CMS Issue Affecting the
Physical Environment
South Carolina Society
of Hospital
p
Engineers
g
Presented November 3, 2011
By Ken Gregory
Vice President, Accreditation
TSIG Consulting, Inc
Who Regulates Hospitals?
Federal Circuit
Courts
Supreme Court
Congress
Centers for Medicaid and
Medicare Services
OIG
Healthcare Integrity Program
Contractors
Departmental
Appeals
PRRB
Regional Offices
Intermediaries
Carriers
PROs
DME Regional Contractors
State Level
• Survey and Certification
• Courts
• Attorneys General
• Medicaid
• Health Boards
• Medical Boards
• Local Governments
• Licensure
YOUR HOSPITAL
Regional Home Health
Intermediaries
DEA
FAA
FDA
OPOs
DOT
SEC
OSHA
IRS
EPA
DOJ
NRC
FTC
FCC
FBI
HHS/ NIOSH
HSS/ HRSA
Treasury
TJC / DNV
DOL
Chart Legend
DEA:
FAA:
OPO:
O
O
SEC:
IRS:
EPA:
FTC:
FCC:
HHS:
HRSA:
NIOSH:
Drug Enforcement Administration
Federal Aviation Administration
Organ
O
ga Procurement
ocu e e t O
Organizations
ga at o s
Securities and Exchange Commission
Internal Revenue Service
Environmental Protection Agency
Federal Trade Commission
Federal Commerce Commission
Health and Human Services
Health Resources and Services Admin
National Institution for Occupational Safety & Health
TJC/DNV:
NRC:
DOL:
FBI:
DOJ:
OSHA:
DOT:
FDA:
OIG:
PRO:
PRRB:
Joint Commission/ DNV Healthcare
Nuclear Regulatory Commission
Department of Labor
Federal bureau of Investigation
Department of Justice
Occupational Safety and Health Admin
Department of Transportation
Food and Drug Administration
Office of Inspector General
Peer Review Organization
Provider Reimbursement Review Board
CMS
Key
y Milestones
In 1965 Medicare and Medicaid were enacted as Title XVIII and
y Act,, extending
g health coverage
g to
Title XIX of the Social Security
almost all Americans aged 65 or older (e.g., those receiving
retirement benefits from Social Security or the Railroad Retirement
Board), and providing health care services to lowlow-income children
deprived of parental support
support, their caretaker relatives
relatives, the elderly
elderly,
the blind, and individuals with disabilities. Seniors were the
population group most likely to be living in poverty; about half had
insurance coverage.
**** The Social Security Act was established in 1935 as “The Old
Age Benefits Program
CMS
Key
y Milestones
1966 Medicare was implemented and more than 19 million
individuals enrolled on July
y 1.
1972 Medicare eligibility was extended to individuals under age 65
with longlong-term disabilities and to individuals with end
end--stage renal
disease (ESRD).
1977 The Health Care Financing Administration (HCFA) was
established to administer the Medicare and Medicaid programs.
1985 The Emergency Medical Treatment and Labor Act (EMTALA)
required hospitals participating in Medicare that operated active
emergency rooms to provide appropriate medical screenings and
stabilizing treatments.
CMS
Key
y Milestones
1988 The Medicare Catastrophic Coverage Act was enacted, which
included the most significant changes since enactment of the Medicare
program, improved
i
dh
hospital
i l and
d skilled
kill d nursing
i ffacility
ili b
benefits,
fi covered
d
mammography, and included an outpatient prescription drug benefit and
a cap on patient liability.
1996 The Health Insurance Portability and Accountability Act of 1996
(HIPAA) had several provisions.
1998 The internet site www.medicare.gov was launched to provide
updated information about Medicare.
2003 The Medicare Prescription Drug, Improvement, and Modernization
Act (MMA) made the most significant changes to Medicare since the
program began.
CMS?
Centers for Medicare and Medicaid Services
– CMS is a “Federal” program, however it is ““State
State
Administered”, therefore each state set’s its own
guidelines based around the Conditions of Participation
(CoP)
§ 482.41 Condition of participation: Physical environment.
– Determines funding reimbursements to healthcare
entities who treat medicare/medicaid patients
CMS?
What is the purpose of CMS as related to the Healthcare
Industries “physical environment”
– NFPA 101
– NFPA 99
– All supporting codes for 101 NFPA & NFPA 99
2000 LSC References to 1999
NFPA 99
8.4.4 exception
8.4.5
9.2.4
18 2 9 2
18.2.9.2
18.2.10.2
Table 18.3.2.1
18.3.2.2
18.3.2.3
18 3 2 4
18.3.2.4
18.5.1.2
18.5.1.3
19.3.2.2
19.3.2.3
19 3 2 4
19.3.2.4
20.2.9.2
20.3.2.1
20.3.2.2
21.2.9.2
21 3 2 1
21.3.2.1
21.3.2.2
The Primary Support Codes
NFPA 10 - Portable Fire Extinguishers
NFPA 25 - Inspection, Testing, and Maintenance of WaterWaterBased Fire Protection Systems
NFPA 70 – National Electrical Code
NFPA 72 – National Fire Alarm Code
NFPA 80 - Fire Doors and Other Opening Protectives
NFPA 96 - Ventilation Control and Fire Protection of
Commercial Cooking Operations
NFPA 110 – Emergency Power and Standby Systems
NFPA 111 - Stored Electrical Energy Emergency and
Standby Power Systems
NFPA 101 Health Care Facilities
Purpose
To provide minimum requirements, with
due regard to function,
function for the design
design,
operation, and maintenance of buildings
and structures for safety to life from fire
fire.
NFPA 99 Health Care Facilities
Purpose
To provide minimum requirements for:
– Performance
P f
– Maintenance
– Testing
– Safe Practices
* No installation criteria except for piped gas
True or False?
NFPA 99 applies to all new construction?
NFPA 99 applies to existing facilities?
Application of NFPA 99
“This document shall apply to all healthcare
facilities Construction and equipment
facilities.
requirements shall be applied only to new
construction and new equipment, except as
modified in individual chapters…”
Patient Care Area
Patient Care Area
Any portion of a healthcare facility wherein
patients are intended to be examined or
treated.
General Care Area
General Care Area
Patient bedrooms, examining rooms,
treatment rooms
rooms, clinics and similar areas in
which it is intended that the patient will come
in contact with ordinary appliances such as
nurse call system, electric beds, examining
lamps telephones
lamps,
telephones, and entertainment
devices.
Critical Care Area
Critical Care Area
Those special care units, intensive care
units operating rooms
units,
rooms…and
and similar areas in
which patients are intended to be subjected
to invasive procedures and connected to
line--operated patientline
patient-carecare-related electrical
appliances.
appliances
Wet Location or Not?
Description of Area
Operating Room
Patient Room
ICU Room
Emergency Exam Room
Ph i l Th
Physical
Therapy
Kitchen
Wet Location?
Wet Location or Not?
Description of Area
Wet Location?
Operating Room
Maybe
Patient Room
No
ICU Room
No
Emergency Exam Room
No
Ph i l Th
Physical
Therapy
M b
Maybe
Kitchen
No
The CMS Survey
Life Safety Code requirements
–
–
–
–
–
–
–
–
Building Construction
Interior Finish
Corridor Walls and Doors
Vertical Openings
Smoke Compartmentation and Control
Hazardous Area
Exit and Access
Exit and Egress
The CMS Survey
Life Safety Code requirements
–
–
–
–
–
–
–
–
–
Illumination and Emergency Power
Emergency Plan and Fire Drills
Automatic Sprinkler Systems
Smoking Regulations
Building Service Equipment
Furnishings and Decorations
Laboratories
Medical Gases and Anesthetizing Areas
Electrical
The CMS Survey
Building Construction
– K11 requires a 2 hr FRR barrier for any common occupancy separation
walls
– K12 sets requirements for acceptable construction types
New
–
–
–
–
I (443), I (332), II (222) any height with complete AASS
II (111) not over three stories with complete AASS
III (211) V (111) IV (2HH) II (000) nott over one story
t
with
ith complete
l t AASS
III (200) V (000) NOT ACCEPTABLE
Existing
–
–
–
–
–
I (443), I (332), II (222) any height
II (111) One story only when non
non--sprinklered
II (111) Not over three stories with complete AASS
III (211) V (111) IV (2HH) II (000) not over two stories with complete AASS
III ((200)) V (000)
(
) not over one storyy with complete
p
AASS
The CMS Survey
Building Construction (cont)
– K103 requires interior walls and partitions in buildings of Type I or Type
II construction shall be noncombustible or limitedlimited-combustible materials
Interior Finish
– K14
Existing interior finish for corridors and exitways, including exposed interior
surfaces of buildings such as fixed or movable walls, partitions, columns, and
ceilings has a flame spread rating of
Class
Cl
A or Cl
Class B
New interior finish for corridors and exitways, including exposed
interior surfaces of buildings such as fixed or movable walls,
partitions, columns, and ceilings has a flame spread rating of
Cl
Class
A or Class
Cl
B.
B Lower
L
portion
ti off corridor
id walls
ll can b
be
Class C
The CMS Survey
Interior Finish
– K15
Existing interior finish for rooms and spaces not used for corridors or
exitways, including exposed interior surfaces of buildings such as fixed or
movable walls
walls, partitions
partitions, columns
columns, and ceilings has a flame spread rating of
Class A or Class B. (In fully sprinklered buildings, flame spread rating of
Class A, Class B, or Class C may be continued in use within rooms
separated in accordance with 19.3.6 from the access corridors.)
New interior finish for rooms and spaces not used for corridors or exitways,
including exposed interior surfaces of buildings such as fixed or movable
walls, partitions, columns, and ceilings has a flame spread rating of Class A
or Class B. (Rooms not over 4 persons in capacity may have a flame spread
rating of Class A, Class B, or Class C).
– K16
Newly installed interior floor finish complying with 10.2.7 shall be permitted in
corridors and exits if Class I. (In smoke compartments protected throughout
by an approved, supervised automatic sprinkler system in accordance with
19.3.5.2, no interior floor finish requirements shall apply
The CMS Survey
Corridor Walls and Doors
– K17
Existing Corridors are separated from use areas by walls constructed with at
least 1/2 hour fire resistance rating.
– In sprinklered buildings, partitions are only required to resist the passage of smoke
and may terminate at the underside of ceilings where specifically permitted by
Code) .
– In non
non--sprinklered buildings, walls properly extend above the ceiling..
– Charting
Ch ti and
d clerical
l i l stations,
t ti
waiting
iti areas, dining
di i rooms, and
d activity
ti it spaces
may be open to corridor under certain conditions specified in the Code.
– Gift shops may be separated from corridors by nonnon-fire rated walls if the gift shop
is fully sprinklered.)
Ne corridor walls
New
alls shall form a barrier to limit the transfer of smoke
smoke. S
Such
ch
walls shall be permitted to terminate at the ceiling where the ceiling is
constructed to limit the transfer of smoke. No fire resistance rating is
required for the corridor walls.
The CMS Survey
Corridor Walls and Doors
– K18
Existing corridor doors, other than hazardous area, shall be:
– Substantial doors, such as those constructed of 1 3/4 inch soldsold-bonded
core wood, or capable of resisting fire for at least 20 minutes
– Doors in sprinklered buildings are only required to resist the passage of
smoke.
– There is no impediment to the closing of the doors
doors.
– Doors shall be provided with a means suitable for keeping the door
closed.
– Dutch doors meeting 19.3.6.3.3 are permitted.
New corridor doors shall be:
– Constructed to resist the passage of smoke.
– Doors shall be provided with positive latching hardware.
– Dutch doors meeting 18
18.3.6.3.6
3 6 3 6 are permitted
permitted.
The CMS Survey
Corridor Walls and Doors
– K19
Vision panels in corridor walls or doors shall be fixed window assemblies in
approved frames. (In fully sprinklered buildings, there are no restrictions in
th area and
the
d fifire resistance
i t
off glass
l
and
d fframes.))
Access to exits shall be marked by approved, readily visible signs in all cases
where the exit or way to reach exit is not readily apparent to the
Vertical Openings Between Floors
– K20
Existing vertical Openings shall be protected with a 1 hr FRR
New vertical openings shall be protected with 1 hr FRR for 3 stories or less
and 2 hr FRR for 4 or more stories
An atrium may be used in accordance with 8.2.2.3.5
The CMS Survey
Vertical Openings
p
g Between Floors
– K21
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke
barrier or hazardous area enclosure shall be permitted to be held open only
b d
by
devices
i
arranged
d tto automatically
t
ti ll close
l
allll such
hd
doors b
by zone or
throughout the facility upon activation of:
– (a) The required manual fire alarm system and
– (b) Local smoke detectors designed to detect smoke
passing through the opening or a required smoke
detection system and
– (c) The automatic sprinkler system, if installed
The CMS Survey
Vertical Openings
p
g Between Floors
– K33
Existing EXIT components (such as stairways) are enclosed with
construction having a fire resistance rating of at least one hour, are arranged
t provide
to
id a continuous
ti
path
th off escape, and
d provide
id protection
t ti against
i t fifire or
smoke from other parts of the building
New EXIT components (such as stairways) in buildings four stories or more
are enclosed with construction having a fire resistance rating of at least two
hours, are arranged to provide a continuous path of escape, and provide a
protection against fire and smoke from other parts of the building. In all
buildings less than four stories, the enclosure is at least one hour.
The CMS Survey
Smoke Compartmentation
p
and Control
– K23
Existing - Smoke barriers shall be provided to form at least two smoke compartments on
every sleeping room floor for more than 30 patients.
New - Smoke barriers shall be provided to form at least two smoke compartments on
every floor used by inpatients for sleeping or treatment, and on every floor with an
occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be
provided on floors that are usable, but unoccupied
– K24
The smoke compartments shall not exceed 22,500 square feet and the travel distance to
and from any point to reach a door in the required smoke barrier shall not exceed 200
feet.
The CMS Survey
Smoke Compartmentation
p
and Control
– K25
Smoke barriers shall be constructed to provide:
– At least a one half hour in existing, (one hour in new) fire resistance rating and
constructed
d iin accordance
d
with
ih8
8.3.
3
– Smoke barriers shall be permitted to terminate at an atrium wall.
– Windows shall be protected by fire
fire--rated glazing or by wired glass panels and steel
frames.
– A minimum off two separate compartments shall be provided on each floor.
f
– Dampers shall not be required in duct penetrations of smoke barriers in fully
ducted heating, ventilating, and air conditioning systems.
– K26
Space shall be provided on each side of smoke barriers to adequately
accommodate those occupants served.
The CMS Survey
Smoke Compartmentation and Control
– K27
Existing door openings in smoke barriers have:
– At least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid
bonded core wood
– Non
Non--rated protective plates that do not exceed 48 inches from the bottom of the
door are permitted.
– Horizontal sliding doors comply with 7.2.1.14.
– Doors shall be self
self--closing or automaticautomatic-closing in accordance with 19.2.2.2.6.
– Swinging doors are not required to swing with egress
– Positive
P iti llatching
t hi iis nott required
i d
New Door openings in smoke barriers have:
– At least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid
bonded core wood.
– Non
Non--rated protective plates that do not exceed 48 inches from the bottom of the
door are permitted.
– Horizontal sliding doors comply with 7.2.1.14.
– Swinging doors shall be arranged so that each door swings in an opposite
direction.
– Doors shall be self
self--closing and rabbets, bevels or astragals are required at the
meeting edges.
– Positive latching is not required
The CMS Survey
Smoke Compartmentation and Control
– K28
Discusses clear widths and vision panel requirements.
– K104
Penetrations of smoke barriers by ducts are protected
by smoke dampers in accordance with 8
8.3.5.
35
The CMS Survey
Smoke Compartmentation and Control
– K29
Existing hazardous areas are:
– Protected by 1 hr FRR (with ¾ hr doors) or automatic fire
extinguishment system and resistant to the passage of smoke,
– Be without windows
– Self closing or automatic closing doors
New hazardous areas are:
– Protected byy a 1 hr FRR ((with ¾ hr door))
– Without windows
– Self
Self--closing or automatic closing doors
The CMS Survey
Smoke Compartmentation and Control
– K30
Gift shops
p shall be p
protected as hazardous areas when
used for storage or display of combustibles in quantities
considered hazardous. NonNon-rated walls may separate
gift shops
g
p that are not considered hazardous,, have
separate protected storage and that are completely
sprinkled.
Gift shops may be open to the corridor if they are not
considered hazardous, have separate protected
storage, are completely sprinklered and do not exceed
500 square feet
feet.
The CMS Survey
Exit a
and
d Exit Access
ccess
– K32
Not less than two exits, remote from each other, are
provided for each floor or fire section of the building.
Only one of these two exits may be a horizontal exit.
– K34
Stairways and smoke proof towers used as exits are in
accordance with 7.2. 18.2.2.4, 19.2.2.3, 19.2.2.4
– K35
Capacity of exits in number of persons per unit of exit
width is in accordance with 7
7.3.
3 18
18.2.3.1,
2 3 1 19
19.2.3.1
231
The CMS Survey
Exit a
and
d Exit Access
ccess
– K36
Existing travel distances:
100 ft from an exit access door to an exit (150 ft if AASS)
150 ft from anywhere in a room (or suite of rooms) to an exit (200 ft
if AASS)
– K37
Existing deaddead-end corridors shall be permitted to be continued to be
used if it is impractical and unfeasible to alter them so that exists are
accessible in not less than two different directions from all points in
aisles, passageways, and corridors.
New deaddead-end corridors shall not exceed 30 ft.
The CMS Survey
Exit a
and
d Exit Access
ccess
– K38
Exit access is so arranged that exits are readily accessible at all
ti
times
iin accordance
d
with
ith 7
7.1.
1 18
18.2.1,
2 1 19
19.2.1
2 1 ((egress chapter)
h t )
– K39
Existing - Width of aisles or corridors (clear and unobstructed)
serving
i as exit
it access shall
h ll b
be att lleastt 4 ffeet.
t
New - Width of aisles or corridors (clear and unobstructed) serving
as exit access in hospitals and nursing homes shall be at least 8
feet In limited care facility and psychiatric hospitals
feet.
hospitals, width of aisles
or corridors shall be at least 6 feet.
– K40
Exit access doors and exit doors used by health care occupants are
of the swinging type and have a clear width per 18/19.2.3.5
The CMS Survey
Exit a
and
d Exit Access
ccess
– K41
All sleeping rooms have a door leading to a corridor providing
access to
t an exit
it or have
h
a door
d
lleading
di di
directly
tl tto grade.
d
– K42
Any room or suite of rooms of more than 1,000 sq. ft. has at least 2
exit
it access d
doors remote
t ffrom each
h other
th
– K43
Patient room doors are arranged such that the patients can open the
door from inside without using a key. (Special door locking
arrangements are permitted in facilities. 18.2.2.2.4, 18.2.2.2.5)
The CMS Survey
Illumination
u
a o a
and
d Emergency
e ge cy Power
o e
– K45
K45--K47
Illumination of means of egress, including exit discharge and exit
discharge
– K105
K105--108
Requirements for life support systems, alarm detection,
communications etc
communications,
etc. be on emergency power
– K48
Written Fire Plan
– K50
Fire Drill requirements
The CMS Survey
Illumination and Emergency
g
y Power
– K51, 52, 155, 53, 54, and 55
Fire Alarm System Requirements
– K56, 154, and 6060-64
Fire Sprinkler Requirements
Smoking regulations
– K66
Smoking regulations shall be adopted and shall include not less
than the following provisions: 18.7.4, 19.7.4
– Smoking shall be prohibited in any room, ward, or
compartment where flammable liquids, combustible gases, or oxygen is used or stored
i any other
in
th h
hazardous
d
llocation,
ti
and
d such
h area shall
h ll b
be posted
t d with
ith signs
i
that
th t read
d NO
SMOKING or shall be posted with the international symbol for no smoking.
– Smoking by patients classified as not responsible shall be prohibited, except when under
direct supervision.
– Ashtrays of noncombustible material and safe design shall be provided in all areas
where
h
smoking
ki iis permitted.
itt d
– Metal containers with selfself-closing cover devices into which ashtrays can be emptied
shall be readily available to all areas where smoking is permitted.
The CMS Survey
Building
u d g Se
Services
ces Equipment
qu p e
– K67
Heating, ventilating, and air conditioning shall comply with 9.2 and shall be installed in
accordance with the manufacturer’s specifications.
– K68
Combustion and ventilation air for boiler, incinerator and heater rooms is taken from and
discharged to the outside air.
– K69
Cooking facilities shall be protected in accordance with 9.2.3.
18.3.2.6, 19.3.2.6, NFPA 96
– K70
Portable space heating devices shall be prohibited in all health care occupancies
occupancies.
Except it shall be permitted to be used in nonnon-sleeping staff and employee areas where
the heating elements of such devices do not exceed 212 F (100 C).
The CMS Survey
Building
u d g Se
Services
ces Equipment
qu p e
– K71
Linen Chutes
– K160
All existing elevators, having a travel distance of 25 ft or more above or below the level
that best serves the needs of emergency personnel for fire fighting purposes, conform
with Firefighter’s Service Requirements of ASME/ ANSI A17.3, Safety Code for Existing
Elevators and Escalators.
All existing escalators, dumbwaiters, and moving walks conform to the requirements of
ASME/ ANSI A17.3, Safety Code for Existing Elevators and Escalators. 19.5.3, 9.4.2.2
Includes escalator emergency stop buttons and automatic skirt obstruction stop. For
power dumbwaiters includes hoistway door locking to keep doors closed except for floor
where car is being loaded or unloaded
unloaded.
All new elevators, escalators, and conveyors comply with ASME/ ANSI A17.1, Safety
Code for Elevators and Escalators (Includes car emergency signaling, firefighters
service phase I key and smoke detector automatic recall, firefighters service phase II
emergency inin-car operation, machine room smoke detectors, elevator lobby smoke
detectors).
The CMS Survey
Building
u d g Se
Services
ces Equipment
qu p e
– K72
Means of egress shall be continuously maintained free of all obstructions or
impediments to full instant use in the case of fire or other emergency. No furnishings,
decorations or other objects shall obstruct exits,
decorations,
exits access thereto,
thereto egress there from
from, or
visibility thereof shall be in accordance with 7.1.10
– K160
All existing elevators, having a travel distance of 25 ft or more above or below the level
– K73
K73--74
Requirements for draperies, mattresses, etc.
– K75
Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in
capacity. The average density of container capacity in a room or space shall not
exceed .5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded
within any 64
64--ft2 (5.9
(5.9--m2) area. Mobile soiled linen or trash collection receptacles
with capacities greater than 32 gal (121 L) shall be located in a room protected as
a hazardous area when not attended.
The CMS Survey
Laboratory Requirements
– K31, 136, and 131
131--134
If high hazard
Emergency Procedures
Spill Procedures
Safety Education
Fume Hoods
Emergency
g
y Shower
Flammable Liquid Storage
– K 7676-78,140
78,140--141, and 142
142--143
Medical Gas Systems
Anesthesia Locations 35% Humidity
Master alarm panels are in two separate locations and have audible and visible signals.
There are high/low alarms for +/+/- 20% operating pressure.
Hyperbaric facilities
Gas & Vacuum Systems
Storage between 300 cubic feet & 3000 cubic feet
– Outdoor space
– Interior space
Noncombustible or limitedlimited-combustible construction
Secured Doors
Vented (but not into corridor)
Gas & Vacuum Systems
Greater than 3,000 cubic feet
– Outdoors
– If indoors, be constructed and use interior finishes of noncombustible or
limited--combustible materials such that all walls, floors, ceilings and
limited
doors are of a minimum 11-hour fire resistance rating
– Shall be provided with dedicated mechanical ventilation systems that
draw air from within 300 mm (1 ft) of the floor and operate continuously.
continuously
A means of makeup air shall be provided.
Gas & Vacuum Systems
Oxidizing gases, such as oxygen and nitrous oxide:
–
–
–
–
shall not be stored with any flammable gas, liquid, or vapor.
5 ffeett from
f
combustible
b tibl materials
t i l iin sprinklered
i kl d areas
20 feet from combustible materials in non
non--sprinklered areas or
An enclosed cabinet of noncombustible construction having a minimum
fire protection rating of ½ hour
Gas & Vacuum Systems
Centralized manifold systems interior room
– 1 hr FRR room & door
– Vented to exterior
– Not located in or have direct access to areas involved in critical patient
care
– Not located in or have direct access to anesthetizing procedures
– Not located near areas storing flammable materials or liquids or
combustible liquids
– Not located near areas with open flames (e
(e.g.,
g kitchen & mechanical
room)
– Not located in area with spark
spark--generating equipment (e.g., emergency
generator)
The CMS Survey
Electrical Systems
y
– K106
The hospital and all nursing homes and hospices with life support equipment has a Type
I Essential Electrical System powered by a generator with a transfer switch and separate
power supply.
p
pp y
– K144
Generators are tested monthly and exercised under load for 30 minutes per month
– K146
The Type I EES is divided into the critical branch, life safety branch and the emergency
system
– K147
Electrical wiring
g and equipment
q p
shall be in accordance with NFPA 70,, National Electrical
Code.
– And last, but not least, K130
Miscellaneous items that are not listed previously, but are deficient.
Electrical Systems
NFPA 110
EPS installed in separate room for Level One installations
EPSS equipment allowed in same room
Room must be 22-hour rated or in an adequate enclosure
outside the building capable of resisting the entry of snow or
rain
No other equipment, except that serving the space, permitted
in room
Electrical Systems
Maintenance & Testing
Maintain to meet 1010-second criteria
Interval 20 to 40 days
12 tests per year
Must meet 30% rated load or load bank
36 M
Month
th ttestt mustt be
b att a minimum
i i
off 3% ffor the
th ffullll 4
hours.
Summary of Hot Items
Corridor Obstructions
Exits not locked/obstructed
Items on Sprinkler lines and supports
Open
O
J-Boxes
JB
Air Pressure Relationships
Fire Drills
EPSS Testing
Documentation Errors
Questions
Ken Gregory
Vice President of Accreditation
TSIG Consulting
1001 Olivia Court
Mount Juliet, TN 37122
(615) 598598-2652
gregoryk@tsigconsulting.com