Feb 28 2018

Testing Requirements

Category: BlogBKeyes @ 12:00 am
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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.

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Jan 30 2018

GFCI Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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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.

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Jan 19 2018

Generator Testing

Category: BlogBKeyes @ 12:00 am
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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.

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Jul 22 2017

Follow-Up From an Earlier Post….

Category: BlogBKeyes @ 12:00 am
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I recently posted on documentation retention, and how long you should keep test/inspection records. A reader contacted me and said they attended a recent ASHE regional event where the speaker said the CMS K-Tags require some records to be kept for the life of the building, and the reader wanted to know if I was familiar with this requirement.

I said no, I was not, but I decided to get an answer direct from CMS themselves. I did receive a reply from CMS which is considered an informal non-public response, and here is a summary of what they said:

  • CMS has not issued any formal policy on retention of records for LS test/inspections.
  • Surveyors typically look back one (1) year to establish compliance.
  • However, the extent of the record review would consider the frequency of a particular test/inspection requirement.
  • If the test/inspection requirement was a monthly requirement, the surveyor may review 12-months’ worth of documentation to confirm compliance.
  • If the test/inspection requirement was an annual requirement, then the surveyor may review 3-years’ worth of documentation to confirm compliance.
  • In addition, retention of records would consider any NFPA, State, or manufacturer requirements.

It’s important to point out that there is a special requirement in NFPA 99-2012, section 5.1.14.4.1 that does require ‘permanent’ records of certain medical gas tests. Permanent would mean retention for the life of the building (or system), but section 5.1.14.4.1 only refers to initial system verification test records… not routine annual inspections. And it only applies to medical gas and vacuum systems, not other mechanical or electrical systems identified in NFPA 99.

CMS K-Tags 907 and 908 refer to a routine maintenance program and a test/inspection program for medical gas systems. These K-Tags says records are to be maintained as required. Since the K-Tags are a CMS product, they are obviously saying maintenance records and routine test/inspection records are to be kept long enough to establish a pattern of compliance. For annual test/inspection records, that would mean you must retain the records for 3-years, not necessarily for the life of the building.

Similarly, K-Tag 921 discusses a testing and maintenance program for electrical equipment, and it says records are maintained for a period of time to demonstrate compliance. This is consistent with the CMS informal comment that a ‘period of time’ would be 1-year for monthly requirements and 3-years for annual requirements.

Since accreditation organizations operate with the authority granted to them by CMS, it would be expected that the accreditation organizations would comply with the same requirements and informal policies as CMS.

But, I will fallback on what I believe: You should never throw away any records that demonstrate compliance with a regulatory requirement. That’s Brads opinion.

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Dec 23 2015

Joint Commission Quarterly Testing Requirements

Category: BlogBKeyes @ 12:00 am
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Q: Do you find that TJC only enforces the quarterly plus or minus 10 days from the MONTH of last test on quarterly inspections (instead of the day)? This is what others are learning at the JCR base camps evidently, and they showed me a page from their training book, which appears to show that TJC is using the ‘month of testing’ as the basis unlike we thought when first discussed.

A: You have touched on an issue that is very interesting. The Joint Commission standards say one thing, but the Joint Commission Engineering Department says something different.

To be sure, Joint Commission has always said that their official position is only found in their standards, in their Frequently Asked Questions and in their Perspectives magazine. No other Joint Commission or Joint Commission Resources publication is official. Therefore, when referencing their ‘official’ position on quarterly testing, we must look at their Hospital Accreditation Standards.

On page EC-3 of the Joint Commission 2015 Hospital Accreditation Standards (HAS) manual, it states: “Quarterly/every quarter = every three months, plus or minus 10 days”. This implies that if the last activity was March 15, then the next activity is due June 15, plus or minus 10 days. So the window for the next activity is June 5 to June 25, or 20 days.

There is no reference in the HAS manual that the “every three months” is from the month of the last activity, just the date of the last activity. Now, representatives from the Joint Commission Engineering department have stated at various times that they are interpreting the above requirement for quarterly testing to be 3 months from the month of the last activity (not the date of the last activity), plus or minus 10 days. This means if the last activity was March 15, then 3 months from March is June, so plus ten days is July 10 and minus ten days is May 21. So, based on this interpretation, you have an open window of 50 days instead of the tighter window of 20 days.

I believe the Joint Commission Engineering Department is honestly trying to help hospitals by making an interpretation that is easier for their clients to have larger window of opportunity for quarterly testing. And who can say that is wrong? But the basic premise is the HAS standards do not clearly state that this is the official interpretation. Since the Engineering Department’s interpretation is not cited in Perspectives, the Frequently Asked Questions, or in the Standards, then it is not official.

As long as the surveyors stick with the Engineering Department’s interpretation you should not have any problems. But what happens when a surveyor holds you accountable to what their HAS standards say? Then you have no recourse since the other interpretations are not official.

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Aug 05 2014

Research for an Article

Category: BlogBKeyes @ 6:00 am
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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…..

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Jul 17 2014

Follow-Up on Documentation

Category: BlogBKeyes @ 5:00 am
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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.

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Jul 03 2014

Smoke Dampers

Category: BlogBKeyes @ 5:00 am
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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.

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Jun 05 2014

Inaccessible Fire Dampers

Category: BlogBKeyes @ 5:00 am
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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.

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May 15 2014

Fire Alarm Test Reports

Category: BlogBKeyes @ 5:00 am
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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.

 

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