Fire Pump ATS

Q: A state surveyor cited us for not doing a monthly fire pump automatic transfer switch (ATS) test. We are doing a weekly churn test and an annual fire pump flow test that includes switching over the ATS. I was not aware that this had to be done monthly.

A: Yes… NFPA 110-1999, section 6-4.5 requires all transfer switches in Level I and Level II systems (hospitals typically have Level I systems) to be tested monthly. The state surveyor is correct. I find that it is not uncommon for some hospitals to overlook the ATS serving the fire pump. I guess they don’t always see that it is part of the Level I emergency power supply system. Out-of-site is out-of-mind!

Generator Batteries

Q: Recently I attended a meeting with our State Fire Marshall Department. One item which became a HOT topic of discussion was the monthly Specific gravity testing of the battery used to start up the generator. The Federal Regulation states that the cap should be unscrewed and then tested. Batteries are now sealed. The Fire Marshall’s response was that you peal off the sticker then pry the caps off. This triggers all kinds of issues, from a safety issue for employees to warrantees on the batteries. There are 3 battery monitoring procedures. 1. The annunciator for the generator monitors Low Battery and Low Charge. 2. Weekly monitoring of the 30 min test. 3. Monthly Load Testing I contend that this should be enough to support the monthly checking “Specific Gravity” checking. How do you see this to be?

A: What you’re referring to are newer style batteries that are sealed, and access to the electrolyte is not available, or necessary. But it really doesn’t matter what you contend or what I contend… it only matters what the State Fire Marshall will allow. It appears that they insist on specific gravity tests (i.e. electrolyte levels) so that is what you must do. You make a good case that opening a sealed battery is dangerous and voids the warranty of the battery. But NFPA 110-1999 Annex section A-6-3.6 says the specific gravity in the batteries must be recorded on a weekly basis.

However, section 1-4 of the same document does say that nothing in the document is intended to prevent the use of systems of equivalent or superior quality. You make a good point that the newer style sealed batteries are better than the older style that have caps and access to the electrolyte levels. One could argue that they are better than the older style. But this must be approved by the AHJ, which in this case is the fire marshal. Present a written plan to the fire marshal’s office and see if they will approve your plan to use sealed lead-acid batteries. Make sure it identifies the hardship, both financial and safety risk to staff, in using the older style batteries.

If they do not approve your plan, then I see no other choice that you have to purchase lead-acid batteries that has access to test the electrolyte levels as required by the AHJ. They are the authority and if you want their approval, then you have to do what they say. It is their prerogative to interpret the standards the way they see fit.

Engine Block Heaters

Q: A consultant told me that emergency generator rooms are required to be maintained at least 40 degrees F. Do I need to maintain that temperature if I have block heaters on the engine?

A: Yes, you do need to maintain at least 40° F ambient room temperature especially when you have engine water jacket heaters that maintains the temperature of the engine water at a minimum of 90° F. Section 5-6.7 of NFPA 110 (1999 edition) clearly states that the emergency power supply (EPS) room temperature must be at least 70° F unless you have water jacket heaters that maintains the water temperature of the engine at 90°F; then you are allowed to lower the EPS room temperature to 40°F. So, this would mean the room needs to be maintained at a minimum of 40°F.

NFPA 110

Q: Which edition of NFPA 110 are we expected to follow? I read that we’re expected to comply with the 1999 edition, the 2005 edition and now the 2010 edition. Which is correct?

A: The 2000 Life Safety Code references the 1999 edition of NFPA 110. The 1999 edition of NFPA 99 also references the 1999 edition of NFPA 110. Since CMS is still on the 2000 LSC, then the 1999 edition of NFPA 110 governs. However, Joint Commission standards references the 2005 edition of NFPA 110 for the 3-year, 4-hour load test, because this load test is not required in the 1999 edition of NFPA 110. Apparently, the accreditor feels the 3-year, 4-hour load test has value and wants their clients to comply with the load test. Joint Commission can do this since the addition of the 3-year, 4-hour load test is not in difference to the 1999 edition of NFPA 110; it is just an addition, so CMS allows it. HFAP and DNV have written similar standards that reference the 3-year, 4-hour load test found in the 2005 edition of NFPA 110.

But last year, CMS issued categorical waivers in their S&C memo 13-58 that will permit hospitals, critical access hospitals, long-term care facilities, ambulatory surgical centers, and inpatient hospices to use the provisions found in the 2010 edition of NFPA 110 immediately without waiting for the new LSC to be adopted. The 2010 edition of NFPA 110 will allow you to reduce the annual load test from 2-hours down to 90-minutes when the monthly load tests do not meet the 30% load capacity of the nameplate value. All of the accreditation organizations recognize and support this CMS position, but be aware that some state agencies do not.

The 2010 edition of the NFPA 110 is referenced by the 2012 edition of the Life Safety Code and will become the rule once the 2012 LSC is adopted. So, for the most part, the 1999 edition of NFPA 110 is the one to use, unless you’re Joint Commission or HFAP accredited, then you must also follow the 2005 edition of NFPA 110 for the 3-year, 4-hour load test. Also, you have the option to use the 2010 edition of NFPA 110 for the annual load test through the use of the CMS categorical waivers. Sounds confusing, but everyone will be on the 2010 edition of NFPA 110 once CMS adopts the 2012 edition of the LSC.

To download your own copy of the CMS S&C memos, go to:

Storage in Generator Rooms

Q: I cannot find a code reference that prohibits storage in the generator enclosure. Is there a specific reference for this in the 2000 edition of the Life Safety Code?

A: Sections 19.5.1 and 9.1.3 of the Life Safety Code (2000 edition) references NFPA 110 Standard for Emergency and Standby Power Systems, 1999 edition, section 5-2.1, which requires the generator to be installed in a separate room for Level 1 installations, which applies to hospitals. NFPA 110 does require a minimum 2-hour fire rating or the generator must be located in an adequate enclosure located outside of the building capable of resisting the entrance of snow and rain at a maximum wind velocity required by local building codes. No other equipment, including architectural appurtenances, except those that serve this space, is permitted in this room. In addition, section 5-2.2 of NFPA 110 does not allow generators to be installed in the same room where normal electrical equipment service is installed. These two sections are being interpreted by many national authorities whereby absolutely nothing is allowed in the same room as the generator. The good news (if there is any), the most recent edition of NFPA 110 (2010 edition) does allow small repair parts, tools and manuals in this generator room, but that edition will not be part of our accreditation process until CMS adopts the 2012 edition of the Life Safety Code. So for now, we must comply with the 1999 edition of NFPA 110.

Generator Rooms

imagesCA0CNZZFNFPA 110 (1999 edition) requires generators to be located in a dedicated room, separated from all other areas and spaces by 2-hour fire rated barriers. NFPA 110 is very clear that nothing else may be located, stored or mounted inside the generator room, which includes normal power distribution equipment.

NFPA 110 (1999 edition) does say it is not a retro-active code, meaning existing conditions may remain except where the authority having jurisdiction determines that nonconformity presents a distinct hazard to life. This is the catch for most national authorities for healthcare applications. The concern is if a generator shares a room with other mechanical equipment, and the other mechanical equipment causes a fire that disables the contents of the room, then the generator is out of service, or at least compromised. Since emergency power is critically important to sustain life in hospitals, most national AHJs are evoking that clause and requiring existing generator rooms to meet the full requirements of NFPA 110 (1999 edition).

Keep in mind, the whole purpose of that 2-hour fire rated barrier separating the generator from the rest of the hospital, is to protect the generator from the rest of the hospital; not to protect the hospital from the generator. The conventional wisdom is, if a fire starts on the outside of the generator room, the generators will operate for 2-hours before the fire breaks through. That should be enough time for the firemen to extinguish the fire and to evacuate the building, if need be.

So, nothing may be stored in the generator room, but NFPA 110 does permit the following emergency power supply system equipment in the generator room:

  • Energy converter (generator)
  • Day tank of fuel
  • Support equipment for the room (HVAC equipment, lighting equipment, etc.)
  • Conductors
  • Disconnecting means
  • Overcurrent protective devices
  • Transfer switches
  • Control devices
  • Supervisory devices
  • Support devices needed for the system to operate as a safe and reliable source of electric power

 The last term (support devices) can be interpreted to include necessary manuals and tools to safely operate the generator, but does not include tools to perform repairs, repair parts, discarded materials, replacement filters and oil.

Battery powered emergency lights are required in the room, connected to the load side of the transfer switch, whereby the lights will illuminate during a normal power outage. The room must be maintained to a temperature of not less than 70°F, unless the generator is equipped with a water jacket heater that maintains the engine temperature at 90°F. Where the generator is equipped with a water jacket heater, the room must be maintained at a temperature of not less than 40°F.

imagesF3QUS2EBThe amount of fuel required to be stored onsite for the generator is based on the amount of run-time. For generators located in seismic risk areas designated as Zone 3 or Zone 4 of the Uniform Building Code (see map, or Google ‘UBC Seismic Risk Map”), a minimum of 96 hours of fuel supply is required to be stored onsite. For generators not located in seismic risk areas Zone 3 or Zone 4, 26 hours of fuel supply is required.

Fire Protection of Equipment Rooms

Q: What is the fire rating supposed to be in the walls of the hospital equipment rooms, such as the generator room, boiler room, chiller rooms, and electrical rooms? We have a disagreement as to what is required and your answer decides who is correct.

A: According to NFPA 110 (1999), section 5-2.1, generator rooms are required to have 2-hour fire rated barriers that protects the room from fire outside the room. Any 2-hour fire rated barrier is required to have 90-minute fire rated doors and frame and if there are any HVAC duct penetrations through the 2-hour barrier, then the HVAC duct opening needs to be protected in accordance with NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating System, which would require a 90-minute fire damper. A boiler room is considered a hazardous area, and according to the 2000 edition of the LSC, sections 18/, the hazardous area is required to be protected with 1-hour fire rated barriers if it is considered new construction, or 1-hour barriers if it is considered existing and is not protected with sprinklers. Existing boiler rooms that are protected with sprinklers only require smoke resistant walls. All door openings in a 1-hour barrier are required to be ¾ hour fire rated, with fire rated frames. However, unlike the 2-hour barrier, a 1-hour fire rated barrier for a hazardous area is not required to have any fire dampers in a HVAC duct penetration, unless the HVAC penetration is not fully ducted. Electrical rooms typically are not required by the LSC to have fire rated barriers (walls), however NFPA 13 (1999 edition) Standard for the Installation of Sprinkler Systems, section 5-13.11 does permit an electrical room to be protected with 2-hour fire rated barriers in lieu of being protected with sprinklers. Therefore if the room does have fire rated barriers for any reason (including local or state building codes) then it would need fire dampers in the HVAC duct penetration if it is 2-hour fire rated or greater. Chiller rooms typically do not require fire rated barriers, unless the chillers are fuel-fired, then they would require the same protection as the boilers. As always, please check with your local and state authorities to determine if there are other regulations that may affect this situation.

Good Luck!

Fire Alarm Monitoring of the Generator

imagesFWTL2IM2Does your fire alarm system monitor the emergency power generator? It may have to. Section 1-5.8.7 of NFPA 72 (1999) requires the fire alarm system to monitor the primary and secondary power supplies for the presence of voltage at the point of connection to the fire alarm system. Failure to monitor either connected power supply should result in a ‘Trouble’ signal. Under normal power conditions, the emergency power from the generator is not connected, and therefore is not monitored. But when the emergency power is connected, it must be monitored, according to NFPA 72. However, there is an exception to 1-5.8.7 that says:

“The power supply of an engine-driven generator that is part of the secondary power supply, provided the generator is tested weekly in accordance with chapter 7”.

So, that means if the generator is tested weekly, then the generator is not required to be monitored. But Table 7-3.2 of NFPA 72 (1999) says engine driven generators must be tested monthly, not weekly. So is this a conflict in the standard? I looked at the 2010 edition of NFPA 72, and apparently the technical committee thought it was, as they corrected their table (Table 14.4.5 which is comparable to Table 7-3.2 of the 1999 edition) which now says the generator must be tested weekly, and Table (of the 2010 edition) on Test Methods, says the test must be in accordance with NFPA 110.

But NFPA 110 does not require weekly operational tests, only weekly inspections. They do require monthly tests of the generators. Again, is this another conflict? Perhaps not, as the frequency of the generator test (weekly) is determined by NFPA 72, but the methods and parameters of the test are determined by NFPA 110.

This is what is apparent to me: NFPA 72 requires the fire alarm system to monitor the voltage at the point of connection on both primary and secondary power supplies. The exception to this requirement for monitoring is if the generator is being tested weekly, but not many organizations are testing their generators weekly. If you are not testing the generators weekly, then make sure your fire alarm system is monitoring the voltage output of the generators when they are connected to the fire alarm system.

Is any national AHJ currently enforcing this issue at the moment? I am not aware that any of them are, but it is a NFPA requirement and healthcare organizations are required to be compliant with all NFPA standards referenced by the Life Safety Code. Better to be on top of this and have your fire alarm system compliant before one of the AHJs asks to see your documentation.


Enclosures for Emergency Generators

Q: Do emergency power generators have to be located in a room by themselves? We have a generator that is located in a mechanical room which is shared with an air-handler, condensate pumps and other equipment. This generator was installed in the 1970’s, but a consultant told us we had to relocate the generator to a 2-hour room where it can be located by itself.

A: NFPA 110 (1999 edition), section 5-2.1 says the generator must be installed in a separate room with a 2-hour fire rating, and no other equipment is permitted in the room. However, section 1-3 of the same standard says NFPA 110 only applies to new installations and existing systems are not required to conform to the standards, unless the authority having jurisdiction (AHJ) determines that nonconformity presents a distinct hazard to life. If the generator has been installed since the 1970’s and no AHJ has cited you for nonconformity, then I suggest it is safe to assume the AHJs that have inspected your facility do not have a problem with the arrangement. If an AHJ attempts to cite this situation for non-compliance with NFPA 110 (1999 edition) section 5-2.1, then I would make the case that it is not required to since this room was constructed long before NFPA 110 was in existence. NFPA 110 was first adopted in 1984 by NFPA, so it was not part of the Life Safety Code until probably the 1985 edition.  Therefore, it may be assumed it met the standards that were in existence in the 1970’s when the building was constructed.

Changes to Joint Commission Standards for 2014: Part 2


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.