Jun 04 2018

Addressable Fire Alarm Systems?

Category: BlogBKeyes @ 12:00 am
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Q: Are you aware of any accrediting organization requiring the hospital to have an addressable fire alarm system installed? If so, what organizations? Please explain the rationale and any supporting code behind this decision. Background: A hospital currently has a fully functional zone fire alarm system installed but heard that accrediting organizations are requiring addressable systems. In my review of NFPA 101 2012, I cannot find anything in chapters 18 or 19 that would differ from the 9.6 reference to NFPA 72 2010.

A: There is no NFPA Life Safety Code requirement for you to have an addressable fire alarm system. There is a requirement that the hospital have a fire alarm system that meets the requirements of 19.3.4 of the 2012 LSC, but that does not include being an addressable system. As far as I know, Joint Commission, HFAP, and DNV do not require an addressable fire alarm system, and CMS does not require an addressable fire alarm system.

Now, a state or local law may exceed the NFPA minimum and require an addressable fire alarm system, but you would have to check with your state and local authorities to find that out.

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Jun 01 2018

NFPA 99 Signs on Doors to Central Supply Systems

Category: BlogBKeyes @ 12:00 am
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Q: According to Joint Commission standard EC.02.05.09 EP4 it is requiring this sign:
“Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” They are referencing NFPA 99 2012-5.1.3.1.1–5.1.3.1.7. Am I understanding correctly that if I have Oxygen, Medical Gas and Nitrous in the Medical Gas Storage Room that this is the correct sign I need?

A: I think you have this twisted a bit. Joint Commission’s standard EC.02.05.09, EP 4 (2018 CAMH) does not reference NFPA 99-2012 5.1.3.1.1 to 5.1.3.1.7. The EP 3 (located above EP 4) does, but EP 4 does not reference any NFPA standard or sub-section of NFPA 99.

So… where did Joint Commission get the information for EP 4? From NFPA 99-2012, section 5.1.3.1.8. But according to NFPA 99-2012, 5.1.3.1, sub-section 5.1.3.1.8 applies only to Central Supply Systems. This sign that 5.1.3.1.8 requires (Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening) is only required for Central Supply Systems, such as gas manifold rooms. It is not required on doors to storage rooms on units that contain less than 3,000 cubic feet of oxidizing gases.

Also, NFPA 99-2012, section 5.1.3.1.9 says locations containing Central Supply Systems or cylinders containing only oxygen or medical air shall have their doors labeled: “Medical Gases: NO Smoking or Open Flame”. Since this is a sub-section of 5.1.3.1, this requirement still only applies to Central Supply System locations, such as gas manifold rooms.

But the way Joint Commission’s EC.02.05.09, EP 4 is written, it does not really limit the signs to just Central Supply Systems….

My advice is to contact the accreditor for clarification.

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May 31 2018

Strange Observations – Part 28

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

Dead-bolt locks… Up until the 2012 edition of the Life Safety Code, dead-bolt locks were not permitted on doors in the path of egress in healthcare occupancies.

The reason why is, it would take two actions to operate the door and the LSC does not allow that.

But the new 2012 edition of the LSC changed that a bit and permits existing dead-bolt locks to remain in service as long as the door does not serve more than 3 occupants.


May 30 2018

Generator Testing

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Q: Does our hospital have to test the generator for 30 minutes every week, and then 1-hour once a month? We have programmed our generators to operate every Wednesday at 12 noon and run for 30 minutes. We do ATS test once a month and record information when running.

A: According to section 9.1.3.1 of the 2012 Life Safety Code, emergency power generators must be tested in accordance with NFPA 110. Section 8.1.1 of NFPA 110-2010 says the routine testing of the emergency power generators must be based on all of the following:

  • Manufacturer’s recommendations
  • Instruction manuals
  • The requirements of NFPA 110
  • The AHJ’s requirements

While NFPA 110 does not have any requirements to operate the generator on a weekly basis, there may be manufacturer requirements or AHJ requirements that do. Section 8.4.1 of NFPA 110-2010 specifically says generators must be inspected weekly but operated under load on a monthly basis. Section 8.4.2 requires the monthly load test to operate for 30 minutes. I suggest you check with your generator manufacturer and your state and local AHJs to see if they have specific weekly run-tests of the generator.

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May 29 2018

Off-Site Monitoring Station for Fire Alarm Systems

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Q: I can’t seem to find anything in NFPA 72-2010 that says a facility is required to transmit a fire alarm signal to an off-site supervisory station. Our health care facility currently does not contract with an off-site station, and our procedure is to contact the fire department directly by phone when an alarm is received. Can you comment and provide some insight on this please?

A: Wait… what? This does not sound very good… What kind of healthcare facility are you? A hospital? An Ambulatory Surgical Center? According to the 2012 LSC, section 19.3.4.3.2.1 for hospitals, and section 21.3.4.3.2.1 for ASC, you need to comply with section 9.6.4 in regards to fire department notification. Section 9.6.4.2 requires that you communicate the fire alarm signal to the local fire department in one of the following methods:

  • Auxiliary fire alarm system
  • Central station fire alarm system
  • Proprietary supervising station fire alarm system
  • Remote supervising station fire alarm system

What you described is a manual transmitting system, which is not permitted for hospitals or ASCs. What I’ve observed most hospitals use is the Central Station Fire Alarm System which uses a modem to communicate to a central monitoring station that automatically relays any fire alarm signals to the local fire department. What you have described is a serious violation and one that CMS would consider to be a trigger for an Immediate Jeopardy decision. I suggest you get this resolved ASAP.

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May 28 2018

Door to Compressed Gas Storage Rooms

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Q: I have an oxygen/med gas storage room that is attached to the hospital, and can only gain access to the room by way of the exterior of building. Does the room have to have a fire-rated door assembly?

A: Well… that depends. If the storage room contains 3,000 cubic feet or more of compressed medical gases, and the room is located indoors, then the room must be constructed with 1-hour fire-rated construction and the door to the room is required to be 1-hour fire rated if new construction, and 3/4-hour rated if existing conditions. (See 5.1.3.3.2(4) of NFPA 99-2012).

However, the intent of 5.1.3.3.2 is to separate the compressed gas storage room from the rest of the facility by requiring 1-hour fire rated barriers, and if the door opening to the storage room opens into the facility, one could easily understand why a fire-rated door is required. However, if the door to the storage room opens to the outdoors (i.e. receiving dock) then one could make a point that the door is not required to be fire-rated, because there is no separation between the storage room and the rest of the facility at that point.

But the problem is, NFPA 99-2012 section 5.1.3.3.2 does not say that and does not appear to have any exception for a door to the storage room that opens to the outdoors. I think a rational, smart, understanding surveyor would agree with that point and not cite you for not having a fire-rated door that opens to the outdoors.

But will you always have a rational, smart, and understanding surveyor?

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May 25 2018

NFPA 99 Risk Assessment – PLEASE READ THIS

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Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a room-by-room perspective, and he provided me a form from ASHE that lists this assessment by room-by-room. Is this true…? Do I have to do this assessment for each room?

A: No… that’s not correct. Yes, ASHE does have a form that does imply a room-by-room assessment is needed for the Chapter 4 risk assessment, but that’s not required by Chapter 4. What is required is an assessment of building systems based on a defined risk assessment procedure. Chapter 4 does not define the risk assessment procedure that you should use, but the Annex section does identify three risk assessments that they suggest, and the ASHE room-by-room assessment form is not included in these three suggestions. To be sure, you may use the ASHE form if you wish, but then you can use any risk assessment form that you want.

The core of the risk assessment is to determine what level or category the following building systems falls under, in the event of a total catastrophic failure of that system:

  • Gas & Vacuum Systems
  • Electrical Systems
  • HVAC Systems
  • Electrical Equipment
  • Gas Equipment

There are 4 levels or categories:

  • Category 1:    Systems in which failure is likely to cause major injury or death of patients or staff
  • Category 2:    Systems in which failure is likely to cause minor injury to patients or staff
  • Category 3:    Systems in which failure is not likely to cause injury to patients or staff
  • Category 4:    Systems in which failure would have no impact on patient care or staff

The process in the assessment is to determine the level of risk to the patient or staff if there is a catastrophic failure of that particular system. Another way of saying this is “Worst case scenario”.

As an example, let’s take the hospital’s electrical system: The risk assessment must assume a catastrophic failure of the entire system. The normal power system fails, and then the emergency power system from the generators fail. In other words, you have no power whatsoever in the building. Now, what is the level of risk to your patients? It will probably be Category 1, right?

You then do that type of catastrophic failure risk assessment for each of the above listed systems. If you want, you can break this down into different assessments of systems that are the same type. Such as HVAC systems: If the HVAC system fails in patient care areas, then that would be a certain high-level of risk to the patients. But if the HVAC system fails in the Administration wing, it would not be a risk to your patients, and it would be a low risk to your staff.

For hospitals, the expectation would be all of the above systems would be assessed as a Category 1 or Category 2. But for a medical building that only has physician offices and administrative support areas, the expectation is the above systems would be assessed as a Category 3 or Category 4. All healthcare facilities must be assessed for the risk level to patients and/or staff.

You have to document your assessment using a defined process. You can down-load a simple one-page risk assessment from my website and see if that meets your expectations.

The ironic thing is, the NFPA 99-2012 Technical Committee on Chapter 4 did not intend for this risk assessment to be conducted on existing systems. I talked with two members of that committee and they said the committee believed it was obvious the way it is written that this risk assessment is only required for new construction, since most (not all) of NFPA 99 is for new construction.

But CMS did not get that message and they require all of their state agencies and accreditation organizations to evaluate the risk assessment during all surveys. In other words; They fully expect all CMS certified healthcare organizations to have the Chapter 4 risk assessments completed by now.

In my opinion, this risk assessment does not require a lot of time to conduct. As I said, CMS expects all hospitals to have Category 1 or Category 2 systems. This is something you and your staff can do.

Just last week I received a call from a friend of mine who is a facility manager in the Midwest. He returned from a regional ASHE meeting where one of his fellow facility managers was recently surveyed by a leading accreditation organization (AO). The surveyor for the AO cited them for not doing their NFPA 99 risk assessment in accordance with the ASHE form, and do a room-by-room assessment. Please understand that this surveyor was incorrect to make that citation.

There is no NFPA requirement, no CMS requirement, and no AO requirement for healthcare organizations to do a room-by-room assessment to be in compliance with Chapter 4 of NFPA 99-2012. As mentioned above, you can use whatever risk assessment format you wish. The only requirement is the risk assessment must be documented and the surveyors will expect it to be reasonable (meaning all systems in a hospital are Category 1 or Category 2 systems).

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May 24 2018

Strange Observations – Part 27

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

Older mechanical equipment rooms are going to be a problem for many hospitals. Ultimately, you will find an air-handler or an exhaust fan that has its belt guard missing.

Now, I believe OSHA allows a no-belt guard for equipment that is up off of floor by a certain amount… don’t know how much.

Time to replace the belt, eh?

 


May 23 2018

Receptacle Testing

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Q: What are the requirements for receptacle testing for hospital grade receptacles for existing and new health care facility?

A: Section 6.3.4.1.3 of NFPA 99-2012 addresses this issue by saying receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, must be tested at intervals not exceeding 12 months.

However, as mentioned in yesterday’s posting, section 6.3.4.1.2 of NFPA 99-2012, does state additional testing of hospital-grade receptacles in patient rooms shall be performed at intervals defined by document performance data.

Whether the building is considered new occupancy or existing occupancy, these requirement apply to all applicable locations in all healthcare facilities, and is not limited to just hospitals.

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May 22 2018

Hospital-Grade Receptacle Testing

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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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