HSO Platform

NFPA 96 — Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

Semi-annual minimum; quarterly if high-volume cooking

Hood, filters, grease traps, ductwork, and exhaust fan

Must be a certified hood cleaning company. Written report must be left on-site with service sticker applied.

NFPA 96 / NFPA 17A — Wet Chemical Extinguishing Systems

Semi-annual inspection and service by licensed fire suppression contractor

Ansul or equivalent wet chemical system, fusible links, pull station, nozzle coverage and positioning

Contractor leaves a tagged inspection report. Retain on-site. Agent quantity verified at each inspection.

NFPA 101 Life Safety Code — Sections 7.9 (Emergency Lighting) & 7.10 (Exit Signs)

Monthly: 30-second functional test (push-button)
Annual: Full 90-minute discharge test

All battery-backed emergency lights and all illuminated exit signs throughout the facility

Record: date, who performed test, each unit tested, pass/fail result, any units flagged for repair. Keep on file for survey.

NFPA 72 — National Fire Alarm and Signaling Code

Annual full inspection by licensed contractor; weekly/monthly visual walk by facility staff

Pull stations, smoke/heat detectors, notification appliances (horns/strobes), fire alarm control panel, monitoring connection

Panel in normal status (no faults), pull stations unobstructed, detectors not painted or covered, notification devices visible and unblocked

NFPA 80 (fire dampers), NFPA 90A (HVAC), NFPA 105 (smoke/combination dampers)

Fire dampers: every 4 years. Smoke and combination dampers: every 6 years per NFPA 105. First test within 1 year of installation.

All fire and smoke dampers at fire-rated wall and floor penetrations throughout the facility

Drop damper, verify full closure, inspect for damage and obstructions, reset, verify proper operation. Document each damper by ID tag number.

NFPA 80 — Standard for Fire Doors and Other Opening Protectives

Annual inspection of all fire-rated door assemblies

Self-closing hardware, positive latching, clearances (max 3/4" at sides/top, 3/4" at bottom), frame integrity, glazing, coordinator function, hold-open devices

A qualified person with knowledge of NFPA 80. Deficiencies requiring repair must be addressed by a qualified contractor.

NFPA 101 Life Safety Code + accreditation body standards

Quarterly per shift — all shifts must be covered annually (day, evening, and night shifts each get at least one drill per year)

Rescue anyone in immediate danger · Alarm — activate the nearest pull station · Confine — close all doors · Extinguish if safe, or Evacuate

Pull the pin · Aim at the base of the fire · Squeeze the handle · Sweep side to side

NFPA 10 — Standard for Portable Fire Extinguishers

Monthly: Visual inspection by staff · Annual: Maintenance by certified vendor · 6-Year: Internal inspection + hydrotest

Max 75-foot travel distance to any extinguisher. Mounted in visible, accessible location. Top of unit no higher than 5 feet. Clear space in front at all times.

In correct location · Visible and unobstructed · Full charge (gauge in green) · Tamper seal intact · Inspection tag current · No damage or corrosion

NFPA 13 (installation) and NFPA 25 (inspection, testing & maintenance)

Weekly: Control valve visual check · Quarterly: Waterflow/tamper alarm test · Annual: Full contractor inspection

Nothing may be stored within 18 inches of any sprinkler head. This is a hard stop — cited on almost every survey where storage is present.

Verify all control valves are in the open position and sealed/supervised. A closed valve means no water to that section — this is a critical finding.

NFPA 99 — Health Care Facilities Code

When new systems are installed, spaces are renovated, or occupancy/use changes. Must be documented before work begins.

Category 1: Failure likely to cause major injury or death · Category 2: Failure may cause minor injury · Category 3: Non-patient areas · Category 4: Administrative/business only

Interim Life Safety Measures — required when life safety systems are impaired. Document activation date, measures taken, and restoration date.

VSQG: ≤100 kg/month · SQG: 100–1,000 kg/month · LQG: >1,000 kg/month. Status determines storage time limits and reporting requirements.

All employees who prepare, handle, or offer hazardous materials for transport must have DOT hazmat training. Refresher every 3 years. Records retained 3 years after employment ends.

Uniform Hazardous Waste Manifest (EPA Form 8700-22) required for off-site transport. Generator retains copy for 3 years minimum.

Chemotherapy waste · Mercury devices · Batteries · Fluorescent lamps · Aerosols · Photographic chemicals

Blue lid: Non-hazardous pharmaceutical waste · Yellow lid: Hazardous pharmaceutical waste (P-listed and U-listed) · Black lid: RCRA hazardous waste

Acutely hazardous pharmaceuticals — must be handled as RCRA P-listed waste. Examples: warfarin (if >0.3%), physostigmine, epinephrine. Strict storage limits apply.

DEA Form 41 for destruction on-site. Reverse distributors require DEA Form 222. Authorized witness and documentation required. No drain disposal of controlled substances.

Proper sharps containers required. Vendor pickup with manifest. Never overfill containers. Trace chemo sharps go into chemo sharps containers — not regular sharps.

§1 Identification · §2 Hazard ID · §4 First Aid · §5 Firefighting · §6 Accidental Release · §8 Exposure Controls/PPE · §11 Toxicology · §13 Disposal

Keep SDS current — update when formulations change. Remove SDSs for chemicals no longer in use. Know how to request an SDS from a vendor if one is missing.

Small spill of known, non-hazardous substance. Staff trained to clean up using standard spill kit. PPE per SDS. Document in incident log.

Large spill, unknown substance, or any amount of chemotherapy or hazardous pharmaceutical. Evacuate area. Call Hazmat/EHS. Announce Code Orange if warranted. Do not attempt cleanup.

Identify and document spill kit locations in your facility. Staff must know where kits are. Inspect kits quarterly for contents and expiration.

Any amount of chemotherapy spill requires chemo spill kit — not standard spill kit. Two-person cleanup minimum. Double-bag all waste in yellow chemo waste containers. Document exposure.

Cylinders must be secured upright with chains or straps at all times. Full and empty cylinders stored separately. Oxygen cylinders stored at least 20 feet from flammable gas cylinders or combustibles, or separated by a 5-foot non-combustible wall.

Always use an approved hand truck or cart designed for cylinders. Never roll, drag, or carry cylinders horizontally. Valve protection cap must be in place during transport. Never transport in an enclosed vehicle.

Open valves slowly. Never use cylinders as rollers or supports. Never drop or strike cylinders. Legibly mark all empty cylinders "MT" or "Empty." Remove regulators before storage or transport.

Return empty cylinders to the vendor. Never attempt to refill, repair, or dispose of cylinders in regular waste. Cylinders with damaged valves should be set aside and vendor notified immediately.

Fuel level ≥3/4 tank · Coolant level & color · Oil level via dipstick · Battery terminals (no corrosion) · No visible leaks · ATS in AUTO position · Control panel normal (no alarms)

Record date, fuel level %, inspector name, any anomalies noted. File weekly. Retained minimum 3 years per NFPA.

Run generator under load (≥30% rated capacity) or no-load for minimum 30 minutes. Verify stable voltage & frequency, proper fuel consumption, no abnormal noise or vibration.

Voltage: ±10% of rated · Frequency: 60±1 Hz · Stable load · No alarms · Coolant temp <180°F · Battery charger functioning · Clean return to standby

Full-load (80–100% rated capacity) test for minimum 2 hours using portable load bank. Proves generator can handle peak facility demand. May defer no more than 30 days if load bank unavailable.

Date & time · Load % applied · Voltage & frequency every 15 min · Fuel consumption rate · Coolant & oil temps · Any alarms · Test duration & pass/fail · Technician name & signature

Verify ATS switches from utility to generator and back. Transfer time: <4 sec (life safety branch), <10 sec (non-critical). Confirm utility sensing detects outage & genset sensing detects return.

Full simulated outage: kill utility mains, confirm transfer in spec time, run under load, confirm retransfer. Document voltage levels, timing, load handling.

No corrosion on terminals · Proper water level (flooded cells) · No cracks or leaks · Charger voltage 27.6 ±0.5 VDC · Specific gravity 1.200–1.300 per cell

Discharge test under load; battery must sustain cranking amps without voltage drop below 10.5V. Recharge & verify charger returns to float. Replace if capacity <80%.

Zone valve actuation test · Alarm panel response to simulated leak · Outlet pressure & flow verification · System purge per NFPA guidelines · Annual piping pressure test at 1.5× operating pressure

O₂: 50±5 psi, ≥15 L/min · Vacuum: 80–120 mmHg, ≥40 CFM · N₂O: 45±5 psi · Compressed Air: 50±5 psi · All zone valves isolate properly · Alarm latches & resets correctly

Each isolated power system (OR, ICU, Cath Lab) requires monthly LIM test. Simulate fault: monitor must alarm when impedance drops below 2 mA threshold. Verify audible alarm, visual light, and annunciator.

Alarm threshold: 2 mA ±20% · Audible alarm ≥70 dB · Visual indicator bright & legible · Annunciator at nurse station · Test circuit: 1.5 kΩ per phase to ground

Failure likely causes death: ventilators, defibrillators, patient monitors, IV pumps in critical care. Requires redundancy, highest inspection frequency, immediate repair.

Failure causes serious harm but not immediately life-threatening: surgical lights, imaging, lab analyzers, medical gas systems. High inspection frequency, timely repair.

Failure causes minimal harm: office blood pressure cuff, thermometer, standard lights. Standard maintenance, repair within reasonable timeframe.

Not connected to patient care: building HVAC, office computers, decorative lighting, furniture. Standard building maintenance applies.

1. Risk Assessment: map all water systems (cooling towers, hot water, decorative fountains, humidifiers) · 2. Control Measures: treatment, flushing, temperature maintenance · 3. Monitoring: sampling & temp logs · 4. Corrective Actions: protocols for positive cultures or deviations

Designate Water Management Program Lead · Facility risk assessment every 2 years · Annual plan review & updates · Staff training on Legionella risks · Documentation of all monitoring & actions · Report positive cultures to State Health Dept

Storage: 140°F (60°C) minimum to kill Legionella · Point of Use: 124°F (51°C) minimum at furthest outlet · Monitoring: daily at tank; monthly at 5+ distribution points

Identify rarely used branches · Flush infrequently used outlets weekly · Install TMVs to prevent scalding (>130°F) · Document flushing dates & temps · Replace stagnant water sections

1. Communications — internal notification, staff hotline, media updates
2. Resources & Assets — stockpiles, mutual aid, vendor contacts
3. Safety & Security — evacuation, lockdown, workplace violence response

4. Staff Roles — IC, section chiefs, department leads, alternates
5. Utilities — emergency power, water, medical gas continuity
6. Patient Care — admission/discharge, medication management during emergency

Natural: earthquakes, floods, hurricanes, tornadoes, winter storms
Technological: power outage, water contamination, hazmat spill, IT failure
Human: mass casualty, pandemic, workplace violence, cyber attack

Rate each hazard: Likelihood (1–5) × Severity (1–5) = Risk Score. Higher scores drive resource allocation & EOP priorities. Annual update reflects new hazards & local threat changes.

Minimum 2 exercises per calendar year · At least 1 must be community-wide or full-scale (not tabletop-only) · All critical EOP functions tested · Document participation & observer notes

After-action report (AAR) within 14 days · Identified gaps & improvement opportunities · Corrective action plan with timelines · Track completion · Share findings with entire EM team

Food & Water: 3 meals/day + potable water for all staff & patients on-site · Medical Supplies: critical drugs, IV fluids, blood products · Linens & Hygiene: sheets, blankets, toiletries

Medical Gases: O₂, compressed air, nitrogen backup · EPSS Fuel: 3–7 days minimum · Mutual Aid: agreements for emergency resupply from suppliers & neighboring facilities

Other hospitals, critical access facilities, outpatient centers, shared services (lab, imaging) · Resources: patient surge capacity, staff, equipment, supplies, utilities (fuel, power)

Specific resources offered/requested · Activation triggers & notification process · Cost reimbursement & liability · PHI sharing permissions · Annual review & contact updates · Tested during exercises

HHS Secretary may issue §1135 waivers during declared disasters, temporarily suspending HIPAA enforcement to allow PHI sharing for emergency response & patient care coordination.

Record PHI disclosed under emergency provisions · Note declaration reference · Accreditation may require after-action justification · Return to standard HIPAA controls when emergency ends

Type A: Inspection/non-invasive work · Type B: Small-scale, short-duration · Type C: Any work that generates moderate-to-high levels of dust · Type D: Major demolition & construction

Group 1: Low-risk (offices, waiting areas) · Group 2: Medium-risk (med/surg) · Group 3: High-risk (oncology, long-term care) · Group 4: Highest-risk (ICU, OR, bone marrow, NICU)

Safety Risk Assessment (EC.01.01.01) · HVA (EM.12.02.01) · Behavioral Health Environmental Audit · PCRA/ICRA (all construction) · Annual review of findings & action plans

Date, assessor name, signature · Scope & methodology · Identified risks rated by likelihood × severity · Corrective actions & responsible parties · Follow-up timelines · Evidence of reassessment post-action