Testing Requirements

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

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

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

What’s the Standard?

Q: In regards to your answer last week requiring plastic coffee pots to be inspected, is this a code requirement or just a ‘best practice’? I’m not talking about equipment patients touch or are treated with… would computers be a part of electrical safety test?

A: This is not a standard. This is an interpretation by CMS. According to the CoP for acute-care hospitals, §482.41(c)(2) says:

“Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.”

The Interpretive Guidelines for this section says:

“The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner that provides an acceptable level of safety and well-being of patients, staff and visitors.”

The way CMS has interpreted this in the field in the past, is they expect all electrical devices, including computers, to be electrically checked first before placed into service. CMS does not expect all consumer items to be placed in the plant inventory, but they do expect the facility to be maintained to ensure an acceptable level of safety. While some accreditation organizations do not enforce this level of scrutiny, I have observed many state agencies who survey on behalf of CMS do enforce this level.

It’s up to you…. If you choose not to do this, you probably will not be cited for a finding under an accreditation survey. But you would take your chances with a CMS validation survey.

Changes to the 2018 Life Safety Chapter

A lot has been said and written concerning the changes that Joint Commission has made in regards to their Life Safety chapter for acute-care hospitals, and for good reason. CMS has been working with the accreditor to make changes and additions to bring the LS chapter up to their expectations. So far, it has been a long and arduous project, but we now have the results of Joint Commission’s hard work: The Life Safety chapter of the 2018 Comprehensive Accreditation Manual for Hospitals.

Nearly every standard in the new LS chapter has received some change or addition with their elements of performances (EPs). We have compared the new chapter to last year’s version and summarized all of the changes and additions found in the new 2018 chapter.

If you are interested in reading about all of the changes in a summary format, go to “Tools” on this website, and look for the “Changes to the 2018 Joint Commission Life Safety Chapter” subheading and down-load the free 9-page .pdf document that describes all of the changes that you need to know for 2018.


Hazardous ER Department

Q: In a hospital emergency department, can the corridors be 6 feet wide? Can the hospital install an 18-inch deep lockable computer cabinet in the 8 foot ED corridor?

A: Well… It depends.

If you claim the ER is a suite, then there would be no problem with a cabinet in the 8-foot wide hallway…. Because there are no corridors in a suite. What looks like a corridor in a suite is a communicating space and you would only have to maintain 36-inches clearance for aisles.

But if the ER is not a designated as a suite, then you must maintain corridor widths. But the required width of the corridor is different depending on the occupancy classification of the ER. CMS has said that Emergency Departments must be classified as healthcare occupancies (HCO) if the ER has patient observation beds. CMS’s logic on this is if patients are under observation in the ED, then they consider this patient sleeping accommodations. In this logic, then all areas providing patient sleeping accommodations must be healthcare occupancies, and the required width of the corridor must be 8-feet.

However, CMS does permit the Emergency Department to be classified as an ambulatory health care occupancy (AHCO) if the ER does not contain any patient observation beds. Then the corridor width is only required to be 44-inches wide.

But keep in mind, the maximum corridor projection permitted by CMS is 4-inches. If your ER is not designated as a suite, then you must maintain corridor widths (either HCO widths of 8-feet, or AHCO widths of 44-inches) and you cannot have corridor projections more than 4-inches, and the cabinet would not be permitted.

Fully Sprinklered Buildings

Q: Our facility is a four story facility, and is a combination of different structures built in different years. All of the different structures are protected with sprinklers except for our power plant. Our power plant is 24 hours manned and has Fire Alarm System devices installed or equipped. Do we need to ask for a waiver as per the new NFPA 101 2012 edition that is to be implemented this year?

A: Existing healthcare occupancy buildings are not required to be fully protected with sprinklers. There is no requirement with the new 2012 LSC to install sprinklers in existing buildings (unless the building is a high-rise) so there is no need to ask for waivers.

Now, it is very desirable for healthcare occupancy buildings to be fully sprinklered because if they are, it allows you to do many terrific things. Take a look at the following 2012 Life Safety Code references, which describes the many advantages of having a fully sprinklered building:

  • – Delayed egress locks are allowed only if the entire building is protected with sprinklers or smoke detectors
  • – Capacity factors for egress components improve if entire building is sprinklered
  • 7.7.2 – No more than 50% of required exits may discharge through the level of exit discharge if area is sprinklered
  • – A hazardous area may not have to have 1-hour fire rated walls if protected with sprinklers (Note: This does not supersede section 18/
  • – Class C interior finishes are permitted in locations where Class B is permitted, and Class B interior finishes are permitted in locations where Class A is permitted, provided the area is protected with sprinklers. (Note: This does not supersede section 18/
  • – Class II interior floor finish is permitted in locations where Class I is permitted providing the area is protected with sprinklers.
  • 10.3.3 – Upholstered furniture must meet the requirements in accordance with NFPA 260 and NFPA 261, unless the furniture is located in rooms protected by sprinklers.
  • 10.3.4 – Mattresses must meet the requirements in accordance with Part 1632 of the CFR 16, and NFPA 267, unless the mattresses are located in a room that is protected with sprinklers.
  • – Lesser levels of Construction Types are permitted if the entire building is protected with automatic sprinklers.
  • Travel distances between any point in a room and the exit increases by 50 feet if the entire building is protected with automatic sprinklers
  • Hazardous areas are not required to be 1-hour fire rated if the walls are smoke resistant and area is protected with automatic sprinklers
  • – No interior floor finish requirements apply in smoke compartment protected with automatic sprinklers
  • – Areas open to the corridor are afforded exceptions if the smoke compartment is protected with automatic sprinklers
  • – Corridor walls are not required to be ½ hour fire rated provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Corridor doors do not have to be 1 ¾ inch thick, solid-bonded wood core or of construction that resists fire for not less than 20 minutes provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Smoke dampers are not required in fully ducted penetrations of smoke barriers provided both smoke compartments served by the barrier is protected with automatic sprinklers.

By the way, CMS will not consider a waiver request until such time the Life Safety Code deficiency has been cited in a report. So, don’t plan on submitting a waiver request until after you have been cited.

Decontamination Activation

Q: Is there a specific time-limit required by the accreditation organizations for decontamination purposes, from activation of a drill to being able to put victims through a decontamination tent?

A: While there is no specific standard which spells out the amount of time required to set-up a decontamination tent, the time-frame must be evaluated to determine its effectiveness.

The emergency management standards require an effective disaster plan which must be written and educated to the staff of the organization. These same standards require disaster drills that are evaluated by observers for effectiveness. The results of the drill observations must be relayed to the Safety Team which uses the information to improve the hospital’s capacity to respond to disasters. The whole disaster response process includes an on-going evaluation to determine the effectiveness of the organization’s emergency response efforts.

So, while the amount of time to set-up a decontamination tent and run your first patient through is not specified, the catch-all is it must be effective. You may ask who judges whether or not the amount of time is effective? First, the hospital makes that determination but ultimately, the surveyor may make a judgment on that as well. If a surveyor decides that the amount of time to set-up a decontamination tent is too long, then that can lead to a finding.

The bottom line: Run a disaster drill which includes setting up the decontamination tent, and make an evaluation of the time it took from the start of the drill to when a patient can first use the tent. Report that process to your safety committee, and have them decide if it is an adequate amount of time. If the safety committee decides it is adequate, then there is a good chance the surveyor will view it the same.

CMS Waiver Approval

Q: If a building changes ownership, do waivers stay active with their 1-year window or do the new owners have to resubmit if the building is cited the same deficiency?

A: Interesting question… I’ve never had this issue come up before.

My guess would be the waivers would be valid only to the organization for which they were approved. The way that CMS writes their approval letters is the approval of the waiver is addressed to the healthcare organization, and not to the building owner. In other words, CMS grants approval to the healthcare organization to not have to comply with a particular section of the Life Safety Code. This approval would not appear to be transferrable, since it is addressed to the healthcare organization.

But if the ownership of the healthcare organization changes hands, then I could see where the waiver approval would follow the healthcare organization. CMS tracks the waiver requests and the subsequent approvals via their own CMS Certification Number (CCN), which is assigned to healthcare organizations, not their owners.

To answer your question, if a deficiency is cited and the healthcare organization chooses to submit a waiver request rather than resolve the deficiency, then yes, a new waiver request would have to be submitted.


AEM Program for Fire Alarm and Sprinklers

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the fire system inspections could be considered preventive maintenance or at least the means to determine what maintenance needs to be completed. Can we use the CMS AEM program to alter our PM activities on the fire alarm and sprinkler systems?

A: You cannot use the CMS AEM program for Fire Alarm inspection and testing requirements. The CMS S&C letter 14-07 that describes the AEM program says the following regarding when the AEM program is not appropriate: “Other CoPs require adherence to manufacturer’s recommendations and/or set specific standards. For example: The National Fire Protection Association Life Safety Code (LSC) requirements incorporated by reference at 42 CFR 482.41(b) has some provisions that are pertinent to equipment maintenance, and compliance with these requirements are assessed on Federal surveys.”

So… you must follow the NFPA requirements specified for sprinkler and fire alarm testing and inspection, and the AEM program is not applicable.

Power Strips

Q: There is so much discussion on the proper use of power strips that it can cause confusion amongst even the seasoned facility managers. There is absolutely no guarantee that the different power strips will remain in their ‘designated areas’. The OR is much easier to control, but as technology quickly progresses, the space between patient care vicinities and non-patient care vicinities quickly losing the defined lines. What’s your thoughts on the power strip issue?

A: I do see your point that power strips may be difficult to control as they may move around the hospital, in and out of patient care vicinities. And I respect your comment that there is confusion on the proper use of power strips. But I find CMS’ explanation regarding power strips under their K-Tag 920 to be refreshingly simple:

  • Power strips in a patient care vicinity are only used on movable patient-care related electrical equipment and are permanently attached to the equipment, and are UL 1363A or UL 60601-1.
  • Power strips in a patient care vicinity may not be used for non-patient-care related electrical equipment, such as personal electronics, except in long-term care resident rooms that do not use patient-care related electrical equipment.
  • Power strips for patient-care related electrical equipment must meet UL 1363A or UL 60601-1.
  • Power strips for non-patient-care related electrical equipment in the patient care rooms, but outside of the patient care vicinity, must meet UL 1363.
  • In non-patient care rooms, power strips meet other UL standards.

Section 3.3.139 defines “patient care vicinity” as a space, within a location intended for the examination and treatment of patients, extending 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extending vertically to 7-foot 6-inches above the floor.

It appears K-Tag 920 is permitting qualified personnel to permanently attach UL 1363A or UL 60601-1 power strips to movable patient-care related electrical equipment, provided it meets section of NFPA 99-2012, which is:

  • The power strip is permanently attached to the equipment assembly;
  • The sum of the ampacity of all appliances connected to the outlets does not exceed 75% of the ampacity of the flexible cord supplying the outlets;
  • The ampacity of the flexible cord is in accordance with NFPA 70-2011, National Electrical Code.
  • The electrical and mechanical integrity of the assembly is regularly verified and documented.

This section does not explain what makes one “qualified”, so that determination should be left to the AHJ and the healthcare facility. While NFPA 99-2012 does not specify how frequent “regularly verified” means, the general consensus is annually, based on annual receptacle inspection requirements in Chapter 6.

You will note that section (5) was deleted per Tentative Interim Amendment (TIA) 12-5.

K-Tag 920 is also clear that outside of a non-patient care room (i.e. OR, PACU, procedure room, patient sleeping room, etc.) CMS no longer regulates which UL power strip to use on non-patient-care related electrical equipment, other than it must be UL listed. That means a power strip used at a nurse station on office equipment, or in an office environment does not have to be UL 1363, UL 1363A, or UL 60601-1; it just has to be UL listed.

Contractors During a Survey

In preparation for a survey hospitals frequently train their staff to only answer the questions of the surveyors without providing any more information. This has proven to be good advice over the years because many deficiencies are discovered by surveyors based on information provided by the staff after they have answered the surveyor’s questions.

An example of this may be when a surveyor asks a hospital worker what they would do in the event of a fire, and the worker correctly replies by describing the actions suggested by the acronym RACE – Rescue, Alarm, Confine, and Extinguish (or Evacuate). But when the surveyor simply does not respond and the awkward silence builds, the hospital worker gets a bit nervous and continues to speak, eventually revealing some errant activity that is not part of the fire safety plan. That often opens the door for disaster.

Nowhere is this more dangerous than when surveyors are permitted to talk with contractors in the hospital. It has always been my belief that as the survey team walks in the front door of the hospital on the first day of the survey all of the contractors should be walking out the back door. For the most part (and I do understand that there are exceptions), contractors should be sent away once you know there are surveyors in the house. Why? Because they will get you in trouble one way or another.

I recently received an email from a reader who shared this story:

During our triennial survey the life safety surveyor asked me how we knew that the fire alarm system signal was received by our monitoring company. I could not immediately answer the question, but we were lucky to have the service contractor in the building doing his quarterly testing and I suggested we ask him.

 The service technician explained that the software in the fire alarm control system will indicate if the alarm is received by the monitoring company within the designated amount of time. I was quite happy with the service technician’s explanation until the surveyor said “Prove that it happened at least quarterly for the past 12 months”. [This was back when the signal was required to be tested quarterly… today it is only required to be tested annually.]

 The service technician said nobody could prove it; we just have to take his word for it. [Wrong answer.] The surveyor asked “Don’t you call them by telephone to confirm they received the signal?” The service technician replied, saying “Well, would you trust me if I said I did call?”

The surveyor was correct to ask the questions that he/she did. The service technician was probably answering them to the best of his ability, but the real problem is the facility manager allowed the surveyor to enter into a conversation with a contractor. During a survey, the hospital staff should try and control the process as much as possible. By allowing a surveyor to ask questions of a contractor, the facility manager lost control of the situation and will suffer any consequences of what a contractor may say.

Contractors are not trained and educated in the regulatory requirements the same way the hospital staff are (or should be). The contractors may not even know or understand the significance of an accreditation survey, or even a CMS certification survey. Service technicians have a tendency to take an attitude that they know more about the system they are working on than the hospital does, and for the most part they do; otherwise, the hospital would not hire them. But the service technician may not know what specific regulations that the hospital must comply with and therefore may say something to a surveyor that may get you in trouble.

I’m not saying you should not be transparent in your processes, but during a survey, you need to control as much as you can of the survey process. This is not unethical or wrong; it is just smart business. Let the surveyor go where he/she wants; let the surveyor ask questions all they want; but eliminate the potential “loose cannons” that are not very well educated on the survey process by sending them home during the survey.

Another reader sent me an email earlier this year explaining that on a day during the accreditation survey a roofing contractor set a pallet of roofing material right in the middle of the exit discharge of a staff entrance/exit to the hospital. Nobody from the hospital was aware that the roofing contractor was about to do that, but the surveyor noticed it as soon as it happened and it went into the survey deficiency report.

When I was a surveyor for The Joint Commission, I would purposely seek out contractors and ask them what training the hospital provided them on fire safety procedures. Ultimately, contractors are expected to know the same fire response procedures as the staff. Invariably they could not answer the question satisfactory and it would be cited in the survey deficiency report.

I know that in some situations you cannot send the contractors home for the duration of the survey, but it seems that a large percentage of them could. At the hospital where I worked as the Safety Officer, I asked the project management team to send the contractors away during the week of the survey (this was when the surveys were announced). The project managers thought that was a good idea, but we were over-ruled by the COO of the hospital, because he did not want the opening of the new renovated unit to be delayed. That ended up being a costly mistake.

The hospital had a policy that every contractor had to receive basic safety orientation before they begin their work on the campus of the organization. Unbeknownst to the hospital, the general contractor brought in a sub-contractor to install flooring in one area, and they did not go through the safety training because the general thought it would be “okay” since the sub was only going to be there for one day. Sure enough, the surveyor found that one sub who had not received the safety training which led to a finding on the survey deficiency report.

You need to control what you can, and sending the contractors away is the smart thing to do during a survey.