The hospital maintains all grounds and equipment.
When planning for demolition, construction, or renovation, the hospital conducts a reconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.
The hospital takes action based on its assessment to minimize risks during demolition, construction, or renovation.
Inspects exits in affected areas on a daily basis.
Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.
Provides additional firefighting equipment.
Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.
Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.
Enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.
Provides additional training to those who work in the hospital on the use of firefighting equipment.
Conducts one additional fire drill per shift per quarter.
Inspects and tests temporary systems monthly.
The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.
The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features.
The hospital maintains a current electronic Statement of Conditions.
When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by The Joint Commission.
The hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy.
The hospital critiques fire drills to evaluate fire safety equipment, fire safety building features, and staff response to fire.
At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches).
Every 3 months, the hospital tests valve tamper switches and water-flow devices.
Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.
Every 12 months, the hospital tests visual and audible fire alarms, including speakers.
Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders.
For automatic sprinkler systems: Every week, the hospital tests fire pumps under no-flow conditions.
For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers.
For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections.
For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow.
Every 5 years, the hospital conducts water-flow tests for standpipe systems.
Every 6 months, the hospital inspects any automatic fire-extinguishing systems in a kitchen.
At least monthly, the hospital inspects portable fire extinguishers.
Every 12 months, the hospital performs maintenance on portable fire extinguishers.
The hospital operates fire and smoke dampers 1 year after installation (commencing Jan 2010) and then at least every 6 years to verify that they fully close.
Every 12 months, the hospital tests automatic smoke-detection shutdown devices for air-handling equipment.
Every 12 months, the hospital tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspections and approvals made by state or local fire control agencies.
The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented.
Ducts that penetrate a 2-hour fire-rated separation are protected by dampers that are fire-rated for 1 1/2 hours.
In existing buildings, ducts that penetrate smoke barriers are protected by approved smoke dampers that close when a smoke detector is activated. The detector is located either within the duct system or in the area serving the smoke compartment.
The fire alarm signal automatically transmits to a Central Monitoring station as described in NFPA 72-1999; 5-2
Means of egress are adequately illuminated at all points, including angles and intersections of corridors and passageways, stairways, stairway landings, exit doors, and exit discharges.
Illumination in the means of egress, including exit discharges, is arranged so that failure of any single light fixture or bulb will not leave the area in darkness.
The hospital maps the distribution of its utility systems.
The hospital's procedures address shutting off the malfunctioning system and notifying staff in affected areas.
The hospital provides emergency power for the following utilities and systems: Alarm systems, as required by the Life Safety Code.
Exit route and exit sign illumination, as required by the Life Safety Code.
Emergency communication systems, as required by the Life Safety Code.
Elevators (at least one for nonambulatory patients).
Equipment that could cause patient harm when it fails, including life-support systems; blood, bone, and tissue storage systems; medical air compressors; and medical and surgical vacuum systems.
Areas in which loss of power could result in patient harm, including operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas.