Compliance Tips

Every week, ASHE will publish a new health care facility compliance tip. The tips are shared in randomized order– be sure to collect them all!
Have a compliance tip you want to share?
We’d love to hear from you. Contact Chad Beebe at cbeebe@aha.org.
6.4.4.1.1.2 The 10-second criterion shall not apply during the monthly testing of an essential electrical system. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm the capability of the life safety and critical branches to comply with 6.4.3.1. Annually interruption of power required for proper ATS testing. #ASHECompliance
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NFPA 110-2010: 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. Battery-powered emergency lighting must be provided for Level 1 and 2 Emergency Power Supply (EPS) locations. Units that are located outdoors in enclosures that do not require walk-in access are not required to have battery-powered emergency lighting. #ASHEComplianceT
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NFPA 101-2012: 9.4.6.2 All elevators equipped with fire fighters’ emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required byASMEA17.1/CSA B44, Safety Code for Elevators and Escalators. #ASHEComplianceT
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NFPA 99-2010: 5.1.3.3.2* (4) If indoors, they shall be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings, and doors are of a minimum 1-hour fire resistance rating. The 2012 and previous editions of the required a 1-hour door. Perhaps this was an oversight by the NFPA committee who in later editions reduced the requirement to 45 minutes. Surveyors will likely look for a 60 minute door. #ASHEComplianceT
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NFPA 13-2010: or thin paper bags shall be used. 6.2.6.4.3 Coverings shall be replaced periodically so that heavy deposits of residue do not accumulate. 6.2.6.4.4 Sprinklers that have been painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2. 6.2.7 Escutcheons and Cover Plates. 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly. 6.2.7.3 Cover plates used with concealed sprinklers shall be part of ...
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NFPA 80-2010: 19.3.1, 19.4.1, 19.4.1.1, NFPA 105-2010: 6.4.1, 6.5.2 - Fire and smoke dampers, or combination fire/smoke dampers are tested when they are installed, and again 1 year after installation. The test and inspection frequency shall then be every 4 years, with the exception of hospitals, which shall be every 6 years. #ASHECompliance
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NFPA 25-2011: 5.3.1 5.3.1.1.1.3* Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals. A quick-response sprinkler, residential sprinkler, and early suppression suppression fast-response (ESFR) sprinklers are examples of fast response sprinklers. If your quick response heads were installed prior to 1999 make sure you have documentation of them being tested or replaced. All heads need to be tested or replaced every 50 years. How do you know if your head is a standard response or a quick response? one of the common indicators ...
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NFPA 101-2012: 19.7.5.7.2* Containers used solely for recycling clean waste or for patient records awaiting destruction shall be permitted to be excluded from the requirements of 19.7.5.7.1 where all the following conditions are met: (1) Each container shall be limited to a maximum capacity of 96 gal (363 L), except as permitted by 19.7.5.7.2(2) or (3). (2)*Containers with capacities greater than 96 gal (363 L)shall be located in a room protected as a hazardous area when not attended. (3) Container size shall not be limited in hazardous areas. (4) Containers for combustibles shall be labeled and listed as meeting the requirements of FM Approval Standard 6921,Containers ...
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NFPA 99-2012: 10.2.3.6    Power strips providing power in the patient care area must be Special-Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1. They must also meet the requirements of NFPA 99: 10.2.3.6.  Power strips providing power to patient care related equipment must be a Healthcare Facility Outlet Assembly (HCOA) and listed as UL2930. #ASHEComplianc
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NFPA 25-2011: 5.2.2.2 Sprinkler piping and sprinkler heads shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. #ASHEComplianceT
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ASHRAE 170-2013: 7, FGI Guidelines for the Design and Construction of Hospitals and Outpatient Facilities Section 4, EC.02.05.01 EP 15. Appropriate air pressure relationships are maintained for areas requiring positive or negative pressure relationships with surrounding areas. Regardless of the system monitors you might have in place, periodically check the room pressure relationship using the good ol' tissue test.  #ASHEComplianceT
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NFPA 25-2011: 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall) . #ASHEComplianceTi
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408.4 Field Identification Required. (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard.. #ASHEComplianceT
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NFPA 25-2011: 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. #ASHEComplianceT
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7.2.4.3 Where monthly manual inspections are conducted the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. #ASHEComplianceT
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5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. #ASHEComplianceTip
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NFPA 25-2011: 5.2.1.1: Sprinkler heads are required to be inspected from the floor annually. #ASHEComplianceTip
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Joint Commission Environment of Care Standards EC.02.01.01 EC 1: Safe and Secure Security risks must be identified. The Joint Commission specifically requires hospitals to identify safety and security risks that could affect patients, staff, visitors and others coming to the facility. #ASHEComplianceTip
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NFPA 101-2012: 8.2.1, xx.1.6 in the occupancy chapters (Example: 18.1.6 for existing healthcare occupancies). While NFPA 101 does not specifically mention fire-proofing of structural steel, NFPA 101 does require specific building types for various occupancies. Structural steel often requires fire-proofing to be installed so that the structural element does not fail during a fire. Different construction types require different fire resistance ratings for structural elements. If the fire-proofing is not installed, or has been damaged or removed, the structural element may no longer meet the requirement for the building construction type, and could be at risk ...
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NFPA 70-2011 760.41 (B): Are You Seeing Red? The circuit disconnecting means for the fire alarm equipment shall have red identification and be labeled as “FIRE ALARM CIR
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NFPA 80: 5.2.13.3 Blocking or wedging of doors in the open position shall be prohibited. #ASHEComplianceTip
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NFPA 99-2012: 11.6.5.2, CMS K926 Comingling of full and empty cylinders is not allowed. Empty cylinders must be marked and kept separate from full cylinders. #ASHEComplianceTip
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Check the batteries in your smoke detectors during daylight savings time. Also, check the date of your smoke detectors - you should replace your smoke detectors every 10 years. Even if the test button works, the sensors may not function as originally installed. #ASHEComplianceTip
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NFPA 99-2012: 5.1.3.3.2(7), 11.6.2.3(11) Gas cylinders must be secured to keep them from falling. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. #ASHEComplianceTip
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NFPA 101 7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3. #ASHEComplianceTi
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NFPA 80 4.6.3.3* Fire exit hardware shall consist of exit devices that have been labeled for both fire and panic protection. #ASHEComplianceTip
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NFPA 72-2011 Table 14.4.5 (20) List fire alarm visual and audible notification devices on an inventory. The inventory is used to verify and document that all fire alarm visual and audible notification devices have been tested. #ASHEComplianceTip
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NFPA 110-2010: 8.4.6 All EPSS transfer switches must be tested monthly. There is often resistance to testing certain transfer switches monthly, but it is a requirement of NFPA 110. #ASHEComplianceTip ​
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NFPA 101-2012: 7.2.1.8.1 A door that is normally required to be kept closed can not be propped open or held open by any means other than an automatic closing device. Wooden wedges and other mechanical means of blocking the door open do not meet the requirements for self-closing or automatic closing. #ASHEComplianceTip ​ #ASHECompliance
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NFPA 101-2012 Chapter 38 and 39: Much emphasis is placed on Life Safety in health care and ambulatory healthcare occupancies. Don’t forget that there are life safety code requirements for business occupancies also, including egress and the ability to quickly exit a building. #ASHEComplianceTip
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NFPA 99-2012: 5.1.3.1.8, 5.1.3.1.9 Central supply locations containing positive pressure gas cylinders other than oxygen or medical air shall have a label on the door that says: Positive Pressure Gases NO Smoking or Open Flame Room May Have Insufficient Oxygen Open Door and Allow Room to Ventilate Before Entering. Locations containing central supply systems or cylinders containing only oxygen or medical air shall have a door label that says: Medical gases NO Smoking or Open Flames #ASHEComplianceTip
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NFPA 10: 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor #ASHEComplianceTi
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NFPA 99-2012; 6.3.4.1.3 Electrical receptacles that are not hospital grade in patient bed locations and locations where general anesthesia is performed must be tested at intervals not exceeding twelve months. #ASHEComplianceTip
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7.2.4.5 Records shall be kept to demonstrate that at least the last 12 monthly inspections have been performed. #ASHEComplianceTip
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NFPA 70-2011: 408.4 (A) Every electrical circuit must be identified as to its clear, evident, and specific purpose or use. For panelboards, a circuit directory is located on the face or inside of the panel door, and for switchboards, each switch or circuit breaker is identified. #ASHEComplianceTi
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NFPA 101 – 2012  Healthcare Occupancies 18/19.3.2.1, Ambulatory Healthcare Occupancies 20/21.3.2.1, Business Occupancies 38/39.3.2.1 Most storage areas in a health care occupancy are classified as hazardous areas. Be sure that hazardous areas meet the requirements for the occupancy type. #ASHEComplianceTip
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Protection of penetrations through fire-rated barriers must be protected by a fire-stop system or device that is tested for that particular application. #ASHEComplianceTip
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NFPA 13: 6.2.9.6* One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system. #ASHEComplianceTip
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If your kitchen is equipped with an automatic fire protection system be sure your staff is trained to activate the system before using the Type K fire extinguisher.  #ASHEComplianceTip
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NFPA 13-2010: 6.2.9 A minimum of six spare sprinklers corresponding to the types and temperature ratings installed in the building are required to be kept on site, stored in a cabinet where the temperature will not exceed 100 degrees F. A wrench for each type of sprinkler is also kept on site. The requirements for the minimum number of spare sprinklers increase with system size. #ASHEComplianceTip
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NFPA 99-2012: 5.1.3.5.13 When an emergency oxygen connection is required on the outside of the building, such as where the bulk cryogenic liquid central supply system is outside of and remote from the building, the emergency oxygen supply connection must be accessible and have a minimum of 3 ft. (1 m) of clearance around it. #ASHEComplianceTip
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