Environment of Care chapter--Testing emergency power sources
New language is underlined.

Standard EC.2.14
Utility systems are maintained, tested, and inspected.

Intent of EC.2.14
The organization maintains, tests, and inspects critical operating components of utility systems and maintains documentation of

a. a current, accurate, and separate inventory of all utility components in the utility management plan;

b. performance and safety testing of each critical component in the plan prior to initial use and at least annually thereafter;

c. preventive maintenance and inspection of utility systems according to a schedule based on current organization experience and ongoing monitoring and evaluation; and

Note: An equipment time frame longer than 12 months may be justified based on previous experience and safety officer or authority approval. The specification of an annual testing interval is not intended to be a single standard of testing needs. It is expected that organizations will apply professional judgment in establishing intervals so that risks and hazards are adequately managed.

d. demonstration of the emergency power system's reliability by conducting

1. monthly testing of each generator for at least 30 minutes under a dynamic load that is equal to or greater than the higher of the following load values:

  • 30% of the nameplate rating of the generator, after applying any applicable rating factors for site conditions, or
  • 50% of either the calculated or greatest known load on the emergency power supply system (EPSS);

Note: Organizations may choose to test to less than 30% of the emergency generator's nameplate or 50% of the total EPSS load. However, these organizations shall (in addition to performing a monthly test for 30 minutes under operating temperature) revise their existing documented management plan to conform to current NFPA 99 and NFPA 110 testing and maintenance activities. These activities shall include inspection procedures for assessing the evidence of wet stacking.*

If diesel-powered generators show evidence of wet stacking, as determined from these inspection procedures, a resistive load bank or additional load test shall be conducted within 12 months (or more frequently if recommended by the generator's manufacturer). The following are the requirements for this test:

  • Duration--until the exhaust is clear of black smoke, but not less than 2 hours, and
  • Load--greater than or equal to 80% of nameplate.

2. monthly testing of all automatic transfer switches;

3. testing of stored emergency power supply systems (SEPSS) whose malfunction may cause a severe jeopardy to life and safety of the occupants** which includes

  • a quarterly functional test for 5 minutes or as specified for its class, whichever is less and
  • an annual test at full load for the full duration for its class***; and

4. testing of all battery-powered lights required for egress which includes

  • a functional test at 30-day intervals for a minimum of 30 seconds and
  • an annual test for a duration of 1Ĺ hours.

*As per NFPA 110, section 6-4.2 (1996 edition), wet stacking is a field term indicating the presence of unburned fuel or carbon in the exhaust system. Its presence is readily indicated by the presence of black smoke during engine-run operation.

**Stored emergency power supply systems (SEPSS) are intended to automatically supply illumination or power to critical areas and equipment essential for safety to human life. Included are systems that supply emergency power for such functions as illumination for safe exiting, ventilation where it is essential to maintain life, fire detection and alarm systems, public safety communications systems, and processes where the current interruption would produce serious life safety or health hazards to patients, visitor, or staff.

Note: Other non-SEPSS battery back-up emergency power systems that an organization has determined to be critical for operations during a power failure (for example, laboratory equipment, medical records) should be properly tested and maintained in accordance with manufacture's recommendations.

***Class defines the minimum time for which the SEPSS is designed to operate at its rated load without being recharged.

Examples of Evidence of Performance for EC.2.14

  • Building tour
  • Inventory of utility components
  • Schedules and test performance for utility components included in the program
  • Schedules and evidence of preventive maintenance for utility components included in the program

Scoring for EC.2.14
There is no change in scoring.



2001 Utility Systems Management

This standard is numbered EC.1.9 in the CAMAC, CAMH, and CAMLTC, and EC.2.7 in the CAMBHC. Revisions become effective January 1, 2001. New language is underlined.

Standard EC.1.9
A management plan addresses utility systems.

Intent of EC.1.9

A management plan describes how the organization will establish and maintain a utility systems management program to

  1. promote a safe, controlled, comfortable environment of care;
  2. reduce the potential for organizational-acquired illness;
  3. assess and minimize risks of utility failures; and
  4. ensure operational reliability of utility systems.

The plan provides processes for

  1. establishing criteria for identifying, evaluating, and taking inventory of critical operating components of systems to be included in the utility management program. These criteria address the impact of utility systems on
    1. life support systems,
    2. infection control systems,
    3. environmental support systems,
    4. equipment-support systems, and
    5. communication systems.

Note: All utility systems, rather than a limited selection of elements based on risk criteria, may be included in the management program.

  1. inspecting, testing, and maintaining critical operating components.
  2. inspecting, testing, and maintaining critical components of piped medical gas system including master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets.
  3. testing piped medical gas systems when the systems are installed, modified, or repaired including cross-connection testing, piping purity testing, and pressure testing.
  4. managing pathogenic biological agents in cooling towers, domestic hot water, and other aerosolizing water systems.
  5. installing and maintaining appropriate pressure relationships, air exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed [see Note 1] to control air borne contaminants (such as biological agents, gases, fumes, and dust).
  6. developing and maintaining current utility system operational plans to help ensure reliability, minimize risks, and reduce failures.
  7. mapping the distribution of utility systems and labeling controls for a partial or complete emergency shutdown.


  1. areas specially designed includes spaces such as operating rooms, special procedure rooms, delivery rooms, rooms for patients diagnosed or suspected of having airborne communicable diseases (e.g., pulmonary or laryngeal tuberculosis), rooms for patients in "protective isolation" (e.g., those receiving bone marrow transplants), laboratories, and sterile supply rooms.

Emergency Management

This standard is numbered EC.1.6 in the CAMAC, CAMH, and CAMLTC, and EC.2.4 in the CAMBHC. Revisions become effective January 1, 2001. New language is underlined.

Standard EC.1.6
A plan addresses emergency management.

Intent of EC.1.6

The emergency management plan describes how the organization will establish and maintain a program to ensure effective response to disasters [see note 1] or emergencies affecting the environment of care. The plan should address four phases of emergency management activities: mitigation, preparedness, response, and recovery. [see note 2]

The plan provides processes for

  1. identifying specific procedures in response to a variety of disasters based on a hazard vulnerability analysis [see note 3] performed by the organization;
  2. initiating the plan (including a description of how, when, and by whom the plan is activated);
  3. defining and, when appropriate, integrating the organizationís role with community-wide emergency response agencies (including the identification of who is in charge of what activities and when they are in charge) to promote inter-operability between the health care organization and the community;
  4. notifying external authorities of emergencies;
  5. notifying personnel when emergency response measures are initiated;
  6. identifying personnel during emergencies;
  7. assigning available personnel in emergencies to cover all necessary staff positions;
  8. managing the following during emergencies and disasters:
    • Patient activities including scheduling, modification, discontinuation of services, control of patient information, and patient transportation;
    • Staff activities (e.g., housing, transportation, and incident stress debriefing);
    • Staff/family-support activities;
    • Logistics of critical supplies (e.g., pharmaceuticals, medical supplies, food supplies, linen supplies, water supplies);
    • Security (e.g. access, crowd control, traffic control); and
    • Interaction with the news media.
  9. evacuating the entire facility (both horizontally and, when applicable, vertically) when the environment cannot support adequate patient care and treatment;
  10. establishing an alternative care site when the environment cannot support adequate patient care including processes that address (when appropriate)
    • management of patient necessities (e.g., medications, medical records) to and from the alternative care site;
    • patient tracking to and from the alternative care site;
    • inter-facility communication between the organization and the alternative care site;
    • transportation of patients, staff, and equipment to the alternative care site; and
  11. continuing and/or re-establishing operations following a disaster.

The plan identifies

  1. an alternative means of meeting essential building utility needs (e.g., electricity, water, ventilation, fuel sources, and medical gas and vacuum system, etc.) when the organization is designated by its emergency preparedness plan to provide continuous service during a disaster or emergency;
  2. backup internal and external communication systems in the event of failure during disasters and emergencies;
  3. facilities for radioactive or chemical isolation and decontamination; and
  4. alternate roles and responsibilities of personnel during emergencies, including who they report to within a command structure that is consistent with that used by the local community.

The plan establishes

  1. an orientation and education program for personnel who participate in implementing the emergency management plan. Education addresses
    1. specific roles and responsibilities during emergencies;
    2. the information and skills required to perform duties during emergencies;
    3. the backup communication system used during disasters and emergencies; and
    4. how supplies and equipment are obtained during disasters or emergencies;
  2. ongoing monitoring of performance regarding actual or potential risk related to one or more of the following:
    1. Staff knowledge and skills;
    2. Level of staff participation;
    3. Monitoring and inspection activities;
    4. Emergency and incident reporting; or
    5. Inspection, preventive maintenance, and testing equipment; and
  3. how an annual evaluation of the emergency preparedness safety management planís objectives, scope, performance, and effectiveness will occur.


  1. disaster is a natural or man-made event that significantly disrupts the environment of care, such as damage to the organizationís building(s) and grounds due to severe wind storms, tornadoes, hurricanes, or earthquakes. Also, an event that disrupts care and treatment, such as loss of utilities (power, water, telephones) due to floods, civil disturbances, accidents, or emergencies within the organization or in the surrounding community. Disasters are sometimes referred to as "potential injury creating events" (i.e., "PICE").
  2. mitigation activities are those a health care organization undertakes in attempting to lessen the severity and impact a potential disaster or emergency may have on its operation while preparedness activities are those an organization undertakes to build capacity and identify resources that may be utilized should a disaster or emergency occur
  3. hazard vulnerability analysis is the identification of hazards and the direct and indirect effect these hazards may have on the health care organization.