© Copyright, The Joint Commission 2009 The Physical Environment Overview Environment of Care Emergency Management Life Safety Chapter Q & A George Mills,

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2009

The Physical Environment

Overview Environment of Care

Emergency Management Life Safety Chapter

Q & AGeorge Mills, Sr. Engineer

Standard Interpretation Group

The Joint Commission

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Overview

Standards Improvement Initiative (SII)

SIG Engineering 2009 - 3

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Re-structuring Highlights

SII did not create any new requirementsDeeming language added for clarity

Replaced bulleted lists with expanded Elements of Performance

Enhance clarity and objectivity of standards and EPsRemoved words like “appropriate”

New numbering conventionsEC.02.04.03 EP 2 The organization inspects,

tests & maintains all life support equipment. These activities are documented. (See also EC.02.04.01 EPs 3 &4; PC.02.01,11 EP 2)


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Re-structuring Environment of Care (EC)

Merging Safety & Security Training moved from HR to EC

Life Safety Chapter (LS)Compliance with the Life Safety CodeMoved ILSM from EC

Emergency Management (EM)Major changes in 2008 Hazard Vulnerability Analysis (HVA)Emergency Operations Plan (EOP)


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CMS Deeming Issue Joint Commission is required to reconcile

our Elements of Performance (EP) with CMS Conditions of Participation (COP)

COPs are the expectations of compliance CMS has related to Medicare/Medicaid reimbursements COPs are federal laws

To reconcile the Joint Commission has added 5 additional EPs

None of these are beyond the current expectations of the Joint Commission


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CMS Deeming Issue: Specifics EC.02.02.01 EP 14

Testing badges for exposure from radiology EC.02.02.01 EP 15

Free from ionizing hazards for patients & staff EC.02.04.03 EP 14

Staff maintain nuclear medicine equipment annually

EC.02.06.01 EP 20 Environment is clean, sanitary and free of

odors LS.01.01.01 EP 4

Maintain documentation of any inspections or approvals by AHJs related to fire safety

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Scoring


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Scoring & Decision Process Scoring Scale

0 = Insufficient Compliance 1 = Partial Compliance 2 = Full Compliance

Requirement for Improvement (RFI) All findings of less than full compliance will

be cited as a RFI All RFIs require resolution through an

Evidence of Standards Compliance (ESC) This includes findings scored partial “Supplemental Findings” (2008 term) are

eliminated


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EP Scoring Categories

A: Structural requirements EP’s scored yes (2) or no (0) May address issues requiring full

complianceC: Based on number of times an EP is not met

Score 2: 0-1 instances of non-compliance Score 1: 2 instances of non-compliance Score 0: > 3 instances of non-compliance

Above is based on a sample of 10

NOTE: The ‘B’ Category has been eliminated


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Example: Category A

EC.02.04.02 EP 2: The hospital inspects, tests &

maintains all life support equipment. These activities are documented.

Did you do it? Yes or No [100%]Is there documentation?


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Example: Category C

EC.02.04.02 EP 3: The hospital inspects, tests & maintains all non-life support equipment identified on the medical inventory. These activities are documented.

How many times did you not do it? Is there documentation?


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Criticality of Findings & Immediacy of Risk

The amount of time for submitting the ESC is based on the criticality of the finding and the immediacy of risk as follows:

Direct Impact 45 Within Days

Indirect Impact 60 Within Days


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Criticality

Criticality defined as “the immediacy of risk to patient safety or quality of care as a result of noncompliance with a Joint Commission requirement.”

4 Levels of Criticality1. Immediate Threat to Life (ITL)

PDA until resolved2. Situational Decision Rules

Based on specific situations at time of survey 3. Direct Impact Requirements

Noncompliance may create an immediate risk to patient safety or quality of care

4. Indirect Impact Requirements Based on planning and evaluation or care processes


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2009 Scoring Decision Model

ITLPDA until resolved

“Situational” Decision Rules

CON & PDA

Direct Impact Requirements “Implementation” Based Requirements

(Short Resolution Timeframe)

Indirect Impact Requirements “Planning” and “Evaluation” Based Requirements

(Longer Resolution Timeframe)

Immediacy of risk to patient care and the organization’s

certification status

Lower

Higher

Timeline for resolution of non-compliant findings

Shorter

Longer


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ITL


Direct Impact Requirements

Indirect Impact Requirements

Immediate Threat to Life Situations, identified during survey, which have or may potentially have a serious adverse effect on patient health and safety.The Joint Commission President can issue an expedited Preliminary Denial of Accreditation (PDA) decision.PDA remains until corrective action is demonstrated, via an on-site validation review.PDA changes to Conditional Accreditation which includes a follow-up review to assess sustained implementation of corrective action.Examples:

Inoperable fire alarm system Lack of Master Alarms for

Medical Gas System



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ITL




Situational Decision Rules Situations in which a decision of PDA or CON is recommended to the Accreditation Committee Demonstration of resolution through submission of Evidence of Standards Compliance (ESC).Onsite review to validate implementation of corrective action. Examples:

Failure to implement corrective action in response to accepted PFI

unlicensed facility


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ITL




Direct Impact RequirementsNon-compliance results in direct impact on quality of care and patient safety“Implementation” based requirementsNon-compliant requirements must be addressed via ESC submission process

Short time-frame (45 days)Decision is pending submission of ESC within established timeframeFailure to resolve results in progressively more adverse decision (e.g., Provisional, Conditional, PDC)Example:

Inspects, tests & maintains Life Support Systems


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ITL




Indirect Impact RequirementsInitially less immediacy of risk; failure to resolve non-compliance increases risk“Planning” and “Evaluation” based requirementsNon-compliant requirements must be addressed via ESC submission process

Longer time-frame (60 days)Decision is pending submission of ESC within established timeframeFailure to resolve = progressively more adverse certification decision (e.g., Provisional, Conditional, PDC)Examples:

Piping used for AASS is not used to support any other item

Hospital provides storage space to meet patient needs


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Direct Impact Count Environment of Care

38 Direct Impact Life Safety Chapter

7 Administrative (LS.01)20 Healthcare (LS.02)56 Total (62 ‘z’ items in 2008)

Emergency Management 3 Direct Impact


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Internal Intensive Review Quantitative measure for identifying organization

whose survey findings should be subject to a more intensive review by Central Office

Bands of screening points have been established to adjust for differences in size and complexity

HAP Screening Points: # Non-compliant Surveyor Days Direct Impact Stds

1 – 4 75 – 6 87 – 9 910 – 13 11> 14 13

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Survey Process


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Life Safety Code Specialist

LSCS Background Facilities or Environment of Care based Prefer CHFM certification

LSCS Agenda On-Site one day (typically on day 1 or day 2) Interfaces with survey team member(s)

LSCS Focus EC.02.03.05 Fire Protection Systems EC.02.05.07 Emergency Power EC.02.05.09 Medical Gas and Vacuum LS.01.01.01 Life Safety Code LS.01.02.01 Interim Life Safety Measures (ILSM)


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Life Safety Code Specialist Update

Other EC “Observations” May also survey

LD.04.01.05 EP 4 LD.03.03.01 EP 4 LD.04.04.01 EP 2

Greater than 750,000 sq ft second survey day for the LSCS

Greater than 1.5 million sq ft third survey day for the LSCS [PROPOSED for 2009]

Critical Access Hospitals ONLY: Survey EC, LS and EM


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Observed but Corrected on SiteFirst and foremost, Surveyors, Reviewers, and LSCS must

use their professional judgment. Draw upon your critical thinking skills that have been honed throughout your careers. Findings that are appropriately documented as "Observed but Corrected On-Site" have the following characteristics:

The deficiencies are easily corrected and do not pose a significant threat to patient safety.

The correction should not require any organizational planning or forethought

The practice is correct but the policy needed amending to coincide with the practice, so the policy was amended

Corrections to a form that was missing an element or piece of information and the change would not impact the process


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Correct Use of “Observed but Corrected on Site” Gap in ceiling tile that is repositioned Stretcher or gurney blocking medical gas shut-

off valves that could easily be moved Food cart parked in front of a fire extinguisher

but can be easily moved Partially burned out exit light that is corrected

on discovery A few cigarette butts on the roof near a piece

of equipment Refrigerator logs missing a few dates, but

temperatures before and after missing dates are within range—no evidence of any trends (could be applied to other types of logs)


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When NOT to allow “Corrected on Site” Penetrations in a rated barrier A policy is written or amended during survey that

requires change in practice, education of staff and/or implementation

Adding a suicide risk assessment to an assessment form (would require careful consideration of the population served, education of the staff in terms of conducting the assessment, etc)

Multiple fire doors fail to latch Refrigerator logs with temperatures out of range

and no apparent action to correct or determination if medications or food are appropriate for use


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Time Defined

For the Physical Environment the Joint Commission has defined time in the Introduction of the EC chapter:

Daily, weekly, monthly and quarterly are calendar references

Semi-annual is 6 months from last occurrence +/- 20 days

Annual is 12 months from last occurrence +/- 30 days


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Does Every mean Every ? EC.02.03.05

EP 2 Every 6 months the hospital tests valve tamper switches and water-flow devices. The completion date of the test is documented. Every 6 months +/- 20 days

EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented. Every 12 months +/- 30 days

At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented. Tested within the calendar month

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Environment of Care


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Environment of Care: Structure Plan (EC.01.01.01) Implement

Safety and Security (EC.02.01.01, 02.01.03) Hazardous Materials and Wastes (EC.02.02.01) Fire Safety (EC.02.03.01, 02.03.03, 02.03.05)Medical Equipment (EC.02.04.01, 02.04.03) Utilities (EC.02.05.01, 02.05.03, 02.05.05, 02.05.07, 02.05.09)

Other Physical Environment Requirements (EC.02.06.01, 02.06.05)

Staff Demonstrate Competence (EC.03.01.01) Monitor and Improve (EC.04.01.01, 04.01.03, 04.01.05)


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Environment of Care: Issues

EC.01.01.01: The hospital plans activities to minimize risks in the environment of care. Note: One or more persons can be assigned to

manage risks associated with the management plans described in this standard.

EP 3 The hospital has a written plan for managing: environmental safety of everyone who enters the hospitals facilities

EP 4 The hospital has a written plan for managing: security of everyone who enters the hospitals facilities


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EC.02.01.01 EPs 1 & 3

1 The hospital identifies safety & security risks associated with the environment of care. Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high risk processes, and from credible external sources such as Sentinel Event Alerts.

3 The hospital takes actions to minimize or eliminate identified safety and security risks in the physical environment.


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Medical EquipmentEC.04.01.01 The hospital manages medical

equipment risks. EP 1 The hospital solicits input from individuals

who operate and service equipment when it selects and acquires equipment.

EP 2 The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory. (see also EC.01.01.01 EP 7)


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Utilities Management

EC.02.05.01 EP 3 The hospital identifies in writing inspection

and maintenance activities for all operating components of utility systems on the inventory. (See also EC.02.05.05 EPs 3 – 5 and EC.02.05.09 EP 1)

NOTE: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability-centered maintenance, interval based inspections, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.


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EC.02.05.07 EP 4 Twelve times a year, at intervals of

not less than 20 days and not more than 40 days, the hospital tests each generator for at least 30 continuous minutes. The completion date of the tests is documented.


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EC.02.05.01, EP 4 The [organization] defines in writing

intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory based upon criteria such as manufacturers’ recommendations, risk levels, and current hospital experience.


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Built Environment Interior spaces meet the needs of the patient

population and are safe and suitable to the care, treatment and services provided

Lighting is suitable for care, treatment and services

Hospital maintains ventilation, temperature and humidity levels suitable to the care, treatment and services provided

Interior spaces accommodate the use of equipment, such as wheelchairs, necessary to the activities of daily living


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Design Criteria When planning for new, altered, or

renovated space the hospital uses one of the following design criteria:State rules & regulationsAIA Guidelines for Design and

Construction of Hospitals and Health Care Facilities (2001 edition)

Other reputable standards and guidelines that provide equivalent design criteria


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PRA EC.02.06.03Preconstruction Risk Assessment

(PRA)Construction or renovation in occupied

healthcare facilities can result in environmental problems such as:NoiseVibration Creation or spread of contaminantsDisruption of essential servicesEmergency ProceduresAir quality

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Life Safety Chapter


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Life Safety Chapter Based on the Life Safety Code®

NFPA 101-2000 Format to be consistent with NFPA CMS K-Tags reconciled Three occupancies

Healthcare Ambulatory Residential

Exception language accepted Annual Life Safety Assessment will occur as part

of Periodic Performance Review


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Life Safety Chapter Removed optional Building

Maintenance Program (BMP) Standards & Elements of Performance LS.01.01.01 Administrative LS.01.02.01 Interim Life Safety

Measures LS.02 - .04

LS.02 Healthcare LS.03 Ambulatory LS.04 Residential

LS.04.01 < 16 Rooming & Lodging LS.04.02 > 17 Hotel & Dormitory


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LS .02 .01 .34

LS .02 .01 .3 4

Life Healthcare Building Protection FireSafety Type Alarm

EPs are sequentially listed Exception language accepted Interim Life Safety Measures (ILSM) applies to LSC deficiencies

Construction and non-construction


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Life Safety ProcessOverview: When an [organization] finds that

it is out of compliance with Standards LS.02.01.10 through LS.04.02.05, the hospital either resolves the deficiencies immediately or manages it through one of the following options: a maintenance management process

that documents the deficiency and corrective resolution within 45 days; or

a Plan For Improvement derived from the Statement of Conditions™; or

a Life Safety Code Equivalency approved by The Joint Commission.


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Life Safety Chapter

LS.01.01.01 (Administrative)EP 3When the hospital plans to resolve a

deficiency through a Plan for Improvement (PFI), the hospital meets the time frame identified in the PFI accepted by The Joint Commission.


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Life Safety Chapter

LS.01.02.01 (ILSM) EP 3The hospital has a written Interim Life

Safety Measures (ILSM) policy that covers periods of construction or situations when the Life Safety Code deficiencies cannot be immediately corrected or when The Joint Commission has not granted an equivalency. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased risk.


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Life Safety Chapter LS.02.01.20 The organization maintains the integrity of

the means of egressEP 13 Exits, exit accesses, and exit

discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice. (For full text and any exceptions, refer to: NFPA 101-2000, 18/19.2.3.3.)

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Emergency Management


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Overview Is now an accreditation manual chapter All Standards and Elements of

Performance from 2008 are incorporated into the 2009 Emergency Management Chapter

No new Standards or Elements of Performance in 2009

This new chapter contains some standards that were in HR, EC and MS

Survey Process is similar to 2008


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History of Disasters

Hospital/Community Debriefings: Tropical Storm Allison-June 2001 Terrorist Attacks-September 2001 Power Outage- Summer 2003 S. California Wild Fires-Summer

2003 SARS (Asia/Toronto)-Spring 2003 Florida Hurricanes (Frances,

Charley, Jeanne) - Aug/Sept 2004 Hurricane Katrina, Rita, Wilma- Aug,

Sept & Oct 2005

G


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Assessment Conclusions

Major Issues Began to Surface: Scalable approach emergency management Problems with Communication Inadequate emergency generator backup Faulty Incident Command Systems Lack of Involvement with Emergency

Operations Center (EOC) The extend of an organization’s planning is

dictated by the impact of their worst recent disaster


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Conduct a Hazard Vulnerability Analysis

Documented Annual Review Site specific: one or many Organization and community partners

prioritize HVA Includes disclosing to community needs and

vulnerabilities HVA to plan mitigation HVA to plan preparedness

EP 8 Documented inventory of resources & assets Fuel Personal Protective Equipment (PPE) Water Medical/surgical supplies Other


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Emergency Operations Plan Emergency Operations Plan (EOP)

describes response procedures Written plan Capabilities to self-sustain for up to 96

hours EOP describes

Recovery strategies Initiation and termination of response

and recovery phases Defines authorities Alternative care sites Actual implementation is documented


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Six Critical Components

1. Communication [EM.02.02.01]

2. Resources & Assets [EM.02.02.03]3. Safety & Security [EM.02.02.05]4. Staff responsibilities [EM.02.02.07]5. Utilities Management

[EM.02.02.09]6. Patient, clinical & support activities

[EM.02.02.11]


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Emergency Management Development

EM.02.02.01 Communication EP 14 establishes backup communication

systems and technologies for communication activities identified in EPs 1 - 13

EM.02.02.03 Resources & Assets EP 3 replenish non-medical supplies EP 6 process to monitor quantities of its

resources and assets during an emergency EM.02.02.05 Safety & Security

EPs 4 & 5 manage hazardous materials EPs 6 & 7 controls access and movement


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Emergency Management Development

EM.02.02.07 Staff Roles & Responsibilities EP 3 Define staff assignments EP 7 Provide training for staff assignments

EM.02.02.09 Utilities Contingencies

EM.02.02.11 Patient Care Issues EP 3 Evacuation strategies EP 11 Evaluate advance preparedness based

on HVA EM.03.01.01 Annual Evaluation EM.03.03.03 Exercise Emergency Management

Plan EP 3 Escalating component


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Surveying Emergency Management

Review of the organizations Emergency Operations Plan

Two themes: Discussion

Prefer to conduct in ICS This EM tracer will be based on a

review of the Hazard Vulnerability Analysis

• Top 3 issues Observations

Integrated with other survey tracers

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2009

The Physical Environment

Questions&

Answers

George Mills, Sr. Engineer

Standard Interpretation Group

The Joint Commission

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Questions & Answers

Q We have rental beds coming in the facility at all hours for Bariatric patients. The beds are being ordered by the Doctors. The standard says that all medical equipment owned or otherwise shall be inspected before use. What can we do about this equipment?

A Manage the equipment

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Questions & Answers

Q. Can you please address decorations on walls.

A. See NPFA 101-200018/19.7.5.410.2.5

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Questions & Answers

Q. Is it acceptable to identify smoke and fire wall penetrations on a life safety drawing for a single floor or area and then enter the deficiencies as a single PFI that references the life safety drawing for location and identification of the deficiency?

A. Possibly

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Questions & Answers

Q. During a recent mock survey, the Engineer surveyor advised that we should complete a SOC, Part 2 for every building within our system. We have off campus facilities that are wood structures, do not have sprinklers, and do not have fire alarms. This would require us to complete a Part 2 for these buildings. We consider these free standing business occupancies and have never completed a Part 2. In addition, this seems to contradict the Frequently

Ask Questions related to the eBBI where it is stated that “Freestanding business occupancies are not required to have en eBBI. Should we now complete a Part 2 for this type building?

A. You are correct

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Questions & Answers

Q. On a mock survey a surveyor quoted "Most of the elevators lobbies do not have the required one hour rated barrier isolating the elevators from occupied areas". LSC 7.2.13.3. My question : Why a barrier is needed in an elevator lobby, when their are two fire doors in the beginning of the two wings next to the lobby and building is 100 % sprinklered?

A. This LSC reference is about using the elevators for fire service evacuation

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Questions & Answers

Q. In an ongoing effort to become fully sprinkled here we added sprinkler heads in a space where we were storing records.

One of my fellow workers was told by CMS in a recent seminar that we could not have sprinkler heads over the records.

I was trying to meet NFPA guidelines for a hazardous space. But I was told CMS said that we either had to install a 200 gaseous system or have fully enclosed metal cabinets to store the records in. This is so that if there were an accidental discharge from

a sprinkler head that the records would not sustain any water damage.

A. The Joint Commission would allow you to add the sprinkler protection in these areas without other restrictions. You will need to address CMS directly or through ASHE’s

Advocacy

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Questions & AnswersQ. There are many redundant LS elements

of performance (EP's) whose only difference is the NFPA code they reference . For example: LS.03.01.50, EP 1 and LS.02.01.50, EP 4.

Both EP's have exactly the same verbiage but reference different NFPA 101-2000 standards, and all references direct you to NFPA 101-2000, 9.4.

LS.02 = HealthcareLS.03 = Ambulatory Healthcare

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Questions & Answers

Q. Environment of Care also has a few issues. Example: EC.02.03.05, EP's 4 and 5. If you are compliant with quarterly testing then it would stand to reason you are compliant with annual testing. Unless I am missing something, isn't EP 4 unnecessary?

EP 4 addresses the fire alarm systemEP 5 addresses notification of the fire

responders (i.e. remote fire dept.)

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Questions & Answers

Q. I was reporting an interim life safety issue in the electronic SOC. The cost was under $1000.50. Is this figure a set limit?

A. No, but some numerical value needs to be here

The $1000.50 is in the default message

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Questions & Answers

Q. JCAHO in EM 03.01.03 ep1, has changed to 2 drills a year with no guide lines to timing (no 4 month 8 month rules). With TJC going to deemed status they are going by CMMS guidelines and regulations. CMMS Physical Environment A-0703 still requires the 4 and 8 month rule. This is a concern. We have to stay with this guide line because we have 20 beds licensed long term. If other of our facilities have SNF beds they can potentially get into a problem on drills.

A. The Joint Commission has removed this criteria, but I have passed it on to DSSM for further review. Thanks.

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Questions & Answers

Q. Where does the information go in the electronic SOC that used to be called Plan for Improvement Long Form?

A. It is still there: see PFI, PFI MENU, Create New, Resolution, then click on Additional Information

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Questions & Answers

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Questions & Answers

Q. A personal concern and experience is that the EC .02.05.05 EP 6 only requires that auto transfer switches be tested and date recorded. I got cited and it has been an issue with a couple of others (one being a local acute hospital got the same hit) that the surveyors want transfer times documented. My form had the date and that the load was carried but he cited me anyway. Why are they allowing the surveyors to be more restrictive than the code states?

A. I will address this internally with the surveyors.

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LS.02.01.70

The hospital prohibits portable space heaters within smoke compartments containing patient sleeting areas and treatment areas. (For full text and any exceptions, refer to NFPA 101-2000 18/19.7.8)

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LS.02.01.70

NFPA 19.7.8 Portable space- heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.Exception: Portable space-heating

devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements if such devices do not exceed 212°F.


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Fire Extinguisher: DatingMonth, day year and initials of inspector as per NFPA 10-

1998 EC.02.03.05 EP 15

4-3.4 Inspection Recordkeeping.

4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.


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PFI: 6 Month Grace PeriodIf an organization realizes that they are running way

behind and are going to have trouble completing the PFI, they need to communicate with The Joint Commission before their planned completion date to make arrangements. But if they are on track to finish as they approach the planned completion date, and know they will run a little over and are sure they will be able to finish within 6 months, they can use that grace period.

Q. Does the Joint Commission still allow a 6 month grace period for completion of a PFI after the planned completion date posted in the eSOC?

A. Yes. See “Managing Compliance with the NFPA Life Safety Code in the introduction to the Life Safety Chapter: “All corrections must be completed within 6 months of the Projected Completion Date.”


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PFI modificationsQ. Can users of the PFI make changes to their PFIs

created since the previous survey, including planned completion dates up to the point that the eSOC is locked for the survey. Is this still true for 2009?

A. Provided the PFI item has not been accepted by a Joint Commission surveyor, the user may make modifications as needed to manage the process.

The View All screen of the PFI indicates modifications have been made, and Joint Commission surveyors may inquire regarding the modification.


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Testing Requirements The Joint Commission Standards and Elements of

Performance identify for accredited organizations compliance requirements.

In the Environment of Care there are requirements for compliance with specific codes found in the National Fire Protection Association (NFPA) body of codes. The NFPA, which is consensus-based code

development body, has a convention of codes and annex material.

The codes are enforceable if adopted by an authority having jurisdiction (AHJ)

Annex material is not enforceable, as it is informational or explanatory material only.


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EC.02.05.09 Tank FarmQ. EC.02.05.09, EP 1 states the hospital

tests, inspects and maintains critical components of the piped medical gas systems. The bulk storage tank(s) and associated systems are critical components of the piped medical gas system but are not referenced in the scope of the EP.

A. This would be a new requirement according to SII guidelines. We would also like to address cylinder handling and storage issues in the future.


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10 Second Transfer: NFPA 99-2009 Resolution

Revise existing Section 4.4.4.1.1.1 to read:Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 4.4.1.1.10 and 4.4.3.1.The 10-second criteria shall not apply during the monthly testing of an essential electrical system. If the 10-second criteria is not met during the monthly test, a process shall be provided to annually confirm the emergency systems capability to comply with 4.4.3.1.


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ATS TestingMaintenance shall be performed in accordance

with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

Substantiation: When testing is performed using a test switch on an ATS, normal power is still available to the system. This presents a significant problem for systems with utility paralleling, closed transition, or in phase transfer to meet the 10-second criteria for picking up the essential load. The standard established the 10-second criteria for whenthe normal power is lost, and not as a testing criterion for the monthly load test.


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Sleeping AccommodationsQ. A sleep center with 8 beds within an

otherwise Business occupancy. Is a sleep study considered "treatment",

and therefore should this be classified as a Lodging and Rooming House occupancy in the eBBI under the Residential Treatment Center heading in the eBBI?

A. No, this is a business occupancy, because the occupants are not rendered incapable of self preservation.


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MASTER ALARM PANEL: LS.02.01.34 EP 2

The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and ¾ hour fire rated doors) that is continuously occupied OR in an area with a smoke detector. NFPA 72-1999 1-5.6 & 3-8.4.1.3.3.2


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General Life Safety Interpretations

Rated doors must have legible labels on the door and jambsJambs prior to 1966 may not have a

rating labelMissing labels may be equivalized if

evidence of compliance is provided to central office

Alternative is to have third party testing agency re-label doors

Are ILSM in place where non-compliant door assemblies are found?


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General Life Safety Interpretations

Fire stop: existing application is acceptable if: It was installed in a manner consistent with

original design specifications It is in acceptable condition currently

If the firestop is cracking, etc, then it is to be removed and repaired using current technologies

Testing has confirmed foam alcohol based hand rub (ABHR) is equivalent to gel

JC does not accept the expanding foam used for insulation in any fire or smoke barrier

This product does have a UL label, for insulation properties

Easily ignited Toxic gases when burned


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Non Flammable Medical Gas Storage: General Issues

<300 ft³: 12 ‘e’ cylinders per smoke compartment, in rack or appropriate holders

• Each ‘e’ cylinder is 24.96 ft³• Smoke Compartment is limited to 22,500 ft²

Between 300 and 3000 ft³ must be stored in a room that is limited construction with doors that can be locked

“In use” verses “in storage” On gurney is considered “in use” In rack is “in storage”

• limited to 12 racked, per smoke compartment “Empty” are NOT considered part of the 12 “in storage”


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Non-Flammable Gas Storage: NFPA 99-2005

NFPA 99-2005 edition has additional language regarding O2 storage requirements, specifically:

Storage of nonflammable gases:9.4.1 > 3000 cubic feet9.4.2 300 – 3000 cubic feet 9.4.3 0 - 300 cubic feetOther:5.1.3.3.2 design and construction5.1.3.3.3 ventilation of locations for manifolds5.1.3.3.3.2 ventilation for motor driven equipment5.1.3.3.3.3 ventilation for outdoors

NOTE: CMS also recognizes the above references


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General Life Safety IssuesFully sprinklered buildings Not required in elevator mechanical

rooms if state codes do not allow (i.e. Ohio, Massachusetts)

Ensure sprinkler piping is not used to support wiring or other material Score as life safety code deficiency

(LS.02.01.35 EP 4)Piping supports are not damaged

or loose (LS.02.01.35 EP 3)


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SIG Support: 630 792 5900

Jerry Gervais, CHSP, CHFM

Engineer SIG

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Senior Engineer SIG

John Maurer CHSP, CHFM

Engineer SIG

Open Position

Engineer SIG

Documents

© Copyright, The Joint Commission 2009 The Physical Environment Overview Environment of Care Emergency Management Life Safety Chapter Q & A George Mills,