MSL Healthcare Partners, Inc. Wild Card EPs Paraphrase K-tag # EC.02.04.03 EP 14 All other electrical K-920 equipment in patient care vicinity NFPA 992012, Chapter 10 K-924 K-928 K-931 K-tag Description Power strips in patient care vicinity or for components of mobile patient care related electrical equipment (PCREE) meet NFPA 99-2012; 10.2.3.6: - Power strips not used for personal electronics in patient care vicinity - PCREE: UL 1363A or UL 60601-1 - Non-PCREE in patient rooms outside vicinity UL 1363 - Extension cords not substituted for fixed wiring Equipment maintenance on anesthesia apparatus and testing after adjustment or repair: -Oxygen concentration -Functioning oxygen analyzer -Defective equipment removed from service -Service areas free of oil, grease, flammables -Manufacturer service manuals used -Scheduled maintenance program Equipment for oxygen enriched atmospheres: -Labeled accordingly -Metering & pressure-reducing regulators labeled "Oxygen Use No Oil" -Equipment labeled for gases intended -Manufacturer's name on metering equipment, pressure reducing regulators, humidifiers, nebulizers -Cylinders labeled per PGA C-7 & color coding not primary method -Durable labeling withstands cleaning Hyperbaric facilities comply with NFPA 99-2012 Chapter 14
EC.02.05.05 EP7 EC.02.05.09 EP 7 All other HVAC & electrical, NFPA 99-2012, Chapters 6 & 9 All other gas & vacuum NFPA 99-2- 12 chapters 5 & 11 K-901 Building categories 1-4 per NFPA 99-2012 risk assessments of gas, vacuum, & electrical equipment K-323 Emergency power function, location for anesthetizing locations: -EES critical branch power for task illumination, fixed equipment, selected receptacles & circuits -EES equipment power to ventilation system -HVAC in according to ASHRAE 170 & equipment manufacturer's recommendations consulted before reducing humidity levels to a lower limit of 20% (in addition to a risk assessment) -Smoke control for windowless anesthetizing locations K-913 ORs are wet locations unless otherwise risk assessed, with documentation -Wet locations have isolated power or ground-fault circuit interrupters K-915 Electrical distribution based on NFPA 99-2012 risk assessment categories K-912, 914, 917, 918 Receptacles: - Hospital grade receptacles in anesthetizing locations tested after installation, replacement, or servicing - Receptacles tamper-resistant or listed cover in pediatric patient rooms, bathrooms, play rooms, and activity rooms (not nurseries) K-903 Medical gas systems categorized per NFPA 99 risk assessment, with documentation K-904 Medical gas alarm systems (master, area, local) comply with appropriate risk category K-907 Gas cylinder storage - Appropriately marked gas cylinders & cylinder location markings - Cylinders used in order received - Storage requirements based on gas volume
EC.02.06.01 EP 1 Safe & suitable interior spaces K-323 General anesthesia locations: -Zone valve locations -Area alarm panels for gas, vacuum, WAGD in areas with surveillance -Alarm sensors K-927, 930, 906 Transfilling: -None in any patient care rooms -Appropriate location for transfilling K-921, 924 Organization library: -Service & instruction manuals -Manufacturers' procedures, maintenance manuals, technical bulletins, specifications for testing maintenance of equipment & systems K-925 Smoking materials: -Removed from patients on respiratory therapy -No sources of ignition within 1 foot of nasal cannula -No sources of ignition within 15 feet of other forms of oxygen administration -No solid fuel burning appliances in area of oxygen administration -No non-medical appliances with hot surfaces or sparking mechanism within area of oxygen administration or 1 foot of nasal cannula K-933 OR fire loss prevention: -Periodic evaluation of fire hazards & prevention procedures -Procedures for OR emergencies, control of chemical spills, and extinguishment of fires -Training to new OR personnel (including surgeons) -Continuing education -Review of incidents -Use of flammable germicides or antiseptics with electrosurgery, cautery, or lasers -Peri-operative time out K-531 Elevator firefighter recall: -Operated monthly -Written documentation K-50, 712, 718, 901,907,9 20, 921, 926,,933 Competency for maintenance, testing, inspection: -Maintenance, testing, inspection of medical equipment, utilities, fire safety systems & equipment -Safe handling of hazmat & waste -Continuing education & training
LS.02.01.10 EP11 LS.02.01.20 EP36 LS.02.01.30 EP25 LS.02.01.34 EP4 18/19.1 means of egress 18/19/2 fire & smoke protection 18/19.3 fire alarm 18/19.3.4 K-111 Building changes & additions: of -Change of use or occupancy complies with NFPA 101-2012 chapter 43.7 - Additions in compliance with NFPA 101-2012 chapters 18 & 43.8 K-112 Sprinkler protection for major renovation of unsprinklered smoke compartments or buildings: -More than 50% or 4500 square feet of smoke compartment K-132 Occupancy types in multiple occupancy buildings: -Outpatient surgical departments must be Ambulatory Health Care, regardless of number of patients served K-221 Patient sleeping room doors: -Unlocked -Locked for specialized security needs with staff able to unlock K-224 Horizontal sliding doors: -Single leaf -Criteria for operation -Can't rebound K-252 Corridors have access to 2 exits K-233 Exit access doors: -Swinging -Required widths K-261 Travel distance to exits within room K-322 Labs with quantities of flammable, combustible, or hazardous materials considered severe K-341 Fire alarm requirements & installation: -Per NFPA 70 and NFPA 72 Master fire alarm panel: -Smoke detector or continuously occupied & 1 hour fire rated -Wiring and transmission paths monitored for integrity K-342 Fire alarm initiation: -Sprinkler or detection device or system -Location of pull stations K-343 Alarm notification: -Automatic to occupants & emergency forces -Visual alarms sufficient in critical care
LS.02.01.35 EP14 LS.02.01.40 EP2 LS.02.01.50 EP8 LS.02.01.70 EP6 automatic extinguishing 18/19.3.5 automatic extinguishing 18/19.4.2 building services 18/19.5.4 operating feature 18/19.7 K-344 Fire alarm: -Automatic activation of fire alarm -Alternative power supply NO NEW K-TAGS NO NEW K-TAGS K-511 Equipment using gas or gas -related piping: -Complies with NFPA 54 & electrical with NFPA 70 -Existing can be used if no hazard to life K-521 HVAC: -HVAC complies with NFPA 101-2012, section 9.2 -Installed per manufacturer K-522 Safety of any heating device other than central plant: - Suspended unit heater safety K-525 Additional fireplace requirements K-532 Escalators, dumbwaiters, moving walks: - ASME/ANSI A17.3 - Emergency stop buttons K-751 Draperies, curtains, cubicle curtains, fabrics, films: -Flame propagation K-752 New upholstered furniture (after 7/5/16): -Cigarette ignition resistance New mattresses (after 7/5/16): -Char length & heat release
LS.03.01.10 EP 9 LS.03.01.20 EP 15 20/21.1 means of egress 20/21.2 LS.03.01.30 EP 16 smoke protection 20/21.3 K-771 Engineered smoke control systems: -Tested per NFPA 92 -Tested per engineering principles -Documentation K-161 -Sprinklers in new buildings -Existing buildings sprinklered based on construction type K-163 -Interior non-bearing walls (type I or II construction) non- or limited-combustible -2 hr fire rated walls (not shaft enclosures) have fire retardant wood enclosed with non or limited combustible materials K-231 -Capacity of means of egress per NFPA 101-2012. section 7.3 K-292 -New buildings where inhalation anesthetics used have illumination of means of egress, emergency lighting, exit signs, directional signs on life safety branch of electrical system K-322 Labs with quantities of flammable, combustible, or hazardous materials considered severe K-325 -Alcohol based hand sanitizers installed per NFPA 101-2012., section 8.7.3.1, LS.03.01.34 EP 6 fire alarm 20/21.3.4 K-324 -Commercial Cooking equipment per NFPA 96, unless for limited cooking or warming K-341 - Fire alarm requirements & installation - Master fire alarm panel location
LS.03.01.35 EP 8 LS.03.01.50 EP 4 LS.03.01.70 EP 6 extinguishing 20/21.3.5 building service 20/21.5 operating feature 20/21.7 K-342 -Fire alarm initiation via sprinkler or detection device or system -Location of pull stations K-343 -Automatic alarm notification to occupants and emergency forces K-344 -Automatic activation of fire alarm -Alternative power supply NO NEW K-TAGS K-511 -Gas equipment & gas piping per NFPA 54 -Electrical equipment per NFPA 70 -Existing equipment can continue if no hazard to life K-521 -HVAC complies with NFPA 101, section 9.2 -HVAC installed per manufacturer's specifications K-522 - Safety of any heating device other than central plant - Suspended unit heater safety K-525 -Additional fireplace requirements K-532 Escalators, dumbwaiters, moving walks - ASME/ANSI A17.3 - Emergency stop buttons K-541 -Trash chute requirements K-751 Ambulatory Care -Draperies, curtains, cubicle curtains, fabrics, films flame propagation
K-752 -New upholstered furniture (after 7/5/16) cigarette ignition resistance -New mattresses (after 7/5/16) char length & heat release K-771 -Testing engineered smoke control systems per NFPA 92 & established engineering principles -Documentation