Audit

EC.02.01.03 - The hospital prohibits smoking except in specific circumstances.

EP1 - The hospital develops a written policy prohibiting smoking in all buildings. Exceptions for patients in specific circumstances are defined. Note: The scope of this EP is concerned with all smoking types—tobacco, electronic, or other.

EP4 - Smoking materials are removed from patients receiving respiratory therapy. When a nasal cannula is delivering oxygen outside of a patient’s room, no sources of ignition are within the site of intentional expulsion (within 1 foot). When other oxygen delivery equipment is used or oxygen is delivered inside a patient’s room, no sources of ignition are within the area of administration (within 15 feet). Solid fuel–burning appliances are not in the area of administration. Nonmedical appliances with hot surfaces or sparking mechanisms are not within oxygen-delivery equipment or site of intentional expulsion. (For full text, refer to NFPA 99-2012: 11.5.1.1; Tentative Interim Amendment (TIA) 12-6)

EP6 - The hospital takes action to maintain compliance with its smoking policy.

EC.02.03.01 - The hospital manages fire risks.

EP1 - The hospital minimizes the potential for harm from fire, smoke, and other products of combustion.

EP4 - The hospital maintains free and unobstructed access to all exits. Note: This requirement applies to all buildings classified as business occupancy. The "Life Safety" (LS) chapter addresses the requirements for all other occupancy types.

EP9 - The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin, including when and how to sound and report fire alarms, how to contain smoke and fire, how to use a fire extinguisher, how to assist and relocate patients, and how to evacuate to areas of refuge. Staff and licensed independent practitioners are periodically instructed on and kept informed of their duties under the plan. A copy of the plan is readily available with the telephone operator or security. Note: For full text, refer to NFPA 101-2012: 18/19.7.1; 7.2.

EP11 - Periodic evaluations, as determined by the hospital, are made of potential fire hazards that could be encountered during surgical procedures. Written fire prevention and response procedures, including safety precautions related to the use of flammable germicides or antiseptics, are established.

EP12 - When flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers, the following are required: - Nonflammable packaging - Unit-dose applicators - Preoperative "time-out" prior to the initiation of any surgical procedure to verify the following: - Application site is dry prior to draping and use of surgical equipment - Pooling of solution has not occurred or has been corrected - Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices (For full text, refer to NFPA 99-2012: 15.13)

EP13 - The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15.

EC.02.03.03 - The hospital conducts fire drills.

EP1 - The hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy by the Life Safety Code. The hospital conducts quarterly fire drills in each building defined as an ambulatory health care occupancy by the Life Safety Code. (See also LS.01.02.01, EP 11) Note 1: Evacuation of patients during drills is not required. Note 2: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms. Note 3: In leased or rented facilities, drills need be conducted only in areas of the building that the hospital occupies.

EP2 - The hospital conducts fire drills every 12 months from the date of the last drill in all freestanding buildings classified as business occupancies and in which patients are seen or treated. Note: In leased or rented facilities, drills need be conducted only in areas of the building that the hospital occupies.

EP3 - When quarterly fire drills are required, they are unannounced and held at unexpected times and under varying conditions. Fire drills include transmission of fire alarm signal and simulation of emergency fire conditions. Note 1: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms. Note 2: For full text, refer to NFPA 101-2012: 18/19: 7.1.7; 7.1; 7.2; 7.3.

EP4 - Staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan.

EP5 - The hospital critiques fire drills to evaluate fire safety equipment, fire safety building features, and staff response to fire. The evaluation is documented.

EC.02.03.05 - The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.

EP1 - At least quarterly, the hospital tests supervisory signal devices on the inventory (except valve tamper switches). The results and completion dates are documented. Note 1: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5. Note 2: Supervisory signals include the following: control valves; pressure supervisory; pressure tank, pressure supervisory for a dry pipe (both high and low conditions), steam pressure; water level supervisory signal initiating device; water temperature supervisory; and room temperature supervisory.

EP2 - Every 6 months, the hospital tests vane-type and pressure-type water flow devices and valve tamper switches on the inventory. The results and completion dates are documented. Note 1: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5. Note 2: Mechanical water-flow devices (including, but not limited to, water motor gongs) should be tested quarterly. The results and completion dates are documented. (For full text, refer to NFPA 25-2011: Table 5.1.1.2)

EP3 - Every 12 months, the hospital tests duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors on the inventory. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5; 17.14.

EP4 - Every 12 months, the hospital tests visual and audible fire alarms, including speakers and door-releasing devices on the inventory. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5.

EP5 - Every 12 months, the hospital tests fire alarm equipment on the inventory for notifying off-site fire responders. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5.

EP6 - For automatic sprinkler systems: The hospital tests electric motor–driven fire pumps monthly and diesel engine–driven fire pumps weekly under no-flow conditions. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 8.3.1; 8.3.2.

EP7 - For automatic sprinkler systems: Every six months, the hospital tests water-storage tank high- and low-water level alarms. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 9.3; Table 9.1.1.2.

EP8 - For automatic sprinkler systems: Every month during cold weather, the hospital tests water-storage tank temperature alarms. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 9.2.4; Table 9.1.1.2.

EP9 - For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 13.2.5; 13.3.3.4; Table 13.1.1.2; Table 13.8.1.

EP10 - For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 13.7; Table

EP11 - For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 8.3.3.

EP12 - Every 5 years, the hospital conducts hydrostatic and water-flow tests for standpipe systems. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 25-2011: 6.3.1; 6.3.2; Table 6.1.1.2.

EP13 - Every 6 months, the hospital inspects any automatic fire-extinguishing system in a kitchen. The results and completion dates are documented. Note 1: Discharge of the fire-extinguishing systems is not required. Note 2: For additional guidance on performing inspections, see NFPA 96-2011: 11.2.

EP14 - Every 12 months, the hospital tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The results and completion dates are documented. Note 1: Discharge of the fire-extinguishing systems is not required. Note 2: For full text, refer to NFPA 13-2011: 4.8.3 and NFPA 12A-2009: Chapter 6.

EP15 - At least monthly, the hospital inspects portable fire extinguishers. The results and completion dates are documented. Note 1: There are many ways to document the inspections, such as using bar-coding equipment, using check marks on a tag, or using an inventory. Note 2: Inspections involve a visual check to determine correct type of and clear and unobstructed access to a fire extinguisher, in addition to a check for broken parts and full charge. Note 3: For additional guidance on inspection of fire extinguishers, see NFPA 10-2010: 7.2.2; 7.2.4.

EP16 - Every 12 months, the hospital performs maintenance on portable fire extinguishers, including recharging. Individuals performing annual maintenance on extinguishers are certified. The results and completion dates are documented. Note 1: There are many ways to document the maintenance, such as using bar-coding equipment, using check marks on a tag, or using an inventory. Note 2: For additional guidance on maintaining fire extinguishers, see NFPA 10-2010: 7.1.2; 7.2.2; 7.2.4; 7.3.1.

EP17 - The hospital conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and every 3 years thereafter. The results and completion dates are documented. Note: For additional guidance on hydrostatic testing, see NFPA 1962-2008: Chapter 7 and NFPA 25-2011: Chapter 6.

EP18 - The hospital operates fire and smoke dampers one year after installation and then at least every six years to verify that they fully close. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 90A-2012: 5.4.8; NFPA 80-2010: 19.4; NFPA 105-2010: 6.5.

EP19 - Every 12 months, the hospital tests automatic smoke-detection shutdown devices for air-handling equipment. The results and completion dates are documented. Note: For additional guidance on performing tests, see NFPA 90A-2012: 6.4.1.

EP20 - Every 12 months, the hospital tests sliding and rolling fire doors, smoke barrier sliding or rolling doors, and sliding and rolling fire doors in corridor walls and partitions for proper operation and full closure. The results and completion dates are documented. Note: For full text, refer to NFPA 80-2010: 5.2.14.3; NFPA 105-2010: 5.2.1; 5.2.2.

EP25 - The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening. Note: For additional guidance on testing of door assemblies, see NFPA 101-2012: 7.2.1.5.10.1; 7.2.1.5.11; NFPA 80-2010: 4.8.4; 5.2.1; 5.2.3; 5.2.4; 5.2.6; 5.2.7; 6.3.1.7; NFPA 105-2010: 5.2.1.

EP27 - Elevators with fire fighters’ emergency operations are tested monthly. The test completion dates and results are documented. (For full text, refer to NFPA 101-2012: 9.4.3; 9.4.6)

EP28 - Documentation of maintenance, testing, and inspection activities for Standard EC.02.03.05, EPs 1–20, 25 (including fire alarm and fire protection systems) includes the following: - 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 Note: For additional guidance on documenting activities, see NFPA 25-2011: 4.3; 4.4; NFPA 72-2010: 14.2.1; 14.2.2; 14.2.3; 14.2.4.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.