Research for an Article

imagesJCU1DVQ4I would like to do some research for an article that I want to write about and I am addressing this appeal to those of you who have an active role in a facilities management department (or related department) in a hospital.

I am interested in learning what surveyors are looking for and finding in respect to sprinkler inspection, testing and maintenance at your facility. As you know, NFPA 25 is the primary document for inspection, testing and maintenance for water-based sprinkler systems and it appears that not all of the accreditation organizations (AO) are enforcing it the same way. Many of you are Joint Commission accredited and some of you are HFAP or DNV accredited. It would be interesting to learn if there are differences between the AOs, and if there are, what those differences may be. Also, if you recently had a CMS validation survey performed by a state agency, I would be interested in learning what they identified as well.

There is a form that you can use as a comparison tool that identifies what NFPA 25 (1998 edition) actually requires for inspection, testing and maintenance of water-based sprinkler systems. This tool is located under the “Tool” heading, and then search under the “Life Safety Document Review Session” heading. It would be interesting to find out if there is anything on the form that the surveyors decided not to ask to see documentation of compliance. Feel free to use it as a tool comparing it with your AO / state agency survey experience.

So, if you are interested in participating, please respond back to me at:   info@keyeslifesafety.com   with your comments on what the surveyors/inspectors identified on your survey deficiency report as well as what they stated unofficially, in regards to inspection, testing and maintenance of your water-based fire protection system. I will keep your comments anonymous in the article unless you grant me permission to quote you.

If possible, I would like your reply by August 18, 2014.

Thank you…..

Follow-Up on Documentation

imagesIDI1GACXMy recent series of articles on Documentation created quite a bit of response. One individual had this question:

“What is your opinion of documentation being kept electronically rather than in hard copy format?  We will have things organized and easy to find and search, but I don’t want to go through the process of electronic files if a surveyor is going to request hard copies.”

My understanding is most authorities will accept electronic documentation provided it meets all of the requirements for documentation. Many AHJs have specific requirements concerning what’s included in the documentation, such as:

Testing & Inspection- Documentation.

Unless otherwise stated, testing, inspection and maintenance documentation must include, at the minimum, the following information:

  1. Name of individual performing the activity
  2. Affiliation of the individual performing the activity
  3. The signature of the individual performing the activity
  4. Activity name
  5. Date(s) (month/day/year) that activity was performed
  6. The frequency that is required of the activity
  7. The NFPA code or standard which requires the activity to be performed
  8. The results of the activity, such as ‘Pass’ or ‘Fail’

An electronic signature typically would be acceptable in lieu of a hand-written signature. That usually means the technician performing the work would have to enter the data in order to create the electronic signature. Most authorities would not accept an electronic signature from a data-entry person in lieu of the technician performing the work. Most authorities also would not accept a data-entry person issuing an electronic signature of another individual, such as a jpg picture of a signature. However, pdf copies of documentation with all of the above requirements is acceptable. Essentially, it would be similar to a photo-copy of a report.

There are stories of the data-entry person not being present during the survey and they were the only one with the passcodes to access the data, or with the knowledge on how to retrieve the data. I also witnessed a situation where weekly reports were turned into a clerical person to enter the data into the computer. The clerical person allowed the reports to accumulate and the data was not entered during the week that the test/inspection was performed. The data-entry person used the ‘default’ date stamp provided by the software platform when the data was entered, which effectively said the test/inspection was not performed during the required time-period.

It is difficult to attach follow-up reports to electronic copies, such as ILSM assessments or repair work orders to a particular LSC deficiency. With paper files, they can easily be inserted into a binder or a folder.

Bottom line: Electronic documentation is permitted, but most hospitals realize the risks do not out-weigh the rewards. I am not a fan of electronic documentation because I have witnessed the problems with using them. But as with all technology, time is needed to work out the problems and make improvements. I’m an old man, and perhaps the younger generation has already implemented solutions to this problem.

I welcome your feedback on the use of electronic documentation.

Main Drain Tests

Q: Where are main drain tests required to be done? This is a large medical facility with nine story towers. Several fire mains feed the various campus buildings. Is the main drain test required to be done only where the fire mains supply the system risers, or does it also need to be done on each floor at the riser as well? Would you please supply your rationale for your answer?

A: According to the 2000 edition of the Life Safety Code, main drain tests are regulated by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. Section 1-5 of NFPA 25 defines a main drain as the primary drain connection on the system riser and also is utilized as a flow test connection. Section 9-2.6 requires a main drain test must be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply and control valves. NFPA 25 does not adequately define what a ‘system riser’ is, so we turn to the Handbook for NFPA 13 Standard for the Installation of Sprinkler Systems which identifies a ‘system riser’ as the above ground horizontal or vertical pipe between the water supply and the mains (cross or feed) that contains a control valve (either directly or within its supply pipe) and a waterflow alarm device. A system riser is more than just a subset of the term riser, which is broadly defined as any vertical piping within the sprinkler system. As indicated by the definition, a system riser can be any aboveground pipe in a vertical or horizontal orientation installed between the water supply and the system mains that contain specific devices. By this definition it appears one could loosely define the locations of a main drain test to be conducted wherever there is a control valve and waterflow alarm switch. In a large multi-story facility such as yours, that would most likely require a main drain test at least on every floor, possibly more. The Accreditation Organizations (AOs, such as Joint Commission, HFAP and DNV) typically do not seek this level of compliance. Most of the AOs only expect main drain tests to be conducted at the base of the risers of the sprinkler system, not at every floor. However, depending on your state agency surveyors who conduct CMS validation surveys, it is very reasonable and possible that they will expect the main drain tests to be conducted at every floor. To continue with additional information, the purpose of a main drain test is covered in the Annex section A-9-2.6, which says main drain tests are used to determine whether there is a major reduction in waterflow to the system, such as might be caused by a major obstruction, a dropped gate, a valve that is almost fully closed, or a check valve clapper stuck to the valve seat. A large drop in the full flow pressure of the main drain (as compared to a previous test) normally is indicative of a dangerously reduced water supply caused by a valve in an almost fully closed position or other type of severe obstruction. After closing the drain, a slow return to normal static pressure is confirmation of the suspicion of a major obstruction in the waterway and should be considered sufficient reason to determine the cause of the variation. A satisfactory drain test (i.e., one that reflects the results of previous tests) does not necessarily indicate an unobstructed passage, nor does it prove that all valves in the upstream flow of water are fully opened. The performance of drain tests is not a substitute for a valve check on 100 percent of the fire protection valving. The main drain test is conducted in the following manner:

  1. Record the pressure indicated by the supply water gauge [Static Pressure]
  2. Close the alarm control valve on alarm valves
  3. Fully open the main drain valve
  4. After the flow has stabilized, record the residual (flowing) pressure indicated by the water supply gauge
  5. Close the main drain valve slowly
  6. Record the time taken for the supply water pressure to return to the original static (nonflowing) pressure
  7. Open the alarm control valve

Smoke Dampers

imagesW9BNC02CWhat do we do with smoke dampers now that the hospital is fully protected with sprinklers? That question is asked many times by facility managers who are looking to cut back on what they believe are unnecessary maintenance costs. For new construction purposes, chapter 18 in the Life Safety Code does not require the installation of smoke dampers in smoke compartment barriers provided the HVAC ductwork that penetrates the smoke compartment barrier is fully ducted (no open return air plenum ceilings), and both smoke compartments served by the smoke compartment barrier are fully protected with quick-response automatic sprinklers. But sprinklers were not always required for healthcare occupancies and only became a rule for new construction in the 1991 edition of the LSC.

Until then, sprinklers were an option (unless state or local laws required it, and the construction type required it), and not all hospitals choose to invest in the systems when the building was constructed. That means smoke dampers had to be installed in the smoke compartment barriers. After the facility became fully protected with sprinklers, many hospitals believed they could remove the smoke dampers (or disable them in place), since new construction specifications did not require the smoke dampers. Section 4.6.7 of the 2000 LSC says whenever alterations or renovations are made, the requirements of new construction must apply. Since new construction (chapter 18) requirements for hospitals did not require smoke dampers where both smoke compartments are protected with sprinklers, facility managers thought they had good ground to stand on.

While this may be acceptable for NFPA, it is not for the International Code Council which publishes the International Building Code (IBC). The organization needs to request permission from their local and state authorities before they remove them. Usually, permission will not be granted because the IBC does not recognize the removal of existing fire safety equipment. I’ve also been told that in those jurisdictions where the smoke dampers were installed prior to the adoption of the IBC, there is a chance that the authorities may permit it.

Bottom line… Don’t be in a hurry to remove the smoke dampers even if you believe they are no longer required. Check with the state and local AHJs and seek their permission. It will save you a lot of work of re-installing them if you don’t ask for permission, and they find out later.

Inaccessible Fire Dampers

Many of you may be familiar with the Joint Commission’s standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose to insert the damper into the Statement of Conditions Plan for Improvement (PFI) list with a 6-year projected completion date. Then the hospital does not have to resolve the inaccessible fire damper, and they will not be cited for not performing the required testing.

Well, no other accreditation organization (AO) or state agency surveying on behalf of CMS has that luxury. CMS has been very clear to all AOs: If you observe a deficiency, then you must cite it. AOs and state agency surveyors are not permitted to not cite a deficiency if they are presented evidence that a feature of the Life Safety Code is non-compliant. And an inaccessible fire damper on a PFI list is clear evidence that it has not been tested.

So, why does Joint Commission continue to allow their hospital clients to not test inaccessible fire dampers and permit them to place them on the PFI list if CMS does not allow this practice? It is my observation that the reason is mainly due to the fact Joint Commission has been operating as an independent authority since 1965 without having to meet CMS’s rules and regulations, until just recently (2009).

For the record, I like the Joint Commission PFI list and think it is a very good deal for hospitals. It provides the hospital an incentive to get out and find their deficiencies before a survey and manage a solution to them through the PFI list. Then a TJC surveyor will not cite them for the deficiency. It’s a win-win situation. Hospitals are motivated to conduct self-examinations of their facilities and find all the LSC deficiencies they can, which results in a safer environment for their patients. I wish all AOs and state agencies had that option. However, CMS is threatening to remove the feature from Joint Commission and if they succeed, then the fear is hospitals will not be pro-active and look for their own deficiencies, and sit back and wait to see if the surveyors will find them during the triennial survey.

Even if Joint Commission allows you to manage the inaccessible fire damper through the PFI list, that’s only good for a Joint Commission survey. You still need to make the damper accessible and then test it for all the other AHJs.

So, when a fire damper cannot be tested because it is inaccessible… you have little choice but to make the fire damper accessible and then test it. There is another option though; you may request a waiver during the Plan of Correction process, provided it is a significant hardship to the hospital. Waivers are much more difficult to get approved lately through CMS but it is the only other option to you.

Fire Alarm Test Reports

fire-alarm-system-detects-protects-24-x-7-250x250[1]Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings and citations, mainly because there are so many devices connected to the fire alarm system. A typical 200 bed hospital may have over 2,000 devices connected to the fire alarm system that need to be tested.

Nearly all of the requirements for the frequency of the tests performed on fire alarm systems can be found under NFPA 72 (1999 edition), section 7-3.2. The one exception would be the requirement for the water-flow switch testing which is found under NFPA 25 (1998 edition), section 2-3.3. (NOTE: This does not take into consideration the recent CMS categorical waivers.)

Often times a contractor performing the fire alarm testing will not test all of the devices listed below, even if your hospital has them in your system. The reasons may differ but the bottom line is the hospital facility manager must review the contract and determine what is actually required. Many times the standard contract (or signed proposal) will state something to the effect the fire alarm system will be tested in accordance with NFPA 72, although it doesn’t always refer to the proper edition (most hospitals are on the 1999 edition of NFPA 72). If the contract says it will test to NFPA 72, then you must hold them accountable for testing everything on the list below.

Make sure the test report lists the complete inventory of each and every device connected to the fire alarm system. All of the initiating devices, all of the occupant notification devices and all of the interface relays must be listed in an inventory complete with their location and whether they passed or failed their test. And don’t forget all of the batteries in the fire alarm system, not just those in the fire alarm control panel. There may be other batteries involved such as those in a remote panel or a Notification Appliance Circuit (NAC) extender panel.

Here is a list of devices that could be connected to the typical fire alarm system in a hospital:

Device/Test

Frequency

Initiating   Devices

Water-flow switches

Quarterly

Smoke detectors

Annually

Heat detectors

Annually

Duct detectors

Annually

Manual pull stations

Annually

Supervisory   Signal Devices

Low air pressure switches

Quarterly

Low water level switches

Quarterly

Tamper switches

Semi-annually

Notification   Devices

Strobes

Annually

Horns

Annually

Bells

Annually

Chimes

Annually

Interface   relays and modules

Magnetic hold-open

Annually

Air handler shut-down

Annually

Kitchen hood suppression sys

Annually

Elevator recall

Annually

Magnetic locks

Annually

Fire pump

Annually

Smoke dampers

Annually

CO2/Clean agent suppression

Annually

Sprinkler dry-pipe/pre-action

Annually

Overhead rolling fire doors

Annually

Control   panel batteries

Charger test

Annually

Discharge test

Annually

Load voltage test

Semi-annually

Smoke   detector sensitivity test

2-years

Off-premises   monitoring transmission equipment

Quarterly

Here are some basic requirements about the fire alarm test report:

  • Make sure the report is dated and signed by the service technician and you (the owner’s representative)
  • Make sure all the devices connected to the fire alarm system are accounted for and inventoried in the report
  • Make sure resettable heat detectors are ‘tested’ rather than ‘inspected’. Lazy technicians may not want to get out the hot-air guns to test the heat detectors so they just ‘inspect’ them
  • Make sure the heat detectors are tested with heat, and not with magnets. Only the one-shot non-resettable heat detectors are permitted to be tested with magnets.
  • When items on the report are identified as having ‘failed’ their test, make sure there is follow-up action to resolve the issue
  • Don’t forget to assesse the failed devices for Interim Life Safety Measures (ILSM)
  • Resolve all deficiencies and staple copies of the paperwork that demonstrates the repair was completed, along with a re-test, to the test report
  • Ensure that the technician performing the fire alarm testing, service and repairs meets the qualifications for certification or licensing. This applies to in-house staff or contracted staff. Have the qualifying documents on file.

Maintain your fire alarm test report at this level of documentation and you should not have any troubles with the surveyors.

 

Fire Alarm Control Panel Batteries

Q: What are the testing frequencies for fire alarm panel batteries and where do you find this requirement?

A: The testing frequencies for batteries for fire alarm control panels (including notification appliance circuit extender panels, or ‘NAC panels’) are found in Table 7-3.2 of NFPA 72 (1999 edition). For years, batteries used in fire alarm systems have been sealed lead-acid type, and there are three (3) tests that need to be conducted:

  • Charger Test                     (Annually)
  • Discharge Test                  (Annually)
  • Load Voltage Test           (Semi-Annually)

The Load Voltage test is usually what trips up the fire alarm testing contractor, as they do not always return on a semi-annual basis to perform the load voltage test. This is not always the fault of the testing contractor, but more of a contract issue with the healthcare organization. Make sure you check the language of your contract to ensure the vendor is performing these tests at the allocated time frequencies.  If you’re scoring this as a Joint Commission deficiency, non-compliant with Table 7-3.2 battery testing could be scored under one of the following:

  • EC.02.05.05,    EP 3
  • EC.02.06.01,    EP 26
  • LS.02.01.34,     EP 4

Be aware that Joint Commission, and many other authorities, will expect the semi-annual test conducted 6 months from the previous test, plus or minus 20 days. The annual tests must be conducted 12 months from the previous test, plus or minus 30 days. Make sure your contract stipulates these requirements and monitor their activity to confirm it.

Changes to Joint Commission Standards for 2014: Part 2

imagesCA0CNZZF

As mentioned in last week’s posting, The Joint Commission announced changes to their standards that takes affect January 1, 2014. We discussed already the change they are making with time defined which will have a significant impact on scheduling fire drills, and other quarterly activities. This week we will look at the other change that the accreditor announced: Monthly generator load testing.

During a recent webinar which was sponsored by ASHE, George Mills, the Director of Engineering for The Joint Commission, announced starting in 2014, monthly generator load testing will be permitted to be accomplished anytime during the month, rather than the current requirement of no less than 20 days and no more than 40 days from the previous monthly load test. Why this change? George did not explain why, but perhaps it is Joint Commission’s attempt to make it easier on the facility manager.

But if that is the case, then I’m not sure it is a favor, as this latest move by the accreditor is not consistent with the Life Safety Code (LSC) for new construction, nor is it consistent with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.

But why did The Joint Commission have the 20 day/40 day requirement for generator monthly load test in the first place? Because it is a requirement of NFPA 99 Health Care Facilities (1999 edition), section 3-4.4.1.1(b), and the LSC (2000 edition) section 18.5.1.2 requires compliance with NFPA 99. Now, chapter 18 is for new healthcare occupancy construction, and chapter 19, which regulates existing healthcare conditions, does not have the same requirement. So, you might think the 20 day/40 day window for monthly testing only applies to new construction (since March 1, 2003) and not existing. Well, I wouldn’t bet on that.

Enter the CMS Conditions of Participation, paragraph 482.41(a)(1) interpretive guidelines says: “The hospital must comply with the applicable provisions of the Life Safety Code…and applicable references such as NFPA 99…for emergency lighting and emergency power.” This CoP standard applies to all healthcare occupancies, regardless whether they are new or existing and is required to be assessed by the LSC Survey Report Form CMS-2786, also known as the K-Tags. Tag K-144 says the following: “Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3-4.4.1, NFPA 110,8-4.2.” This means CMS requires the generator monthly load tests to be conducted within the 20 day/40 day window of opportunity.

As a deeming authority who has been approved by CMS, Joint Commission is required to have standards that are at least equal to or greater than CMS’s CoP. This new change announced by Joint Commission appears to establish their standards less than what CMS’s CoP requires. Will CMS hold them accountable to this difference? If history is an indication of future events, I suspect they won’t.

As a side-note, during the Q&A session of the ASHE sponsored webinar, my good friend George Rivas of TSIG Consulting asked George Mills if Joint Commission surveyors will allow monthly generator load tests conducted on the 30th of one month, and then next on the 1st of the following month, essentially just 1 day apart. Mills kind of hesitated and said he wouldn’t know why a facility manager would want to do that, but he agreed it would be permissible.

So… What does all this mean? Joint Commission can do what they want, and they often do. But this change to their standards will only provide temporary relief for the healthcare facility managers. On this issue, CMS has more restrictive requirements, so it would be wise for facility managers to continue to conduct their generator monthly load tests within the 20 day/40 day window, so they are ready if the CMS approved state agency inspectors show up to do a validation survey.

Changes to Joint Commission Standards for 2014: Part 1

calendar_quarterly[1]Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define time, and the other…. well we will discuss that in a later posting.

Currently, Joint Commission defines the period of time between required activities, such as testing and inspecting, to be as follows:

  • Weekly, or ‘every 7 days’:   Anytime during the week
  • Monthly, or ‘every 30 days’:   Anytime during the month
  • Quarterly, or ‘every 3 months’:   Anytime during the quarter
  • Semi-annually, or ‘every 6 months’:   6 months from the previous activity, plus or minus 20 days
  • Annually, ‘every 12 months’:   12 months from the previous activity, plus or minus 30 days
  • 3-Years:   36 months from the previous activity, plus or minus 30 days

The change beginning in 2014 involves Quarterly and 3-Year intervals. Now, Joint Commission will define Quarterly as follows:

Quarterly, or ‘every 3 months’:   3 months from the previous activity, plus or minus 10 days.

This change has far-reaching consequences, especially for fire drills. When I was a safety officer at the hospital where I worked, I was responsible for fire drills. Now, I will tell you that I did not enjoy conducting fire drills, as most of the people that participated in the drill, complied only because they had to, and they considered it a major inconvenience to their daily routine. My staff and I understood the importance of doing fire drills, but we were pretty much the only ones. Therefore, since I didn’t enjoy doing fire drills, I tended to ‘put them off’ or procrastinate in doing them, until the last days of the quarter. I was not as organized in doing them as I should have been.

If other hospital safety officers are like me, then this new change in how Joint Commission defines “Quarterly” will be a serious issue. They will have to develop a specific schedule of doing the drills in accordance with the new description, and be disciplined enough to stick with it. This will require organization skills. Make note of this and if you are not the individual responsible for fire drills in your organization, then send this post to the person who is.

Also, this affects all other quarterly testing and inspection activities, such as:

  • Waterflow switches
  • Supervisory signal devices (not tamper switches)
  • Off-premises monitoring transmission equipment (usually conducted with the fire drill)
  • Fire department connections (FDC)

During a recent webinar sponsored by ASHE, George Mills of the Joint Commission explained that this change in how they defined “Quarterly” came from another department and he unsuccessfully argued against the change.

The other change in how Joint Commission defines time between testing and inspection activities is the 3-Year test. It will now read as follows:

3-Years: 36 months from the previous activity, plus or minus 45 days

This is a change from “plus or minus 30 days” and can only be considered a positive for the facility manager. What is strange about this issue, is I heard George Mills says “pus or minus 45 days” for 3-Year testing intervals a couple of years ago at an ASHE annual conference, so I advised my clients as such. Then, last year when one of my clients went 36 months, plus 40 days between the 3-Year generator load test, the surveyor cited them for non-compliance. We wrote a clarification on the finding saying plus or minus 45 days was acceptable, and Joint Commission denied it. So, I’m glad they finally made a decision and let’s hope they stick to it.

Next week’s posting: We will discuss the changes to the monthly generator load testing.

 

Sprinkler Inspection Frequencies for Business Occupancies

Q: What is the required inspection frequency on sprinkler systems for a building classified as business occupancy?  Is it less than what would be required for the main hospital?

A: No, it is not less than what would be required for the hospital. The testing and inspection frequency of sprinkler systems is not determined by the occupancy they are installed in. The frequency is the same no matter what occupancy they are in. For accreditation purposes, the standard in which you maintain your sprinkler systems is found in NFPA 25 (1998 edition), which has the same frequency of testing and inspection as a sprinkler system for all occupancies, including hospitals. Annual sprinkler and piping inspections are required, as well as annual main drain tests, and annual exercise of the sprinkler system control valves. Semi-annual tamper-switch testing is required, and quarterly fire department connections are required, as well as quarterly water-flow switch testing. Fire pumps, if the building has one, must be tested weekly at no-flow condition, and annually for a flow-test condition. These are just a few of the common requirements that apply to all buildings that have sprinkler systems, regardless of their occupancy designation.

What you may be thinking of, but not saying, is the enforcement of the testing frequencies. NFPA 25 on testing procedures and frequencies applies to those off-site medical buildings and office buildings if they have sprinklers. Whether or not NFPA 25 is enforced by an AHJ is another question.