1. 2009 The Physical Environment Overview Environment of Care Emergency Management Life Safety Chapter Q & A
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission

2. Standards Improvement Initiative (SII)
Overview
Standards Improvement Initiative (SII)

3. Re-structuring Highlights
SII did not create any new requirements
Deeming language added for clarity
Replaced bulleted lists with expanded Elements of Performance
Enhance clarity and objectivity of standards and EPs
Removed words like “appropriate”
New numbering conventions
EC EP 2 The organization inspects, tests & maintains all life support equipment. These activities are documented. (See also EC EPs 3 &4; PC.02.01,11 EP 2)

4. Re-structuring Environment of Care (EC) Life Safety Chapter (LS)
Merging Safety & Security
Training moved from HR to EC
Life Safety Chapter (LS)
Compliance with the Life Safety Code
Moved ILSM from EC
Emergency Management (EM)
Major changes in 2008
Hazard Vulnerability Analysis (HVA)
Emergency Operations Plan (EOP)

5. 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

6. CMS Deeming Issue: Specifics
EC EP 14
Testing badges for exposure from radiology
EC EP 15
Free from ionizing hazards for patients & staff
EC EP 14
Staff maintain nuclear medicine equipment annually
EC EP 20
Environment is clean, sanitary and free of odors
LS EP 4
Maintain documentation of any inspections or approvals by AHJs related to fire safety

7. Scoring

8. 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

9. EP Scoring Categories A: Structural requirements
EP’s scored yes (2) or no (0)
May address issues requiring full compliance
C: 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

10. 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?

11. 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?

12. 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

13. 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 Criticality
1. Immediate Threat to Life (ITL)
PDA until resolved
2. 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

14. 2009 Scoring Decision Model

15. 2009 Scoring Decision Model
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

16. 2009 Scoring Decision Model
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

17. 2009 Scoring Decision Model
Direct Impact Requirements
Non-compliance results in direct impact on quality of care and patient safety
“Implementation” based requirements
Non-compliant requirements must be addressed via ESC submission process
Short time-frame (45 days)
Decision is pending submission of ESC within established timeframe
Failure to resolve results in progressively more adverse decision (e.g., Provisional, Conditional, PDC)
Example:
Inspects, tests & maintains Life Support Systems

18. 2009 Scoring Decision Model
Indirect Impact Requirements
Initially less immediacy of risk; failure to resolve non-compliance increases risk
“Planning” and “Evaluation” based requirements
Non-compliant requirements must be addressed via ESC submission process
Longer time-frame (60 days)
Decision is pending submission of ESC within established timeframe
Failure 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

19. 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

20. 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 –
5 –
7 –
10 –
>

21. Survey Process

22. 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 Fire Protection Systems
EC Emergency Power
EC Medical Gas and Vacuum
LS Life Safety Code
LS Interim Life Safety Measures (ILSM)

23. Life Safety Code Specialist Update
Other EC “Observations”
May also survey
LD EP 4
LD EP 4
LD 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

24. Observed but Corrected on Site
First 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

25. 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)

26. 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

27. 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

28. Does Every mean Every ? EC
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

29. Environment of Care

30. Environment of Care: Structure
Plan (EC )
Implement
Safety and Security (EC , )
Hazardous Materials and Wastes (EC )
Fire Safety (EC , , )
Medical Equipment (EC , )
Utilities (EC , , , , )
Other Physical Environment Requirements (EC , )
Staff Demonstrate Competence (EC )
Monitor and Improve (EC , , )

31. Environment of Care: Issues
EC : 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

32. EC 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.

33. Medical Equipment
EC 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 EP 7)

34. 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 EPs 3 – 5 and EC 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.

35. Utilities Management 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.

36. Utilities Management 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.

37. 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

38. Design Criteria
When planning for new, altered, or renovated space the hospital uses one of the following design criteria:
State rules & regulations
AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities (2001 edition)
Other reputable standards and guidelines that provide equivalent design criteria

39. PRA EC.02.06.03 Preconstruction Risk Assessment (PRA)
Construction or renovation in occupied healthcare facilities can result in environmental problems such as:
Noise
Vibration
Creation or spread of contaminants
Disruption of essential services
Emergency Procedures
Air quality
One type of risk assessment that most of us are familiar with is the infection control risk assessment (ICRA).
An ICRA needs to be conducted when construction or renovation in occupied healthcare facilities can result in environmental problems, examples of this include (go over list) 39

40. Life Safety Chapter

41. 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

42. Life Safety Chapter
Removed optional Building Maintenance Program (BMP)
Standards & Elements of Performance
LS Administrative
LS Interim Life Safety Measures LS
LS.02 Healthcare
LS.03 Ambulatory
LS.04 Residential
LS < 16 Rooming & Lodging
LS > 17 Hotel & Dormitory

43. LS .02 .01 .34 EPs are sequentially listed Exception language accepted
Life Healthcare Building Protection Fire
Safety Type Alarm
EPs are sequentially listed
Exception language accepted
Interim Life Safety Measures (ILSM) applies to LSC deficiencies
Construction and non-construction

44. Life Safety Process
Overview: When an [organization] finds that it is out of compliance with Standards LS through LS , 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.

45. Life Safety Chapter LS.01.01.01 (Administrative) EP 3
When 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.

46. Life Safety Chapter LS.01.02.01 (ILSM) EP 3
The 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.

47. Life Safety Chapter LS
The organization maintains the integrity of the means of egress
EP 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 , 18/ )

48. Emergency Management

49. 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

50. 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

51. 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

52. 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

53. 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

54. Six Critical Components
Communication [EM ]
Resources & Assets [EM ]
Safety & Security [EM ]
Staff responsibilities [EM ]
Utilities Management [EM ]
Patient, clinical & support activities [EM ]

55. Emergency Management Development
EM Communication
EP 14 establishes backup communication systems and technologies for communication activities identified in EPs
EM Resources & Assets
EP 3 replenish non-medical supplies
EP 6 process to monitor quantities of its resources and assets during an emergency
EM Safety & Security
EPs 4 & 5 manage hazardous materials
EPs 6 & 7 controls access and movement

56. Emergency Management Development
EM Staff Roles & Responsibilities
EP 3 Define staff assignments
EP 7 Provide training for staff assignments
EM Utilities
Contingencies
EM Patient Care Issues
EP 3 Evacuation strategies
EP 11 Evaluate advance preparedness based on HVA
EM Annual Evaluation
EM Exercise Emergency Management Plan
EP 3 Escalating component

57. 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

58. 2009 The Physical Environment Questions & Answers
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission

59. 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

60. Questions & Answers Q. Can you please address decorations on walls.
A. See NPFA
18/
10.2.5

61. 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

62. 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

63. 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 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

64. 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

65. Questions & Answers LS.02 = Healthcare LS.03 = Ambulatory Healthcare
Q. There are many redundant LS elements of performance (EP's) whose only difference is the  NFPA code they reference . For example:
LS , EP 1 and LS , EP 4. Both EP's have exactly the same verbiage but reference different NFPA standards, and all references direct you to NFPA , 9.4.
LS.02 = Healthcare
LS.03 = Ambulatory Healthcare

66. Questions & Answers
Q. Environment of Care also has a few issues. Example: EC , 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 system
EP 5 addresses notification of the fire responders (i.e. remote fire dept.)

67. Questions & Answers
Q. I was reporting an interim life safety issue in the electronic SOC. The cost was under $ Is this figure a set limit?
A. No, but some numerical value needs to be here
The $ is in the default message

68. Questions & Answers
Q. JCAHO in EM 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.

69. 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

70. Questions & Answers

71. Questions & Answers
Q. A personal concern and experience is that the EC 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.

72. LS
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 /19.7.8)

73. LS
NFPA 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.

74. Fire Extinguisher: Dating
Month, day year and initials of inspector as per NFPA EC EP 15
4-3.4 Inspection Recordkeeping.
Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
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.

75. PFI: 6 Month Grace Period
If 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.”

76. PFI modifications
Q. 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.

77. 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.  

78. EC Tank Farm
Q. EC , 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.  

79. 10 Second Transfer: NFPA 99-2009 Resolution
Revise existing Section 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 and 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

80. ATS Testing
Maintenance 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 when the normal power is lost, and not as a testing criterion for the monthly load test.

81. Sleeping Accommodations
Q. 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.

82. 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 &

83. General Life Safety Interpretations
Rated doors must have legible labels on the door and jambs
Jambs prior to 1966 may not have a rating label
Missing 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?

84. 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

85. Non Flammable Medical Gas Storage: General Issues
<300 ft³: 12 ‘e’ cylinders per smoke compartment, in rack or appropriate holders
Each ‘e’ cylinder is 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”

86. Non-Flammable Gas Storage: NFPA 99-2005
NFPA edition has additional language regarding O2 storage requirements, specifically:
Storage of nonflammable gases:
9.4.1 > 3000 cubic feet
– 3000 cubic feet
cubic feet
Other:
design and construction
ventilation of locations for manifolds
ventilation for motor driven equipment
ventilation for outdoors
NOTE: CMS also recognizes the above references

87. General Life Safety Issues
Fully 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 EP 4)
Piping supports are not damaged or loose (LS EP 3)

88. SIG Support: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer SIG
Jerry Gervais, CHSP, CHFM Engineer SIG
John Maurer CHSP, CHFM Engineer SIG
Open Position
Engineer SIG