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.
NFPA 23-2011: 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 Fire Safety Survey Report 2012 Code – Health Care K926 Comingling of full and empty cylinders is not allowed. Empty cylinders are segregated 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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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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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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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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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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