Nov 27 2014


Category: BlogBKeyes @ 6:00 am







The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that performs surveys on behalf of CMS.

I recently read your article on Decorations. I thought the advice was really good information. I was contacted by a facility not too long ago that asked me if a large, homemade tapestry brought to a resident’s room would need to be fire retardant if it was hung up. The question from the engineer was valid as it was to be hung as a “decoration”, was made of flammable material and the family wanted to hang it in the corridor. He wanted to know if it should be fire-treated. His argument was focused on not allowing the family to bring it in at all, mostly because he found it objectionable. I related to him the code; how it could be both stringently and loosely interpreted and suggested, as you pointed out, to err on the side of caution and either treat it or suggest to the family it wasn’t allowed by the standard. The main issue was that the family wanted to hang it in the corridor, which I pointed out could potentially affect safe egress. I then asked him what he felt would be a surveyor’s opinion if this same decoration was hung inside the room, or used as a blanket.

I pointed out that many times I am in a facility where the family has brought in a blanket, or other homemade decoration to make their loved ones feel at home during their stay, or possibly their final hours. I stated I view those items based upon the possible risk, and the intent of the standard. More often than not I find they pose no greater risk to the facility’s other occupants than the same person’s bathrobe knitted by their aunt (when solely used or displayed inside their respective room).

Point being that speaking for myself, I view it solely based on each individual situation: If the facility is providing it and it poses a possible risk to the safe housing or evacuation of all occupants, I will look at that risk and evaluate the issue, citing it if it is apparent and substantiated. I will not unnecessarily burden a resident, patient, client, family or staff member for the purpose of removing something that falls within the letter of the rule for the sole purpose of demonstrating that rule. As always, “it depends”.

I find it refreshing that a state surveyor would have compassion and evaluate issues on a case by case basis. But if this is not done carefully, it can lead to inconsistent interpretations and cause problems when AHJs do not agree on the same issue.

I think hospitals have too many AHJs conducting inspections and surveys in their facility, as it often leads to differences of opinion on how an issue should be interpreted by the AHJs. Ultimately, the hospitals often have to ‘do-over’ a construction project because they receive poor advice from an architect, or an incorrect interpretation from an AHJ.

No wonder healthcare costs so much…

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Nov 21 2014

Christmas Decorations

Category: BlogBKeyes @ 6:00 am

I received the poem below from Jeff Clouse, Safety Officer at Baptist Health in Lexington, KY. He says it is his way of using humor with the staff of his hospital to stay compliant with the Life Safety Code during the holiday decorating season.




‘Tis about a month before Christmas, and all through the halls,

I endeavor to walk, inspecting the walls.

Looking for wreaths made of twigs, and Santas of paper,

Don’t hide them from me, I will solve the caper.



Fake snow, pine cones and *gasp* open flames,

Get rid of these things; I will not play games!

Hang nothing from sprinklers, do not block the exits.

If you do, I’ll call Santa then for you…NO PRESENTS!


No real trees, no branches, no needles of pine,

Just please help me out, and save all the whine constructive input.

If these things spark up and begin to smoke,

It’ll be hard to get out, and that’s not a joke.


Now I’m almost done, but I need to mention,

Bring no cords here, not for extension.

Lights can be used, plugged right in the wall,

But not if they’re hot and stretch across the hall.


I’m not being mean; my heart’s not of stone,

But I just can’t leave those fire regulations alone!

And, hey, listen up, don’t be filled with woe,

Fire retardant decorations you can have; that’s the way to go!


Great people you are, be safe, that’s the trick,

Keep helping and healing our weary and sick.

I care, too; and that is the reason,

I want us to be safe, this entire holiday season!


Do you use something unique to reinforce your decorations policy?

If so, send it to me and I’ll place it in the blog for all to see.

Merry Christmas!


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Nov 20 2014

Temporary Construction Barriers

Category: BlogBKeyes @ 6:00 am

imagesPE2I5ORAI was a co-presenter in a recent HCPro webinar on the new 2012 Life Safety Code along with my good friend and colleague Jim Murphy, and I received quite a bit of feed-back after the session. In the webinar we covered many of the changes that may add to the work-load of the facility manager. In a handout, I summarized them as follows:

  • Annual fire door inspections
  • New stairwell identification signs
  • Certain wheeled equipment will be allowed to be left unattended in corridors
  • Existing high-rise hospitals will need to be fully sprinklered within 12 years of the adoption of the 2012 LSC
  • Changes to the NFPA 72 fire alarm system test report
  • Changes to temporary construction barriers

And that last item on my list (changes to temporary construction barriers) was the one that I received the most feed-back. It appears that this issue is catching facility managers off-guard, probably because not many organizations are actually discussing this change.

To be sure, no one knows how accreditation organizations and state agencies inspecting on behalf of CMS will actually enforce this issue. First, they have to be aware of this change and as mentioned, not many organizations are talking about it, so perhaps the accreditation organizations and state agencies are not aware of the new requirements.

The issue of temporary construction barriers is found in section 18/ of the 2012 LSC, and says:

The means of egress in any area undergoing construction, repair, or improvements shall be inspected daily for compliance with and shall comply with NFPA 241, Standard for Safeguarding Construction, Alterations, and Demolition Operations. is the chapter 7 requirement for marking the means of egress. The edition of NFPA 241 which is referenced by the 2012 LSC is the 2009 edition, and it says this about temporary construction barriers: Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.  Walls shall have at least a 1-hour fire resistance rating.  Opening protectives shall have at least a 45-minute fire protection rating.*  Nonrated walls and opening protectives shall be permitted when an approved automatic sprinkler system is installed.

A.   Construction tarps would not be considered appropriate barriers or opening protectives.

There are still some unknowns about this new requirement that are not clear yet:

  • Will flame retardant plastic visqueen be permitted as temporary nonrated walls when the construction area is protected with sprinklers? The portion that says “construction tarps” in NFPA 241 is found in the Annex section which is explanatory information and is not considered part of the enforceable standard.
  • Will accreditation organizations and state agencies allow a ‘grace’ period from the start of demolition until such time that the construction area is fully protected with sprinklers, without the need for 1-hour barriers? At times, it may take multiple days to demo the suspended ceiling before temporary upright sprinklers are installed.
  • Are the 1-hour fire rated temporary barriers only required where the construction area is contiguous to occupied means of egress areas (corridors), or are the 1-hour barriers required wherever the construction area is contiguous to occupied areas?

My advice: Start working now with your construction people to not only be aware of this new requirement, but to begin incorporating 1-hour temporary barriers in their projects. When the new 2012 LSC is finally adopted, you will be expected to be in full compliance with this, as well as all the new changes. Eventually, the accreditation organizations and the state agencies will explain what their expectations are.

For a copy of the handout that I made for the webinar, go to “Tools”, and click on “Changes the New 2012 Life Safety Code Will Bring”.

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Nov 13 2014

Use of Fire and Smoke Doors During a Fire Drill

Category: BlogBKeyes @ 6:00 am


I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with:

The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/ of the 2000 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary. Section 4.7 of the same code also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what you are referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who you are referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/ of the 2000 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standards (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that a ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4th floor ICU, you do not want all 1200 workers to rush up to the 4th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped you with your question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If you are really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.

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Nov 06 2014

A Follow-Up to “Comments on Corridor Clutter”

Category: BlogBKeyes @ 6:00 am

The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment Officer for DNV.GL Healthcare, Inc. This comment is from a representative from a state agency that performs surveys on behalf of CMS.

First, I totally agree with both Randy and you. Both in principle and standard we should be  more up to date and facilities should know what the standard is and how to  follow it. Oddly, I spend more time assisting facilities on this issue even when I cite it. I tend to smile when they announce I have arrived and wonder ”Were you in compliance yesterday?”

As a surveyor doing checks on all occupancies, I have found none ever seem to not have some issue with space and where to place those items needed for patient/resident care. Having worked in a healthcare facility, I can also fully relate that focus being first and foremost.

That being said, the standard is there for a reason and has been for some time.  Even though my initial peek into 2012 finds some increasing awareness of how clutter is viewed, I still believe that we have a wide arrangement of options if, as both you and Randy point out, senior management buys into it and
supports either their Safety Manager or Maintenance staff.

Inevitably, these are the ones who take it very personally when I cite a facility for a blocked or obstructed corridor. Administrators, Chief Nursing Officers on down need to understand the reasoning behind the code and what steps it takes to stay in compliance. I feel a majority of the time the facility management thinks “Oh we clear everything when the drills happen”. Now imagine those corridors filled top to bottom with smoke. The scenario will change considerably. I hope all who read your article and Randy’s comments take it to heart.

I think this representative for a state agency makes a very good point: The healthcare industry needs better education on the need to keep the corridors clear from clutter. I suspect we have become insensitive to this issue because the frequency of fires in hospitals has dropped dramatically since the mid-1980′s, when smoking was restricted in hospitals.

But fires still occur in healthcare settings as documented in either this blog or in the HCPro’s Healthcare Life Safety Compliance newsletter. And it is the belief of Randy and I (and this representative from a state agency) that corridor clutter still needs to be taken seriously.

In my opinion, it did not help that the NFPA Life Safety Code technical committee decided to allow certain unattended items in corridors of 8 feet as described in the 2012 edition. It also didn’t help that CMS decided to endorse this section of the 2012 edition last year as a categorical waiver. The decision on the technical committee to do this was not unanimous, as a representative from a state agency who surveys hospitals (not the same individual quoted above) enthusiastically opposed the decision. Since he had first-hand observation on how hospitals abuse codes and standards, he did not want to allow them to store items in the corridor.

I suspect corridor clutter will remain a problem until senior leadership decides to take an active role in resolving it.

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Oct 30 2014

Cellophane Bags on Sprinklers

Category: BlogBKeyes @ 6:00 am

imagesZ6JZWAQ6I was conducting a mock survey at a hospital and during the building tour I came to their maintenance shop. They had a spray paint booth and in the booth was a sprinkler head.  Over the sprinkler head was what looked like a plastic bag. I said you can’t cover up the sprinkler heads with plastic bags like that, even in a spray booth. The hospital facility manager told me he received permission from their state agency that it was permissible to cover the sprinkler heads to keep paint overspray from covering the heads.

I knew the state agency people so I called them and asked if they in fact said that. It turns out they did, and they referenced NFPA 25 (1998 edition) section 2-4.1.5, which says:

Sprinklers protecting spray coating areas shall be protected against overspray residue. Sprinklers subject to overspray accumulation shall be protected using plastic bags having a maximum thickness of 0.003 inches (0.076 mm) or shall be protected with small paper bags. Coverings shall be replaced when deposits or residue accumulate.”

Hmm… That just didn’t seem right to me. Plastic bags wrapped around the sprinkler heads? I understand that you do not want paint overspray on the sprinkler head, but plastic? NFPA 25 says you cannot have any foreign material on sprinkler heads, and now the same standard says you can in spray booths? Well, I had to let it go since the NFPA standard permits it.

Fast forward to the 2011 edition of NFPA 25. The technical committee at NFPA addressed this issue and they changed the standard… a little. Now, section says sprinklers subject to overspray accumulations shall be protected using cellophane bags having a thickness of 0.003 inches or less, or thin paper bags. Now NFPA 25 no longer says plastic bags, but says cellophane bags or thin paper bags must be used when protecting sprinklers from overspray. According to the commentary in the NFPA 25 handbook, here is the reason why:

“Testing has shown that lightweight cellophane or paper bags will not adversely affect the operation of the sprinkler. Sprinklers protected by the lightweight cellophane or paper bags may require more frequent inspection than the annual inspection outlined in to prevent excessive buildup on the bags. Depending on the use of the spray coating area, the inspection and subsequent replacement of the bags may need to be done daily. In prior editions, NFPA 25 allowed the use of a plastic bag, but this was changed due to concerns about the potential for a plastic bag to shrink prior to sprinkler activation and disrupt the discharge pattern.”

So… My suspicions were partly justified. A plastic bag on a sprinkler head would melt and disrupt the spray pattern of the sprinkler. I thought it could delay the sprinkler head from operating, especially if it coated the thermal sensing bulb (or solder) and act as an insulator. Anyway, once the new 2012 LSC is adopted, then it will reference the 2011 edition of NFPA 25, and the covers to protect the sprinklers from overspray due to a spray paint booth must be cellophane or paper. And, they need to be changed frequently, perhaps as much as daily, depending on the use of the spray booth.

Today, I would just recommend the hospital remove the spray booth all-together, from their building. It doesn’t seem that the risk of failure to change out the bags once they are accumulated with paint, is worth the advantage of having a spray paint booth.




Oct 23 2014

Infant Abduction Locks

Category: BlogBKeyes @ 6:00 am

Hospitals want to keep their nurseries, mother/baby units, and pediatric units secure, so they lock the doors. This causes a problem with the Life Safety Code because you can’t lock the doors in the path of egress in a hospital, other than three exceptions: 1) Clinical needs locks, which nurseries, mother/baby units, and pediatric units do not qualify; 2) Delayed egress locks; and 3) Access-control locks. Access-control locks really do not lock the door in the path of egress because a motion sensor will automatically unlock the door as a person approaches. So, in this situation the doors can only be locked using the delayed egress provision (found in section of the 2000 Life Safety Code).

But hospitals want the infant security systems used on the babies. These systems have a bracelet that is attached to the baby, and some have bracelets to attach to the mother as well. If the bracelet gets too close to the exit door, an alarm will sound and the door will lock. The problem is, these infant security systems do not comply with any of the three exceptions for locking the doors in the path of egress, listed above. Even if the doors will unlock on a fire alarm the hospital says, that is still not enough to qualify for the any of the three exceptions.

But then the hospital says their accreditation organization approved this door locking arrangement. Why should it be considered non-compliant if the accreditor allows it?  Sorry… just because the accreditation organization says it is okay, still does not make it compliant with the requirements of the Life Safety Code. When the state agency who surveys on behalf of CMS takes a look at it, they will not be as benevolent as the accreditor, and they will cite it as a deficiency.

So, to be compliant with the Life Safety Code, when the doors lock because the bracelet gets too close to the door sensor, the doors should lock into a delayed egress mode (again… see section in the 2000 Life Safety Code). Then it would be legal. But the 2012 LSC has made a change in this area and will allow locks on doors for the specialized protective measures for the safety of the occupants (see section 18/ in the 2012 LSC). This will allow you to lock the doors without delayed egress, provided you meet the requirements listed in that section. CMS has already approved categorical waivers to allow hospitals to begin using this new section of the 2012 LSC before they adopt it.

Take a look at your locks that are used on the nurseries, pediatric, mother/baby units, and even the ICUs and the ERs. If they are not delayed egress, then take a look at the CMS categorical waivers and consider modifying the doors to meet those requirements.

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Oct 16 2014

Fire Alarm System Interface Relays

Category: BlogBKeyes @ 6:00 am

Fire Alarm Interface RelayOut of sight is out of mind. It is the master illusionist’s greatest asset. He gets you looking at something that is distracting your attention away from the object at hand, and before you know it he makes it seem that through a magical intervention, something appears. Or disappears. Or… whatever. The point is, while your attention is located elsewhere, something else happened that you did not notice.

When I was a kid they called that a trick. Actually, it still is a trick, but now they call it something else, like an illusion. Harry Houdini was first called a magician before he was called an escape artist. But I don’t remember seeing anything in print where they called him an illusionist. The word “illusionist” sounds so much nicer and professional for today’s environment than “magician”. But, I digress… That seems to have very little to do with what I want to share today.

A review of the survey deficiency reports indicates surveyors are looking for documentation that the hospital has tested the interface relays and modules on the fire alarm system. I guess that’s the bridge between the illusions and the interface relays: You can’t see them. The interface relays are “out-of-sight and out-of-mind”. If you can’t see them, you tend to forget they are there, and then they are not included in the fire alarm testing report.

Many facility managers rely on the fire alarm contractor to provide a complete test report without actually checking what was tested. This is a grave mistake. No offense to fire alarm testing contractors, but you should never rely on their advice or opinion on the level of testing. You (as the facility manager) have to be smarter than the fire alarm testing contractor to ensure they did everything correctly. They don’t necessarily know what codes and standards (or what editions) you need to comply with, but you should know. That makes you the expert.

Not long ago I was consulting in a hospital and reviewing their fire alarm test report. The report failed to indicate that they tested their interface relays. I asked the facility manager about it and he called the sales representative from the fire alarm testing contractor who happened to be nearby. He stopped in while I was there and I asked him why they did not test the interface relays. He said he knew they were supposed to be tested, but told me (and this is a direct quote): “The hospital would not let me test them”. This surprised the facility manager and myself, and the sales rep explained further.

“We had to bid our services to the hospital based on a request for proposal. Nothing in the request indicated that the interface relays were included. We submitted a bid strictly based on what was requested in the proposal. Had we added anything that was not requested, we would not have been awarded with the contract.”

Some would say that the fire alarm testing contractor was unethical for not informing the hospital of all the items that needed to be tested that were not included in the RFP. I don’t know if that is unethical or not, but I will tell you this: That hospital got exactly what it asked for in the RFP. Unfortunately.

So, back to the point: Get those fire alarm interface relays included in the fire alarm testing process and document each one individually, with a “Pass” or a “Fail” notation. Here is a list of the most common interface relays used in hospital fire alarm systems:

  • Magnetic hold-open devices
  • Air handler shutdown
  • Kitchen hood suppression system
  • Elevator recall
  • Magnetic locks
  • Fire pump
  • Smoke dampers
  • Clean agent suppression systems
  • Sprinkler dry pipe/pre-action systems
  • Overhead rolling fire doors

Take a look at your latest fire alarm test report. Does it include interface relays? If not… better get on the phone to the company or individual conducting the testing for you.

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Oct 09 2014

Tamper Resistant Electrical Receptacles

Category: BlogBKeyes @ 6:00 am

images[5]Every surveyor has his/her own specialty that they like to look for during a survey. I know of one surveyor that writes up every hospital he surveys if the fire alarm panel is not marked with the electrical panel number and circuit that feeds the power to the fire alarm system. It’s a requirement, but he’s the only surveyor that I know who is writing it.

Another surveyor that I know is very astute on construction type to the point where he wrote up a hospital for having combustible siding on the exterior of the building. The hospital was 20 years old and the plywood siding was original. They were upset because for two decades the siding was never an issue, then all of a sudden ‘Boom’; it’s a problem. The hospital contacted the architect who originally designed the hospital, and he wrote a thundering letter of protest. That one I checked with NFPA and it turns out the surveyor was correct. The hospital will have to remove the combustible siding or submit an equivalency or a waiver request.

When I surveyed for The Joint Commission, I remember paying special attention to how fire dampers were installed at the hospitals I surveyed. I did this because the hospital where I worked got cited for improperly installed fire dampers by the state agency conducting a validation survey on behalf of CMS. I learned the hard way on the proper method of installing fire dampers, and used that newly gained knowledge when I surveyed.

Which leads me to the issue concerning tamper resistant electrical outlets. I don’t think you will see any specific standard in a Joint Commission, HFAP or DNV, manual (or in a CMS CoP for that matter) on tamper resistant electrical outlets, but this issue is being observed on more and more survey reports. Apparently, some surveyors have a strong background in the National Electric Code (NFPA 70) and uses that knowledge during surveys.

If you are not already doing so, please be checking the electrical receptacles in pediatric areas to be sure they are the tamper resistant type. Section 19.5.1 of the 2000 Life Safety Code requires compliance with section 9.1, and section 9.1.2 requires compliance with NFPA 70 National Electric Code (1999 edition). Article 517-18(c) of NFPA 70 says the receptacles rated for 15 or 20 amps, 125 volts, intended to supply patient care areas of pediatric wards, rooms, or areas in healthcare facilities, shall be listed tamper resistant or shall employ a listed tamper resistant cover.

 The areas where tamper resistant receptacles are required are areas where children are likely to found; which include areas outside of a pediatric unit such as the cafeteria, main lobby, waiting rooms, and play areas. The tamper resistant receptacles would not be required in adult patient rooms, corridors, physician consultation rooms, etc., as these areas, even if children are present, would have supervising adults present.

It is not wrong, or unethical for a surveyor to cite an organization on an issue just because he/she has special knowledge about that issue. After all; the hospital is required to comply with that issue, right? What’s frustrating is there usually is no warning that some surveyors are looking for a particular issue and it surprises facility managers when it happens. No one likes those kinds of surprises.

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Oct 02 2014

Private Fire Service Mains

Category: BlogBKeyes @ 6:00 am

imagesS9VJZMEONFPA 25 (1998 edition), section 4-3.1 has a requirement listed to test the Private Fire Service Mains once every 5 years. The standard says the test must be performed on exposed fire service mains and underground fire service mains. The handbook that accompanies the NFPA 25 standard explains this water-flow test on the private fire service mains applies to only private exposed and underground fire service mains that are outside the facility, such as piping to a private fire hydrant. The piping inside the facility is covered under a different section of the NFPA 25 standard.

The Annex section A-4-3.1 of NFPA 25 says this flow test can be performed through yard fire hydrants; a fire department connection (once the check-valve is removed); and other connections. Typically, the test is conducted at a fire hydrant that is connected to the private fire service mains due to it accessibility. The test must be able to measure flow in gallons per minute (GPM), and the results are measured against the original acceptance data. The key thing to understand at your facility is whether or not you own the fire hydrants that are close to your building, or if they are owned by the city or municipality. Surprisingly, many facility managers simply do not know. If they are privately owned, then you need to conduct the 5-year private fire service main flow test.

Nat all surveyors are asking to see this documentation during a survey, but it is becoming a more frequent request. Remember: The 2000 Life Safety Code, section 9.7.5 requires compliance with the entire NFPA 25, so everything in the standard must be followed as long as you have the equipment.

Not all accreditation organizations are consistent in reviewing this documentation, but as time progresses, you will see more and more surveyors ask to review this test report. This 5-year private fire service main water-flow test should not be confused with the annual water-flow of the private fire hydrants and the 5-year internal inspection of sprinkler piping.

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