Qualifications of Personnel

Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or inspections on fire alarm systems and sprinkler systems?

A: NFPA 72-2010, section 10.4.3.1 requires a certified individual to perform service, testing, inspection and maintenance on fire alarm systems and components. The certification must be one (not all) of the following:

  • Factory trained and certified for the specific type and brand of systems being serviced
  • Persons who are certified by a nationally recognized certification organization (NICET, IMSA, etc.)
  • Persons who are registered, licensed or certified by the state
  • Persons who are employed and qualified by an organization listed by a national recognized testing laboratory for servicing fire alarm systems.

I have seen some larger hospitals that do employ people who meet one of the above requirements, but most hospitals contract this work to a qualified vendor who has these credentials. When it comes to sprinkler system testing/inspecting, NFPA does not require certification of the individuals performing the test/inspection. However, please check with your state and local AHJ to determine if they have additional requirements.

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.

Monthly Fire Pump Test

Q: I have always tested my fire pumps on a weekly basis, but now I’ve heard from a consultant there is a new standard that says only a monthly run is required. Is this true?

A: Yes, it is. With the adoption of the 2012 Life Safety Code, the 2011 edition of NFPA 25 is now the standard to use regarding inspection, testing and maintenance of sprinkler systems. Section 8.3.1.2 of NFPA 25-2011 now allows electric-motor driven fire pumps to be tested under no-flow conditions on a monthly basis rather than weekly, which was required under previous editions of NFPA 25. However, engine-driven fire pumps still must be tested weekly.

Generator Testing

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.

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.

Testing Requirements

Q: On annual testing requirements, how many days do you have on either side of the test date?

A: If the NFPA standard simply says the test is required ‘annually’, then that can be interpreted differently depending on the many different authorities having jurisdiction. I do know that CMS is okay with an ‘annual’ test requirement to happen once per calendar year, as long as you do not exceed 12 months. This means if you tested something on July 1, the next test may occur anytime between January 1 and June 30 the following year. You just cannot exceed 12 months between tests. But not all accreditation organizations (AOs) agree with that. They typically have a more restrictive requirement, such as ‘annual’ means 12 months from the previous test, and must be conducted during the 12th month. So, if you did the test on July 1, then you must do the next test between June 1 and June 30. Some AOs even have said 12 months from the previous test, plus or minus 30 days. But CMS has told them that they do not like the “plus 30 days” because that exceeds 12 months between tests. So that pretty much limits the test to 12 months from the previous test, minus 30 days.

But CMS has said in informal communications with the AOs that they will honor the NFPA 72-2010 3.3.106 definition of annual testing for fire alarm system components, which is no sooner than 9 months and no later than 15 months from the previous annual inspection/test. But there is no guarantee that the AOs will honor this. And, this only applies to fire alarm system testing… not any other feature of life safety.

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.

Generator Testing

Q: We have a generator that doesn’t meet the 30% load for the monthly run so we have to do an annual run with the load at 50% for 30 min and 75% for 60 min for a 90-minute continuous run. Our contractor did the annual run but he ran it with 52 % for 30 min , 75% for 30 min and 81% for 30 min, then he continued to run it for 2½ more hours dropping the percentages as he went for 4 continuous hours at not less than 30%. My question is does these meet the intent of the standards for both an annual and a 3-year load test?

A: Yes… I would say the test as you described meets both the annual requirements and the 3-year test requirements. The generator load testing requirements are minimum load settings, and it is permitted to exceed these minimums.

Generator Testing

Q: In a business occupancy and an ambulatory occupancy do we need to test our generator on load each month or can we do a load bank test once per year?

A: Yes… Monthly load tests are required for emergency power generators at ambulatory healthcare occupancies and business occupancies. According to the 2012 Life Safety Code, sections 20/21.5.1.1 for ambulatory healthcare occupancies and 38/39.5.1 for business occupancies, compliance with section 9.1 on utilities is required (just like healthcare occupancies).

Section 9.1.3 requires compliance with NFPA 110-2010 regarding emergency power generators, and section 8.4.1 of NFPA 110 requires monthly load tests.

Now… there is an exception to all of these testing requirements…. Section 9.1.3 says emergency generators, where required for compliance by the LSC, must be tested and maintained in accordance with NFPA 110-2010. So, if you are not required to have emergency power generators at the ambulatory healthcare occupancy or the business occupancy, then you do not have to maintain them according to NFPA 110.

Fire Door Testing

Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any new interpretation on rated corridor doors (20 minute and up) that are installed in non-rated wall assemblies. In looking at most publications from different authorities, they have interpreted that all rated doors need to be annually inspected since it could be obvious to the public. Section 4.6.12.3 of the 2012 Life Safety Code says existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. However, section 4.4.2.3 says where specific requirements contained in Chapters 11 through 43 differ from general requirements contained in Chapters 1 through 4, and Chapters 6 through 10, the requirements of Chapters 11 through 43 shall govern. If the chapters 11-43 govern over chapters 1-10 why are the authorities not recognizing 19.3.6.3.3 where it states compliance with NFPA 80 shall not be required? Unfortunately, it doesn’t say this for “smoke barrier” doors, so the authority’s logic could still have reason. In my interpretation of 4.6.12.3 and reading the appendix it seems that NFPA is referring to first response Life Safety features, like a pull station, fire extinguisher, strobe lights, fire panels etc….. If Joe Public is seeing a fire door do its thing, it’s probably too late. Certainly, first response LS features should always work even if they are not required.

 A: You make many excellent points. But the way I see it (and interpretations by most of the AOs and CMS agree), section 8.3.3.1 of the 2012 LSC requires compliance with NFPA 80 for fire doors and windows. There are no exceptions in 8.3.3.1 that exclude fire-rated doors located in non-fire-rated barriers. Compliance with 8.3.3.1 is required by section 19.1.1.4.1.1. Where section 19.3.6.3.3 says compliance with NFPA 80 is not required, they are speaking about non-fire-rated corridor doors, which are in smoke partitions that separate a corridor from another area or room.

Smoke barrier doors are often not corridor doors; they are cross-corridor doors. But at times, a smoke barrier can (and does) include a corridor wall and what appears to be a corridor door is now also a smoke barrier door. In those situations, the hospital has to comply with the most restrictive requirements.

To me, it is plain: If you have a fire-rated door (regardless if it is located in a fire-rated barrier or not), then it must comply with NFPA 80 and you must test and inspect it on an annual basis.  I’ve been told that the opinions from the staff at NFPA do not agree with this, but NFPA does not enforce the LSC, so we need to comply with those interpretations made by the authorities who enforce the Life Safety Code, such as CMS and the AOs.