Maintenance and Operations Flashcards

A hospital's Computerized Maintenance Management System (CMMS) is primarily utilized to achieve which of the following maintenance and operations goals?

Answer: Track and document maintenance activities for regulatory compliance.

A healthcare CMMS is a critical tool for managing assets, scheduling preventive maintenance, and tracking work orders. A key function is to create a detailed record of all maintenance and inspection activities, which is essential for demonstrating compliance with regulatory and accrediting bodies like The Joint Commission, CMS, and NFPA.

As part of a water management program to mitigate Legionella risk, what is the minimum hot water temperature that ASHRAE Standard 188 recommends be maintained at the points of use throughout a hospital?

Answer: 122°F (50°C)

To inhibit the growth of Legionella bacteria, ASHRAE Standard 188, which is referenced by CMS, recommends maintaining a minimum temperature of 140°F at the water heater and ensuring the water temperature remains above 122°F at the distal points of use. Temperatures below this range, particularly between 77°F and 113°F, are optimal for Legionella growth.

According to NFPA 110, Standard for Emergency and Standby Power Systems, how often must a fuel quality test be performed on the diesel fuel stored for a Level 1 Emergency Power Supply System (EPSS)?

Answer: Annually

NFPA 110, Section 8.3.7, explicitly states that a fuel quality test shall be performed at least annually using appropriate ASTM standards. This is critical for Level 1 systems, where failure could result in loss of life or serious injuries, as degraded fuel is a common cause of generator failure.

A technician discovers that a Protective Environment (PE) room, designed to protect immunocompromised patients, has lost its positive pressurization relative to the adjacent corridor. According to ASHRAE 170 principles, what is the most appropriate immediate action?

Answer: Notify nursing and infection control to relocate the patient if the room is occupied.

A Protective Environment (PE) room requires positive pressure to protect the patient from airborne contaminants in adjacent areas. Loss of this pressure poses an immediate risk to the patient. The first priority is patient safety; therefore, nursing and infection control must be notified immediately to determine if the patient needs to be relocated while the facilities department investigates and corrects the HVAC issue.

Per NFPA 80, Standard for Fire Doors and Other Opening Protectives, what is the required inspection and testing frequency for fire and smoke dampers in a hospital after the initial one-year inspection?

Answer: Every 6 years

NFPA 80 and NFPA 105 specify that after the initial acceptance test and the first one-year inspection, fire and smoke dampers must be tested and inspected. For most buildings, the frequency is every 4 years, but an exception is made for hospitals, where the required frequency is every 6 years.

To comply with NFPA 99, Health Care Facilities Code, how often must the facility's medical gas master alarm systems be tested to verify actual alarm activation at the required pressure set-points?

Answer: Annually

While the push-button test for audible and visual signals is typically done monthly, NFPA 99 requires periodic testing of the actual alarm function. It is an industry best practice and strongly recommended by standards like ASSE 6000 to perform an actual activation of master alarm pressure switches annually to ensure they trigger an alarm at the correct high/low pressure set-points (typically a 20% deviation from normal pressure).