CMS SOM App. Z, Tag E-0041

(e) Emergency and standby power systems. The hospital must implement

emergency and standby power systems based on the emergency plan set forth in

paragraph (a) of this section and in the policies and procedures plan set forth in

paragraphs (b)(1)(i) and (ii) of this section.

§483.73(e), §485.625(e)

(e) Emergency and standby power systems. The [LTC facility and the CAH] must

implement emergency and standby power systems based on the emergency plan set

forth in paragraph (a) of this section.

§482.15(e)(1), §483.73(e)(1), §485.625(e)(1)

Emergency generator location. The generator must be located in accordance with

the location requirements found in the Health Care Facilities Code (NFPA 99 and

Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, and TIA

12–6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12–1,

TIA 12–2, TIA 12–3, and TIA 12–4), and NFPA 110, when a new structure is built

or when an existing structure or building is renovated.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2)

Emergency generator inspection and testing. The [hospital, CAH and LTC facility]

must implement the emergency power system inspection, testing, and [maintenance]

requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety

Code.

482.15(e)(3), §483.73(e)(3), §485.625(e)(3)

Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an

onsite fuel source to power emergency generators must have a plan for how it will

keep emergency power systems operational during the emergency, unless it

evacuates.

*[For hospitals at §482.15(h), LTC at §483.73(g), and CAHs §485.625(g):]

The standards incorporated by reference in this section are approved for

incorporation by reference by the Director of the Office of the Federal Register in

accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material

from the sources listed below. You may inspect a copy at the CMS Information

Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National

Archives and Records Administration (NARA). For information on the availability

of this material at NARA, call 202–741–6030, or go to:

http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.

html.

If any changes in this edition of the Code are incorporated by reference, CMS will

publish a document in the Federal Register to announce the changes.

(1) National Fire Protection Association, 1 Batterymarch Park,

Quincy, MA 02169, www.nfpa.org

, 1.617.770.3000.

(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11,

2011.

(ii) Technical interim amendment (TIA) 12–2 to NFPA 99, issued August 11,

2011.

(iii) TIA 12–3 to NFPA 99, issued August 9, 2012.

(iv) TIA 12–4 to NFPA 99, issued March 7, 2013.

(v) TIA 12–5 to NFPA 99, issued August 1, 2013.

(vi) TIA 12–6 to NFPA 99, issued March 3, 2014.

(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.

(viii) TIA 12–1 to NFPA 101, issued August 11, 2011.

(ix) TIA 12–2 to NFPA 101, issued October 30, 2012.

(x) TIA 12–3 to NFPA 101, issued October 22, 2013.

(xi) TIA 12–4 to NFPA 101, issued October 22, 2013.

(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010

edition, including TIAs to chapter 7, issued August 6, 2009.

Interpretive Guidelines applies to: 482.15(e), §485.625(e), §483.73(e).

NOTE: For CAHs under §485.625(e)(2) “maintenance” is not included in the

regulatory language.

NOTE: Hospitals, CAHs and LTC facilities are required to base their emergency power

and stand-by systems on their emergency plans and risk assessments, and including the

policies and procedures for hospitals. The determination of the appropriate alternate

energy source should be made through the development of the facility’s risk assessment

and emergency plan. If these facilities determine that a permanent generator is not

required to meet the emergency power and stand-by systems requirements for this

emergency preparedness regulation, then §§482.15(e)(1) and (2), §483.73(e)(1) and (2),

§485.625(e)(1) and (2), would not apply. However, these facility types must continue

to meet the existing emergency power provisions and requirements for their

provider/supplier types under physical environment CoPs or any existing LSC

guidance.

Emergency and standby power systems

CMS requires Hospitals, CAHs and LTC facilities to comply with the 2012 edition of the

National Fire Protection Association (NFPA) 101 – Life Safety Code (LSC) and the 2012

edition of the NFPA 99 – Health Care Facilities Code in accordance with the Final Rule

(CMS–3277–F). NFPA 99 requires Hospitals, CAHs and certain LTC facilities to install,

maintain, inspect and test an Essential Electric System (EES) in areas of a building where

the failure of equipment or systems is likely to cause the injury or death of patients or

caregivers. An EES is a system which includes an alternate source of power, distribution

system, and associated equipment that is designed to ensure continuity of electricity to

elected areas and functions during the interruption of normal electrical service. The EES

alternate source of power for these facility types is typically a generator. (NOTE: LTC

facilities are also expected to meet the requirements under Life Safety Code and NFPA

99 as outlined within the LTC Appendix of the SOM). In addition, NFPA 99 identifies

the 2010 edition of NFPA 110 – Standard for Emergency and Standby Power Systems as

a mandatory reference, which addresses the performance requirements for emergency and

standby power systems and includes installation, maintenance, operation, and testing

requirements.

NFPA 99 contains emergency power requirements for emergency lighting, fire detection

systems, extinguishing systems, and alarm systems. But, NFPA 99 does not specify

emergency power requirements for maintaining supplies, and facility temperature

requirements are limited to heating equipment for operating, delivery, labor, recovery,

intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment

spaces, and general patient/resident rooms. In addition, NFPA 99 does not require

heating in general patient rooms during the disruption of normal power where the outside

design temperature is higher than 20 degrees Fahrenheit or where a selected room(s) is

provided for the needs of all patients (where patients would be internally relocated), then

only that room(s) needs to be heated. Therefore, EES in Hospitals, CAHs and LTC

facilities should include consideration for design to accommodate any additional

electrical loads the facility determines to be necessary to meet all subsistence needs

required by emergency preparedness plans, policies and procedures, unless the facility’s

emergency plans, policies and procedures required under paragraph (a) and paragraph

(b)(1)(i) and (ii) of this section determine that the hospital, CAH or LTC facility will

relocate patients internally or evacuate in the event of an emergency. Facilities may plan

to evacuate all patients, or choose to relocate internally only patients located in certain

locations of the facility based on the ability to meet emergency power requirements in

certain locations. For example, a hospital that has the ability to maintain temperature

requirements in 50 percent of the inpatient locations during a power outage, may develop

an emergency plan that includes bringing in alternate power, heating and/or cooling

capabilities, and the partial relocation or evacuation of patients during a power outage

instead of installing additional power sources to maintain temperatures in all inpatient

locations. Or a LTC facility may decide to relocate residents to a part of the facility, such

as a dining or activities room, where the facility can maintain the proper temperature

requirements rather than the maintaining temperature within the entire facility. It is up to

each facility to make emergency power system decisions based on its risk assessment and

emergency plan.

If a Hospital, CAH or LTC facility determines that the use of a portable and mobile

generator would be the best way to accommodate for additional electrical loads necessary

to meet subsistence needs required by emergency preparedness plans, policies and

procedures, then NFPA requirements on emergency and standby power systems such as

generator installation, location, inspection and testing, and fuel would not be applicable

to the portable generator and associated distribution system, except for NFPA 70 -

National Electrical Code. (See E-0015 for Interpretive Guidance on portable generators).

Emergency generator location

NFPA 110 contains minimum requirements and considerations for the installation and

environmental conditions that may have an effect on Emergency Power Supply System

(EPSS) equipment, including, building type, classification of occupancy, hazard of

contents, and geographic location. NFPA 110 requires that EPSS equipment, including

generators, to be designed and located to minimize damage (e.g., flooding). The NFPA

110 generator location requirements apply to EPSS (e.g. generators) that are permanently

attached and do not apply to portable and mobile generators used to provide or

supplement emergency power to Hospitals, CAHs and LTC facilities. (See E-0015 for

Interpretive Guidance on portable generators).

Under emergency preparedness, the regulations require that the generator and its

associated equipment be located in accordance with the LSC, NFPA 99, and NFPA 110

when a new structure is built or an existing structure or building is renovated. Therefore,

new structures or building renovations that occur after November 15, 2016, (the effective

date of the Emergency Preparedness Final Rule) must be in compliance with NFPA 110

generator location requirements to be determined as being in compliance with the

Emergency Preparedness regulations.

Emergency generator inspection and testing

NFPA 110 contains routine maintenance and operational testing requirements for

emergency and standby power systems, including generators. Emergency generators

required by NFPA 99 and the Emergency Preparedness Final Rule must be maintained

and tested in accordance with NFPA 110 requirements, which are based on manufacturer

recommendations, instruction manuals, and the minimum requirements of NFPA 110,

Chapter 8.

Emergency generator fuel

NFPA 110 permits fuel sources for generators to be liquid petroleum products (e.g., gas,

diesel), liquefied petroleum gas (e.g., propane) and natural or synthetic gas (e.g., natural

gas). Generators required by NFPA 99 are designated by Class, which defines the

minimum time, in hours, that an EES is designed to operate at its rated load without

having to be refueled. Generators required by NFPA 99 for Hospitals, CAHs and LTC

facilities are designated Class X, which defines the minimum run time as being “other

time, in hours, as required by application, code or user.” The 2010 edition of NFPA 110

also requires that generator installations in locations where the probability of interruption

of off-site (e.g., natural gas) fuel supplies is high to maintain onsite storage of an alternate

fuel source sufficient to allow full output of the ESS for the specified class.

The Emergency Preparedness Final Rule requires Hospitals, CAHs and LTC facilities

that maintain onsite fuel sources (e.g., gas, diesel, propane) to have a plan to keep the

EES operational for the duration of emergencies as defined by the facilities emergency

plan, policy and procedures, unless it evacuates. This would include maintaining fuel

onsite to maintain generator operation or it could include making arrangements for fuel

delivery for an emergency event. If fuel is to be delivered during an emergency event,

planning should consider limitations and delays that may impact fuel delivery during an

event. In addition, planning should ensure that arranged fuel supply sources will not be

limited by other community demands during the same emergency event. In instances

when a facility maintains onsite fuel sources and plans to evacuate during an emergency,

a sufficient amount of onsite fuel should be maintained to keep the EES operational until

such time the building is evacuated.

For information regarding permanently installed generators, please refer to applicable

NFPA Codes and Standards as discussed under Tag E-0015. In the event a health

surveyor is unclear whether the facility is complying with these requirements, the health

surveyor must consult with their LSC surveyors. Generally, tag E-0041 should be

reviewed by a LSC surveyor.

Survey Procedures

• Verify that the hospital, CAH and LTC facility has the required emergency and

standby power systems to meet the requirements of the facility’s emergency plan and

corresponding policies and procedures.

• Review the emergency plan for “shelter in place” and evacuation plans. Based on

those plans, does the facility have emergency power systems or plans in place to

maintain safe operations while sheltering in place?

• For hospitals, CAHs and LTC facilities which are under construction or have existing

buildings being renovated, verify the facility has a written plan to relocate the EPSS

by the time construction is completed.

For hospitals, CAHs and LTC facilities with permanently attached generators:

• For new construction that takes place between November 15, 2016 and is completed

by November 15, 2017, verify the generator is located and installed in accordance

with NFPA 110 and NFPA 99 when a new structure is built or when an existing

structure or building is renovated. The applicability of both NFPA 110 and NFPA 99

addresses only new, altered, renovated or modified generator locations.

• Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source

maintains it in accordance with NFPA 110 for their generator, and have a plan for

how to keep the generator operational during an emergency, unless they plan to

evacuate.