RSSAll Entries in the "Life Safety Code" Category

If you’re the AHJ, it really isn’t an “interpretation,” is it?

I’m sure we all have stories about Authorities Having Jurisdiction (AHJ) whose “sense” of what is required by code was less operationally friendly than one might have preferred. The instructor at my first educational program at NFPA headquarters indicated that there is a single response to any question than can be asked regarding compliance with (in this case, but it applies fairly universally) the Life Safety Code®: “It depends.” There may be some that think that that was a rather flippant thing to say, but in my experience it holds way more truth than hyperbole, pretty much to the point of embracing it as a central concept for pursuing compliance. The corollary that extends from that is one of the other compliance “truths”: Any AHJ can disagree with any decision you’ve made, or, indeed, anything that they or another (competing) AHJ might have told you in the past. A good example of this is when you run into a state surveyor who is not particularly inclined to “honor” an existing waiver or equivalency. If I’ve learned anything over the past X number of years, it’s that results of previous encounters have little bearing on future encounters.

At any rate, I recently received a question regarding the audibility of occupant notification appliances as a function of NFPA 72 and the interpretation of an AHJ that there is no such thing as an “average ambient sound level.” It would seem that this particular interpretation is based on the “sense” that “average ambient sound level” (and it’s cousin “ambient sound level”) are unrelated to any measurements taken by a contractor or through the AHJ’s office. As we know (being the stewards responsible for ensuring that care environment is as functionally quiet as possible), NFPA 72 does indeed invoke (for audible public mode appliances) that the sound level of those appliances must have a sound level of at least 15 dB above the average ambient sound level or 5 dB above the maximum sound level having a duration of at least 60 seconds, whichever is greater, etc. NFPA 72 also stipulates a process for making that determination, calling for sound pressure level being measure over the period of time any person is present, or a 24-hour period, whichever time period is lesser. And to be honest, I don’t know that I’ve ever seen (perhaps because I never asked for it, but I may start) any documentary evidence of that measurement when determining the sound levels for a fire alarm system.

So, the thought occurs to me that it is entirely possible that, based on his observations and experience, his statement regarding the measurement of ambient noise levels is accurate to the extent of that experience, etc. He may know the contractor that installs fire alarm systems in his jurisdiction and received feedback that the process stipulated under NFPA 72 is not routinely included in acceptance testing of a system. Or it may be that, in his determination, the standard industry practice in his jurisdiction is not sufficiently consistent to allow for the use of the ambient noise levels as a determining factor and has identified an acceptable range for his jurisdiction (75 to 110 dB). He also knows that his office is not performing this measurement, so his statement, while perhaps a bit hyperbolic, is accurate from his standpoint. But I know there are areas in which even 75 dB can make quite a racket (I’m thinking recovery rooms, ICUs, etc.), which leads me to a closing anecdote.

Back when I was responsible for day-to-day operations, I had (on a number of occasions) tried to convince my local AHJ that we could reduce the volume of the notification appliances in the PACU (which, of course, begs the question of why anyone would spec audible devices in the PACU, but sometimes…) and still achieve the same level of safety in the event of fire, etc. (primarily based on staffing levels), but I couldn’t sell that scheme. This went on over the course of several years until one day I happened to find out this individual was coming in for surgery and darn if there wasn’t a fire alarm activation when he was in the PACU. Long story, short: His next visit resulted in him signing off on reducing the volumes on the appliances (I couldn’t get my boss to sign off on replacing them—lean budget times, but sometimes you have to take what you can get).

Hope you’re staying away from any exceptionally pesky AHJs, but if you’re dealing with an unbending presence, I hope you get the opportunity to cast some illumination on your “interpretation.”

Take care and stay safe!

And it makes me wonder…sure does!

And it’s not just a bustle in your hedgerow, so alarm might be warranted…

Lately, I’ve been using this space to muse on the potential for changes to the survey process, particularly as a function of the inclusion of outpatient clinic settings and the impact of life safety surveyor attention to these facilities might have on survey results. If your immediate thought was “more findings in the physical environment,” I fear you are more correct than you might have wanted to be.

While I don’t have access to the official results just yet (the wheels of bureaucracy grind ever slowly), I was able to be front and center last week for a full federal Conditions of Participation survey. The most notable aspect of the survey (for me) was the attention paid to outpatient clinics being managed as business occupancies by the life safety portion of the survey process. There was a lot of focused document review for these offsite locations, with the expectation that the degree/level of exactitude in the documentation for your main campus is to be extended to the outpatient settings. Inventory lists of devices, making sure sensitivity testing is being done (with specific values—not just a pass/fail note for each); focused attention on how spare sprinkler heads are being managed—including ensuring that the correct wrench or wrenches are in place; quarterly fire drills (and yes, you read that correctly; it seems that the days of annual fire drills in business occupancies is drawing to a close), etc.

Those of you managing your outpatient settings through your own processes will have a leg up on the process, but if you rely on documentation provided by landlords, etc., you probably want to start kicking those tires and having the discussions now. The other piece of this is that the expectation is that any requested documentation would be readily (pretty darn close to immediately) available for review by the surveyor, so you may want to consider how you are managing that process. Do you have site-based binders or do you provide electronically? The surveyors definitely don’t want to hear that (for whatever reason) the documentation is not available.

As a final thought for this week, in light of this week’s coverage, you may want to give some thought as to how you might memorialize the ligature resistance risk assessment in the outpatient areas (don’t forget to make it thoughtful). As you can see from the link, the FAQ is aimed at the “hospital and hospital clinics” settings, so I think we can see where this could (and, let’s face it, probably will) go.

Until next time, I hope this finds you well and somehow managing the current currents—not sure what it will look like when we finally get past these rapids, but I hope that we all get through together!

Do you still BBI? Also, how do you spell survey finding?

N-O-I-N-V-E-N-T-O-R-Y

While I am not convinced it every truly went away, next month marks the official return of one of the most (in)famous acronyms in surveydom: BBI, which we all know stands for Basic Building Information (details can be found here). So, for those of you for whom survey is imminent, you might (if you have not already done so) want to hop on to your online Statement of Conditions portal to make sure that all your information is up to date, all required responses are in place, etc. Since this is nominally a “new” requirement, I think it best to presume that the Life Safety surveyors are going to be reviewing the contents, so you want to make sure you have a good read on your square footage numbers and all the rest of it. I don’t see this representing a particularly great risk of survey exposure, but I’d hate to see somebody out there in the audience to get tapped for something so simple.

In other news (and I would consider this more troubling in the long term), back in September, the updates to some of the Environment of Care performance elements for office-based surgery practices were published (details here). While the updates relate mostly to invocation of the 2012 edition of the Life Safety Code® and the applicable reference documents, it also (and this may me being a touch paranoid—’tis always the season) may be indicative of a shift in focus for what documentation might be requested for care locations that are nominally business occupancies. I have definitely seen this (though I wouldn’t yet call it a trend, though it’s getting there) in state surveys of larger healthcare organizations, so it may just be a matter of time before evidence of compliance is requested for all the various life safety systems in place at your offsite locations (remembering that this does not mandate the presence of fire alarm systems, sprinkler systems, etc.—it only requires you to appropriately maintain any existing systems).

On a final note for this week, it would seem that some folks are using their work order system to provide evidence of scheduled activities like monthly testing/inspections of battery-powered lights, exit signs, task lighting, etc., and I just wanted to let you know that in the absence of an inventory of devices by location, there are some surveyors (and perhaps even more than just some surveyors) that will not accept a completed/closed out work order as evidence of compliance for these activities. Recognizing that the standards-based requirement for the “inventory” (in all its glory) has not specifically been extended to utility systems equipment (though I have anticipated that extension for a while), I think it may be time to start including the same level of detail as required for life safety systems inspection, testing and maintenance activities:

  • Name of the activity
  • Date of the activity
  • Inventory of devices, equipment, or other items
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

I suppose to a fair degree it makes sense for inspection, testing, and maintenance documentation to have a standard format and it certainly helps to establish compliance in a fashion that is recognizable to surveyors. I guess we’ll just have to keep a watchful eye on this one…

One size fits all…or one size fits none

In a world in which the economies of scale don’t always economize, I keep running into situations and/or conditions that result from trying to make something do too much. The classic example (other than those one-size-fits-all bunny suits in ORs across this great land of ours—I always end up looking like late-model Elvis, Vegas edition) is the temperature log that is used for food refrigerators, medication refrigerators, etc. As a general rule of thumb, unless the temperature range for each of the refrigerators being monitored is the same (and never mind trying to mix Fahrenheit and Celsius), then you are just asking for trouble. “Pushing” staff to have to discern between competing “out of range” temperature values requires an almost infinite amount of attention, and while there is, in certain instances, some overlap (food is usually 33-40 degrees F and medication 36-46 degrees F, so 36-40 works for both), it just makes so much more sense to limit confusion to the extent possible. And, to my mind, that means individualized temperature logs. One quick note regarding temperature logs for freezers, if your log doesn’t have a temperature “safe” range clearly indicated, I’ve been seeing a lot of mix-ups regarding those pesky negative numbers. For instance, if you establish a target of -15 degrees or colder, -10 degrees would be considered an -out-of-range value, but in talking with the folks doing the monitoring, they “think” of “10” being less that “15,” kind of missing the whole negative number dynamic. I won’t say that this is happening everywhere, but I have run into it in a couple of instances, so that’s something to keep an eye on.

Turning to the Oddities page, I was cruising through The Joint Commission’s FAQ page (admittedly, looking for blog fodder) and came across something of a puzzle; in the text of the FAQ dealing with the “old” requirement of the building assessment as a function of the Statement of Conditions (the old Part 3, which is no longer available) and has not been since 2007. But if you look at the text of LS.01.01.01, the second performance element indicates that a building assessment is required (at time frames to be determined by each organization) to determine compliance with the Life Safety chapter of the Joint Commission manual. I guess the thing that struck me about this happenstance is that the FAQ would have a good opportunity to indicate that the building assessment has evolved (or mutated—your pick) into its present day purpose  as an exercise in assessing your building for compliance with the LS chapter. Maybe they just haven’t gotten around to updating this FAQ (it is a ways down the FAQ page), and I suppose it is no more than a curiosity.

Walls and Bridges: Managing construction projects large and small

As you might guess, part of my approach when I’m doing onsite client work is to review the process for managing construction projects, inclusive of the risk assessment process (infection control, life safety). To my mind, there is no more risky business in the physical environment (the management of ligature risks notwithstanding) than undertaking construction or renovation projects, particularly when those projects are in spaces adjacent to occupied patient care (or indeed, any occupied) areas. And with the adoption of the 2012 Life Safety Code® (LSC) and the growing invocation of Chapter 43 Building Rehabilitation, it would seem that the tip of the regulatory spear is getting sharper by the moment.

One of the things that I encounter with some regularity is a fundamental flaw in how the risk assessment actually captures/identifies the risks to be managed as a function of what strategies are to be implemented to eliminate/mitigate the impact of those risks. For example, I can’t tell you how many times I’ve seen assessments of a project that is going to include construction barrier walls in a corridor for which the assessment indicates no impact on egress. Now, you can certainly indicate that, based on the implementation of X, Y, and Z, you have mitigated the impact on egress, but to indicate in the assessment that there was no impact on egress from a barrier wall that has encroached on the corridor, is inaccurate at best—and possibly could draw the ire of a literalist surveyor. As I like to tell folks when I encounter this: You don’t get credit for doing the math in your head; the assessment should indicate that there was an impact, but the impact was mitigated by the implementation of ILSM(s).

Similarly, if you remove the suspended ceiling in a project area, you have impaired the smoke detection/sprinkler protection in the area. Now it may be that the impairment is sufficiently minor in nature to not require implementation of ILSMs, based on your policy, but you still have to indicate that such is the case. You can’t say there was no impact or impairment, because the condition you have represents an impairment and so, there’s got to be some level of impact.

I think perhaps the way to look at this is much in the vain of our emergency management Hazard Vulnerability Analysis (HVA) process. There is no harm/no foul in identifying risks for which you would need to be prepared (you could make the case that there are few things as disruptive to an organization as a construction project) as long as you have a strategy for managing those risks. So, if you carry over the philosophy to construction/renovation, it makes it “easier” to frame the assessment as a proactive management of risks rather than trying to figure out how to do as little as possible (and I do see pre-construction risk assessments that seem to be aimed at a de minimis implementation strategy). But using the HVA algorithm (likelihood, impact, preparedness, response) you might find that your “packaging” is a little tidier than it was previously.

As a final note on this subject, I really think you need to get in the habit (if the habit has not already formed) of posting infection control permits, ILSM permits, etc., outside of construction/renovation areas so it is clear what the expected conditions and/or practices might be. You can’t be looking over the shoulder of the contractors every minute, so it helps to have some eyes in the field (with a reasonable knowledge base) keeping watch. There is definitely an expectation of regulatory surveyors that these will be posted in conspicuous locations (yeah, I know there’s no rule that says you have to, so chalk this up to a best practice invocation), so better to have visible postings.

Please let me close things out with best wishes for a joyous and restful (Can you combine those two? I think you can!) Thanksgiving to you and your families. 2018 whipped along at a pretty good clip and I suspect that the holidays will launch us into 2019 before too long, so take a few deep breaths and enjoy the day.

I may not be perfect, but I’m perfect for you: CMS rates the accreditation organizations!

Another mixed bag of stuff for you this week, leading off with a quick spin through CMS’ report card to Congress.

While the numbers have shifted around a little, infection control is making a move on the outside, but the physical environment is still the big point of focus, though you can see where the two are starting to cross over at a greater frequency. I think issues relating to ligature risks are going to be a very sharp focus, particularly with CMS surveys. Although it is interesting to note that (at least at the moment) when ligature risks come up in the CMS survey process, those risks have been cited under the Patient Rights Condition of Participation (each patient has a right to receive care in a safe setting), so we may see Patient Rights at the top of the heap next year. One way you can avoid that little dance of ignominy is to make sure that you have completed a comprehensive ligature risk assessment in those areas in which you are managing behavioral health patients, including mitigation strategies for items that cannot be immediately corrected and solid anticipated completion dates. They are taking ligature risks very seriously because of the potential for harm to patients and you don’t want to have a whole lot of open-ended plans of correction. It almost comes down to a sense that everything that exists is a potential risk to be managed and while I am hopeful that cooler heads will prevail, right now this is a very, very hot topic.

One other thing to note with the report card is a section that deals with an analysis of survey disparity relating to Life Safety Code® compliance and health and safety considerations. I’ve looked at the contents of this section, including their conclusions and recommendations, and I have a hard time thinking that this is ever going to go away as a survey focus. While I tend not to rely on absolutes when it comes to periods of time, I can say quite confidently that there will always be stuff to find during a survey. You can look today and find stuff, you can look tomorrow and find different stuff, you can look the day after and—you guessed it! Stuff happens; people do stuff we don’t want them to, including unauthorized field modifications. The list is literally and figuratively endless. I know they have to find something, but as a collective, I think most hospitals are very well maintained and managed as a function of the physical environment. But if the big “C” knocks on the door (and I guess we have to include the minions as well), there’s going to be a list of stuff. Our job is to keep that list to a minimum. Good luck with that!

Everybody here comes from somewhere: Leveling the post-survey field

Well, if the numbers published in the September Perspectives are any indication, a lot of folks are going to be working through the post-survey Evidence of Standards Compliance process, so I thought I would take a few moments to let you know what has changed since the last time (if ever—perhaps your last survey was a clean one) you may have embarked upon the process.

So, what used to be a (relatively) simple accounting of Who (is ultimately responsible for the corrective action), What (actions were taken to correct the findings), When (each of the applicable actions were taken), and How (compliance is going to be sustained) has now morphed into a somewhat more involved:

  • Assigning Accountability (for corrective actions and sustained compliance)
  • Assigning Accountability – Leadership Involvement (this is for those especially painful findings in the dark orange and red boxes in the SAFER matrix – again, corrective actions and sustained compliance)
  • Correcting the Non-Compliance – Preventive Analysis (again, this is for those big-ticket findings – the expectation is that there will be analysis of the findings/conditions cited to ensure that the underlying causative factors were addressed along with the correction of the findings)
  • Correcting the Non-Compliance (basically, this mashes together the What and When from the old regimen)
  • And last, but by no means least, Ensuring Sustained Compliance

This last bit is a multifocal outline of how ongoing compliance will be monitored, how often the monitoring activities will occur (don’t over-promise on those frequencies, boys and girls; keep it real and operationally possible), what data is going to be collected from the monitoring process, and, to whom and how often, that data is going to be reported.

Now, I “get” the whole sustaining correction “thing,” but I’ve worked in healthcare long enough to recognize that, while our goal may be perfection in all things, perfection tends not to exist within our various spheres of influence. And I know lots of folks feel rather more inadequate than not when they look at the list of findings at the end of survey (really, any survey—internal, external—there’s always lots to find), which I don’t think brings a ton of value to the process. Gee thanks, Mr. Surveyor, for pointing out that one sprinkler head with dust on it; gee thanks, Ms. Surveyor, for pointing out that missing eyewash check. I believe and take very seriously our charge to ensure that we are facilitating an appropriate physical environment for care, treatment, and services to be provided to patients in the safest possible manner. If I recall, the standards-based expectation refers to minimize or eliminate, and I can’t help thinking that minimization (which clearly doesn’t equal elimination).

Ah, I guess that’s just getting a little too whiny, but I think you see what I’m saying. At any rate, be prepared to provide a more in-depth accounting of the post-survey process than has been the case in the past.

The other piece of the post-survey picture is the correction of those Life Safety Code® deficiencies or ligature risk items that cannot be corrected within 60 days; the TJC portal for each organization, inclusive of the Statement of Conditions section, has a lot of information/instruction regarding how those processes unfold after the survey. While I know you can’t submit anything until you’ve been well and truly cited for it during survey, I think it would be a really good thing to hop on the old extranet site and check out what questions you need to consider, etc., if you have to engage a long-term corrective action or two. While in some ways it is not as daunting as it first seems, there is an expectation for a very (and I do mean very, very) thorough accounting of the corrective actions, timelines, etc., and I think it a far better strategy to at least eyeball the stuff (while familiarity is said to breed contempt, it also breeds understanding) before you’re embroiled in the survey process for real.

Documentary evidence: Sounds like you’re going to have to push a little more paper next survey!

A few weeks ago, our friends in Chicago upped the ante in releasing the updated documentation list for the Life Safety portion of the survey (you can find it—and I really, really, really suggest that you do so sooner rather than later—by logging into your Joint Commission portal and the clicking through the following internal links: > Survey Process, > Survey Activity Guide, > Additional Resources). And this is definitely a case of the list having shifted towards documentation of activities and conditions for which folks have been struggling to get in line. Now, from anecdotal discussions with folks, there’s not always a ton of time available for document review. So, in a lot of instances, the focus is on inspection, testing and maintenance of fire alarm and suppression systems equipment, emergency and standby power supply systems, medical gas and vacuum systems, with some “drift” into fire drills and other more or less standard areas of concern/coverage, including the management plans (sometimes—and those don’t appear to have earned a mention on the updated list).

However, according to that same updated document list, looks like a lot of focus on inventory lists (operating components of utility systems; high-risk operating components on your inventory, infection control components); “embracing” (you can think of that as reviewing and adopting) manufacturer recommendations for inspection, testing and maintenance of utility systems or outlining the Alternative Equipment Maintenance program being used. And the same types of things for medical equipment—inventory, high risk equipment, consideration of manufacturer recommendations, etc. It also appears that there will be focus on sterilizer inspection, testing, and maintenance; compliance of your hyperbaric facilities (if you have them) with Chapter 14 of NFPA 99-2012; testing manual transfer switches in your emergency power supply system. Let’s see, what else…oh yes, for those of you with recently (I’m guessing that pesky July 6, 2016 date is the key point in time) constructed or renovated procedural areas, you need to make sure that you have (and are testing) task lighting in deep sedation and general anesthesia areas (the annual testing requirement is for a 30-minute test).

I’m sure there’s other stuff that will pop to the surface as we move through this next phase of the survey process; I’m curious about how much in-depth looking they’re going to be able to do and still be able to get to the lion’s share of your building (unless they start using unmanned drones…). I’m also curious that they don’t specifically indicate the risk assessment identified in Chapter 4 of NFPA 99-2012 (it has been asked for during CMS surveys), but that may be for the next iteration. Part of me can’t help but think back to those glory days when we wished for adoption of the 2012 Life Safety Code®; I guess we can take full advantage of the operational flexibilities inherent in suite configuration and a couple more things, but it never really seems to get any easier, does it?

At any rate, please hop on your organization’s TJC portal and give the updated list a look. If you see something that gives you hives, sing out: we’re all here to help!

Inadvertent inundations: Oh, what fun! 2017 most frequently stubbed toes during survey!

As luck would have it, the latest (April 2018) edition of Perspectives landed on the door step the other day (it’s really tough to pull off the home delivery option now that it is an all-electronic publication) and included therein is not a ton of EC/LS/EM content unless you count (which, of course, we do) the listings of the most frequently cited standards during the 2017 survey season. And, to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots (I remain firm in my “counting” IC.02.02.01 as a physical environment standard—it’s the intersection of IC and the environment and always will be IMHO).

While there are certainly no surprises as to how this list sorts itself out (though I am a little curious/concerned about the rise of fire alarm and suppression system inspection, testing & maintenance documentation rising to the top spot—makes me wonder what little code-geeky infraction brought on by the adoption of the updated Life Safety Code® and other applicable NFPA standards has been the culprit—maybe some of it is related to annual door inspection activities cited before CMS extended the initial compliance due date), it clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until such time as it starts to decline in “fruit-bearing.” I do wish that there was a way to figure out for sure which of the findings are coming via the LS survey or during those pesky patient tracer activities (documentation is almost certainly the LS surveyor and I’d wager that a lot of the safe, functional environment findings are coming from tracers), but I guess that’s a data set just beyond our grasp. For those of you interested in how things “fell,” let’s do the numbers (cue: Stormy Weather):

  • #1 with an 86% finding rate – documentation of fire alarm and suppression systems
  • #2 with a 73% finding rate – managing utility systems risks
  • #3 with a 72% finding rate – maintenance of smoke and other lesser barrier elements
  • #4 with a 72% finding rate – risk of infections associated with equipment and supplies
  • #5 with a 70% finding rate – safe, functional environment
  • #6 with a 66% finding rate – maintenance of fire and other greater barrier elements
  • #7 with a 63% finding rate – hazardous materials risk stuff
  • #8 with a 62% finding rate – integrity of egress
  • #9 with a 62% finding rate – inspection, testing & maintenance of utility systems equipment
  • #10 with a 59% finding rate – inspection, testing & maintenance of medical gas & vacuum systems equipment

Again, I can’t imagine that you folks are at all surprised by this, so I guess my question for you all would be this: Does this make you think about changing your organization’s preparation activities or are you comfortable with giving up a few “small” findings and avoiding anything that would get you into big trouble? I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment (if so, congratulations! And perhaps most importantly: What’s your secret?), so it does look like this is going to be the list for the next little while.

You don’t have to be a weather(person)man to tell: Kicking off survey year 2018!

Your guess is as good as mine…

Just a couple of brief items (relatively—you know how I do go on, but I will try) of interest. I don’t know that there’s a common theme besides an effort to anticipate in which direction the survey winds might blow in 2018:

  •  Previously in this space, I’ve mentioned the work of Matt Freije and his team at HCInfo as they have done yeoman’s (yeoperson’s?) work in the field of water systems management and the “fight” against In response to last year’s letter of intent by CMS to take a more focused look at how hospitals and nursing homes are providing appropriately safe water systems for their patients, Mr. Freije has developed a checklist to help folks evaluate their current situations and has posted the checklist online for comment, suggestions, etc. I’m having a hard time thinking that this might not become something of a hardship for folks arriving late to the party, so if you’ve not yet embraced poking around this subject (and even if you have), you’d do well to check out the checklist.
  •  A couple of inspection items relative to the ongoing rollout of the various and sundry changes wrought by the adoption of the 2012 Life Safety Code®, some of which have yet to migrate in detail to the accreditation organization publications (at least the ones that I’ve seen), but have popped up during recent CMS surveys:
    • Make sure you fire alarm circuit breakers are clearly marked in red (check out NFPA 72 10.5.5.2 for the skinny on this).
    • Make sure your ILSM/fire watch policy/process reflects the appropriate AHJs—you need to make sure that you know for sure whether your state department of public health, et al, want to be notified. They do in California, and probably elsewhere.
    • In NFPA 25, chapters 5 and 13 indicate some monthly inspections of gauges, valves for condition, appropriate position (open or closed) and normal pressures—again, they’re not specifically listed in the accreditation manuals yet, but I suspect that they’ll be coming to a survey report near you before too long.
    • A final note for the moment in this category, NFPA 70 (2011 edition) 400.10 indicates that “flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints of terminals.” Keep an eye on power strips, particularly in your IT and communications closets for those dangling power strips (and some of them aren’t so much dangling as they are pulled across open spaces, etc. I suspect you know what I mean.) I know the folks who manage this stuff think that we are just being pains in the butt, but now you may have a little codified leverage.
  •  In my post a couple of weeks ago, I don’t think I played the personal protective equipment (PPE) card with sufficient gravity; part of folks’ understanding of the hazards of using chemicals is recognizing the importance of actually using appropriate PPE as identified on the product SDS. When you think about it, the emergency eyewash station is not intended to be the first line of defense in the management of exposures to chemical hazards, but rather what happens when there is an emergency exposure. If the use of PPE is hardwired into the process, then the only time they’ll need to use the eyewash equipment is when they do their weekly testing. At that, my friends, is as it should be.