Jun 18 2018

Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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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.

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Jun 06 2018

Monthly Fire Pump Test

Category: BlogBKeyes @ 12:00 am
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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.

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May 30 2018

Generator Testing

Category: BlogBKeyes @ 12:00 am
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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.

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May 23 2018

Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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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.

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Feb 28 2018

Testing Requirements

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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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