During the National Fire Protection Association’s (NFPA’s) Conference & Expo in June 2023, the Healthcare Interpretations Task Force (HITF) was asked to clarify several questions pertaining to the 2012 editions of the NFPA 101®, Life Safety Code®; NFPA 99, Health Care Facilities Code; and their respective referenced publications. The Centers for Medicare & Medicaid Services’ (CMS’) Conditions of Participation references these documents, making them enforceable in most health care facilities across the United States.

The HITF meets at least annually to discuss interpretation issues. The task force is comprised of members representing key organizations, such as accrediting organizations (AOs), Department of Defense facilities, Veterans Health Administration facilities and others that are involved in the code-making process for health care facilities, including Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of the American Society for Health Care Engineering Regulatory Affairs.

“The HITF meetings give us an opportunity to debate the code when it is not entirely clear and determine how it should be enforced so that all authorities can be consistent,” Beebe says.

One of the issues discussed at the June 2023 meeting was spare electrical circuit breakers. Specifically, the question posed to the task force was, “Does the 2011 edition of NFPA 70®, National Electrical Code®, and subsequent editions require properly labeled spare breakers to be kept in any specific position, either ‘on’ or ‘off?’”

Even though NFPA 70 is silent on the issue, the positioning of spare circuit breakers, either on or off, has become a matter that surveyors are noting as deficiencies during surveys.

Although the task force determined the answer to that question to be, “No. They can be in either the on or off position,” The Joint Commission has taken a different stance. Leaders from the AO say the organization sees it as a safety issue and requires all spare breakers to be in the off position for its accredited hospitals.  

“The code is silent on this issue, so it’s not a code issue. But for The Joint Commission, it is still a safety issue,” notes Herman McKenzie, MBA, CHSP, director of the physical environment department in the Standards Interpretation Group at The Joint Commission.

The Joint Commission has clarified that it still considers properly labeled spare breakers in the on position to be a safety risk based on the experiences of Joint Commission surveyors, leading many surveyors to question the accuracy of the “spare” label when it is in the on position.

“What our surveyors are experiencing is that when they question representatives from the facility about the position of the spare breaker that is in the on position, the facility staff are unwilling to turn it off, not trusting that the label is correct.”

The Environment of Care (EC) Chapter of The Joint Commission’s Comprehensive Accreditation Manual requires that, “The Hospital manages risks associated with its utility systems (EC.02.05.01). If a spare breaker was noted not to be in the off position, it would be a deficiency under Element of Performance 9, which states, ‘The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.’”

Facilities that are not accredited by The Joint Commission should reference the HITF decision if questioned by a surveyor about the position of breakers labeled as “spare.”