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ASK AHCA 2021

ASK AHCA 2021 question period is now closed for this year. Thanks to all who asked a question.

Be sure to attend the Main Speaker Session at 8:30 AM on Tuesday morning to hear the answers to the questions that were asked and posted below.

Questions Submitted

Name of Code, Standard, Law or if applicable: 2018 FGI

Chapter, Section, Paragraph or Identifying location: 2.1-8.5.2.3 Technology Distribution Room (TDR)

(2) Size. All TDR's shall provide a minimum three-foot clearance on all sides of the equipment rack(s).

Add background information: Equipment racks are available as either open free-standing, Wall mounted, or enclosed (deadfront). Equipment racks are typically ganged together in a lineup, or as single rack.

NFPA-99 '7.3.1.2.3.5 Working Space.' says the working clearances are to meet NFPA-70 110.26(A)

Question: 1) Are Wall-mounted equipment racks still allowed for these spaces?

2) Are enclosed racks still allowed for these spaces?

3) Can single enclosed or free-standing racks be installed with one side against an outside wall, or must they be located in the center of the room?

4) Do FGI requirements override the NFPA-99 and NFPA-70 110.26(A) requirements which could allow (by special permission) reduced working clearances where the voltages are less than 30Vrms?

Question 1

Name of Code, Standard, Law or if applicable: NFPA 99

Chapter, Section, Paragraph or Identifying location: Chapter 6.4

Add background information: There is a multi story building under design with a skilled nursing home on the first floor and two floors of Assisted Living Facility above. One owner and operator are licensed to operate both the ALF and the nursing home. The building is being designed with one Level I, 500 kVA generator for both the nursing home and the ALF to power the entire building.

Question: Is it permitted to have one Level 1 generator to power the building for both occupancy types?

If the answer is "No" Why not?

If the answer is "Yes" then the following questions are provided:

  1. Is a 4th transfer switch required to isolate the ALF from the Nursing Home?

  2. Is load shedding required to protect the generator?

   3. If the ALF is sold in the future to another operator, will the electrical system have to be separated into two systems and will another generator be required to be installed to meet the ALF requirements?

Question 2

Question 3

Name of Code, Standard, Law or if applicable: 2018 FGI

Chapter, Section, Paragraph or Identifying location: 2.1-8.5.2.3 

Technology Distribution Room (TDR)  (2) Size. All TDR's shall provide a minimum three-foot clearance on all sides of the equipment rack(s).

Add background information:

Equipment racks are available as either open free-standing, Wall mounted, or enclosed (deadfront).

Equipment racks are typically ganged together in a lineup, or as single rack.

NFPA-99 '7.3.1.2.3.5 Working Space.' says the working clearances are to meet NFPA-70 110.26(A)

Question: 

1) Are Wall-mounted equipment racks still allowed for these spaces?

2) Are enclosed racks still allowed for these spaces?

3) Can single enclosed or free-standing racks be installed with one side against an outside wall, or must they be located in the center of the room?

4) Do FGI requirements override the NFPA-99 and NFPA-70 110.26(A) requirements which could allow (by special permission) reduced working clearances where the voltages are less than 30Vrms?

Question 4

Name of Code, Standard, Law or if applicable: FGI 2018 for Hospitals and Imaging rooms Classification

Chapter, Section, Paragraph or Identifying location: FGI Table 2.2-2 Classification of Room Types Imaging Services

Add background information: An owner wants to do an equipment upgrade to a room IE CT Scan to new CT Scan

Question: Equipment exchange for imaging equipment where the owner wants an equipment exchange however the requirements of 2.2-2 may conflict with the existing spaces. What justifies as an equipment exchange? Functional program is critical when it comes to defining Diagnostic and Therapeutic procedures (not defined in FGI). What is the threshold for allowing existing services to continue the the same room with new equipment?

Question 5

Name of Code, Standard, Law or if applicable: 59A-3

Chapter, Section, Paragraph or Identifying location: 59A-3.080(d) An infection control risk assessment (ICRA) and a life safety plan indicating temporary egress and detailed phasing plans indicating how the area(s) to be demolished or constructed are to be separated from all occupied areas shall be submitted for review and approval when demolition or construction in and around occupied buildings is to be undertaken. Submissions that fail to provide an ICRA or depict the safety measures

prescribed by the ICRA will not be approved.

Add background information: According to the Joint Commission, "A few extra hours in training is well worth saving the cost and infection risk to your patients in an area designed to improve their care!" The COVID pandemic has brought to light facility adverse occurrences which increase risk and vulnerabilities affecting the patients, staff, vendors, and contractors during construction which could be addressed by revising the Rule.

Question: Would a revision to 59A-3.080(d) F.A.C. be the effective means to require that vendors and contractors involved in a healthcare facility receive minimum training such as 1 hr. "Infection Control Awareness" for workers, and a 12 hr. "Infection Control Requirements" prior to starting the construction for supervisors and project managers?

Question 6

Name of Code, Standard, Law or if applicable: NFPA 25

Chapter, Section, Paragraph or Identifying location: Fire department connection pressure testing and results.

Add background information: This is a newer requirement from dating back to 2014 but most recently diligently enforced.  The standard calls for pressure testing the fire department connection to the standpipe needed because of failures of these systems in the event needed in actual emergency situations. MOST local AHJs refer this to underground installations.  When the ENTIRE FDC connection pipe to the standpipe is visible (not underground or concealed) and less than 2-3 feet in length.

Question: These short pipes are difficult to pressure test and as the local AHJ does not see it necessary why does AHCA insist on these to be inspected?

Question 7

Name of Code, Standard, Law or if applicable: NFPA 72

Chapter, Section, Paragraph or Identifying location: Fire Alarm system testing and inspection. Duct detectors.

Add background information: This is a multi-part question.  Premised by the mechanical code requiring smoke (duct) detectors in mechanical equipment.

* Duct detectors in any healthcare occupancy are problematic and difficult sometimes to properly access and check.  In many jurisdictions the local AHJ / fire marshal has opted and approved these devices as "supervisory" signaling devices only.  If installed in facilities that are fully sprinklered as supervisory devices, the actual intended functionality of the device is compromised as if activated it does not then shut down the air handling system associated with it and does not provide for an alarm condition in the facility.

* Added testing over the years includes smoke sensitivity testing and differential pressure testing; both expensive only and for just the duct detectors.

Question:  It seems unnecessary service and maintenance to "calibrate" and test operating functionality of a device that provides no essential services within the facility.

 

It seems that these devices if installed in a fully protected / sprinklered facility could be removed by change and local devices in accordance with mechanical code provisions installed (not connected to the fire alarm system but integral to the equipment).

 

This would eliminate unnecessary useless expenditure of maintenance and testing funds for devices having no practical function or use within the facility.

Name of Code, Standard, Law or if applicable: NFPA 110

Chapter, Section, Paragraph or Identifying location: Section 8 Maintenance

Add background information: Many generators run less than 20 hours annually for all testing. The service chart states reference to an annual oil change requirement.  Many generator hold 8-10 gallons of oil not only is this expensive but it involves a waste disposal fee and operation as well. It has been the practice if the generator engine is on an oil analysis program the oil change may be extended to when the oil analysis indicates change is necessary. This is helpful as the oil analysis provides diagnostic information to address other generator issues before failures occur.

Question: Is this practice acceptable in ASCs and other generator applications?

Question 8

Question 9

Name of Code, Standard, Law or if applicable: NFPA 72 Third Party Certification and Verification of the fire alarm system

Chapter, Section, Paragraph or Identifying location: 10.18.2.4* Verification of Compliant Installation

Add background information: Where required, compliance of the completed installation with the requirements of this Code, as implemented via the referring code(s), specifications, and/or other criteria applicable to the specific installation, shall be certified by a qualified and impartial third-party organization acceptable to the authority having jurisdiction.

Question: With all of the "compliance items" the fire alarm system still remains a mystery at times.  A lot of fire departments are not requiring 3rd party certification of the Fire Alarm System. I thought this was excessive but after going through this several times now I think it is a great idea.  I have seen so many “modified” systems that it is amazing that some of these systems still work.  This would avoid that issue.

It is in the standard and for licensed AHCA facilities, why is this not required?

Question 10

Name of Code, Standard, Law or if applicable: All standards of compliance and FAC

Chapter, Section, Paragraph or Identifying location: 

AHCA's Agencies 

AHCA-Plans and Construction

AHCA - Licensure - Life Safety Compliance

Add background information: As frequently occurs the final results of AHCA-OPC reviews does not address required initial reports of systems testing mandated by AHCA-LICENSURE LS surveyors and also accreditation and CMS initial surveys.  The absence of these reports and inspections affects life safety compliance for the facility (many times administrators are not familiar with what is needed) on initial licensing surveys, future accreditation surveys and CMS initial surveys.

Missing reports are often on Medical Gas systems, HVAC installations (air exchanges and T & B), Fire alarm systems both listing of devices and testing, Initial electrical outlet testing, and fire sprinkler systems.

Question: Would it be possible for AHCA OPC and AHCA LICENSURE to coordinate or develop a checklist to ensure that these initial requirements are adequately covered by the agency departments for the convenience of the end users to make certain all elements of initial compliance criteria, after construction or remodeling, are met by the providing contractors, and acceptable to all relevant review points of the participating AHJs?

Question 11

Name of Code, Standard, Law or if applicable: NFPA 99 Chapter 10

Chapter, Section, Paragraph or Identifying location: Chap 10.5.2.1.1

Add background information: 

Traditionally, all equipment has been electrical safety checked semi-annually in ambulatory care settings and this is universally still enforced and accepted.

10.5.2.1.1 allows the facility to set inspection intervals and at the least includes: by 10.5.2.1.2 before usage and after any repairs are effected to the equipment if so adopted by the board of governance.

Previous exceptions allowed through risk ranking Life Safety biomedical equipment which could by fault possibly create a conductive pathway to the patients heart as the only exception 10.5.2.2 which would require semi-annual testing.

Question: In routine surveys and assessments surveyors require semi-annual testing.

Stated as required by equipment migration throughout the facility.  All equipment is Ambulatory care equipment and can be tested at an interval of periodic (not defined by NFPA but defined by accreditation) or when damaged, serviced or upon arrival to the facility.

 

If risk ranked and accepted by governance as periodic testing does the facility for AHCA-Licensure compliance still have to perform semi-annual testing?

Question 12

Name of Code, Standard, Law or if applicable: NFPA 99 Electrical Systems

Chapter, Section, Paragraph or Identifying location: 6.3.2.3

Add background information: 

If a operating room is considered or designated by risk assessment to be a wet location the avenues of providing protection are isolated power Class A GFCI protection.

Question: When retrofitting an operating room with Class A GFCI protection (an AHCA-OPC reviewable project) it previously was not considered acceptable to allow panel mounted GFCI devices to protect outlets.

Far into 6.3.2.3 it lists as an acceptable means of protection panel installed GFCI devices limited to protecting only ONE duplex outlet.

Is this acceptable?

Question 13

Name of Code, Standard, Law or if applicable: Florida Uniform Fire Code

Chapter, Section, Paragraph or Identifying location: In general

Add background information: In the past there have been discussions related to ambulatory care facilities specifically Ambulatory Surgery Centers not being considered to be subject to conditions set forth in the Uniform Fire Code which applies largely to Skilled Nursing and Acute care settings (Hospitals).

Question: If that is the case it has been argued that the ASC would be only responsible for basic compliance items under NFPA 1, parts of NFPA 101 and only those sections of NFPA 99 that are directly referenced by NFPA 1 or by NFPA 101,  from the Ambulatory Health Care Occupancies chapters, 20 and 21.

Please clarify if this is the case?

Name of Code, Standard, Law or if applicable: NFPA 99, Electrical Systems

Chapter, Section, Paragraph or Identifying location: 6.3.2.3.6

Add background information: Existing facilities. All operating rooms considered as wet locations should have some form of interrupt protection installed. This section shows an alternative for EXISITNG FACILIITIES. 

For facilities having wet location operating rooms (by risk assessment) qualifying for this consideration the standard shows compliance as NOT to require retrofitting the physical plant to provide GFCI or Isolated power if the facility is not so designed or equipped. It does require additional testing which may be considered over and above typical compliance testing for these spaces such as: Regular continuity testing To be performed: 1. Initially (when designated as wet location - not specified)

2. Whenever damage is noted, and  3. Whenever repairs are made.

Question: Is this line item acceptable to AHCA as a compliance item and if so and in the absence of a properly performed continuity testing program as part of the initial acceptance of an EXISTING FACILITY would a current testing as baseline be acceptable for this compliance item?

If a facility qualified for consideration of this exception it would then be COMPLIANT if conditions were met even though Operating rooms were considered WET LOCATIONS by compliance with this exception and not have to install GFCI or isolated power systems?

Question 14

Question 15

Name of Code, Standard, Law or if applicable: NFPA 75, Fire Protection of Information Technology Equipment

Chapter, Section, Paragraph or Identifying location: Chapter 1.3 and Chapter 4

Add background information: 

 NFPA 75, Fire Protection of Information Technology Equipment, is adopted by the Florida Uniform Fire Code for hospitals and nursing homes and referenced in NFPA 1 for ambulatory surgical centers. It has been used by some AHCA reviewers to require every ITE room or closet in a hospital, nursing home or ambulatory surgical center be enclosed with 1-hour fire rated barriers. But NFPA 75, in the Application chapter, states, “the mere presence of the ITE shall not constitute the need to invoke the requirements of this standard”. Further it states,  “the application of this standard is based on the risk considerations outlined in Chapter 4.”

 

NFPA 75 is a Standard that covers many different occupancies and uses, not just health care. Many of the elements to be considered to determine acceptable risks are fire protection elements all health care occupancies already are required to have such as is meant to protect data and continuity of operation from fire events when there are no other protections. But Health Care already has, automatic fire detection and suppression, manual fire extinguishers, complete alarm systems with direct tie to emergency responders and passive life safety elements for the patients, staff, and public. The single risk element a health care facility may have to determine would be the facility’s data access, storage, and continuity of service.

Question: Does AHCA require all ITE  rooms in a hospital, nursing home or ambulatory surgical center to be enclosed with 1 hour fire rated barriers?

Question 2: If not, does AHCA leave that decision up to the facility to determine their own fire protection needs for their ITE based on their own risk assessment? 

Question 3: Will a statement in the Functional Program stating a risk assessment was completed and does not require additional protection to the ITE be enough to satisfy AHCA? If the answer is “No” what more does AHCA need to see from the facility to not require the facility to enclose the ITE in a 1 hour fire rated barrier?

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37th Annual AHCA Seminar & Expo

Sunday, Oct. 17 - Tuesday, Oct. 19, 2021

Disney's Coronado Springs Resort

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