HIPAA Compliance Fire Protection for Paper Records: HIPAA & HITECH Act Blog by Jonathan P. Tomes with Guest Commentator John J. Cadiero

JonTomesOne of the nice things about giving HIPAA seminars around the country is the great people that I meet—and not only at the seminars but also sometimes serendipitously. On a recent trip, I went to dinner at “The Yard” in Manchester, New Hampshire, which was the only restaurant within walking distance of my hotel, which did not have a restaurant. After having presented a seminar all day and having driven more than two hours to my next seminar location, I was not interested in driving out to dinner, but The Yard was within walking distance and had great prime rib. While waiting at the bar for my meal, I got into a conversation with the man next to me, John J. Cadiero. When I learned that he was an expert in protecting assets from fire, I asked him to write a blog post on the subject because, as you may recall, one of the main goals of HIPAA compliance is to maintain the confidentiality, integrity, and availability of medical records.
John is a technician who has worked for security service providers and has been responsible for installing, programming, troubleshooting, and inspecting fire alarm systems of all types. His licenses include the following: Massachusetts State Class D Electrical License; Nicet Level 2; Connecticut State Class C6 License; Boston F1 License; Burlington License; EST 3 Fire Alarm Certified, Installation and Programming; FCI 7200 Installation and Programming; and Radionics D9000 Series Certified. He agreed to write a blog post on fire protection systems for doctor’s offices (which would work just fine for other providers, such as physical therapists, psychologists, chiropractors, and the like) with special emphasis on records protection. You can reach John at 12 Dearborn Street, Medford, MA 02155, (617) 799-0009, vokie98@gmail.com. Thank you, John, for writing the following item:

Fire Protection System Designed for a Doctor’s Office with Special Considerations for Records Protection

When designing a fire protection system, I use “City of Boston” standards because Boston has some of the highest standards of fire protection requirements in the country. Basically, a system designed to “City of Boston” standards will be more than adequate for a majority of scenarios found elsewhere. One exception would be to also incorporate “State of Rhode Island” wiring color coding for easier installation and future repairs or additions.
An automatic sprinkler system should be installed in all areas with the exception of records storage and other areas where water damage is unacceptable, such as IT/server rooms, and so forth. The sprinkler system should be installed to current IBC (International Building Code) and NFPA 13 standards with the more stringent code being applied in the event of any conflicting requirements. This system should be integrated to the building’s fire alarm system.
Server rooms, records storage rooms, and other areas where a water-based sprinkler system would cause unwanted damage should be protected with a dry chemical protection system, such as halon, argon, FM200, and so forth. This system should be installed to IBC and NFPA-17 standards and should take into consideration temperature controls and equipment manufacturers’ recommendations. I also recommend having temperature and air-flow sensors integrated into the building’s fire alarm system. This step will allow for immediate notification if the room temperature gets too high for the equipment or if the air-flow system malfunctions.
The building’s fire alarm system is the most important aspect of fire protection because it is where all other systems will be integrated and notification of proper authorities will take place. The system should be designed in cooperation with the local authorities because they will be the ones responding during an event. It is of the utmost importance that the system is designed with the first responders in mind. The system must be designed to be not only adequate to provide the required fire protection but also easy enough to understand and operate for a local official to operate during an emergency.
The fire alarm system should also be installed to IBC and NFPA-72 standards with all wiring adhering to NFPA-70 Standards. I also recommend giving special consideration to the following. As stated above, the State of Rhode Island has a unique wiring color coding method, which, if installed properly, is a benefit to the installer and future workers. The extra upfront cost of the wiring should be offset over time with reduced service and troubleshooting costs.
The system should be designed with an attempt to use class “A” wiring methods wherever possible. This wiring method, when combined with survivability requirements and circuit isolation features, provides for a fire rated redundant wiring system. This redundant system is important so that a shorted circuit or broken/open wiring circuit does not impair the function of the remainder of the system.
Every system is going to be unique to its particular setting and environment and should be designed by an engineer or other experienced professional. Blue prints, manufacturer’s documentation, wiring diagrams, and so forth should be located both onsite and offsite and should be stored at or near the fire command center in a locked cabinet.
Also, consider the potential of future expansion and technologies. No system should be designed to use more than 75 percent of its maximum capabilities. I highly recommend using a product that is designed for integration of future unknown technologies. This step ensures that a newly installed system is not obsolete within a few years of its installation.
These considerations are just a few of many to take into account when designing a complete fire protection system. The design should always begin with taking into consideration the customer’s concerns and then meeting with the local fire chief to understand their requirements and concerns. All work should be done by a team of installers who are experienced in their fields.

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