1. National Fire Protection Association Update
PJ Cooper
Life Safety Program Manager
Office of Health Facility Licensure and Certification
August 10, 2018
Canaan Valley Resort, Davis, WV

2. NFPA Update
Health Care Facilities Code includes all health care facilities other than home care. It is intended for those involved in the design, construction, maintenance, and inspection of health care facilities as well as the design, manufacture, and testing of appliances and equipment used in patient care rooms of health care facilities. The 2012 edition of the Health Care Facilities Code has had many revisions. This presentation will provide an overview of the codes related to health care facilities.

3. Fire Safety Requirements and Health Care Facilities
On May 4, 2016, the Centers for Medicare & Medicaid services (CMS) published a final rule titled “Medicare and Medicaid programs: Fire Safety Requirements for Certain Health Care Facilities,” which updates the fire safety requirements for health care providers and suppliers. This regulation requires certain providers and suppliers to meet the requirements of the 2012 edition of the Life Safety Code (LSC), National Fire Protection Association (NFPA) 101 and the 2012 edition of the Health Care Facilities Code, NFPA 99. The final rule can be located at:

4. Fire Dampers
Fire dampers are inspected one year after installation and then every four years for nursing homes and every six years for hospitals. Documentation includes:
Location of damper
Date of inspection
Name of inspector
Deficiencies covered

5. Power Cords and Extension Cords
Power strips in patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assemblies that have been assembled by qualified personnel and meet the conditions of Power strips in patient care vicinity may not be used for non-PCREE, except in long-term care resident rooms that do not use PCREE. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of Reference: (NFPA 99), (NFPA 99), (NFPA 70), (D) NFPA 70).

6. Rated Storage Rooms
Hazardous areas are protected in accordance with The areas shall be enclosed with a one hour fire rated barrier, with a ¾ hour fire rated door without windows in accordance with Doors shall be self-closing or automatic-closing in accordance with Hazardous areas are protected by a sprinkler system in accordance with 9.7, , and 8.4.

7. Sprinkler and Light Fixtures
Check light fixtures and exit signs to assure no restriction of sprinkler coverage.
Nursing homes and hospitals, where required by construction type, are protected throughout by an approved sprinkler system in accordance with NFPA 13.
Table Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/ SSP)
Distance from Sprinklers to Side of Obstruction (A)
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.) (B)
Less than 1 ft - 0
1 ft to less than 1 ft 6 in - 2½
1 ft 6 in to less than 2 ft - 3½
2 ft to less than 2 ft 6 in - 5½
2 ft 6 in to less than 3 ft - 7½
3 ft to less than 3 ft 6 in - 9½
3 ft 6 in to less than 4 ft - 12
4 ft to less than 4 ft 6 in - 14
4 ft 6 in to less than 5 ft - 16½
5 ft and greater - 18
For SI units, 1 in. = 25.4 mm; 1 ft = m.
Note: For (A) and (B), refer to Figure (a).

8. Electrical Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement or servicing.
Additional testing is performed at intervals defined by documented performance data.
Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months.
Line isolation monitors (LIM), if installed, are tested at intervals of less than one month by activating the LIM test switch per , which activates both visual and audible alarm.
For LIM circuits with automated self-testing, this manual test is performed at intervals less than 12 months.
LIM circuits are tested per after any repair or renovation to the electrical distribution system.
Reference: NFPA

9. Electrical Maintenance and Testing, Cont’d.
Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.
Reference: NFPA

10. Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source.
A centralized computer system, e.g., building information system, is not to be substituted for the alarm annunciator.
Reference: NFPA ,

11. Electrical Safety Test
Concentrators must be tested annually.

12. Internal Sprinkler Inspection
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25. This is standard for inspection, testing, and maintaining of water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
Date sprinkler system last checked
Who provided system test
Water system supply source
d. Five year internal inspection and water storage interior tank inspection

13. Cooking Equipment
Heat producing devices under the exhaust hood must have a fuel source cut upon activation of the Ansul system. Cooking equipment is protected in accordance with NFPA 96.

14. Fire Doors and Opening Protectives
NFPA 80
Chapter 3 – Definitions
Qualified Person
A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.
Deficiencies found during annual testing must be corrected and documented.

15. Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions.
Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift.
The staff is familiar with procedures and aware that drills are part of established routine.
Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of audible alarms.
Sections: Life Safety Code through , through

16. Portable Space Heaters
Portable space heating devices shall be prohibited in all health care occupancies, unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). Sections: Life Safety Code ,

17. Questions

18. Contact
PJ Cooper, Life Safety Program Manager West Virginia Department of Health and Human Resources Office of Inspector General Office of Health Facility Licensure and Certification (OHFLAC) 408 Leon Sullivan Way Charleston, WV OHFLAC.wvdhhr.org