Nov 07 2013

Changes to Joint Commission Standards for 2014: Part 2

Category: BlogBKeyes @ 5:00 am


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-, and the LSC (2000 edition) section 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.

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Oct 31 2013

Changes to Joint Commission Standards for 2014: Part 1

Category: BlogBKeyes @ 6:00 am

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.


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May 16 2013

Monthly Elevator Recall Test

Category: BlogBKeyes @ 6:00 am

Elevator RecallOne of the requirements that CMS and Joint Commission surveyors is requesting from hospitals and nursing homes is documentation that the elevators have been tested  for ‘Recall’. Elevator recall is a test that the Life Safety Code requires to be accomplished on a monthly basis. Section 9.4.6 of the 2000 edition of the LSC says all elevators equipped with Fire Fighter Service shall be subject to a monthly operation. Now, the phrase ‘elevator recall’ is a bit of a misnomer, as the monthly test requires activating all of the Fire Fighter Service functions, not just the recall portion.

LSC sections 18/19.5.3 requires compliance with section 9.4, which in turn requires all existing elevators that travel a distance of 25 feet or more above or below the level that bests serves the needs of the emergency personnel, to comply with the Fire Fighter Service Requirements found in ASME/ANSI A17.3 Safety Code for Existing Elevators and Escalators. This code references other ASME/ANSI publications which describes the specific requirements for the installation of Fire Fighter Service for the elevators. Furthermore, LSC section 9.4.6 requires the Fire Fighter Service in each elevator to be tested once a month with a written record of the test and findings maintained on the premises. The elevator recall portion is commonly referred to as “Phase 1” and the in-car manual control system for fire-fighters is commonly referred to as “Phase 2”. Both phases, if equipped, must be tested for each car. Please check with your local and state authorities on the qualifications to conduct this test, as some AHJs only permit trained or certified individuals to conduct this test.

If you have never performed this Fire Fighter Service test, then I suggest you have your elevator maintenance company show you how it is done the first time, then you can continue to do it on a  monthly test. But, in lieu of that, here is how a monthly elevator recall test is performed:

  1. Take a copy of the elevator recall key, insert it in the corridor keyed switch on the level best used by the responding fire department, and turn it to the “Test” position. This key should be available from the elevator service company.
  2. This will recall all the elevators in that bank of elevators to the floor that you are on. The elevator will ‘recall’ to that floor and open the doors. The controls inside the elevator will not respond and the elevator car will sit there waiting for a fire fight to take control. The elevators will be “out of service” during this test, so plan on doing this test when it will least impact your operations.
  3. Remove the key from the recall corridor switch (leave it still in the “Test” position) and enter one of the elevator cars. Take the key and insert it in the keyed switched labeled “Fire Fighter Service”, and turn it to the “Test” position (I think it will say “Test”, but if not, turn the switch anyway). Now you have manual control on the elevator buttons inside the car.
  4. Push a button to another floor, holding it until the doors closed. The elevator will travel to that floor, but the doors will not open. If you push the “Door Open” button, then the doors will open, and stay that way until another floor button is pressed.
  5. While in the elevator car, test the function of the emergency telephone in the car.
  6. Return the elevator car to the recall floor, and test any other cars in that bank. Remove the key and go back to the corridor switch and return the switch to the normal setting.

That is a monthly ‘Elevator Recall’ test, which must be done each month to all elevators. You may find that the fire alarm system will become alerted during this test and before the elevators return to normal service you may have to reset the fire alarm system.


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Aug 28 2012

Main Drain Tests- Part 1: Why Are They Required?

Category: BlogBKeyes @ 5:00 am

Main drain tests are required by section 9.7.5 of the 2000 edition of the Life Safety Code, which requires sprinklers systems to be tested and maintained according to NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition.  The purpose of a main drain test is covered in the Annex section A-9-2.6, of NFPA 25, which says:

“…(main) drains also are used to determine whether there is a major reduction in waterflow to the system, such as might be caused by 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 previous tests) 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 Annex section A-9-2.6 also continues to describe what a main drain test is:

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”

I find that many hospitals, especially the older hospitals, do not have the requisite pressure gauge, drain valve and a suitable drain to collect the substantial flow of water to properly conduct a main drain test. Also, I always recommend to my clients to shut off the fire pump and leave on the jockey pump during the main drain tests. Shutting off the fire pump for this test constitutes an impairment, and appropriate interim life safety measures must be considered, according to the organization’s policy.

Please be aware that a main drain test is required downstream of any control valve that has been closed, then opened. Also starting with the 2002 edition of NFPA 25, a single quarterly main drain test is required downstream of all backflow preventers in the system. This will be a requirement once the 2012 edition of the Life Safety Code is finally adopted.

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