Electrical equipment upkeep as a compliance issue

Most hospital facilities professionals realize that power system maintenance is an important reliability issue and the impact of robust inspection, testing and maintenance programs cannot be underestimated.

But, behind these best practices are a set of regulatory issues and industry guidelines of which health facilities professionals also must be aware. This area where electrical system maintenance and compliance meet can provide a framework for a power management strategy.

Key references

Key among these documents and references, which are listed in the sidebar on Page 50, are information from the Centers for Medicare & Medicaid Services (CMS), the American Society for Healthcare Engineering (ASHE) and the National Fire Protection Association (NFPA), among others. They include:

CMS maintenance guidance. The revised CMS State Operations Manual provides guidance for state personnel surveying hospitals on behalf of CMS. Readers are encouraged to refer to the complete manual to assess the full impact of the interpretive guidelines. The Interpretive Guidelines section 482.41(a) provides instruction and guidance on facility equipment maintenance. It advises surveyors that the hospital must ensure that “routine and preventive maintenance and testing activities are performed as necessary, in accordance with … laws, regulations, and guidelines and manufacturer’s recommendations … .” CMS also requires that hospitals establish maintenance schedules and conduct ongoing maintenance inspections to identify areas and equipment that need repairs.

The CMS interpretive guidelines apply to facility equipment that supports the hospital’s physical environment. CMS requires that all equipment be “inspected, tested and maintained to ensure their safety, availability and reliability.” The default CMS position historically has been that hospitals comply “when they follow the manufacturer-recommended maintenance activities and schedule.” CMS also has stated that when equipment is maintained in this manner, “the hospital must maintain documentation of those recommendations and the hospital’s associated maintenance activity for the affected equipment.”

However, in response to continued input from the health care community, the Joint Commission and others, CMS issued Survey and Certification Letter S&C:14-07-Hospital in December 2013. That document superseded a December 2011 CMS ruling on the same subject and relaxed some of the previous CMS requirements for both medical and facilities equipment maintenance to be in full accordance with the manufacturer’s recommendations.

CMS now permits an alternate equipment management program in certain circumstances. However, any organization wishing to undertake this alternate equipment management approach should closely review the complete requirements published by CMS as well as any accreditor-specific requirements. As with many Authority Having Jurisdiction (AHJ) requirements, the devil in this case is very much in the details. The S&C letter includes 11 pages of detailed guidance to state surveyors that should be required reading for those who manage hospital facilities equipment maintenance as well as medical equipment maintenance.

Maintenance managers also should note that the alternate equipment management program approach is not permitted if, as stated in the S&C letter, “other federal or state law; or hospital Conditions of Participation (CoPs) require adherence to manufacturer’s recommendations and/or set specific requirements” or if “new equipment without a sufficient amount of maintenance history has been acquired.”

The new CMS S&C letter permits alternate equipment maintenance activities and frequencies other than those recommended by the manufacturer under certain conditions. If hospitals elect this approach, they must meet all of the CMS conditions and must document compliance. And the alternate equipment management program “must be based on generally accepted standards of practice for facility or medical equipment maintenance.” CMS has listed as an example of these generally accepted standards of practice the ASHE 2009 publication Maintenance Management for Health Care Facilities. CMS also stated that there may be similar documents issued by other nationally recognized organizations that hospitals might choose to reference.

The Joint Commission has had several ongoing sets of requirements for utility equipment maintenance in multiple Environment of Care chapter standards. It recently made several changes to Standards EC.02.05.01 and EC.02.05.05 to reflect the CMS-approved alternate equipment management program.

The May 2014 issues of both the Joint Commission’s Environment of Care News and Perspectives include a “clarifications and expectations” article by the Joint Commission’s George Mills, director of engineering, titled “Implementing a Robust Equipment Maintenance Program.” The article includes a 12-item checklist, “Is Your Equipment Maintenance Program Defensible?” This checklist should be obtained and reviewed by all hospital directors, managers and supervisors responsible for equipment maintenance. It contains content that also can serve as a robust equipment maintenance tracer.

ASHE maintenance publication. On first glance, the CMS-referenced ASHE maintenance management publication’s recommendations for electrical power equipment maintenance might appear to be limited to the following:

• Electrical panels (Procedure 401F);
• Electrical transfer units (Procedure 402F);
• Emergency generators (Procedure 403F);
• Emergency lighting packs (Procedure 404F).

However, a large part of the ASHE document includes recommendations for many other types of systems that also include recommendations for the maintenance of electrical power equipment within those systems. The environmental maintenance documents require maintenance of receptacles, grounding systems, ground fault circuit interrupters, maintaining code-required working clearances and lighting equipment.

The compressors, cooling systems, heating systems, water systems, conveyor systems and environmental services documents require maintenance of the motors, motor starters and wiring, along with controls, safeties and batteries. Besides those elements, the central services, dietetics equipment and refrigeration equipment documents also require maintenance of heating elements where applicable.

The ASHE maintenance management publication contains an appendix on electrical safety procedures. Facilities professionals should augment this information by consulting the latest published edition of NFPA 70E, Standard for Electrical Safety in the Workplace, for the most recent industry thinking on electrical safety matters. Another appendix provides three basic electrical safety tests: electrical receptacle testing, ground fault circuit interrupter testing, and an incoming electrical inspection checklist.

NFPA maintenance requirements. The 2012 edition of NFPA 99, Health Care Facilities Code, states in paragraph 6.4.4.1.1.3 Maintenance [of the Essential Electrical System] “shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.” Most hospitals are aware of recommended generator maintenance programs, but the requirements of NFPA 110 also apply to the transfer switches, paralleling switchgear (where installed) and all other components of the emergency power supply systems (EPSSs).

NFPA 110 provides criteria for testing and maintenance of EPSSs including all associated components (the EPSS covers the entire system from the generator set downstream to the load terminals of the transfer switches; it does not extend downstream of the transfer switch load terminals): 8.1.1 — The routine maintenance and operational testing program shall be based on all of the following: (1) manufacturer’s recommendations; (2) instruction manuals; (3) minimum requirements of this chapter; (4) the authority having jurisdiction.

Although the paragraph reference has changed since the 1999 edition of NFPA 110, these criteria have not changed.

Although most NFPA standards only apply to new installations, readers should be aware of the following wording that was added to NFPA 110 in the 2010 edition: “1.3 Application. This document applies to new installations of EPSSs, except that the requirements of Chapter 8 shall apply to new and existing systems … .” If any AHJ adopts a newer edition of NFPA 110, then Chapter 8 on Routine Maintenance and Operational Testing may apply regardless of other criteria.

NFPA safety requirements. The 2012 edition of NFPA 70E requires maintenance of electrical distribution system equipment in accordance with manufacturers’ instructions or industry consensus standards.

According to 205.3, General Maintenance Requirements, for instance, “Electrical equipment shall be maintained in accordance with manufacturers’ instructions or industry consensus standards to reduce the risk of failure and the subsequent exposure of employees to electrical hazards.” Likewise, according to 205.4, Overcurrent Protective Devices, “Overcurrent protective devices shall be maintained in accordance with the manufacturers’ instructions or industry consensus standards. Maintenance, tests and inspections shall be documented.”

One industry consensus standard mentioned in the 2012 NFPA 70E handbook, Handbook for Electrical Safety in the Workplace, is NFPA 70B, Recommended Practice for Electrical Equipment Maintenance.

Also mentioned by the 2012 NFPA 70E handbook is the American National Standards Institute (ANSI)/InterNational Electrical Testing Association Standard for Maintenance Testing Specifications for Electrical Power Equipment and Systems.

Finally, another industry standard is Institute of Electrical and Electronics Engineers (IEEE) 3007.2, the IEEE Recommended Practice for the Maintenance of Industrial and Commercial Power Systems. This is an update of the long-used IEEE Yellow Book.

There are differences among these documents, but they are all excellent resources. And they are regularly updated by their sponsoring organizations. Health facilities professionals should consult all three documents as well as the manufacturers’ recommendations when reviewing their electrical power equipment maintenance programs.

NFPA arc-flash mandates. Maintenance personnel safety is always important and code changes have introduced new criteria over the past decade that have required action by hospitals and other facilities. Over a decade ago, NFPA 70, National Electrical Code, introduced a new Section 110.16, in response to the issue of electrical arc flash hazards. That section now is called Arc-Flash Hazard Warning in NFPA 70-2014 and mandates such labeling.

Informational notes refer readers to NFPA 70E-2012 for its electrical safety content (determining potential exposure, planning safe work practices, arc flash labeling and selecting personal protective equipment) and to ANSI Z535.4-1998 for the Occupational Safety & Health Administration-required safety signs and labels. Both types of safety labeling are required, not just one or the other.

Some recommendations

Health facilities professionals should conduct their own vulnerability analyses or risk assessments to ascertain which electrical power equipment needs more comprehensive maintenance. They also should be careful not to rely on one source of information when creating a maintenance program for their critical electrical power equipment.

The consensus industry standards have been developed for this purpose and should be considered. The resources in this article and in the sidebar include some excellent sources of which maintenance personnel and maintenance managers should be aware, but are not all-inclusive.

Most electrical power equipment manufacturers publish recommended maintenance activities and intervals for their equipment. The manufacturers’ recommendations must be used if an alternate equipment management program is not permitted for some electrical power equipment.

When an alternate equipment management program is permitted, health facilities professionals should consider the manufacturers’ recommendations along with the other industry sources when developing their electrical power equipment maintenance program. An organization’s insurance company also may have specific maintenance criteria to be followed.

Electrical power equipment maintenance is a combination of common sense and highly technical activities around and inside high-energy equipment with a downside potential for disastrous results.

Power equipment often needs planned shutdowns for much of the important required maintenance, and continually deferring maintenance because the shutdowns are too hard is a risky proposition in its own right.

David L. Stymiest, PE, CHFM, CHSP, FASHE, is a senior consultant at Smith Seckman Reid Inc., specializing in facilities engineering and regulatory compliance. Although he is chair of the NFPA technical committee on emergency power supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this article shall not be considered the official position of NFPA or any of its technical committees and shall not be considered to be, nor be relied upon as, a formal interpretation. He can be reached at DStymiest@SSR-Inc.com.

This Maintaining Power Systems article originally appeared in the August 2014 issue of Health Facilities Management.

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