Know the changes to NFPA 99 Chapter 6
New sections were added to NFPA 99-2021 health care facilities electrical systems acceptance testing and electrical preventive maintenance
- Understand why sections were added to NFPA 99: Health Care Facilities Code for site acceptance testing and electrical preventive maintenance.
- Know the requirements of NFPA 99 regarding electrical site acceptance testing.
- Recognize the requirement of NFPA 99-2021 regarding electrical preventive maintenance.
NFPA 99: Health Care Facilities Code was first published in 1984. Since then, the document has evolved to be used by owners, design professionals and enforcement officials to establish the minimum requirements within all health care facilities for performance, maintenance and testing of electrical systems.
Current issues such as climate change and the global pandemic dramatically reinforce the importance of resiliency and reliability within our nation’s health care facilities. In February 2021, the widespread power failures caused by unusually cold temperatures and winter storms in Texas left many hospitals without water and/or heat.
The latest version of NFPA 99 provides several updates to help ensure that the electrical infrastructure within health care facilities is prepared to cope with changing conditions. Among the updates are two new sections within the electrical systems chapter (Chapter 6) that clarify the requirements for inspection, testing, maintenance and commissioning of health care electrical systems to ensure patient and staff safety.
What was added to NFPA 99-2021?
Before the addition of these new sections, a small grouping of standards existed that described best practices for inspection, testing, maintenance and commissioning of electrical systems.
For example, NFPA 70B: Recommended Practice for Electrical Equipment Maintenance contains detailed information on maintenance of electrical system components including testing and documentation methods. Despite the specificity of this document, it is only a “recommended practice” and is not formally enforced as a code.
One of the only standards before the latest iteration of NFPA 99 that called for specific acceptance testing is NFPA 110: Standard for Emergency and Standby Power Systems Section 7.13, while NFPA 110 Chapter 8 calls for routine maintenance of emergency power systems. As can be inferred from its very title, while NFPA 110 defines these requirements for emergency and standby power systems, it does not address myriad electrical components that have a tremendous impact on the patients and staff that use the facility.
The Centers for Medicare & Medicaid Services is the federal organization responsible for making sure that hospitals meet established federal standards. Reimbursement from federally funded programs such as Medicare and Medicaid are contingent upon adherence to the standards enforced by CMS.
Federal Rule 42 CFR 482.41 designates conditions of participation for the physical environment of a hospital. This rule states, “The hospital must be constructed, arranged and maintained to ensure the safety of the patient and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.”
Enforcement and adherence to this standard is often left to third-party entities that are approved by CMS to certify compliance. The most common entity in the industry is The Joint Commission to which many health care organizations pay a fee to be included in their survey process. Receiving a successful certification from The Joint Commission deems a hospital eligible to receive Medicare and/or Medicaid reimbursement.
The Joint Commission requires that all accredited hospitals identify high-risk components of the utility systems. High-risk indicates there is a serious risk of serious injury or death to a patient or staff member in the event of an item’s failure. Once a component is identified as high-risk, the hospital must also develop written procedures outlining the maintenance, inspection and testing of the listed components.
The Joint Commission does not prescriptively call out what these requirements shall be other than to state that any such strategies developed must include activities completed at a frequency recommend by a manufacturer’s recommendations. The Joint Commission also allows for an alternative equipment maintenance program to be developed. This openness does allow facilities great latitude in their operations; however, it does not provide a consistent methodology for facilities to follow or authorities having jurisdiction to enforce.
While having an equipment maintenance plan is universally enforced, lack of consistent standards and procedures in this area of facilities management can adversely impact patient outcome in the event of failure. After every major catastrophic climate event, while there are countless stories of the heroics of front line workers; there are also unfortunately stories of tragedies that have occurred because a system failed and injury occurred. In addition to the immeasurable cost of the injuries and lost lives that are sometimes sustained to patients and staff, lawsuits often follow causing further financial loss to the health care facility.
The changes in this latest version of NFPA 99 are targeted at providing a standard to ensure patient safety via thorough testing of systems at installation and beyond with effective preventive maintenance — a precedent that will likely be followed by other standards in the future.
Site acceptance testing
The new code revisions call for site acceptance testing of the electrical system including all components serving Category 1 and Category 2 spaces. To provide clarity, NFPA 99 has required for several versions a risk assessment be completed to determine the risk category of the spaces being delivered. NFPA 99 defines Category 1 and 2 spaces as follows:
- Category 1: Failure of the system or equipment is likely to cause major injury or death to patients or caregivers.
- Category 2: Failure of the system or equipment is likely to cause minor injury to patients or caregivers.
In NFPA 99-2021, Annex A184.108.40.206 and A3.3.14. give a few examples of what Category 1 and 2 spaces are:
- Category 1 (rooms listed below or of similar purpose):
- Special care patient rooms used for critical care.
- Intensive care patient rooms.
- Angiography laboratories
- Cardiac catheterization laboratories.
- Delivery rooms.
- Operating rooms.
- Post Anesthesia care units.
- Trauma rooms.
- Category 2 (rooms listed below or of similar purpose):
- Inpatient bedrooms.
- Dialysis rooms.
- In vitro fertilization rooms.
- Procedural rooms.
The site acceptance testing must occur for all new construction as well as major renovations before placing a system into service. The test needs to be completed in accordance with “industry-recognized standards and practices for equipment testing and systems commissioning.” As mentioned previously, a lack of consistent definitions of what procedures should be followed can cause ambiguity and thus risk. NFPA has addressed this by recommending the use of NSI/NETA ATS: Standard for Acceptance Testing Specifications for Electrical Power Equipment and Systems and Chapter 31 of NFPA 70B. By following these standards, health care facilities can develop proper procedures and/or ask their consultants to use them to create consistent, clear and concise site acceptance testing procedures.
NFPA 99-2021, however, takes the site acceptance testing one step further requiring records of the testing to be kept and maintained. The records must be maintained for a minimum period of five years and can be paper or electronic media. The code also requires that the medium on which the records are stored must be able to survive the five-year retention term. As this code gets adopted, these records must be available at the request of the AHJ.
NFPA 99 does not require that the testing and record keeping be carried out by a third-party commissioning agent or other independent testing agency. It is, however, anticipated that the use of qualified firms certified in electrical system testing protocols will become best practice as the code is adopted across jurisdictions.
As stated previously, the testing is a requirement only after initial installation or major renovation before the system being placed in service. The acceptance testing is not mandated by the new code revision to be repeated. NFPA 99 has a newly added section 6.9 to address the ongoing electrical preventive maintenance procedures that are aimed at completing repetitive maintenance, testing and record keeping.
Electrical preventive maintenance
Like the site acceptance testing, NFPA 99’s latest revisions require the creation of an EPM program for all electrical components serving Category 1 and 2 spaces. The minimum criteria for the EPM program shall be:
- Listing of all equipment and systems included as part of the program.
- Schedule of inspection, testing and servicing (maintenance) of equipment.
- Survey and analysis of electrical equipment and systems to determine maintenance requirements and priorities.
- Scheduled routine inspections and tests.
- Reviews of inspection and test reports so that proper corrective measures can be prescribed.
- Performance of necessary work.
- Complete records.
To provide clarity of what an acceptable minimum standard of maintenance activities could be, NFPA 99-2021 Annex A 220.127.116.11 references an included table. The table refers to NFPA, NEMA and ANSI standards that provide recommended maintenance activities for several major components. The time interval for these components is also prescribed in the new code section through NFPA 99-2021 Table 18.104.22.168. The combination of activities and duration provide a guide for the EPM program to follow aimed at creating consistency for all health care facilities.
To illustrate an example of an EPM plan for a specific component, NFPA 99-2021 Table 22.214.171.124 outlines an EPM interval of every three years for circuit breakers. Table A.126.96.36.199 then supplements that with appropriate sections of NFPA 70B-2019 to reference for recommended maintenance activities for these devices. NFPA 70B also provides Annex H with several examples of forms that can be used as part of the EPM program to guide maintenance, testing and record keeping related to the device.
The record keeping of the EPM is very important. All EPM activities must be recorded and maintained using the same requirements previously mentioned for site acceptance testing.
Under the new code requirements, items identified as requiring corrective measures during the maintenance program implementation, must be addressed. Documentation of the corrective measures must also be integrated into the record keeping of the EPM.
While the new section of NFPA 99-2021 aims to reduce ambiguity in hospital EPM programs, it is acknowledged that there may be instances and/or components that are not specifically addressed by the new code and its annex materials. As such, the allowance of an alternative equipment maintenance program is provided in NFPA 99-2021 188.8.131.52.1. This section also includes the minimum requirements that the program should include to be an acceptable compliance pathway.
How to start a pathway to compliance
Establishing a thorough set of criteria for site acceptance testing or electrical preventive maintenance are both quite cumbersome tasks. Facilities that meet current federal rules enforced by CMS should all have robust plans in place already for maintenance, but many may not already have established standards for site acceptance testing.
The good news is that most firms that provide commissioning, testing and other facilities conditions assessment and management services are already well-versed in providing site acceptance testing criteria and maintaining the appropriate record keeping. Such companies likely also offer services to provide planning and record keeping for maintenance services as well. Care must be taken when selecting a company to aid in providing these services. First and foremost, they must be highly experienced in the health care setting. Equally important is that care must be taken in considering the long-term validity of those entities to ensure their methodologies, software and deliverables will meet the intent and the data retention requirements of the new code.
Health care facilities are where Americans go in the darkest times to seek out care. The reliability and resiliency of health care facilities is paramount. Having any sort of ambiguity in how building professionals test and maintain the nation’s health care facilities could potentially leave gaps in the health care system should critical systems fail.
With the latest changes in NFPA 99-2021 that address electrical system reliability, there is now a nationally recognized source by which hospitals can build site acceptance testing and EPM plans to provide a consistent standard of care for patient and staff safety across our health care infrastructure, improving the ability to deliver care.