Sign Pennsylvania Work Order Mobile

Document type sign work order pennsylvania mobile

now I'd like to introduce our speaker for the webinar Charley Schlegel is the director for the division of safety inspections at the Pennsylvania Department of Health he has over 18 years of experience in the healthcare safety inspection arena working in the private industry as well as the state government charley is currently responsible for all life safety code inspections and plan reviews for new construction and renovations for approximately 2,000 healthcare facilities throughout Pennsylvania Charley I will not turn the program over to you thank you very much Terry and good afternoon everybody that's on the phone so we'll get started today is the overview we're really going to talk a lot about the Life Safety Code and its requirements for alcohol based hand rub placement or hand sanitizers you'll see that unfortunately there's lots of abbreviation so I'll do my best to to spell them out but you definitely hear me talk about the live state to code throughout and you'll see that abbreviated as that let's see CMS emergency preparedness changes that's something we'll go over next they have some recent updates and earlier this year and then just some general by state to code requirement updates that a lot of folks could benefit from either just making sure that they know or there's some cost-saving items that got added to the the newest addition which is the 2012 edition that we're using now and there's some things in there that could really help out your facility and being in compliance so as we talked about CMS adopted the 2012 light state D code and also the health care facilities code which some folks know is NFPA 99 you'll see some pictures there of NFPA 101 you'll hear me talk later in reference to every licensed or certified healthcare facility really should you know have a copy of the book so that you know what you're getting a survey - and this is for about 14 facility types to include hospitals you'll see inventory of surgical facilities or sometimes surgery centers nursing homes or as CMS likes to call long-term care facilities those are some of the big facilities that have to be compliant with the life State Dakota and healthcare facilities code so when you're talking about enhanced sanitizers hand rods the first requirements came out and about April 2004 so they've been out there about 15 years but there's still a lot of you know confusion over you know where I can put them how do I install them so that's what we thought it was important to talk about that today so you'll see here are the sections and that codebook I said that everybody should own you can find it at eighteen or nineteen depending on your new or existing three to six for hospitals and nursing homes and if your surgery center Surgery surgical facility its 2021 three to six and what you're going to find is the requirements are exactly the same so whether you go to the hospital chapter or the surgery center chapter they're going to be exactly the same and we'll go over those here shortly so one of the biggest questions I've been getting a lot is are alcohol-based hand rubs permitted in operating rooms and what I'm going to share is the 2012 NFPA 99 section 1513 3 and that way everybody has it in the slide so in case there's any confusion you can just show them right here here's the section here's what it says and you'll see that alcohol-based hand sanitizers including those dispersed as aerosols shall be permitted to be used in in emphasizing locations so that is your operating room so yes and one of the big things going to take from today is the ability to to have these hand sanitizers in your operating rooms but we're going to have to you know follow the rules there are going to be rules and requirements on how to do it so we're going to get into those here shortly but this is an important slide if you work in an operating room or have operating rooms and you've been told no you can't have it yes you can we just have to make sure they're installed properly so back in 2004 when I came out with the first requirement there's a little bit different than what we have now the division changes but this is from the 2012 edition it's the most recent this is what we survey - so you're going to see the first one is where installed and a quarter the quarter is going to be six feet in width maximum individual dispenser flute capacity 1.2 liters for dispensers and rims and quarters and 2 litres for dispensers and Suites of rooms so we're really talking about the ones you see in health care there's many major provider suppliers then they're attached to the wall this is not I have two teenage daughters so I find you know glitter hand sanitizer ones that smell differently that they have a clear throughout the house yeah we're talking two totally different things as you know in health care is very much more regulated so we're not looking at the the ones that you find this is similar in your home we're really finding the ones that you're going to find in hospitals and nursing homes and surgery centers that are made and and just for you know those uses so where aerosol containers are used maximum capacity shall be 18 ounces and limited to level one for NFPA thirty B so you can use air assaults you just want to make sure that we're meeting these requirements and whoever your manufacturers should be able to show you that they're they're meeting those requirements dispensers must be at least four feet apart we'll talk about that later it doesn't mean you go down your hallway and put them every four feet we do have some requirements that limit how many you can put in there but they have to be at least four feet apart for fire safety purposes so there's we'll go over this but the area is highlighted in yellow that's one of the other big takeaways that I have for you today so you'll see it says not more than 10 gallons of solution or 1135 ounces of level one aerosol or combination of the two shall we used outside of a storage cabinet in a single smoke compartment which we'll talk about smoke compartment with the following exception you can have one dispenser per room and located in that room shall not be included in the total so you can go and put one dispenser in each room and it's not counted towards the 10 gallons that you can have outside of the room it's a common misconception a lot of people think they're limited by how many rooms they have in their smoke compartment and when we talk about smoke compartment in health care we do a lot of defend in place so I have a little bit of a floor plan here so typically it gets a little complicated when you're starting to look at smoke compartments so as a facility if you're looking to figure out how much you can have personal compartment first thing you really have to do is figure out where your smoke compartments are every facility is required to have a portable life state to code plan such as this one where it shows your smoke compartments so you'll see here that this facility is kind of broken into twos so that there is some type of fire they can evacuate from one side to the other so when we talk about how many hand sanitizers you can have persue smoke compartment we're doing one here on this side you see on the left and one on the right hand side you could have 10 gallons total on either side so when you're looking and doing these calculations and trying to figure out how to set up your facility this is one of the first things you need to do is pull all your life State decay plan and say okay where are my smoke compartments at now I can start figuring out where I can install the hand sanitizers you'll see stories greater than five gallons in a single smoke compartment must comply with NFPA 30 which means yet to put in a rated storage cabinet so the storage cabinet will say right on it that is NFPA 30 compliant so if you there I guess if there's a big sale and you have them in your clean linen room or wherever you're storing them you just want to make sure that if you go over five gallons you have to have it in the cabinet that's rated for NFPA thirty dispensers cannot be installed one inch above below or to the side of an ignition source when the regs first came out they said six inches so some people might say six that's fine with me as long as it's at least one inch away because one of the first things we want to do is we want to install the the hand sanitizer right at the doorway when you're coming into the room and that's right where you also have your light switch so we just have to make sure that we're installing them away from the light switches and you'll see a picture later that will kind give you a nice guidance on the one-inch above below or to the side dispensers can't be installed over carpet unless you're fully sprinklered we don't see a ton of carpet in healthcare we will see them sometimes in our areas maybe where you're you're doing registration and waiting so you just want to make sure that if those areas aren't sprinklered then we can actually have the spencer's installed over carpet the solution shall not exceed 95 percent alcohol content by volume which is an increase in from the past so so we're in pretty good shape there and because we are rule makers we like to make lots of rules so these are in here some of them are a little bit harder to you try to make sure that we're in compliance with but this is really something where the manufacturer is going to you know make sure that you're in compliance and this is why we buy you know from manufacturers that are familiar with healthcare not going to you know I see a sale and I'm going to go to Costco Walmart or wherever a Target and buy a bunch they're not made to the same standards to this will make sure that we're meeting these requirements first once a and dispenser should not release its contents except when is activated by manual or touch free activation activation shall only occur when an object is placed within 4 inches of the sensing device an object placed within activation zone to not cause more than one activation so if you leave your hand in there shouldn't just keep dispensing I mean the dispenser shut not to spend some more solution than the amount required for hand hygiene consistent with label instructions that's that's the one is a little bit you know tough to to figure out for compliant with but that's what we really have to rely on our manufacturers to make sure that their have dispensers that are working properly and the dispenser shall be designed constructed operated in a manner that ensures that accidental or malicious activation of the device is minimized and that's something that we need to really look into as well if you have a behavioral health unit if you have an area that's a pediatric we worry about kids trying to get in you know maybe we don't have these dispensers in areas where you know these folks can get in and you know do something you either try to drink out a dispenser or you know something else so we just want to be careful on some of the locations that we put them and the dispenser shall be tested in accordance with manufacturer's care and use instructions each time a new refill is installed so most people don't underst there's you know this requirement that every time you you replace it whoever's replacing it should be making sure that they test to make sure it's working properly so I try to keep things simple and for me it was kind of like algebra going from liters to gallons but I checked them a couple times or quite a few times to make sure I get the information correct but if you're doing the math I never talked about 2-liter dispensers but that was for Suites of rooms which gets in a lot of Life Safety Code terminology is a little difficult so I just kept it to 1.2 liter dispensers so you could have 10 gallons per smoke compartment and use it in storage which is 31 1.2 liter dispensers so the first thing we have to remember is that one dispenser program does not count towards the total so everyone that's you have where you just have one dispenser if you have more than one dispenser in that room then however many more that you have them one does count but one dispenser program does not count so we take those out rooms have four walls and a door so if you're in an emergency department where you might have privacy curtain Bay's it can make it a little bit more challenging because those won't count as rooms and then storage within a fire rated cabinet does not count towards the total so you can have up to five gallons in a storage room without being a cabinet but if you want more dispensers out on the unit or out in your area then the idea is to put those five gallons in a rated cabinet so that you can get the full 10 gallons in use out in any other healthcare area where we're providing care so there it is is 31 you can go to and just remember we have to be highlighted earlier that one per room does not count towards that total so here's the picture I promised earlier we're showing a electrical receptacle but also a light switch or anything else that might be an emission source so even you see how the green extends above so if your outlets down by the floor you still need to stay one inch over to the side and then the other question we get quite a bit is in reference to cars and installing hand sanitizers on carts so moveable carts and additional dispensers in a room so how do we handle those so like we said before trying to keep it simple I would recommend using the same dispensers to route that way you're ordering the same ones they're all the same type if you want to use something different there's nothing saying that you can't have different types of dispensers throughout your facility but for me it just keeps it more simple if we were to staying with the same one and whether it's on the wall or on a cart as well count these dispensers and the total for your compartment ensuring they don't go over ten gallons so if you have a dispenser on a cart and it's your anesthesia card it's your med card whatever type of card it is and you know it's going from room to room or does it stay in just the room if it's something that just stays in the room we can count it as the one in the room if it's the second one in the room then it's going to count towards that 31 total because there's you can only have one free one in the room if it's something that goes from out and a quarter into different rooms then we would definitely want to count it as one of our 31 outside of the room so have some policies and procedures in place just to make sure you train your folks and everybody to understand you know what your policies and procedures are but like I said you can use the slides before to say that we're going to follow the requirements on how to install them and here's how we install them you know here are all the requirements that the slides our storage is found in clean utility room you know 100 or wherever you have your storage and you know this is how much we're storing there if it said before you have the one dispenser located in most rooms not counted towards the aggregate total and rooms have four balls in the door additional hand rubs can be found in quarters in the following locations and counted towards aggregate total so if you know we're going to keep some of the quarters and we're going to also have some carts that are in ORS you know one through ten then we want to just make sure that you know that you know these are the ones that we have we want to stay under that ten gallons or less and then just make sure that we train everybody so that you know everyone understands okay I have it on this cart so I can't push the cart up against this wall over here because I have all these electrical receptacles and I still need to make sure I'm not you know may have put it within an inch of electrical receptacle and you know that way it one they are familiar with where they're at they can use them because even though on the fire safety side we worry about these you have the threat of fire and spreading the fire it's yeah we understand that you know it's a great product to use in healthcare and we want you to use it I mean we want to you know you know ketose infections down so we just have to make sure that we follow those rules to to stay in compliance in oth the fire safety side as well so in emergency preparedness the the rule came out 1116 2016 was when I became final and and they've made a number of changes to the what they put out to try and clarify CMS has when their last clarification came out and in February of this year and for those of you are familiar with CMS I used to have these occult mess and see letters but now they changed their name to qso so now they're QSO 19 all murdered Paris updates to Appendix II of the state operations manual and appendix D and state operations manual they tells states how to serve a facilities so you're getting the same information that we're getting on how to serve a facilities so we'll have some updates to include emergency and emerging infectious diseases there are some things for new home health agencies so if your home health agencies there's some information out there for you and they try to clarify some generator and alternate source of power I think they made a little bit more confusing so we'll try to make it less confusing but we'll see how that goes so you'll see here in their definition for CMS for an all-hazards approach to your emergency preparedness plan that they added planning for using an all-hazards approach it also included emerging infectious diseases AI DS so examples VI DS include influenza Ebola Zika virus and others if you need information on those the CDC is great the Centers for Disease Control is great to to go to and get that information they have all sorts of great information on all these this is a tags so this is via deficiency tag e zero zero zero four for emergency preparedness surveys and you'll see it applies to all facility types with the exception of transplant centers and what they did is when you're there saying when you're doing your All Hazards approach to your plan and you're developing a plan you'll see there's natural disasters man-made disasters loss of power and then at the end they added pids such as influenza Ebola Zika virus and others so this is something new and then we want to make sure that everybody adds it to their plan and if you haven't had your survey since if you had a surge before February you would have seen this but after February this is something we're looking for and everybody's playing this is tag e:00 15 and here and where they added the red text is the new text that they really tried to clarify so we'll go over this the same facilities are not required to upgrade our alternative energy source or electrical systems but after review of their risk assessment they might think you know what I do need to upgrade my system and an example of this would be a pure facility that has either limited emergency power or you have a generator but maybe just powers lighting and some select receptacles if there is some type of loss of power then your first the first thing you have to look at is when am I going to start evacuating the residence to patients the clients demand your facility type because if you have no power and it's just doing lightning and here in Pennsylvania of the fourth season so it could be really hot in the summer so let's get really hot later this week and it's coming where those things where how long can we keep folks in here where until we get you know started getting too hot or you know no Center then you turn around it's going to be freezing cold so we have the you know the area there too so when facilities are looking at their the risk assessment they might say I don't really want to evacuate right away when we lose power so let's look into adding to our mercy power system but if you don't add to your emergency power system and your your emergency power system does kind of minimal requirements then you're just going to have to make sure your plan says that we're going to start evacuation pretty much as soon as we could have a temperature range and it the only ones that really have a temperature range that's written in as long-term care facilities you'll see 71 81 but that's kind of a you know a good guide so if you start saying you know we're going to start dropping into the 60s we're going to get you know into mid 80s or higher we really should start looking at evacuating the the patients in our facility of the residents and in our facility if your surgery center might be a little bit easier where you can just say I'm going to stop doing procedures I'm not going videos come in and we're going to evacuate but facilities that have overnights Dave just becomes a little more difficult and you'll see here everybody set up so much differently some places will have common areas that have heat and cooling some places will have you know more areas that are that they can heat and cool but all depending on what your facility is like while they're set up we can have the ability to keep folks in there longer if we have the ability to heat and cool but if we don't have that ability then we have to make sure that we understand that we have to start our evacuation plan and that's really truly what they're trying to say here and all this extra red text so here again they added a little bit of a new text to talk about excuse me portable and mobile generators rather than a permanent generator and we really I just want to clarify that this is not going to yeah some type of store and buying something off the shelf and running and and they are plugging everything in into the outlets on that type of generator this is more of a portable generator for example down in Philadelphia where we had lots of power from a steam line and the power companies themselves said hey we're going to bring a generator in because you lost power and then we hook it into the you know the power sister lateral system at the facility so these are more what we're looking at and when we go through these requirements you can kind of see why so if you're using a portable generator they're listing some of the wiring and where you can locate it and then your ventilation obviously you're not putting the generator inside and you're having the exhaust issues and then some of the big things you're going to see here no extension cords could be used with the portable generator so we're not talking about one they might have fado that your hunting camp or if you have a camper out somewhere these are more if you have an emergency your local power company brings a portable generator in there trying to say that's acceptable and they're trying to give leeway for facilities to say yes I'm a brought in a generator but no you don't have to maintain it the same way because there's annual you know maintenance that we're not going to ask you for because it was just a temporary generator during that timeframe this one sounds like a lot of common sense but they CMS added it so if your local community region or state declares a state of emergency and is requiring a mandatory evacuation of the area you really should evacuate so they added that to tag 18 this one's pretty good for if you have multiple facilities and you have staff to go between them so this in this case is they're talking on a nutritionist at an ICF for any a care facility so if you have contracted individuals that are providing services at multiple facilities they're not to go we're not going to ask you to have them trained at every single facility so we don't expect them to go to if they go to five different facilities to go to five different trainings but we do expect them to go through a training and that they know their role with an emergency plan and when we interview them we expect them to to understand what their role is and how you know that they did go through training but we're not looking for them to get trained at each facility because it could be really redundant in in training this is just clarification that if you in the past I said if you had a an actual emergency you can count that as one of your two drills for the year now they're saying if you have two emergencies not only are you super unlucky but you can use them and use those as both of your drills your community-based full-scale exercise and your facility based Martha's a drill if you have two emergencies in that same year you could use those emergencies in lieu of having to do any exercises here again we're talking about generators and this part is more about maintenance and we're saying is there's different maintenance for portable generators and we're not expecting you to maintain the same as a generator that you would have on-site at your facility as permanently installed and here again pretty much the same thing so there are requirements for portable generators but they're not the same as for permanently installed generators if you have any questions I guess I should really probably get this updated and kissing the names have changed but our health care coalition contacts and this is from 2018 but I'm sure that if you call in and there's a different name or number they can then get that for you but if you look on here and see you know what area you're in and you call up these are great resources that will help you with your plan I'll help you know conduct the drills let you know when other folks are doing drills so you can really talk to these people email them I would pick their brain if you have any questions because this is you know really what they're out there for and they really want to help out so the CMS 2012 like safety code adoption so some of the things that we want to stress here is a few that we're going to go over or some of the requirements that have changed if you really want to read the whole rule is quite a few hundred pages it probably go to sleep at night so the link is in there and you know that you know CMS and when they did adopt it they didn't adopt everything so there are some things that are a little bit different they made a couple changes to make it their own and those can all be found at the final rule at that link here's another example I talked earlier where I talked to a making sure you had the book so one of the changes that they made that I think is a really good change is that all K tags are are three digits and organized by Life Safety Code section subsection and then in numeric order or in that subsection so if you've been around like me and okay 18 there's always doors but now you're going to see that that was changed de que 363 and we'll show y que in 29 with hazards areas now it's K 321 but the really neat thing is you open in your book and if you got cited for K 363 you can go if you're an existing Hospital nursing home health care facility you can go to chapter 19 which is existing healthcare occupancy and you go to the three point six point three and you got cited for corridor doors and you can read down through the requirements for corridor doors so in the past it was just a number now that number actually takes you to the book and takes you to the section of code and it's a it's really nice to have especially if you have that book that you knew on would you're getting survey two and like we said here's K 3:21 as hazardous areas but rather than just knowing that through memorization you can actually open the book and see here again we're in the existing facility chapter 19 existing healthcare for occupancy and we're going to three point two point one which is hazardous areas and then you could read down through and see what the requirements are for hazard areas one of the things that has been a huge change and it's been one it's been kind of difficult facilities to meet because it was not something that was part of the survey process before but you'll see that fire rated door assemblies have to be inspected and tested in the corners with NFPA 80 so NFPA 80 is a separate book from an FA 101 and it talks about fire rated assemblies to include doors and this was added to the survey process and November and 2016 you'll see some pictures here it's not just closing doors and then we'll go over the the requirements you're measuring gaps you'll see there's gaps at the bottom of the door or the side of the door the one gentleman there is looking at the the self closing device on the door so there's a lot of things we have to look at here first thing is very important applies to new and existing installations a lot of times new requirements only apply to new facilities or new installations but this one applies to new and existing inspected and tested not less than annually so we should have already gotten to in but we're we're still going to go over these because it's something that a lot of facility types are struggling with trying to make sure that they're they're meeting the requirements a written record shall be signed and kept for inspection by the authority having jurisdiction and this is a comprehensive document it's not just a checkbox saying today Charlie checked all the doors this is you know door one at this location this is what we checked it for is today here's who checked it and it's going to talk about functional testing by knowledgeable individuals and a lot of questions about that what is a knowledgeable individual and this is something that we do through the survey product through the interview process like we talked about earlier in in reference to we're going to do an interview with the staff saying okay so you're the one test of these doors let's go to a door okay this door has an astragal and that they can't explain how they tested astragal then we're going to start wondering you know if they should be the ones testing the doors you can get certified I will I've been to a two-day door class fire door class they have since May today one door one day door class I've been told which in my opinion is a very good thing two days on fire doors is a little long it was extremely good but there was a way much inference there's a whole lot of information there's a lot of information that I didn't know I needed to know but now I do know it on fire doors so you can have the training and say that you know here it is I'm certified and if you want that information you can always my contact information is at the end but it doesn't require that you have to be trained and certified and then repair Sulli made without delay I'll tell you that doors are especially fire-rated doors they're typically made to order it's very hard to to get them without the delay so it's one of those things where we're showing we did order the door the doors coming in if you're a nursing home you might need at a time limited waiver because if it's going to take more than 90 days to get in and get installed so there's a lot of things with that but without delay we're really looking to make sure there's some type of paper trail showing that we're at least working to get that door fixed or replaced so on your swinging doors so before you test the door you have to do the visual inspection of both sides you know they're talking about no holes if you have light vision panels we're looking at those no visible signs of damage to the door no parts are missing or broken door clearances are appropriate and door clearances there are depending on the type of door where the clearance is being measured there's lots of different clearances that have to be maintained so those are the ones if you have double doors there's a gap between the doors so there's a lot of door clearances that weber's testing these they need to understand what the cleaners does need to be sup the clothing device is operating properly I want to live it easier so if you have a coordinator the coordinators working latching Hardware no exhilarate are drain'd so that would interfere with the proper operation on the door so you know we're putting the you know the the wreaths on or other decorations it's one of those things that you know that might be something that you can close the door it's very important that you don't have something on there that's going to keep the door from closing and it's also something that you see a lot of wedges or wedges where they're they're wedging the door open you know things like that those are not only bad for the the door you're really hurting on the hinges but it's also an out loud and you see no field modifications that would void the label so a lot of the manufacturers will tell you that you can do much you can't there's not really much you can do to a door that you know if you want to make any changes to the door it's really the manufacturer or their representatives that can do it if you do it yourself you could be avoiding the label on the door and if you would have a fire they're gonna say well you made a change to the door and we don't know if that door wasn't tested that way so we're not sure if it's going to work properly um gasoline and edge seals are required or inspected so here again you know if we have gassed and we just mean to make sure it's properly rated for the door and you'll see similar requirements for horizontal sliding vertical slotting and rolling doors and then you know it's one of those where anybody in health care you know industry knows you could go around and probably check the doors in the morning and if somebody has a cart they knocked into the door the door know is no longer latching a residence family might have a nice little brick that somebody knits their initials into and then puts the brick into that and puts it in front the door but you just want to make sure that staff you know even you know not just your maintenance staff but whether it's the nursing staff or other folks that are on the floor you know if they see a door and maybe it keeps you know creaking close you'll creep and close and said of staying open rather than selling wedging it up and it might be something good to pass on to maintenance or you know if you see somebody you know smacked the door with the car door somebody's trying to hold the door open whether you know putting supplies in and out of a storage room maybe they're just better ways then then the things that they're doing so that they don't you know do it into the doors of a damage them and then require you to spend a lot of money to those far away the doors are expensive so we don't want to have to be replacing them all the time so in the 2012 NFPA healthcare facility field NF 899 what you're going to find is testing for your medical gas systems are especially connected by saying a party that's technically competent and then you have to meet the requirements of ASSE 6030 so here you're going to see before we talked about knowledgeable individual here you're going to see that they actually say whoever is doing your your verification your testing in this case has to meet ASSE 60/30 so that's only part of the paperwork that we look at when we come to your survey if you have medical gas in your building very similar persons maintaining the system they have three options here one is training and certification through the healthcare facility that's something we'll talk a little bit on the next slide also you have the two requirement sixty forty or sixty thirty so we're really looking to see anybody is maintained in your system has those qualifications and we will ask for those qualifications if you're going to try and do train a certification through the facility you might have a some hospitals out there have a program where they've had somebody has been in testing maintaining or they might be maintaining the medical gas system and they've been doing it for twenty years and it's just something a day they learned on the job so we're just going to try and see you know if we're going new folks what the training program and what the policy procedures and to make sure that you're demonstrating compliance with training or like we said before you can meet those those two requirements and I have to worry about training certification at the facility this is important for medical gas systems that have boons non-stationary boons so if you have booms you're going to have flexible hoses flexible connectors and they added a new requirement that every 18 months or if we can have some type of risk assessment done but I would start with eighteen months that you have to have these flexible connectors inspected so this is something that was added in so we need to make sure it's getting done because with the adoption of 2016 of the life safety code in the healthcare facilities code this is now something that facilities are being surveyed for because it's been 18 months what were 18 months since adoption so you're going to see there's quite a bit of requirements on this so we I put all the requirements in so you can see what they're supposed to be doing but the important thing is if you have booms out there you need to make sure that we're we're checking the flexible connections 2010 NFPA ten is for fire extinguishers so some of the changes that they made is the folks that are doing your your one year or maybe your hydrostatic testing the other testing not the folks that do the monthly quick checks but everybody else other than a monthly quick checks has to be certified in NFPA ten principles so they went to so we're going out and we're doing their your fire extinguisher inspection whether requirements that were going to ask is saying that you know who did your fire extinguisher testing on annual and where is their certification in the beginning we've had a lot of folks try to say well I'm certified I trained somebody else no we're looking for the person that was on-site so one of the big changes that you'll see as well was with privacy curtains so I've been warning people if you see a big sale and privacy curtains is probably because they meet the old requirements but not the new but the new requirement is that the mesh has to extend down to 22 inches from the ceiling so this is only applies for for new curtains so you can still have existing curtains with 18 inches of mesh but the new requirement is 22 so if you renovate build new we're going to be looking for 22 inches and you'll see that mesh at the top of the privacy curtain you could also drop the fabric curtain down as well but the new requirement is is 22 inches and you'll see here typically says newly introduced curtains have to comply with NFPA 13 so that's where we're only looking at new so we've always talked about the 18 inch rule we're always trying to keep 18 inches down from the sprinkler is it now the 22 inch rule is no the 18 inch rule still applies to everything else but they did some studies and they found the privacy curtains we needed to get the mesh down to 22 inches to get the proper sprinkler coverage on either side of the curtain so this is something you have a little bit of time on so you're looking at November of 2021 I recommend not everybody waiting or where the smoker companies probably know that you need to have it done and I'll charge you extra but internal inspection of the piping was as added so it's every 5 years you're going to see you're going to have to do this additional test and it's it's one of the things that once they open it up there there might be more things that they have to do so if anybody has ever seen sprinkler water it's not something you're going to want to drink is not the prettiest water out there but what you want to find is you just want to make sure that your facilities are your sprinkler companies are aware that you have to do this 5-year test and that you definitely want to make sure you get it done by November 2021 because that's when we're going to start a surveying for that so you do have a little time for that one so the last couple slides here are in reference to some of the changes that were made that I'm sure a lot of folks know that could save you some money especially with the maintenance time frames and then we'll open it up for questions but this is NFPA 25 2011 edition sections 5.3 and 8.3 so one of the things you have to check to see if you have but if you have a electric motor-driven a pump assembly for your sprinkler system the requirement was changed from weekly to monthly so a lot of people are still out there doing the the old way they're still doing it weekly that's fine you could do it daily if you want but you're now about to go out to to monthly and maybe you can use that time doing some other maintenance one of the other things that have changed that really hasn't changed with anybody there's a lot a lot of folks still do it the old way and is that your semiannual testing vane type and pressure switch type water flow devices on your sprinkler system so the previous requirement was quarterly and that was the main driver of the where we gassed you for your quarterly sprinkler inspections but and they now are at semiannual so there's a good chance that you taught your sprinkler company that you could be doing your sprinkler inspections semi-annually instead of quarterly like before but like I was saying in some times and you've been doing it for 20 years as always when quarterly you're more than welcome to keep it that way but there is the ability to go to from quarterly just semi-annual and this is back to and des generators so if you have a diesel generator does not maintain the minimum gas temperatures as recommended or does not reach at least 30% of the nameplate during your monthly generator exercises what happens is and when the diesel doesn't burn properly it can wet stacking and get in your exhaust and can cause a lot of problems when you do need your generator to run so there's an annual load Bank exercise and in the past that was two hours you'd have to somebody would come in and he would have a load that they could put on your generator and they would run it at different percentages for different time periods for total of two hours which is the old standard so now it's down to 1.5 hours so if you're one of the facilities that has a diesel generator and you always have the load bank test note that you can save yourself some fuel and I'll be some money and go down to 1.5 hours Oh at this time there's we're in the question and answer session yes thank you this is Terry Lee if you have any questions please type them into the Q&A box found at the bottom of your screen again please hover over the bottom of your screen and you'll see three dots click on the dots to open the Q&A panel and direct your questions to all panelists and we will try to answer as many questions as we can and Charlie we do have some already the first two were back when we were talking about the alcohol-based hand rub you had mentioned that we did not permit alcohol-based hand rub over carpeted areas does that include throw rugs so I would um and my personal opinion I would say yes so you wouldn't want to throw a rug right underneath the handstand hazard for the same purpose of it being under carpet I believe with the concern is the sometimes when we have it on our hands we're also when we rub it in we're getting it on the wall and also some of these getting on the floor so you don't want to have that potential for the floor to to burn okay thank you and the next one again came in when we were talking about the alcohol-based hand rub the bathroom the bathroom in the room is that counted in the room is what the question is and I assume what is being asked is when you have alcohol-based hand rub in the room is the one in the bathroom how as well I'm friendly you can clarify that for me if I got that wrong so I would so if the question is can you have one in the bathroom and one in the room I would consider that to within that that room so we would just have to make sure then that we calculate that for our smoke apartment thank you the next one is can you clarify without repairs this is in regards to the fire doors without repairs made without delay many fire door parts and hardware take four to six weeks to receive and I think you did address that but if you could just review that again yeah and that's a great question so I would say the important part is communication with your your survey agency so so here in Pennsylvania if if it's going to take four to six weeks for some type of hardware to come in the biggest thing is making sure you communicate that and you're playing a correction saying I did contact the the door hardware folks that is something that has to be made it's going to be shipped this is how long it's going to take and then you know this is who can install it for us and this is when they can come in so unfortunately it takes a lot of work with the fire doors but in the end fire doors or when we talk about defendant place or one of our our biggest protection measures out there so there's a lot of focus on making sure that we're keeping those up to speed okay and bredda did clarify it for us we did answer that correctly for her so Thank You Brenda the next one if we could flip flip back to slide number 54 there's a question on slide 54 and it should it's a 2021 I'm not seeing the numbers on oh well you're you're way back on 39 so we need to go over keep going couple more right there okay so yeah so this is one of those ones where since the NFPA 101 2012 edition was adopted on January 5th of 2016 and we're says conducted every five years the first one we're going to really start enforcing is five years from 2016 date so that would be 2021 so the the question is right in the fact that that's the first year we're going to start asking for word starting July fifth and after and then it's going to be every five years after that so it'll the requirement will start at five years from January 5th 2016 thank you the next question is can you please review the requirements for the outside switch required for generators okay so the emergency stop there I would there's a lot lot to this one and there's some communication and I can send from from NFPA in the healthcare interpretations Task Force where they they kind of talked about if you have your generator in some type of enclosure maybe you could put it on the outside of the enclosure compared to the outside of the building but this one might be a better one if someone has a significant to their facility that they they call an hour email afterwards so we could talk about their specific location okay thank you next as far as the qualified medical gas maintenance does this mean that the maintenance personnel who change the tank system or our actual inspection so for the medical gas systems these are the the folks that are doing your annual testing and inspections and you'll see like that 18-month flexible connectors it's going to be those folks and also anybody that's working on a system so it's a good question it wouldn't be the general changing out of your your tanks is going to be when they come in to either do some new work to the medical gas system or it's going to be the folks that come in to do the maintenance and the test name okay thank you the next questions do we have a 30-minute monthly load Bank test on generator since we do this yearly so you're still just to do them the monthly and weekly maintenance so they're still going to be your your your your runs other than the the load bank at the end the load Bank kind of extra if you're not running the diesel enough that you're burning off all the carbon so that the problem of it running is so if your generator meets the requirements not to have a load bank you wouldn't have to do it at all but it's because the generator doesn't have sometimes a generator salesmen are very good and they sell you much bigger generator than you need and then what happens is it doesn't run properly because there's not enough load on the generator to do so and that's when we have to do that extra low bang test okay the next question is we have a facility that's doing renovations and they want to make sure they understand that the mesh height for privacy curtains is now 22 inches but if they have the 18 inches in the rooms that have not yet and renovated is that okay another great question is a great group so that that is okay so as you go from room to room if you if you replace if you run out of eight five rooms and a wing but you don't get to the next five rooms for another couple months it would just be the five rooms at a time or if you just do you know one wing and replace it they're just one room it would just be those spaces that you renovated and the next question is are you limited to one wall-mounted alcohol-based hand sanitizer dispenser in an operating room so you're not limited but what happens is the ones in addition to that one would count towards your 31 in MO compartment so what we want to do is evaluate you know wher your smoke compartment is and then we would add those to that 31 total thank you the next question is we were told we needed an emergency stop button outside of the generator where does this need to be located yes so each facility emit a little bit different so the emergency stop button those ones were probably better if they say here's where my generator is here's where my building can you you know which we can see a plan or picture and then we could talk about so the webinar will be ending soon but we have a time for a few more questions before we get to end the program and I see we have several here I will go ahead with those the one panelist asked that to our load bank is now one and a half hours what about the for our low bank every three years is that so a requirement right so that is still going to be requirement and if as a good one I prize you to have that added in there to that slide because that one does stay as every three years thank you for boom testing how is it typically performed by maintenance staff special equipment or manufacturer evaluation so for the boom testing this is typically done by the certified individuals that test your and inspect your medical gas system on an annual basis they just add the 18-month boom testing for the flexible connections in it as well and it's something from what I've told is in the past there are some issues with the flexible connectors leaking so they had to add that to the to the maintenance so that we don't have a you know any of the dangers of having a gas leaking inside and causing issues okay this looks like a good question here corridor doors such as a client bedroom it has a fire rating tag does this door have to be inspected as part of the yearly safety life safety inspections the bedroom doors are not considered a fire barrier and do not have to be rated right and that is a great question so I've been trying to work with with CMS I know Joint Commission which might not apply here is put out some information that you can kind of cover up the tag but there has been some talk in reference to if the door is tagged even though it's not a fire rated now the fire barrier and it's but it's tagged anyway that it should be part of your survey program we're trying to get something from CMS to try and put some information out there about that on what their expectations are but that's been a little bit difficult so to be honest with you since a lot of our facilities get surveyed not just by us but also CMS will come in afterwards until we get something from CMS I would caution you if the door has a tag I would I was still I keep that as part of your your program until we can work to get some type of information from CMS where maybe they'll permit the same thing as Joint Commission with covering the tag or something similar well thank you charlie we have a lot of great questions I think we were able to answer all of them this concludes our webinar