NFPA 99 Risk Assessment

Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never had an assessment done in the past but it is my understanding that it became a requirement in 2016. The CMS has established compliance requirements (K Tag) for risk assessment and its completion. Who would be the qualified personnel to perform this procedure and create a formal and documented risk assessment?

A: According to members of the Technical Committee who wrote the new Chapter 4 in NFPA 99-2012, the original intent was the risk assessment only applies to new construction. However, the way chapter 4 is written, it is not clear that the risk assessment is only applicable to new construction.

CMS has instructed the accreditation organizations and the state agencies who survey on the behalf of CMS to require all hospitals to have completed their NFPA 99 risk assessment for new as well as existing construction. Therefore, hospitals must conduct the risk assessment for new and existing conditions. These assessments are not difficult to do and only takes a few minutes.

There is no requirement to make a room-by-room assessment, but the intent is to assess the risk of the entire system if it were to fail and there were no back-up systems. It would stand to reason that most hospital systems would be Category 1 or Category 2. Anyone may conduct the assessment, but would have to have knowledge of the risk assessment process and knowledge of the facility.

Risk Assessments

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk level on the impact to patients/staff assuming the item being assessed would not be available or functional? We are performing a risk assessment on facility systems and medical equipment and are wondering what the standard is in the approach.

A: It sounds like you’re referring to the NFPA 99-2012 risk assessment for building system categories. If so, then the assessment is conducted with the assumption of the worst-case scenario, whereby the systems being evaluated fail and back-up systems (i.e. emergency power generators) fail as well. According to section A.4.1 of NFPA 99-2012, the category definitions apply to equipment operations and are not intended to consider intervention by caregivers or others. Also, the Introduction to Chapter 4 in the NFPA 99-2012 Handbook, the authors say:

“Each system must be evaluated for its impact on both the patients and the caregivers if the system should fail. Based on the worst-outcome scenario of a failure’s impact, the system is assigned a category. The chapter on that system the describes the requirements for the selected category.”

Be aware that the chairman of the Technical Committee who wrote this new chapter 4 for NFPA 99-2012 told me the intent was for the risk assessment to be on new equipment only, and existing equipment was exempted. However, chapter 4 of NFPA 99-2012 does not say that, and CMS is requiring all certified hospitals to have this risk assessment conducted on existing equipment as well as new. So, I recommend to my clients to do the assessment (it only takes a few minutes) on all existing and new equipment until such time CMS changes their minds.