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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 - PowerPoint PPT Presentation
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The Life Safety Surveyor
Healthcare Engineering Consultants
How Should I Prepare for the Life Safety Surveyor Documentation Session?
The LSS Document Review
Healthcare Engineering Consultants
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
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
Fire System Tests
Healthcare Engineering Consultants
Points to Remember:
Every fire system device must be individually inventoried, 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”
Fire System Tests
Healthcare Engineering Consultants
Points to Remember
The chart on the right indicates the probable order in which the surveyor will review the documentation – put the test records in this order, 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
Fire System Component Test Schedule
Standard Element of Performance Scoring Category
Test Interval
NFPA Reference
EC. 02.03.05
Fire Component Tests
1 Supervisory switches
C Q NFPA 72
2 Tamper switches, flow devices
C S/A NFPA 72
3 Duct detectors, door releasing devices
C A NFPA 72
3 Smoke and heat detectors, pull boxes
C
A NFPA 72
4 Audible and visual alarms
C A NFPA 72
5 Off-premises transmission equipment
A Q NFPA 72
6 Fire pump churn test
C W NFPA 25
7 Water tank level alarms
C S/A NFPA 25
8 Water tank level alarms (cold weather only)
C M NFPA 25
9 Main drain tests on system risers
C A NFPA 25
10 Fire department connections
A Q NFPA 25
11 Fire pumps (flow test)
A A NFPA 25
12
Standpipe test C 5 yr NFPA 25
13 Kitchen extinguishing systems
A S/A NFPA 96
14 Carbon dioxide/ gaseous extinguishing systems
A A NFPA 2001
15 Portable fire extinguishers (visual check)
C M
NFPA 10
16
Portable fire extinguishers (preventive maintenance)
C A NFPA 10
17 Occupant hoses
C 3 yr–hydro 5 yr–new
NFPA 25, 1962
18 Smoke/ fire dampers
C 6 years NFPA 80, 105
19 HVAC smoke detectors w/ shutdown
A A NFPA 90A
20 Horizontal/ vertical fire doors
C A NFPA 80
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Descriptions
Healthcare Engineering Consultants
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
Fire System Test Monitoring
Healthcare Engineering Consultants
Regulatory Compliance Dashboard for Fire System Tests
Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments Supervisory Devices
1/15 X X X
Tamper Switches
1/15 X X X
Water Flow Devices
1/15 X X X
Duct Detectors
1/22
Door Releasing Devices
X
Smoke Detectors
X
Pull Boxes
1/18 X
Audible Alarms
X
Visual Alarms
X
Signal Time to FD
1/6 X X X
Fire Pump Churn Test
4, 11 25
W W W W W W W W W W W
Fire Pump Flow Test
X
Water Tank Level Alarms
N/A X X X X X X X
Main Drain Riser Test
X
Fire Dept. Connections
1/12 X X X
Standpipe Test
X 5 yr
Kitchen Systems
X X
Best Practice for Monitoring Compliance
Fire System Test Monitoring
Healthcare Engineering Consultants
Regulatory Compliance Dashboard for Fire System Tests (continued)
Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments CO2/ Gaseous Systems
X
Portable Extinguishers
1/23 X X X X X X X X X X X
Portable Extinguishers
X
Occupant Hoses
X 3 yr
Smoke/ Fire Dampers
X 6 yr
HVAC Shutdown
1/25 X
Horiz/ Vertical Fire Doors
X
Key to dashboard symbols: X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required A/R – Indicates that action is required when applicable Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Emergency Power Systems
Healthcare Engineering Consultants
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
Emergency Power Systems
Healthcare Engineering Consultants
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
Emergency Power Systems
Healthcare Engineering Consultants
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
Emergency Power Systems
Healthcare Engineering Consultants
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 full class duration 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-SEPSS UPS systems should be tested per manufacturer specifications
The LSS Documentation Review
Healthcare Engineering Consultants
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 and source valve
- Master signal panels and area alarms
- Automatic pressure switches and shutoff valves
- Flexible connectors and outlets
The LSS Documentation Review
Healthcare Engineering Consultants
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
The LSS Documentation Review
Healthcare Engineering Consultants
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:
Parameter Limit Value
Pressure dew point 39 degrees F
Carbon monoxide 10 ppm
Carbon dioxide 500 ppm
Gaseous hydrocarbons 25 ppm (as methane)
Halogenated hydrocarbons 2 ppm
The LSS Documentation Review
Healthcare Engineering Consultants
Medical Gas and Vacuum System PM Recommendations
Component Description
Recommended Test Frequency
Gas cylinder manifold pressure
Daily
Gas cylinder manifold changeover signal
Daily
Liquid cylinder manifold pressure
Daily
Liquid cylinder manifold changeover signal
Daily
Liquid cylinder reserve/ in-use signal
Annually
Bulk liquid system contents gauge
Daily
Bulk system pressure gauges
“Regularly” (weekly)
Bulk system master signal
“Periodically” (monthly)
Main line vacuum system gauge
Daily
Medical air intake location
Quarterly
Medical air pressure gauge
Annually
Medical air high level water sensor
Annually
Medical air receiver drain
Daily
Medical compressed air alarms
Annually
Medical air compressors/ vacuum pumps
Per manufacturer specifications
Dew point sensor/ CO monitor
Annually
Warning system components
Annually
Audible/ visual alarms
Monthly
Shut-off valve leak test
“Periodically” (annually)
Outlet leakage and flow
“Periodically” (annually)
Medical air purity
As determined by facility
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”
The LSS Documentation Review
Healthcare Engineering Consultants
Interim Utility System Measures Interim Utility System Measures
Project Number: _________________ Date: ____________________ Affected System: Fire System: _____ Emergency Power _____ Medical Gas: _____ Description of Project: ______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Interim Measures Required: _____ Affected staff notified Comments: ______________________________________ _____ Additional Equipment Required Specify: _________________________________ _____ Back-up Procedures in Place Specify: ___________________________________ _____ Emergency Procedures Reviewed Comments: ____________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ Additional Comments: ______________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Date Project Completed: ___________________ Reviewed By: ____________________
Best Practice!
Strongly recommended to document that interim measures have been implemented to compensate for utility systems that are taken out of service
Interim Life Safety Measures
Healthcare Engineering Consultants
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”
Interim Life Safety Measures
Healthcare Engineering Consultants
The Interim Life Safety Measures Process Includes the Following Steps:
1. Is an ILSM evaluation required? Y or N
2. If Yes, does the ILSM evaluation require the implementation of ILSM? Y or N
3. If Yes, which interim measures apply?
4. 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
Interim Life Safety Measures
Healthcare Engineering Consultants
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”
Interim Life Safety Measures
Healthcare Engineering Consultants
Example Interim Life Safety Measures Policy Purpose The purpose of this interim life safety measures (ILSM) policy is to address situations during periods of construction or renovation, or whenever Life Safety deficiencies exist and cannot be immediately corrected, so that an equivalent level of Life Safety is maintained. This policy also includes criteria for evaluating when and to what extent the hospital follows special, temporary measures to compensate for increased life safety risk. Policy This policy provides information and guidelines for evaluating and implementing interim life safety measures during times when a Life Safety deficiency is present due to construction or whenever an existing building deficiency is identified. Procedure When the hospital identifies Life Safety deficiencies during surveillance rounds, during periods of construction or renovation, or through other means, and the deficiency cannot be immediately corrected, the hospital performs an analysis to determine whether the implementation of interim life safety measures is necessary. This analysis is documented using the Interim Life Safety Applicability Form (ILSAF) attached to Appendix A of this policy. Completion of the ILSAF form is not required for routine work orders, or superficial projects that do not impact life safety in the hospital. If the completion of the ILSAF indicates that interim life safety measures are not required, then the completed form is maintained in a document file for reference purposes. If the ILSAF indicates that interim life safety measures are required to be implemented, then the Interim Life Safety Measures Chart (ILSMC) form is completed (refer to Appendix B) to determine which interim measures must be implemented and documented. The ILSMC form should be completed by referring to the following “Typical Triggers” for each of the possible interim measures listed below. Note: The following list of “Typical Triggers” are suggestions only and may be revised on the ILSAF form based on the judgment of hospital personnel. Measure 1: Notify the fire department, and initiate and document a fire watch. Typical Trigger Criteria: When the fire alarm or sprinkler system is out of service for more than 4 hours in a 24-hour period in an occupied building, as defined by the fire watch decision grid in Appendix C. Measure 2: Inspect exits in affected areas on a daily basis and document the inspection.
Interim life safety measures evaluation exception for “routine work orders or superficial projects that do not impact life safety”
Interim Life Safety Measures
Healthcare Engineering Consultants
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
Interim Life Safety MeasuresAppendix A - Interim Life Safety Applicability Form
Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location: ________________________________________________________________ Instructions: Determine whether any of the “ILSM Triggers” listed in the chart below apply to or will occur during this project. Description of ILSM Trigger
Applicable?
Hot work
Y N
Blocked exit
Y N
Alternate egress
Y N
Excessive combustible materials
Y N
Removal of part or all of the fire detection system
Y N
Removal of part or all of the extinguishing system
Y N
Significant breach of smoke or fire wall
Y N
Significant breach of smoke or fire door
Y N
Y N
Y N
Y N
If one or more of the ILSM triggers listed above are marked “Yes”, then interim life safety measures apply and must be evaluated using Appendix B, Interim Life Safety Measures Chart ______ ILSM measures do not apply ______ ILSM measures do apply _____________________________ _________________________ ______________ Signed Title Date
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
Interim Life Safety Measures
Healthcare Engineering Consultants
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
Interim Life Safety Measures
Healthcare Engineering Consultants
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
Interim Life Safety Measures
Healthcare Engineering Consultants
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 of any 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
Interim Life Safety Measures (ILSM)
Healthcare Engineering Consultants
Applicability Grid Example for Interim Life Safety Measures
Compromise egress X X X X X X
Breach compartmentation
X X X X X X X X X
Impair fire detection, alarm, suppression
X X X X X X X X
Hot work X X
Large quantities of combustibles
X X X X X X X X
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Interim Life Safety Measures
Healthcare Engineering Consultants
Example for Interim Life Safety Measures Chart
Appendix B - Interim Life Safety Measures Chart
Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location: ________________________________________________________________ Instructions: Based on the project or deficiency described above, determine and document which of the following interim life safety measures apply in the chart below. Description of Interim Measure
Applicable?
Fire watch (see Appendix C)
Y N
Signage signifying alternative exits
Y N
Daily inspections in affected area
Y N
Temporary and equivalent fire alarm and detection systems
Y N
Additional portable fire extinguishers
Y N
Temporary construction partitions (non- or limited combustibility)
Y N
Increased surveillance of buildings, grounds or equipment
Y N
Additional storage, housekeeping and debris removal
Y N
Additional staff training for portable fire extinguishers
Y N
Additional fire drills
Y N
Monthly tests and inspections of temporary systems
Y N
Additional staff training for construction hazards, temporary measures
Y N
Additional staff training for impaired fire safety features
Y N
Additional comments related to required measures: ____________________________ ______________________________________________________________________ _____________________________ _________________________ ______________ Signed Title Date
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
Interim Life Safety Measures
Healthcare Engineering Consultants
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
Interim Life Safety Measures
Fire Watch Requirements
Healthcare Engineering Consultants
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”?
Fire Watch “Decision Grid”
Healthcare Engineering Consultants
Appendix C – Fire Watch Decision Grid
Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location of Project or Deficiency: ____________________________________________ Fire Watch Notification: ______ Fire Department ______ Other Responders ______ Insurance Company ______ Internal Hospital Staff ______ Other Instructions: Based on the “Out of Service” description listed in the chart below, the requirement for a fire watch is indicated. Circle each “Yes” below, as applicable. Description of Fire Alarm or Sprinkler System “Out of Service” Condition
Fire Watch Required?
Multiple fire alarm or sprinkler system components out-of- service for less than 4 hours in a 24-hour period
No
Fewer than 6 smoke detectors in the same area out-of- service for more than 4 hours in a 24-hour period
No
Extinguishing system in less than a single smoke compart- ment out-of-service for more than 4 hours in a 24-hour period
No
Fire alarm system in “bypass” mode due to testing
No
More than 5 smoke detectors in the same area out-of-service for more than 4 hours in a 24-hour period
Yes
Extinguishing system in more than a single smoke compart- ment out-of-service for more than 4 hours in a 24-hour period
Yes
Any combination of fire detection and extinguishing devices out of service > 4 hours in a 24-hour period at the same time
Yes
Failure of the fire alarm annunciator panel (any time period)
Yes
Failure of the entire fire detection system (any time period)
Yes
Failure of the entire extinguishing system (any time period)
Yes
Failure of the fire pump (any time period)
Yes
Y N
Y N
_____________________________ _________________________ ______________ Signed Title Date
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”
Functional Environment
Healthcare Engineering Consultants
Issue: Pre-Construction Risk Assessment (PCRA)
Biggest Pitfall: Only ICRA and ILSM are evaluated
Best Practice: Include all seven of the items listed below in the PCRA evaluation
● Noise ● Emergency procedures
● Vibration ● Utility failures
● Air quality ● Interim life safety measures
● Infection control
Infection Control Risk Assessment (ICRA) – Best Practice Grid
Healthcare Engineering Consultants
Risk Criteria for Infection Control
Type A Type B Type C Type D
Group 1 (lowest) I II II III
Group 2 (medium) I II III IV
Group 3 (medium high) II III III IV
Group 4 (highest)
III
IV IV IV
Construction TypePatient
Risk
Functional Environment
Healthcare Engineering Consultants
Issue: Documentation of PCRA
Achieving Compliance:
• Evaluate measures 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
Functional Environment
Healthcare Engineering Consultants
Issue: Pre-Construction Risk Assessment (PCRA)
Best Practice: Include MCRA changes during the project
Pre-Construction Risk Assessment Timeline Chart
Project number: __________________________ Date: _____________________ Completed by: ____________________________
PCRA Category
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Comments
Noise
Vibration
Air Quality
Infection Control Risk Assessment (ICRA)
Interim Life Safety Measures (ILSM)
Emergency Procedures
Utility Failures
The Life Safety Surveyor Document Review
Questions?
Healthcare Engineering Consultants