Illuminated Pumpkin – CORRECTION

On October 23, 2018, I posted a picture of this illuminated pumpkin and wrote that the extension cord could not be used since Article 400.8 (3) of NFPA 70-2011 says flexible cords could not be used as a substitute for fixed wiring. But just recently, a reader asked why this illuminated pumpkin would not qualify for Article 590.3(B) that permits extension cords on holiday decorations for up to 90-days.

After reviewing NFPA 70-2011, I discovered I was incorrect in my original posting and thanked the reader for bringing this to my attention. I then made changes to the original posting to ensure the correct code interpretation was stated.

To be sure, NFPA 70-2011, Article 590.3(B), says extension cords are permitted to be used for holiday decorations up to 90-days. But Article 590.2(A) does say all other requirements of the code would have to be met. implying the extension cord would have to be listed by a national listing agency (i.e. UL). Also, Article 590.2(B) says temporary wiring is acceptable if it is approved based on the conditions of use. So, you would not be able to abuse the concept of an extension cord used on holiday decorations.

This also means that individual organizations could have policies specific to their staff that limit or prohibit the use of extension cords on holiday decorations beyond what NFPA 70-2011 provides.

I apologize for this error, and appreciate the reader for bringing this to my attention.

Strange Observations – Part 37

Continuing in a series of strange things that I have seen while consulting at hospitals…

See anything unsafe about this electrical panel…?

Here is another example that equipment rooms are really not all that safe.

The inner safety panel is missing from this electrical circuit breaker panel, thereby allowing access to the 480 volt buss bars.

Take a close look at your mechanical rooms, and do monthly inspections in them.

Non-Patient Care Electrical Equipment

Q: What required inspections are needed for non-patient care electrical equipment and at what intervals should they be completed in. I cannot find anything definitive in NFPA 99 – 2012.

A: CMS will expect that you conduct the maintenance activities (i.e. PM’s) as recommended by the manufacturer, for all electrical equipment regardless if it is considered patient care or non-patient care equipment. In addition, this electrical equipment must be on the facility’s inventory of equipment.

This is based on CFR §482.41(c)(2) which is also known as A-0724 in the State Operations Manual (SOM) Appendix A. This document is available at no charge by searching “CMS SOM Hospitals”. Since it is a CMS standard, then all of the accreditation organizations and state agencies must have standards that are equal to that.

So, the answer to your question is: Whatever the manufacturer recommends, you must comply. And this is based on a CMS requirement, not an NFPA 99 requirement.

CMS does offer an Alternative Equipment Management (AEM) program that would allow you to conduct PM activities that differ from the manufacturer’s recommendations, but there are a lot of challenges to this AEM program and it is not for everyone. You can read all about it in CFR §482.41(c)(2).

Hospital-Grade Receptacle Testing

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).

Electrical Room Storage

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.

GFCI Receptacle Testing

Do you ever have the feeling for every step forward, you take two steps backward? Regulatory compliance in the healthcare industry is getting tougher and tougher each year with new interpretations by the authorities. Just when you learn about the latest new requirement, and make the necessary adjustments so you are in compliance, along comes a new interpretation that throws a wrench into your process and you have to re-boot again.

Take the example that a reader sent me last December: Their hospital was having an inspection by their state agency representing CMS and the surveyor for the state said they were going to cite the hospital for not testing their GFCI receptacles on a monthly basis. She wrote me an email and asked me if testing the GFCI receptacles on a monthly basis was a requirement. I looked it up in the NFPA 99-2012 code and could not find any requirement to test GFCI receptacles. I did find a requirement in NFPA 70-2011, Article 517.17 (D) that does require the GFCI receptacles to be tested upon the initial installation, but nothing was mentioned about monthly testing requirements.

The state agency eventually submitted their report and the hospital was cited under K-914 for not providing any documentation that monthly testing was conducted on the Ground Fault Circuit Interrupter (GFCI) receptacles at various locations in the hospital, in accordance with the manufacturer’s instructions on testing.

Even though NFPA does not require monthly testing of the GFCI receptacles, the manufacturer does recommend it, and the CMS surveyor cited the hospital for not following the manufacturer’s recommendations. The reader sent me a copy of the survey report and asked if this made sense to me. I replied that yes, it is a legitimate finding, because the hospital was not following the manufacturer’s recommendation for testing the GCFI receptacles. CMS Condition of Participation CFR §482.41 (c)(2) Interpretive Guidelines is clear that hospitals must follow the manufacturer’s recommendations for maintenance activities, or they must comply with the Alternate Equipment Management (AEM) program. But, in a larger picture, it does not make sense to me to start citing healthcare organizations for a little-known requirement without first providing some warning.

Why can’t CMS make an announcement and say they will start holding certified healthcare organizations accountable for monthly testing of their GFCI receptacles and provide a year’s moratorium until they begin enforcement? When I was a surveyor for Joint Commission, the accreditor used to do that. They would make an announcement that they would begin holding hospitals accountable for a new requirement, but would give the healthcare organization at least 6-months, and sometimes a year, to become compliant before that issue was enforced.

So… for now, the lesson we all need to learn from this, is to begin a monthly testing program of all your GFCI receptacles. Do your own survey of your facility and inventory the location where each GFCI receptacle is at. Purchase one of the GFCI testing devices (~$10) in the picture and have your technicians do the test on a monthly basis. Document each monthly test with the date, location, a “Pass” or “Fail” decision of the test, and a signature by the technician. There is a report template on my “Tools” webpage that you can down-load and use for free.

But that takes care of the this ‘flavor-of-the-month’. What will be the next surprise by the CMS surveyors that will catch most healthcare organizations off-guard? The way CMS is putting pressure on their state agency surveyors to find deficiencies that the accreditation organizations over-look, it makes the survey process more of an enforcement interrogation rather than a collaborative and educational event.

Coffee Pots

Q: What’s the standard to test small electrical appliances such as plastic coffee pots, etc. with no ground and the patients do not handle in a health care environment?

A: You may classify that as ‘consumer equipment’, and it would not have to be included in the plant equipment inventory. However, the expectation is the hospital does an initial equipment inspection that checks for continuity to ground… even if it is all plastic. The check should be recorded, and a sticker on the equipment is sufficient.

Electrical Panels

imagesCATTF4OXThere are quite of few issues concerning electrical panels that need to be addressed during a survey. Hospitals frequently take electrical panels for granted and overlook some of the more obvious requirements. Surveyors are better educated and prepared to evaluate your electrical panels during the survey.

Access to electrical panels must not be obstructed. There must be at least 36 inches clearance in front of the electrical panels and at least 30 inches clearance to one side of the electrical panel. The width of the electrical panel is included in the 30 inch side clearance.

While there are no direct standards that say the electrical panels must be locked, the risk of unauthorized access by unscrupulous individuals who could turn off circuit breakers controlling vital functions is a risk that must be addressed. In other words; access to the electrical panels should be secure, unless the healthcare organization has conducted a risk assessment that addresses the risk of unauthorized access. An example where a risk assessment may indicate an unlocked electrical panel is acceptable is where the circuit breakers in the panel do not serve a vital function of safety.

Circuit breakers are required to be labeled as to the circuits that they serve, or are required to be labeled as “Spares”. In older healthcare facilities this may be a problem since renovations may change what is served by the circuits and the breaker schedule may not be up to date. A breaker turned “Off” because it is a spare still needs to be labeled as such.

Tamper Resistant Electrical Receptacles

images[5]Every surveyor has his/her own specialty that they like to look for during a survey. I know of one surveyor that writes up every hospital he surveys if the fire alarm panel is not marked with the electrical panel number and circuit that feeds the power to the fire alarm system. It’s a requirement, but he’s the only surveyor that I know who is writing it.

Another surveyor that I know is very astute on construction type to the point where he wrote up a hospital for having combustible siding on the exterior of the building. The hospital was 20 years old and the plywood siding was original. They were upset because for two decades the siding was never an issue, then all of a sudden ‘Boom’; it’s a problem. The hospital contacted the architect who originally designed the hospital, and he wrote a thundering letter of protest. That one I checked with NFPA and it turns out the surveyor was correct. The hospital will have to remove the combustible siding or submit an equivalency or a waiver request.

When I surveyed for The Joint Commission, I remember paying special attention to how fire dampers were installed at the hospitals I surveyed. I did this because the hospital where I worked got cited for improperly installed fire dampers by the state agency conducting a validation survey on behalf of CMS. I learned the hard way on the proper method of installing fire dampers, and used that newly gained knowledge when I surveyed.

Which leads me to the issue concerning tamper resistant electrical outlets. I don’t think you will see any specific standard in a Joint Commission, HFAP or DNV, manual (or in a CMS CoP for that matter) on tamper resistant electrical outlets, but this issue is being observed on more and more survey reports. Apparently, some surveyors have a strong background in the National Electric Code (NFPA 70) and uses that knowledge during surveys.

If you are not already doing so, please be checking the electrical receptacles in pediatric areas to be sure they are the tamper resistant type. Section 19.5.1 of the 2000 Life Safety Code requires compliance with section 9.1, and section 9.1.2 requires compliance with NFPA 70 National Electric Code (1999 edition). Article 517-18(c) of NFPA 70 says the receptacles rated for 15 or 20 amps, 125 volts, intended to supply patient care areas of pediatric wards, rooms, or areas in healthcare facilities, shall be listed tamper resistant or shall employ a listed tamper resistant cover.

 The areas where tamper resistant receptacles are required are areas where children are likely to found; which include areas outside of a pediatric unit such as the cafeteria, main lobby, waiting rooms, and play areas. The tamper resistant receptacles would not be required in adult patient rooms, corridors, physician consultation rooms, etc., as these areas, even if children are present, would have supervising adults present.

It is not wrong, or unethical for a surveyor to cite an organization on an issue just because he/she has special knowledge about that issue. After all; the hospital is required to comply with that issue, right? What’s frustrating is there usually is no warning that some surveyors are looking for a particular issue and it surprises facility managers when it happens. No one likes those kinds of surprises.

Relocatable Power Taps (Power Strips)

12-120-878-TS[1]There has been a lot of discussion about power strips (or relcoatable power taps, as some authorities call them) lately, and most of it is not to our advantage. None of the discussion is actually news to us, it’s just a re-hash of existing positions.

During the recent NFPA Annual Conference in Las Vegas earlier this month, George Mills, the Director of Engineering for The Joint Commission said he approached the NFPA Healthcare Interpretation Task Force (HITF) back in 2007 and asked them to make a ruling on whether power strips are acceptable for use in patient care areas. George said after much discussion, the HITF did not come to a consensus, and therefore no interpretation was issued.

Since then, The Joint Commission surveyors have been allowing power strips in patient care areas, and some surveyors even required the devices to be UL listed for the application. Then, earlier this year, the leadership at The Joint Commission asked George what the accreditor’s official position was on the use of power strips, so he decided to contact the CMS home office in Baltimore to see what they allow.

George reported at the May AAMI Annual Conference in Philadelphia that CMS is taking the hard line of saying power strips (relocatable power taps) are not to be used in anesthesia areas and on medical equipment. This is based on NFPA 99 (1999 edition), section 7-5.1.2.5 which only allows relocatable power taps provided they are an integral part of the equipment assembly and permanently attached; and the sum of the ampacity of all appliances connected to the relocatable power tap shall not exceed 75% of the ampacity of the relocatable power tap. A regular program to verify the integrity of the above permanently attached relocatable power taps is required.

This piece of information was picked up by a lot of different healthcare news outlets, blogs and online notification services (including yours truly) and re-distributed to the point where CMS had to make an unofficial email announcement to their deemed accredited organizations (and presumably to their state agencies) that in fact no new issuance of a policy or an announcement was made concerning power strips, and they referred to NFPA 99 as their standard. Now ASHE has made an announcement acknowledging CMS’ position, and to say they are working to convince CMS to consider issuing a categorical waiver to allow the immediate use of NFPA 99 2012, which seems to have a more user friendly approach to power strips.

But, the bottom line is The Joint Commission (and the other accreditors) do not have any option but to follow this difficult interpretation of the standard as dictated by CMS. George Mills unofficially said they will enforce no power strips in patient care areas, and no power strips on medical equipment, unless it meets the requirement of NFPA 99 7-5.1.2.5 and it is integrated with the medical equipment, and this is all regardless of the UL listing. So power strips like UL 1363A which are listed for use in anesthetizing locations would not be acceptable to the accreditors.

For the record, the HITF wrestled with the issue of power strips once more this year in Las Vegas but again did not arrive at a conclusive interpretation. Chad Beebe representing ASHE said he wants to take this issue to CMS to attempt them to change their minds on the rigid interpretation.  I guess you need to stay tuned to see what transpires next…