Volume 2024 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
CHAPTER 13: LIFE SAFETY 13.02.01 Fire alarm system – Installation and maintenance 13.02.02 Fire alarm system - Testing
11.07.03 Ventilation, Light, and Temperature Controls Overview of the requirement:
The hospital must meet guidelines for temperature, humidity, ventilation and air pressure relationships based on the function of the space. Compliance is evaluated through observation, interview, and document review. Most deficiencies were due to incorrect air pressure relationships. Also noted were the lack of policies on temperature and humidity in key areas and the adoption of low humidity levels without regard to the effect on equipment and supplies.
Comment on deficiencies:
Overview of the requirement:
Fire alarm systems are installed, tested, and maintained per NFPA 101 Life Safety Code (2012 edition and NFPA 72 National Fire Alarm Code (2010 edition). All basic and secondary components are included in the testing protocol. Compliance is assessed through observation and document review. Surveyors noted that smoke detectors were often installed too close to components of the HVAC system. Other installed features were made inaccessible by moveable objects providing obstruction. Testing frequency and corrective action for failed components were compliance issues for 13.02.02.
Comment on deficiencies:
Frequency of citation:
61%
Examples of surveyor findings:
n The surgery safety policy did not address processes to follow during periods when temperature and humidity are out of range. n Air pressure in the sterile processing department was negative to the adjacent supply room. Temperature and humidity were not monitored. n The infection prevention policy for temperature, humidity and pressurization identified the humidity range of 20-60%. The hospital facilities department has been maintaining a range of 30-60%. If the organization chooses to allow for the 20-60% range, it must conduct a risk assessment of all equipment and supplies manufacturer’s instructions for use. If the organization chooses to adhere to 30-60% humidity, it must revise the policy. n The OB soiled utility room pressure was observed to be positive pressure to the corridor and should be negative pressure. The morgue was observed to have a positive pressure relationship to the corridor and should be negative pressure. OR decontamination was observed to be neutral pressure to the corridor and should be negative pressure. Sterile processing air pressure was observed to be neutral pressure to the corridor and should be positive pressure. The preop surgery soiled utility room pressure was observed neutral pressure to the corridor and should be negative pressure. n Review policies to ensure that these conditions are addressed for function- specific spaces. n Conduct a risk assessment for equipment and supplies used when considering adopting the CMS waiver for a relative humidity range of 20 to 60%. n Take action as soon as readings indicate the environment does not meet required conditions.
Frequency of citation:
13.02.01: 37%; 13.02.02: 45%
Examples of surveyor findings:
n The ground floor fire alarm panel did not have a smoke detector within the required distance per NFPA 72 10.15. n Access to pull stations was blocked in various units (by furniture, trashcans, and signage). n Smoke detectors were installed too close to air supply diffusers (within 36 inches). n Two on-call sleeping rooms lacked fire alarm notification devices. n The annual fire alarm testing report did not include a list of the audible and visual devices tested. n Annual testing of waterflow switches was documented but semi-annual testing is required. n The most recent annual fire alarm system test report indicated that 20% of the notification devices (audible/visual) failed during the test. The Life Safety Specialist indicated that the failure was largely construction related and had been corrected. The hospital could not show documentation of correction and retesting of the failed devices. n Air handler shut-down interface relays for 39 devices were recorded as failed on the testing log from September 2023 and had not been corrected to date. The hospital did not conduct an ALSM Risk Assessment to determine what measures to implement to compensate for the life safety code deficiency. n Recognize that any deficiency with the fire alarm system that cannot be corrected in the same day must prompt an ALSM assessment. n Review smoke detector locations relative to other features to ensure compliant placement. n Develop a testing calendar including requirements as defined by NFPA. Develop logs to demonstrate that testing was performed and include follow- up actions for testing failures.
Tips for compliance:
Many reversed air pressure relationships are corrected at the time of survey. Implement more frequent monitoring and immediate correction to avoid citations.
Tips for compliance:
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