Current through Reg. 49, No. 38; September 20, 2024
(a) Flammable germicides. If flammable
germicides, including alcohol-based products, are used for preoperative
surgical skin preparation, the facility must:
(1) use only self-contained, single-use,
pre-measured applicators to apply the surgical skin preparations;
(2) follow all manufacturer product safety
warnings and guidelines;
(3)
develop, implement and enforce written policies and procedures outlining the
safety precautions required related to the use of the products, which, at a
minimum, must include minimum drying times, prevention and management of
product pooling, parameters related to draping and the use of ignition sources,
staff responsibilities related to ensuring safe use of the product, and
documentation requirements sufficient to evaluate compliance with the written
policies and procedures;
(4) ensure
that all staff working in the surgical environment where flammable surgical
skin preparation products are in use have received training on product safety
and the facility policies and procedures related to the use of the
product;
(5) develop, implement and
enforce an interdisciplinary team process for the investigation and analysis of
all surgical suite fires and alleged violations of the policies; and
(6) report all occurrences of surgical suite
fires to the department in care of the Facility Licensing Group within two
business days, and complete an investigation of the occurrence and develop and
implement a corrective action plan within 30 days.
(b) Flammable and nonflammable gases and
liquids. Flammability of liquids and gases shall be determined by National Fire
Protection Association 329, Handling Releases of Flammable and Combustible
Liquids and Gases, 1999 edition. All documents published by National Fire
Protection Association (NFPA) as referenced in this section may be obtained by
writing or calling the NFPA at the following address or telephone number:
National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101,
Quincy, MA 02269-9101 or (800) 344-3555.
(1)
Nonflammable gases (examples include, but are not limited to, oxygen and
nitrous oxide) shall be stored and distributed in accordance with Chapter 5 of
the National Fire Protection Association 99, Standard for Health Care
Facilities, 2002 edition (NFPA 99).
(A)
Medical gases and liquefied medical gases shall be handled in accordance with
the requirements of NFPA 99, Chapter 9.
(B) Oxygen shall be administered in
accordance with NFPA 99, §9.6.
(2) Piped flammable gas systems intended for
use in laboratories and piping systems for fuel gases shall comply with
requirements of NFPA 99, §11.11.
(3) Flammable gases shall be stored in
accordance with NFPA 99, §11.10.
(4) Flammable and combustible liquids used in
laboratories shall be handled and stored in accordance with NFPA 99,
§11.7, and National Fire Protection Association 101, Life Safety Code,
2003 edition, §18.3.2.2.
(5)
Other flammable agents shall be stored in accordance with NFPA 99, Chapter
7.
(c) Gasoline and
gasoline powered equipment. No motor vehicles including gasoline powered
standby generators or any amount of gasoline shall be located within the
hospital building. Other devices which may cause or communicate fire, and which
are not necessary for patient treatment or care, shall not be stored within the
hospital building. All such devices and materials when necessary shall be used
within the building only with precautions ensuring a reasonable degree of
safety from fire.
(d) Gas fired
appliances. The installation, use and maintenance of gas fired appliances and
gas piping installations shall comply with the National Fire Protection
Association 54, National Fuel Gas Code, 2002 edition. The use of portable gas
heaters and unvented open flame heaters is specifically prohibited.
