Strange Observations – Part 47

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

Clearance to all electrical equipment (i.e. panels and disconnect switches) must be maintained for 36 inches in front of the panels from the floor to a point 6-feet 6-inches above the panels, or to the top of the panels whichever is higher.

That means the table and shelving unit need to be removed.

Strange Observations – Part 33

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

Equipment rooms can be a major source of findings for surveyors.

Mostly because equipment rooms are often out-of-sight / out-of-mind. And because often times no-one is assigned to maintain the equipment rooms in safe condition.

Here we have a trash cart and a water machine obstructing access to electrical panels and a fire extinguisher.

Receptacle Testing

Q: Is there a code in the 2012 LSC about testing electrical receptacles around hospital beds?

A: Well… actually, that would be in the NFPA 99-2012 code/standard, and the answer is yes, all receptacles in patient care rooms must be tested. But the frequency of that test is different, depending on whether the receptacle is a hospital-grade receptacle or not.

Section 6.3.4.1.1 says hospital-grade receptacles must be tested after initial installation, replacement, or servicing of the device.

Then section 6.3.4.1.3 says 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.

But section 6.3.4.1.2 does say additional testing of receptacles (including hospital-grade receptacles) in patient care rooms shall be performed at intervals defined by documented performance data. This means you do have to test hospital-grade receptacles at a frequency determined by the healthcare organization based on information such as historical data, risk assessments, or manufacturer’s recommendation.

So, if you do install hospital-grade receptacles in the above locations, then you do have to test them after the initial installation, but at intervals that you get to determine.

Receptacle Testing

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.

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).

Strange Observations – Part 16

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

Another storage room with a bunch of empty boxes obstructing access to the electrical panel.

Clearance needs to be maintained for 36 inches in front of the panel.

Strange Observations – Part 10

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

Access to this electrical panel was obstructed. Staff that was with me did not understand that 36 inches clearance needed to be maintained.

What was the person thinking when they built the shelves?

Strange Observations – Part 9

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

The odd thing about this situation is the receptacle has been changed out since the fire, but they didn’t do anything to repair the wall or to paint over the burn marks.

And this was in a very busy storage room with lots of boxes… the staff that was with me had no idea that this was there.

Electrical Safety Program

Q: I work in a psychiatric hospital. One of the therapies used here involves our clients doing their own personal laundry, so we have multiple laundry rooms off the units with residential grade laundry equipment. Our staff supervises the use of the equipment, but the clients operate the appliances themselves. When I arrived here, there was no electrical safety program in place. Is a program required, and how extensive?

A: Yes… every hospital must have a program for electrical safety, but the codes and standards are not real specific on the matter. If you are Joint Commission accredited, you are required by EC.01.01.01, EP 8 to have a written Utility Management program, and EC.02.05.01 requires the hospital to manage the risks associated with the utility systems. Electrical safety is considered part of the Utility Management plan and needs to be addressed in the written plan. Also, EC.02.06.01 requires the hospital to establish and maintain a safe, functional environment. If a surveyor were to observe any unsafe activity involving electrical safety, he/she could cite a finding under any of these standards.

The accreditation organizations expect hospitals to comply with other regulatory agencies, such as OSHA, state regulations and local ordinances. OSHA expects compliance with NFPA 70E on electrical safety which may involve all of your maintenance staff. In addition, section 9.1.2 of the 2012 Life Safety Code requires compliance with NFPA 70 for all issues requiring electrical wiring and equipment. So, there are multiple regulations and standards that require healthcare organizations to have a safe electrical environment, and the accreditation organization requires that to be included in the written form of the Utility Management plan. How specific you want to make your electrical safety program is up to you and the regulations enforced by the other authorities.

Restricted Access to Electrical Closets

Q: My questions are in relation to access control into electrical closets and life safety equipment closets. We have several electrical closets “locked down” by our IT department because they have installed network switches in these closets. One closet in particular also has an ATS switch and our fire alarm panel for that building. This closet is locked down to those who have “card access”. There are several closets that have life safety equipment inside that are also locked down with only card access. My questions are:

  1. Are there any compliance codes to refer to in accordance with life safety that states directly to our issue?
  2. Are there compliances that state “qualified persons” for access to electrical closets?
  3. Access to these electrical closets is limited. What codes or compliance regulation could this be violating?

A: From a Life Safety Code perspective the only compliance regulation that may apply concerns doors locked in the path of egress, which is section 19.2.2.2.4 of the 2012 Life Safety Code. It is permissible to lock the door going into the closet, but once you’re in the closet you cannot lock the door getting out of the closet. There are exceptions, and for closet it is rare to see any of the exceptions used under 19.2.2.2.4. Otherwise, I am not aware of any Life Safety Code issues that would prevent the locking of doors. In fact, HIPAA regulations would require the locking of closets that contain access to health information, so that is why the IT people want the doors to the intermediate distribution frame servers locked.

There are no regulations in the NFPA standards that state ‘qualified persons’ only for access to electrical closets

In an emergency, authorized individuals need to have access to electrical circuit breaker panels, disconnect controls, and the fire alarm panel. As long as the IT people allow unlimited access to certain Engineering-type staff (i.e. maintenance people) to the electrical equipment in these closets, I don’t see any problems.