Healthcare facilities playing catch-up with Joint Commission guidelines

Facilities and service providers in the healthcare industry are having to make some changes to keep up with recently adopted updates to National Fire Protection Association 101.

The 2012 issue of NFPA 101 was adopted in place of it's 2000 predecessor in July of last year, and with it came many changes that left healthcare management scratching their heads. It's been quite a while since changes to this code have been adopted, and now hospitals are playing catch-up while trying to get up to code by complying to 12 years worth of change.

The biggest confusion surrounds the timeframe in which these changes need to be implemented. Several updates to NFPA 101 require that items be inspected more regularly, but those guidelines are often misinterpreted by facilities managers. Under the new regulations, fire and life safety equipment should be inspected immediately and subsequently within 1 to 3 years. If these codes aren't adhered to immediately, the facility is not following codes.

So what exact changes should now be implemented? There are many, but listed below are several that directly and immediately impact healthcare facilities:

● NFPA now requires healthcare facilities to conduct a risk assessment to determine what category of risk their facility falls under. The hospital or health system may use whatever form or template they wish to conduct this assessment.
● A centralized computer system is permitted to be used in lieu of one of the required master alarms for medical gas systems.
● Operating rooms must be considered 'wet procedure locations' unless a risk assessment conducted by the health care governing body determines otherwise. This means wet procedural locations need to be protected with ground-fault circuit interrupters, or isolated power systems.
● Fire exit drills must be conducted annually in operating rooms and surgical suite locations.
● Written procedures are required for operating room and surgical suite fire emergencies. The procedures are to include alarm actuation, evacuation, and equipment shutdown, and for extinguishing drapery, clothing or equipment fires.
● All fire door assemblies, including side-hinged swinging fire doors, must be tested and inspected annually.
● Fire hose valves are now required to be inspected quarterly. Fire hose valves sized 1 ½ inches are required to be tested once every 3 years, and valves sized 2 ½ inches must be tested annually.
● Buildings greater than 75 feet tall are required to have automatic sprinkler systems installed.
● The evacuation of a building or the instituting of an approved fire watch is now required when a sprinkler system is out of service for more than 10 hours in a 24-hour period, and remains a requirement until the system has been returned to service.
● New generator controllers must be monitored by the fire alarm system for the following alerts:
○ Generator running
○ Generator fault
○ Generator switch in no automatic position

Additionally, a brand new chapter (Chapter 43) has been created, entitled "Building Rehabilitation." This chapter focuses on the application of the new requirements for new construction versus the requirements for existing construction, which vary based on the type and extent of rehabilitation work being done to a given building.

Why are these codes important? If hospitals and healthcare facilities miss the window for inspection, they get a "hit." Too many of these "hits" can put them at risk of losing their accreditation from the Joint Commission, Healthcare Facilities Accreditation Program (HFAP), or any other regulatory agency. In turn, they could lose all federal funding (AKA: Medicaid).

Health systems must also be diligent in the paperwork done with all testing and procedures required by NFPA, because the Joint Commission will require this during the accreditation process. For example, if a company owns 100 fire extinguishers, it was formerly acceptable to state that 3 out of the 100 were working incorrectly, then fix those three. Now, if three are working incorrectly, each specific fire extinguisher must be documented separately, so every unit has its own history. If the same piece of equipment continues to malfunction, providers know that this unit needs to be replaced completely. Documentation on this is also extremely important, as the Joint Commission now requires three years worth of documentations from previous inspections.

The best way to make sure you're caught up on new changes to NFPA is to consult a professional fire and life safety company. These professionals are skilled when it comes to all things fire and life safety, and are knowledgeable about what new codes mean for your facility. By hiring a professional company to keep you compliant, you're ensuring that all inspections and paperwork are done according to Joint Commission guidelines.


About Billy Findley:

Billy Findley is the Vice President of Service Management at Koorsen Fire and Security.

About Koorsen Fire & Security:

Koorsen Fire & Security has been protecting lives & property since 1946. Family-owned and founded in Indianapolis, the company has since vastly expanded its reach, now serving 28 markets. With a backbone of strong family values, each Koorsen location is dedicated to community involvement and philanthropic causes within their respective markets. Koorsen is also home to the nationally-acclaimed, Koorsen Training Center. The largest and most advanced of its kind in the industry, the Training Center features both hands-on training rooms for each discipline, as well as traditional classroom settings, to produce the best-trained technicians in the industry. Need an expert source in life safety? Our instructors are highly-knowledgeable, NICET-certified trainers with decades of experience in fire protection and life safety.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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