Doing the waive: Categorical waivers are still in the mix…
By Steve MacArthur, Hospital Safety Consultant
In preparation for last week’s missive on the transmission of fire alarm signals during fire drills (more on that in a moment), I ran across a CMS categorical waiver that was posted early last fall (September 25, to be exact) that provided some relief for folks wishing to use corrugated medical tubing in certain circumstances, rather than the rigid copper tubing required under NFPA 99-2012, due what CMS might consider an unreasonable hardship as corrugated medical tubing can be installed more efficiently and economically than rigid copper. The basis of the waiver is due to a more recent version of NFPA 99 (the 2018 edition) in which there are provisions that provide for installation of the corrugated. At this point, we all know the drill: You have to read the whole thing very carefully to ensure you don’t step on any regulatory toes, but if you’ve got some tricky installations coming up, this might be something of a relief. You can find all the details here.
Now, the reason I bring up the transmission of fire alarm signals deal is that the most recent edition of NFPA 101 (2021) includes some clarification in this regard (a shout out to Grant Finch out in Oregon for his detective skills on this). As noted last week, the current language indicates transmission of a fire alarm signal (with no additional information to be found as defining what that means, leaving things in the hands of the interpretive dance masters). The 2021 edition, in section 19.7.1.4, requires fire drills to include the simulation of emergency for fire conditions (much as it does now), but it goes on to say “include activation of the fire alarm system notification appliances.” Section 19.7.1.7 still provides for the coded announcement between 2100 and 0600 hours, so that piece of it remains the same.
At any rate, I am hopeful that, with this current version clarification, even if there is no categorical waiver forthcoming, the accreditation organizations will stop fussing about the fire alarm signal transmission and move on to other things. After all, the truly applicable code for testing fire alarm signals is NFPA 72, so why would need to include signals in our fire drills—which reminds me, you still need to document the elapsed time of the fire alarm signals generation to its receipt at the central monitoring service, etc. I’ve been running into a spate of vendors that are not including that in their documentation, so you probably want to give your latest testing documentation a look. And while we’re on the subject, I personally think it’s bogus for your testing vendor to just give you a printout of the month’s alarm activity in which the test occurred; they should either highlight it on the sheet or pull the dates/times/results off the printout. I suspect that they are being more than adequately compensated for their services, which (to my mind) includes a summary of the results, particularly any deficiencies. I don’t think you should have to hunt for the deficiencies and now with the rollout of the virtual survey process (something on that next week), surveyors will have more time than ever to comb through your reports for those funky little missed devices, etc. Your fire alarm (and sprinkler system) ITM vendor should be highlighting the “to do” list so you can get it “to done.”
Hope you’re having a safe and productive week. See you on the flip side!
About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.