attracting good qualified younger engineers and mechanics into our business, why would someone want to come into an industry where common sense is treated with absolute disrespect? We’ve taken smoking out of buildings, sprinkled most everything, you can’t find hospital fires in the literature yet we still treat +1/8″ gaps as death traps. Sprinkler piping is designed to support weight well in excess of the piping and water yet one cable on a pipe is a finding? The 1/4″ extra distance on the projection will result in more money being spent with no added value. Even your recent post about data closets and gaps around the conduit through the ceiling tile stretches the imagination about how much smoke or heat will bypass a detector or sprinkler head.

 I looked at the ASHE agenda for Seattle and I didn’t see anything there where we as a group are ready to say either “I’m mad as hell and I’m not going to take it anymore” or “Calling BS” on this. Thanks for the opportunity to rant, this is the most discouraged that I have ever been about what we do.

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May 14 2018

Fire Drills in a Hospital

Category: BlogBKeyes @ 12:00 am
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Q: I work in a hospital. When we conduct our routine scheduled fire drills are we required to actually activate the fire alarm pull station, horns or strobes? Are we required, during a fire drill, to check that a signal was sent from our facility to the fire department/alarm company? This could be problematic as horns and strobes are very disruptive. We test these functions during the alarm testing but we have not been activating the alarms during fire drills. Should our procedures be changed?

A: Yes… All of the occupant notification devices (i.e. horns, chimes, strobes, bells, whistle, etc.) MUST be activated during all fire drills, with the exception of those drills conducted during the hours from 9:00 pm to 6:00 am. During the evening hours, a coded announcement may be used in lieu of activating the audible devices. Section 19.7.1.4 of the 2012 LSC is very clear… Fire drills in healthcare occupancies must include the transmission of a fire alarm signal and simulation of emergency fire conditions. Section 19.7.1.6 continues to say fire drills must be conducted quarterly on every shift to familiarize staff with the signals and emergency action required under varied conditions.

The purpose of a fire drill is multi-fold:

  • For staff to become familiar with the emergency process
  • To evaluate the staff’s response to the fire alarm signal
  • To evaluate the building’s response to the fire alarm signal
  • To evaluate the fire alarm system’s response

Section 19.7.1.2 says all employees must be periodically instructed and kept informed with respect to their duties under the fire response plan. This is accomplished by conducting fire drills, and then having trained observers in certain locations of the hospital to evaluate the staff’s response.

Some accreditation organizations have specific standards that requires all staff to participate in every drill in accordance with the hospital’s fire safety plan. This means if the fire alarm is initiated on the 4th floor, what do you expect staff to do on the 1st floor? Basically, they need to close their doors and be prepared to receive evacuated patients from the 4th floor. How do you know if the staff did this on the 1st floor if you don’t have observers watching for it?

Yes… horns and strobes can be disruptive… That’s the whole idea of a fire alarm notification system: To disrupt the normal activity and alert everyone that there is a fire emergency. Routine fire drills should be anything but routine. Every hospital should take fires seriously and be prepared for the unfortunate event should it ever occur. Therefore, fire drills are the utmost importance, and everyone (as much as practical) should participate in each drill. Don’t forget that one of the purposes of the fire drill is to educate staff on the emergency process. That is why the Life Safety Code requires so many each year.

No… there is no requirement to ensure the fire alarm signal is received at the local fire department for each fire drill.

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May 11 2018

Electrical Room Storage

Category: BlogBKeyes @ 12:00 am
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Q: Are ladders allowed to be stored in electrical closets as long as the egress path is maintained and the 3ft clearance is applied? We had an inspector site 1910.303(g)(1)(ii) “Working space required by this standard may not be used for storage.” I referenced NFPA 70-2011 section 110.26 regarding the clearance which permits ladder storage but the surveyor ignored it. All our rooms are sprinklered and 1-hour fire rated.

A: The most restrictive requirement applies… You are correct that NFPA would permit storage of ladders in the electrical closet provided clearance to all electrical equipment is maintained. But this particular surveyor knew the OSHA requirements, and section 1910.303(g)(1)(ii) does prohibit storage in the electrical room.

It’s frustrating when you work hard to be in compliance with all NFPA codes and standards just to find out you are out of compliance with OSHA. If this was a CMS state agency survey or an accreditation survey, then I would say this finding is legitimate because 4.6.1.2 of the 2012 LSC says any requirements that are essential for the safety of the building occupants and that are not specifically provided for in this LSC, shall be determined by the AHJ. The surveyor, who is the AHJ, apparently did determined that the OSHA standard 1910.303(g)(1)(ii) is essential for your safety, and therefore it applies.

I guess you will have to deal with it and find a new home for ladders. Also, better post signs inside your electrical room advising everyone to not store anything in the room.

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NOTE: Since this article was posted, I have received numerous comments from people much smarter than I on OSHA requirements, stating they believe the surveyor was incorrect in his citation. According to the readers, OSHA says if the ladder is not in the working space then they think that it should be permitted.

Please use your own best judgement when considering any changes to storage in electrical rooms.

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May 10 2018

Strange Observations – Part 25

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things that I have seen while consulting at hospitals…

I guess I like my smoke detectors mounted tight to the ceiling….


May 09 2018

Bio-Hazard Waste Holding Room

Category: BlogBKeyes @ 12:00 am
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Q: Our facility has a soiled utility room near the main laundry that also holds bagged, sealed, boxed, then sealed again bio-hazardous wasted awaiting removal by the contractor. Is this room required to have a dedicated air exhaust ventilation system to the outside of the building?

A: Yes… I believe it is required to have a dedicated air exhaust system to the outdoors. This is a requirement based on multiple entities. According to the FGI Guidelines, a soiled holing room is required to have the following:

  • Negative air pressure
  • 2 ACH minimum for outside air
  • 10 ACH minimum total
  • Room must exhaust directly to outdoors
  • No room unit ventilator air recirculation

In addition, according to the OSHA Bloodborne Pathogen standard 1910.1030(e)(4), if the storage area is also a HIV and HBV production area, then the room is required to have a dedicated exhaust system. So, it appears to me that the room is required to have a system that exhausts the air directly to the outdoors.

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