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The Life Safety Surveyor

The Life Safety Surveyor. How Should I Prepare for the Life Safety Surveyor Documentation Session ?. Healthcare Engineering Consultants. The LSS Document Review. Documents likely to be reviewed include: Fire system detection and extinguishing test documents

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The Life Safety Surveyor

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  1. The Life Safety Surveyor How Should I Prepare for the Life Safety Surveyor Documentation Session? Healthcare Engineering Consultants

  2. The LSS Document Review • Documents likely to be reviewed include: • Fire system detection and extinguishing test documents • Electrical system test documentation including emergency generators, battery lights and SEPPS units • Medical gas and vacuum system test results and new installation certifications • Interim life safety measures policy and documentation • Pre-Construction Risk Assessment (PCRA) policy and documentation • Statement of Conditions (SOC), unless already reviewed during the Preliminary Planning Session Healthcare Engineering Consultants

  3. The Life Safety Surveyor (LSS) • It is likely that the LSS will arrive with the team on the first or second day, less likely later in the survey • The LSS will be scheduled for at least two days “on-site”, with extra days for >1.5 million square feet and three or more surveyable healthcare occupancy buildings (could be up to 5 days “on-site”!) • The LSS will spend several hours on dedicated documentation review, but much more time on the facility tour • Other responsibilities assigned to the LSS will depend on the survey team member preferences and responsibilities – they will probably conduct the Physical Environment Interview and Emergency Management review • The other survey team members will also observe life safety issues, but not as detailed as the LSS – it is not likely that the nurse and physician will request a ladder and flashlight! • If the LSS observes deficiencies outside of their defined responsibility (example: medical records privacy or medication security), they will report it to the other team members Healthcare Engineering Consultants

  4. Fire System Tests • Points to Remember: • Every fire system device must be individuallyinventoried, with each test result documented as “PASS” or “FAIL” • Test records should be sorted by device type, not as a combination of devices, and placed in a binder that is tabbed by each device type • Written test procedures and references to the NFPA standards should be readily available • Documentation should be available to indicate the resolution of all identified deficiencies • A method should be used to track when fire system tests are scheduled and when they have been completed, such as a monitoring grid or “dashboard” Healthcare Engineering Consultants

  5. Fire System Tests Points to Remember • The chart on the right indicates the probable order in which the surveyor will review the documentation – put the test records inthisorder, either in a binder or in folders • The test interval may vary (example: flow devices, fire pump churn tests), depending upon adoption of the CMS “Categorical Waivers” • Be sure to indicate on the documentation (or chart) the NFPA code reference for each test, as required in standard EC.02.03.05, EP 25 Healthcare Engineering Consultants

  6. Fire System Test Descriptions • Supervisory Devices • Test interval: Quarterly • Be prepared to explain which devices are considered “supervisory”(not including tamper switches!) • Supervisory signals are defined in the 2000 Life Safety Code in section 9.7.2 as: “…monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves” • Typically, the surveyor will ask about documented test results for power off and phase loss conditions for the fire pump and low air pressure on dry sprinkler systems Code Reference: NFPA 72, 1999 edition, Table 7.3.2 Healthcare Engineering Consultants

  7. Fire System Test Descriptions • Waterflow Devices • Test interval:Quarterly, unless the CMS “Categorical Waiver” has been adopted, which then requires semi-annual tests • Time delay documentation on device activation recommended • “Categorical Waiver” applies to vane-type and pressure switch-type waterflow alarm devices Code References: NFPA 25, 1998 edition, section 2-3.3 without the waiver; NFPA 25, 2011 edition, sections 5.3 and 8.3 with the waiver Healthcare Engineering Consultants

  8. Fire System Test Descriptions • Duct Detectors • Test interval:Annually • Must be tested to ensure that the device will sample the airstream • Tests must be in accordance with the manufacturer’s instructions • Physical verification of damper closure and/ or air handler shutdown must performed (EC.02.03.05, EP19) and is required by NFPA 90A, 1999 edition, section 4-4.1 • Failure to test and document the damper closure and/ or air handler shutdown will result in a Direct Impact finding Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2, and NFPA 90A Healthcare Engineering Consultants

  9. Fire System Test Descriptions • Smoke Detectors • Test interval:Annually; Sensitivity: AHJ • Must be tested in place to ensure smoke entry into the sensing chamber and alarm activation • Tests must be in accordance with the manufacturer’s instructions, including type of test smoke and/ or aerosol • Smoke detector sensitivity tests must use a calibrated test method, manufacturer’s approved instrument, or other test method acceptable to the AHJ Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2 Healthcare Engineering Consultants

  10. Fire System Test Descriptions • Off-Premises Transmission Equipment • Test interval:Quarterly • Two tests required: 1. Receipt of signal by off-site “responders” (local fire department) – Joint Commission requirement 2. Receipt of signal by “receiving station” (can be off-site stations such as ADT, Simplex, etc. or fire department) within 90 seconds (reference to NFPA 72) Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2 Healthcare Engineering Consultants

  11. Fire System Test Descriptions • Fire Pumps • Test interval:Annual flow test; weekly churn test • Weekly churn test unless CMS “Categorical Waiver” is accepted, which requires a monthly test (electric pumps) • Churn test must be activated by dropping water pressure • Electric pump: 10 minute test; Diesel pump: 30 minutes • Annual flow test should include a graph of test results Code References: NFPA 25, 1998 edition, sections 5-3.2.1, 5-3.2.2; with CMS waiver, NFPA 25, 2011 edition Healthcare Engineering Consultants

  12. Fire System Test Descriptions • Main Drain Test • Test interval:Annual • Either test the system low point or all system risers • Perform the test using the following steps: 1. Record the initial static pressure 2. Open the main drain valve, record residual pressure 3. Slowly close the main drain valve 4. Record the time to return to initial static pressure • Changes in the return time indicate possible obstructions Code References: NFPA 25, 1998 edition, sections 9-2.6 and Appendix A-9.2.6 Healthcare Engineering Consultants

  13. Fire System Test Descriptions • Fire Department Connections • Test interval:Quarterly • Perform and document the following checks: 1. Connections and ID signs are visible and accessible 2. Couplings and swivels rotate smoothly 3. Plugs, gaskets and caps are in place and undamaged 4. Check valve is not leaking 5. Automatic drain valve operates properly • Intended to be outside fire department connections Code Reference: NFPA 25, 1998 edition, section 9-7.1 Healthcare Engineering Consultants

  14. Fire System Test Descriptions • Standpipe Waterflow Test • Test interval:Every Five Years • Perform and document the following checks: 1. Flow the system at the highest design pressure to the hydraulically most remote or highest hose connection of each standpipe system 2. Consult the local AHJ for the appropriate test location Code Reference: NFPA 25, 1998 edition, section 3-3.1.1 Healthcare Engineering Consultants

  15. Fire System Test Descriptions • Kitchen Extinguishing Systems • Test interval:Semi-annually • Perform and document the following checks: 1. Inspect the extinguishing system and hoods 2. Test all actuation components (pull stations, detectors, dampers, mechanical and electrical devices, etc.) 3. Replace fusible links and sprinkler heads annually 4. Service and/ or replace detection according to manufacturer recommendations • Discharge of the system is not required Code Reference: NFPA 96, 1998 edition, section 8-2 Healthcare Engineering Consultants

  16. Fire System Test Descriptions • Gaseous Extinguishing Systems • Test interval:Annual • Perform and document the following checks: 1. Inspection and tests (4-1) 2. Clean agent containers (4-2) 3. System hose inspection (1-year), test (5-years) (4-3) 4. System maintenance (4-5) 5. Training of staff who inspect (4-6) • Discharge of the system is not required Code Reference: NFPA 2001, 1996 edition, section 4-1 Healthcare Engineering Consultants

  17. Fire System Test Descriptions • Portable Fire Extinguishers • Test intervals:Monthly, Annual and 6-Year • Monthly checks require the following: 1. Proper location, no restriction to access or visibility 2. Instructions for use legible and seals/ indicators OK 3. Fullness determined by “hefting” or weighing 4. Evidence of physical damage and gauge reading 5. Documentation with date/ month/ year/ initials • Annual preventive maintenance required • 6-Year extinguisher recharge Code Reference: NFPA 10, 1998 edition, sections 4-3 and 4-4 Healthcare Engineering Consultants

  18. Fire System Test Descriptions • Smoke and Fire Dampers • Test intervals:Initially, 1-year and 6 years thereafter • All smoke and fire dampers must be tested initially and one year after installation • Re-testing is every four years except 6 years for hospitals • Inaccessible dampers should be placed on a PFI with a 6-year timeframe for re-evaluation (document ILSM!) • The 1-year test after installation only applies to dampers installed after January 1, 2008 Code References: NFPA 80, 2007 edition, section 19.4.1.1; NFPA 105, 2007 edition, section 6.5.2 Healthcare Engineering Consultants

  19. Fire System Test Descriptions • Sliding and Rolling Fire Doors • Test interval:Annual • Test must include proper operation and full closure • Re-setting the release mechanism must be done according to manufacturer specifications • Fusible links and other release devices must not be painted or prevented from operating by sealing gaps with intumescent materials Code Reference: NFPA 80, 1999 edition, section 15-2.4 Healthcare Engineering Consultants

  20. Fire System Test Monitoring Best Practice for Monitoring Compliance Healthcare Engineering Consultants

  21. Fire System Test Monitoring Healthcare Engineering Consultants

  22. Emergency Power Systems • EC.02.05.07: Emergency Generators • Perform and document weekly generator visual checks Code reference: NFPA 110, 2005 edition, section 8.4.1 • Perform and document monthly generator tests with at least 30% of the rated load for 30 minutes • Document that all automatic transfer switches are exercised monthly • Conduct 2-hour annual load bank tests if the 30% load is not achieved and manifold temperatures are not sufficient • If the CMS “Categorical Waiver” is adopted by the hospital, then the 2010 edition of NFPA 110 will require a 1.5 hour annual load bank test with a 50% load for 30 minutes, and a 75% load for 60 minutes Healthcare Engineering Consultants

  23. Emergency Power Systems • EC.02.05.07: Emergency Generators • Combining the annual and trienniel tests can be performed by starting the load at 30% of nameplate for the first 30 minutes of the test, then continuing with: 50% of load for 30 minutes; 75% load for 60 minutes, and; any load greater than 30% for the remaining 2 hours Note: If the CMS “Categorical Waiver” is adopted, then the combined tests require a 50% load for 30 minutes, a 75% load for 1.5 hours and any load greater than 30% for the remaining 2.5 hours • Document the static or dynamic 4-hour trienniel test for all generators • Test fuel oil quality annually per ASTM D-975, unless fuel is consumed from the entire tank over the course of 12 months Code Reference: NFPA 110, 2005 edition, section 8.3.8 • Utilize “Interim Emergency Power Measures” (IEPM) when necessary Healthcare Engineering Consultants

  24. Emergency Power Systems • EC.02.05.07: Emergency Battery Lights • Required in all anesthetizing locations (NFPA 70: 517.63 ) “administration of nonflammable inhalation anesthetic agents in the course of examination or treatment” Note: Grandfathering usually permitted in existing OR’s w/o lights • Required in “Level 1 or Level 2 EPS equipment locations”, which is normally interpreted as transfer switch locations (NFPA 110: 7.3.1) • Required in some business occupancies for egress lighting where emergency power is not required or not available (NFPA 101: 7.9.1.1) • Monthly 30-second push-to-test and annual 90-minute discharge test required for all battery installations, whether for task or egress lighting • Annual battery replacement is acceptable in lieu of 90-minute discharge test, but 10% of lights must be tested for 90 minutes annually, even if the batteries are changed Healthcare Engineering Consultants

  25. Emergency Power Systems • EC.02.05.07: Stored Emergency Power Supply Systems (SEPSS) • Standard applies to Level 1 systems (NFPA 111: 4.5.1) Level 1:“failure of the equipment to perform could result in loss of human life or serious injuries” • Testing requires: 1. Quarterly functional test (5 minutes or class specification) 2. Annual full-load test for 60% of SEPSS class duration Note 1: NFPA 111 requires a monthly inspection, quarterly functional test and annual full load test for fullclassduration for Level 1 systems Note 2: The Joint Commission references exit lighting, life support ventilation, fire detection and alarm systems, and public communications systems as Level 1 systems, but most are not SEPSS systems, since they are backed up with emergency generators; non-SEPSSUPS systems should be testedper manufacturer specifications Healthcare Engineering Consultants

  26. The LSS Documentation Review • EC.02.05.09: Medical Gas and Vacuum Systems • Medical gas and vacuum system preventive maintenance program is required (facility must define PM) and must include: - Bulk medical gas and vacuum system components andsource valve - Master signal panels and area alarms - Automatic pressure switches and shutoff valves - Flexible connectors and outlets Healthcare Engineering Consultants

  27. The LSS Documentation Review • EC.02.05.09: Medical Gas and Vacuum Systems • Testing per NFPA 99 is required for new installation, modification or repair (cross-connections, purity, pressure) • Main supply valves and area shut-off valves must be accessible and clearly labeled • Utilize “Interim Medical Gas Measures” (IMGM) when necessary Note: Significant changes for testing have been included in NFPA 99, the 2012 edition, but it has not yet been adopted by CMS or the Joint Commission, except for the “Categorical Waiver” tht permits one master alarm monitor location to be a computer Healthcare Engineering Consultants

  28. The LSS Documentation Review • EC.02.05.09: Medical Gas and Vacuum Systems • Certification of installers and verifiers per ASSE 6000 series is required • Medical air quality must meet NFPA 99 requirements below: Healthcare Engineering Consultants

  29. The LSS Documentation Review Medical Gas and Vacuum System PM Recommendations Note 1: The recommendations provided in the chart to the right are from NFPA 99, the 2005 edition, Appendix C, section 5.2. Tests that are required due to new system installations, renovations or repair are listed in Chapter 5 of NFPA 99 Note 2: Significant changes for medical gas system tests have been added to NFPA 99, the 2012 edition, but have not yet been adopted by either CMS or the Joint Commission, except for the single master alarm panel “Categorical Waiver” Healthcare Engineering Consultants

  30. The LSS Documentation Review Interim Utility System Measures Best Practice! Stronglyrecommended to document that interim measures have been implemented to compensate for utility systems that are taken out of service Healthcare Engineering Consultants

  31. Interim Life Safety Measures Interim Life Safety Measures Requirement Standard LS.01.02.01 from the Joint Commission Accreditation Manual: “The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction” Healthcare Engineering Consultants

  32. Interim Life Safety Measures • The Interim Life Safety Measures Process Includes the Following Steps: • 1. Is an ILSM evaluation required? Y or N • If Yes, does the ILSM evaluation require the implementation of ILSM? Y or N • If Yes, which interim measures apply? • Implement and document the required measures • Note: An interim life safety measures policy must be written and address each of the four steps listed above Healthcare Engineering Consultants

  33. Interim Life Safety Measures • Step 1: Is an ILSM evaluation required? • The need for an interim life safety measure evaluation is normally required whenever there is a life safety deficiency that is found, or renovation or construction activities create life safety deficiencies. • Be sure to do an ILSM evaluation for PFI’s! • Include in the ILSM policy “exclusions” for evaluations, such as “routine work orders” or “superficial projects” Healthcare Engineering Consultants

  34. Interim Life Safety Measures Interim life safety measures evaluation exception for “routine work orders or superficial projects that do not impact life safety” Healthcare Engineering Consultants

  35. Interim Life Safety Measures • Step 2: Are interim life safety measures necessary, based on the evaluation? • Interim life safety measure “trigger points” include the following: • Egress is compromised, and alternative exits are necessary • Compartmentation is breached,and is considered serious • Part or all of the fire detection or extinguishing system has been taken out of service • “Hot Work” is being performed • Large quantities of combustible materials are present • Other conditions determined by the organization Healthcare Engineering Consultants

  36. Interim Life Safety Measures Check which “triggers” (if any) apply for the project Add other “triggers, as desired If none of the “triggers” are marked “Yes”, then no additional action is required Healthcare Engineering Consultants

  37. Interim Life Safety Measures Step 3: Which interim life safety measures apply? The use of an ILSM “applicability matrix” that helps to determine which interim measures apply is helpful. The matrix can either be “pre-filled” for specific conditions or left blank until the evaluation process occurs. The ILSM policy should describe how the interim measures are selected, based on criteria developed by the hospital Healthcare Engineering Consultants

  38. Interim Life Safety Measures • Possible Interim Life Safety Measures Include: • Fire watch • Alternative exit signage • Daily inspection of exits • Temporary, but equivalent fire alarm and detection systems • Additional fire fighting equipment • Temporary, smoke-tight, noncombustible partitions • Increased surveillance of buildings, grounds and equipment • Storage, housekeeping and debris removal practices • Additional staff training for staff who use fire equipment Healthcare Engineering Consultants

  39. Interim Life Safety Measures • Possible Interim Life Safety Measures Include (continued): • Additional fire drills • Inspect and test temporary systems monthly • Additional staff training related to the interim measures • Additional training to compensate for impaired fire or building features Note: Implementation ofany or all of the interim life safety measures noted in the list above are based on criteria developed by the hospital and should be listed in the hospital interim life safety measures policy Healthcare Engineering Consultants

  40. Interim Life Safety Measures (ILSM) Applicability Grid Example for Interim Life Safety Measures Ensuring Egress Interim Measure Notify Fire Dept Barriers Fire equipment Operational LS Fire drills Reduce combust. Fire watch Prohibit smoking Other Staff training Surveillance Deficiency Healthcare Engineering Consultants

  41. Interim Life Safety Measures Example for Interim Life Safety Measures Chart One or more of the interim measures listed on the chart may be selected, based on the scope of the project and the type of deficiency that exists Healthcare Engineering Consultants

  42. Interim Life Safety Measures Step 4: Implement and document the required measures Whichever interim measures are selected must be implemented and documented Remember:Failure to implement or document interim life safety measures, when required, can result Contingent Accreditation from the Joint Commission! Healthcare Engineering Consultants

  43. Interim Life Safety Measures Healthcare Engineering Consultants

  44. Fire Watch Requirements LS.01.02.01: EP 1 “The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented” Question:What constitutes when “a fire alarm or sprinkler system is out of service”? Healthcare Engineering Consultants

  45. Fire Watch “Decision Grid” The requirement for a fire watch is determined by the hospital staff. NFPA 101, section A.9.6.1.6 states: “it is not the intent of the Code to require notification of the AHJ for a single non-operating device or appliance” Healthcare Engineering Consultants

  46. Functional Environment Issue: Pre-Construction Risk Assessment (PCRA) Biggest Pitfall: Only ICRA and ILSM are evaluated Best Practice: Include allseven of the items listed below in the PCRA evaluation ● Noise ● Emergency procedures ● Vibration ● Utility failures ● Air quality ● Interim life safety measures ● Infection control Healthcare Engineering Consultants

  47. Infection Control Risk Assessment (ICRA) – Best Practice Grid Risk Criteria for Infection Control ConstructionType Patient Risk Healthcare Engineering Consultants

  48. Functional Environment • Issue: Documentation of PCRA • Achieving Compliance: • Evaluatemeasures to reduce risk and minimize the impact of the construction activities • Perform daily monitoring in all construction areas • Use a monitoring checklist • Post required permits, such as hot work, ICRA, above-the-ceiling work, ILSM, etc. on door entrance to construction area Healthcare Engineering Consultants

  49. Functional Environment Issue:Pre-Construction Risk Assessment (PCRA) Best Practice:Include MCRA changes during the project Healthcare Engineering Consultants

  50. The Life Safety Surveyor Document Review Questions? Healthcare Engineering Consultants

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