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So You Want to Service Health Care Facilities
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by Stan Oman, NAFED Technical Training Manager

We know how to maintain life safety equipment, but some of us struggle when we do any work at an accredited health care facility. We need to understand what is required from us when we do business at a health care facility.

We know the definitions of the life safety equipment we service, but we do not always know the definitions when working in a health care environment. I like to call this “The Language of the Joint Commission.” If we speak the language of the health care facility, it could go a long way in keeping or picking up new business.

In addition to all the challenges that health care facilities face on a daily basis, last year the Joint Commission and CMS (Centers for Medicare & Medicaid Services) adopted the 2012 edition of NFPA 101 and 99. This means that there are twelve years of changes that health care facilities have to deal with.


Any health care facility that wants to accept federal money (e.g., Medicare/Medicaid) has to be accredited. There are many organizations that can accredit health care facilities; one of these is the Joint Commission.

For us to be able to meet all the life safety requirements for the Joint Commission, we need to know specifically how the health care facility is accredited. To be sure, “How are you accredited?” would be one of the first questions you should ask.

Below is a list of the ways that a facility can be accredited, with descriptions:
  • Ambulatory Healthcare: Primary care providers and non-surgical settings
  • Behavioral Healthcare: Mental health centers, addiction treatment services
  • Critical Access Hospitals: Maintains no more than 25 total beds. Hospitalized 96 hours or less
  • Home Care: Home health, personal care, hospice
  • Hospitals: General, children’s, long term acute care, oncology, psychiatric, rehabilitation, specialty (cardiac, surgical)
  • Laboratory Services: Almost any lab
  • Long-Term Care: Non-acute settings, such as assisted-living facilities, rehabilitation centers, and chronic care facilities
Once you know how they are accredited, you will be able to determine which Joint Commission standards need to be followed.

The Language of the Joint Commission

The following are just a few definitions to know and understand:

Authority Having Jurisdiction (AHJ): Yes we know what this is, now add the Joint Commission to the list

Joint Commission: An independent not-for-profit organization

Electronic Statement of Conditions (E-SOC): A management tool that identifies, assesses, and resolves Life Safety Code definitions

Environment of Care (EOC): This section is made up of three basic elements: The building 2) The equipment 3) The people

Interim Life Safety Measures (ILSM): A series of eleven administrative actions intended to temporarily compensate for significant hazards posed by life safety deficiencies or construction activities

Plan For Improvement (PFI): There is a big change here. The Joint Commission is now using the SAFER MATRIX

Computers On Wheels (COWS): This is part of keeping corridors clear. Path of egress

National Patient Safety Goals (NPSG): These goals focus on problems in health-care safety and how to solve them

Element of Performance (EP): List of elements of performance (EPs) that require written documentation

Basic Building Information (BBI): Collects general information about each building occupied by patients/residents/clients

Servicing Life Safety Equipment

So, back to what we do. If we look in the front of NFPA 101 it lists “referenced publications.” We need to make sure we are servicing the life safety equipment to the correct NFPA edition year for what we are servicing. Yes, we normally service using standards that have been adopted in the state the building operates in. The Joint Commission is in every state, and they always follow NFPA 101, 2012 edition—period.

What about the paperwork you leave this customer? This can also be an issue. We need to list a lot of what we service separately: we need to list the NFPA code we are following, we need to list the Joint Commission standard, and the “EP” (see definition above). We also need to list every piece of life safety we service. This is called “inventory.” Let’s say you are servicing two hundred fire extinguishers. You would need to have a separate line listing each and every fire extinguisher. No rubber stamping, no ditto marks, pass/fail, and you must sign your name.

The Joint Commission has no power over a vendor; they have struggled over the years looking at different reports from a multitude of life safety vendors. So, in recent years, the focus has been on the paperwork that the health care facilities give the inspector during a recertification survey. In many cases, the facility fails miserably!

Example of a work order that we would have to show to the Joint Commission.

Changes in the 2012 Edition of NFPA 101

Resident cooktop or range must have all the following:
  1. A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range.
  2. The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.
  3. The switch is on a timer, not exceeding a 120-minute capacity that automatically deactivates the cooktop or range, independent of staff action.
  4. Not less than two AC powered photoelectric smoke alarms.
Out-of-service condition
Would require a fire watch (a person or persons assigned to an area for the express purpose of notifying appropriate people during an emergency) or building evacuation if a fire alarm is out of service for more than four hours or if the sprinkler system is out of service for more than ten hours. This is where your ILSM would kick in.

Annual test/inspection of all fire-rated door assemblies, by someone "with knowledge and understanding of the operating components of the type of assembly being subject to testing."

Sprinkler systems
  • All high-rise buildings over 75’ would be required to be fully sprinkled within twelve years.
  • Quarterly main drain testing should be performed on one system riser downstream of the backflow preventer where the sole water supply to the sprinkler system is through a backflow preventer.
  • Annual test of the 2.5-inch fire hose valves.
  • 3-year test of the 1.5-inch fire hose valves.
  • 5-year internal inspection of sprinkler pipe.

This example shows how one company tests a 2.5-inch fire hose valve in the stairwell.

Mock surveys
You can recommend carrying out a mock survey for life safety. This is a good way of building a relationship with your point of contact at the hospital.

A mock survey can help you find things like this beat-up fire door.

A mock survey can help you uncover things like these cables going through a fire wall with poorly applied fire caulk.

A mock survey is a good selling tool for those monthly inspections. A lot of hospitals utilize security people to do the monthly.

Additional Resources

  • NFPA 101 (2012)
  • NFPA 99 (2012)
  • Joint Commission Standard (2017)
  • Joint Commission Resources
Copyright NAFED 2017. Do not reuse without permission.

See also:
Health Care Facilities and NFPA Standards: What’s New
Fire Extinguisher Inspections at Health Care Facilities
more Calendar

5/10/2018 » 5/11/2018
2018 Conference - St. Louis

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