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Codes & Compliance

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  1. Codes & Compliance

  2. What does the sinking of the TITANIChave to do with Building Codes?

  3. Water-tight Compartments Bulwarks thresholds/ doors # Life boats Steel strength Crew training Smoke & fire compartments 2 hr. walls fire doors # Exits Materials fire ratings Staff training Codes and TITANIC

  4. Why the TITANIC was a disaster • Pressure from White Star line • Poor judgement on Captain’s part • Hole exceeded compartments • Inadequate # of lifeboats • Steel was brittle (sulfur content too high: in cold water lost strength) • Crew not trained to deal with situation

  5. Code Compliance JCAHO NFPA OSHA HIPPA EPA

  6. Code Compliance Organizations have a moral and legal obligation to provide a safe environment for building occupants. Building codes and government regulations mandate the minimum requirements and standard for public health and safety.

  7. Code Compliance OSHA and building code enforcement agencies hold owners and operators accountable for the safe and sanitary maintenance of their facility. The Authority Having Jurisdiction may very from facility to facility. The AHJ for Life Safety is appointed by the Governing Board.

  8. AIA ANSI Building Codes ADA EPA JCAHO NFPA CDC ASHRAE FDA Document & Demonstrate Compliance With:

  9. Required Permits • Emission • Boilers • Incinerators • ETO Usage • Burn Permits • Confined Space • Elevators • Heliports NOTE: Many are unique to local, state, & city codes.

  10. Code Compliance The word “Shall” indicates mandatory requirement.

  11. "Always do right- this will gratify some and astonish the rest." • - Mark Twain (1835-1910)

  12. Life Safety • Design, construction, and compartmentation • Provision for Detection, alarm, and extinguishment. • Fire prevention and the planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building.

  13. Life Safety • The National Fire Protection Association Manual (NFPA) 101, 2000 Edition • Joint Commission Accreditation of Healthcare Organizations Comprehensive Accreditation Manual for Hospitals

  14. Life Safety • NFPA 72, National Fire Alarm Code, 1999 Edition • NFPA 110 Standard for Emergency and Standby Power Systems, 2002 Edition

  15. Life Safety Assessment • Statement of Conditions (SOC) • A current organization-wide SOC must be completed for all buildings housing and treating an organization’s patients, regardless of ownership.

  16. Life Safety Assessment • Statement of Conditions • The exception is Business Occupancy that are (1) freestanding or (2) connected to a health care occupancy but separated by a two-hour fire barrier and do not serve as a required means of egress from the health care occupancy.

  17. Life Safety • Fire Drills – Hospitals require one per shift per quarter • Interim Life Safety Plan—Hospitals require a minimum of two per shift per quarter

  18. Life Safety • At least 50% of required drills are unannounced. • External illuminated exit sign require 6 inch letters. Internal illuminated exit signs require 4” Letters

  19. Response Training Fire response training evaluated at least annually • When & how to sound alarms • When and how to transmit for offsite fire responders • Containment of smoke and fire • Transfer of patients to areas of refuge • Fire extinguishment • Specific fire response duties • Preparation for building evacuation.

  20. Life Safety • NFPA 101 requires doors to readily open from the egress side. Be aware! • Exception 1, allows for the door to be locked in the interest of the patient —subject to the approval from the Authority Having Jurisdiction.

  21. Life Safety • Egress Capacity is the ability of an egress component or system of components to meet the demand of occupants traversing the means of egress • The Public Way is defined as a street, alley or other similar parcel of land open to the outside air, dedicated to public use, with a clear width and height of at least 10 feet.

  22. Life Safety • Dead-end corridors occur where an occupant may enter a corridor thinking there is an exit and must retrace the path traveled to find an exit. In the 2000 Edition of NFPA 101, 30 feet corridors are allowed for new construction.

  23. Life Safety • Equivalencies—are alternative approaches to life safety and require a Fire Safety Evaluation System (FSES). FSES are the responsibility of the Authority having Jurisdiction.

  24. Life Safety • Class A fire extinguishers are used for ordinary combustibles such as wood, paper, cloth, household rubbish, rubber and many plastics. • Class C fire extinguishers are used for Energized Electrical Equipment

  25. Life Safety • Portable Fire Extinguishers should be inspected every 30 days • Travel distance to any fire extinguisher should not be more than 75 feet from any point

  26. Life Safety • Health Care Occupancy • Business Occupancy • Ambulatory Health Care Center

  27. Life Safety • Fire Alarm systems involve three functions • Initiation • Notification • Control • In general, the order of precedence for fire alarm signals is alarm, supervisory, and trouble signals.

  28. Life Safety • Pull Stations should be unobstructed, accessible, and within the natural path of travel. • There should be at least one pull station at each required exit • Additional ones located so that the total travel distance to a pull station does not exceed 200 feet.

  29. Life Safety Patient care areas are categorized into three types: • General Care Areas • Critical Care Areas • Wet Locations NFPA 70, Article 517-18, 517-19 and 517-20

  30. Life Safety NFPA groups essential electrical systems in to three major categories. • Type 1 • Type 2 • Type 3 NFPA 99 2002 edition 4.4

  31. Life Safety • Hospitals require Type 1 Essential Electrical System (EES). • It should include • exit route illumination, • emergency communication, • illumination to exit signs, • critical equipment/systems • and critical service areas. • The EES shall be installed IAW applicable standard (NFPA 70 Article 517-30)

  32. Life Safety • The EES, Type 1 system is subdivided into two branches • Critical branch • Life Safety branch • Any device connected to the life safety branch must be restored to operation within 10 seconds (NFPA 99 4.4.2.1.4 (d))

  33. ESSENTIAL ELECTRICAL SYSTEM (EES) FOR HEALTHCARE FACILITIES TYPE 1 TYPE 3 TYPE 2 • Hospitals • Ambulatory Care with Critical Care Areas Emergency System Equipment System Life Safety Branch Critical Branch

  34. Life Safety Branch Devices allowed on Life Safety Branch • Illumination for means of egress • Exit Signs • Alarm and alerting devices • Fire ALARMS • Alarms for systems specified for vacuum systems • Hospital communications • Generator Set Task Illumination • Elevator cab lighting, control, communication • Automatic Doors • Auxiliary functions of the Fire Alarm (NFPA 72)

  35. Equivalency • An equivalency is method of protection that provides equal to or greater level of protection dictated by code. • It “IS NOT” a waiver or deletion of the code requirement. (NFPA 101 1.5.1, 2000 edition.)

  36. Life Safety The Life Safety Code is administered and enforced by the authority having jurisdiction designated by the governing authority. (NFPA 101, 1.7.1)

  37. JCAHO Standards • The JCAHO Environment of Care standards state that all health care facilities will prohibit patients, visitors, and staff from smoking inside of any buildings in which healthcare services are rendered.

  38. "The significant problems we face cannot be solved at the same level of thinking we were at when we created them." - Albert Einstein (1879-1955)

  39. NFPA 101 – Life Safety NFPA 99- Standard for Health Care Facilities NFPA 110 - Generators NFPA 72 – Fire Alarms NFPA 45– Labs Using Chemicals NFPA 80 – Fire Doors NFPA 13 – Sprinklers NFPA 70 - NEC JCAHO is not a code Where to Find the Answers

  40. Back up slides

  41. Inspecting, Testing, and Maintaining Fire Protection Medical Gas Testing Utility Management Plan PM Schedules Life Cycle Replacement Equipment Inventory Generator Testing

  42. Inspecting, Testing, and Maintaining • All Supervisory Signal Devices – Quarterly • Valve tamper switches and water flow devices – Semiannually • Smoke Detectors – Annually • Electro-mechanic releasing devices – Annually • Heat Detectors – Annually • Manual Fire Alarm Boxes – Annually • Occupant Alarm Notification Devices - Annually

  43. Inspecting, Testing, and Maintaining • Fire Pumps – churn (no flow) – Weekly • Fire pumps – full flow – Annually • Water tank high and low level alarms – Semiannually • Water Tank low-temperatue alarms (cold weather – Monthly • Main drains (at all system risers) – Annually • Connections – Fire Department (Inspect) --Quarterly

  44. Inspecting, Testing, and Maintaining • Package suppression systems over cooking equipment – Semiannually • CO2 and other gas package suppression systems – Annually • Standpipe systems – Every Five Years • Required Fire Dampers – Test & Maintain --Every Four Years • Required Smoke Dampers – Every Four Years

  45. Inspecting, Testing, and Maintaining HVAC Shutdown Devices – Annually Sliding and Rolling Fire Doors/Windows – Annually Battery-powered lights required for egress includes a functional test at 30-day intervals for a minimum of 30 seconds; and annual test for a duration of 1 ½ hours

  46. Inspecting, Testing, and Maintaining • Maintenance & Testing of Healthcare Emergency Power Supply System • NFPA 110 states that the manufacturer is the final word on generator maintenance • NFPA 110 requires one set of EPSS manuals be kept on premises

  47. Inspecting, Testing, and Maintaining • Generators need only to be inspected on a weekly basis (not exercised) • NFPA 99 states “Generator sets shall be tested twelve (12) times a year with testing intervals between no less than 20 days or exceeding 40 days” IAW NFPA 110. The tests shall be conducted for at least 30 continuous minutes under a dynamic load that is at least 30 percent of the nameplate rating of the generator.

  48. Inspecting, Testing, and Maintaining • JCAHO states that all equipment in the utility management plan must be tested at least annually. • A routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests. • The maximum time period of 10 seconds before the EPSS kicks in applies no matter what the circumstance and without exception.