Qualifications of Personnel

Q: We recently acquired a hospital that has been performing segments of their own fire system testing. What are the specific requirements or qualifications for an individual conducting testing or inspections on fire alarm systems and sprinkler systems?

A: NFPA 72-2010, section 10.4.3.1 requires a certified individual to perform service, testing, inspection and maintenance on fire alarm systems and components. The certification must be one (not all) of the following:

  • Factory trained and certified for the specific type and brand of systems being serviced
  • Persons who are certified by a nationally recognized certification organization (NICET, IMSA, etc.)
  • Persons who are registered, licensed or certified by the state
  • Persons who are employed and qualified by an organization listed by a national recognized testing laboratory for servicing fire alarm systems.

I have seen some larger hospitals that do employ people who meet one of the above requirements, but most hospitals contract this work to a qualified vendor who has these credentials. When it comes to sprinkler system testing/inspecting, NFPA does not require certification of the individuals performing the test/inspection. However, please check with your state and local AHJ to determine if they have additional requirements.

Fire Alarm System Strobes

Q: I work in a healthcare facility and we are in need to find an answer to a question regarding strobe lights. When we test our fire alarm system, and we silence the alarm, the strobe lights do not continue to flash. We were told that this is not “code” and the lights need to continue to flash even if system is silenced. I cannot seem to find this located in any part of the Life Safety Codes. Also, this is an older facility, so at some point/date do some healthcare facilities get grandfathered in if this is a newer code?

A: No… older facilities do not get to be grandfathered, or in any other way, exempt from complying with the code.

Section 19.7.1.4 of the 2012 Life Safety Code requires the transmission of the fire alarm signal during a fire drill. That means you cannot silence the audible alarms and you cannot disable the visual (i.e. strobe) notification devices. If you are doing either during a fire drill, then you are non-compliant and need to discontinue this practice and make sure the audible notification devices and the visual notification devices operate properly during each fire drill.

Now, having said that, there is one exception that you may qualify for and that is found in section 19.7.1.7 of the 2012 Life Safety Code, which says when drill are conducted between 9:00 pm and 6:00 am a coded announcement is permitted to be used instead of the audible alarms. But, the visual notification devices (i.e. strobes) must operate.

Fire Door Inspector

Q: My accreditation organization has a standard that says “testing and inspection of fire door assemblies needs to be conducted by a qualified person.” By what specifically do they mean when they say “qualified” and where are we able to find where they define their interpretation of what qualified is?

A: You will find the interpretation of what ‘qualified’ means under section 5.2.3.1 of NFPA 80-2010, which says functional testing of fire doors and window assemblies must be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. You may hire this responsibility out to a contractor with this knowledge and understanding, or you may assign the responsibility to test the fire doors to one of your own staff individuals, provided you ‘qualify’ them by determining they have the knowledge and understanding to perform this test.

If you decide on the latter, you need to document this decision by describing why you believe this individual has this knowledge and understanding of fire door operating components, and retain that document in case the surveyor asks to see how you qualified that individual. Your own staff individual could be qualified based on a certification course they may have taken (please understand there is no requirement that the person conducting the fire door inspections be certified, but it can be a good source of education), or the individual may be qualified simply because they have worked on doors for years and have accumulated this knowledge and understanding. The key is you may need to defend this decision, so it is best to document the decision and retain that to show to a surveyor.

Addressable Fire Alarm Systems?

Q: Are you aware of any accrediting organization requiring the hospital to have an addressable fire alarm system installed? If so, what organizations? Please explain the rationale and any supporting code behind this decision. Background: A hospital currently has a fully functional zone fire alarm system installed but heard that accrediting organizations are requiring addressable systems. In my review of NFPA 101 2012, I cannot find anything in chapters 18 or 19 that would differ from the 9.6 reference to NFPA 72 2010.

A: There is no NFPA Life Safety Code requirement for you to have an addressable fire alarm system. There is a requirement that the hospital have a fire alarm system that meets the requirements of 19.3.4 of the 2012 LSC, but that does not include being an addressable system. As far as I know, Joint Commission, HFAP, and DNV do not require an addressable fire alarm system, and CMS does not require an addressable fire alarm system.

Now, a state or local law may exceed the NFPA minimum and require an addressable fire alarm system, but you would have to check with your state and local authorities to find that out.

Off-Site Monitoring Station for Fire Alarm Systems

Q: I can’t seem to find anything in NFPA 72-2010 that says a facility is required to transmit a fire alarm signal to an off-site supervisory station. Our health care facility currently does not contract with an off-site station, and our procedure is to contact the fire department directly by phone when an alarm is received. Can you comment and provide some insight on this please?

A: Wait… what? This does not sound very good… What kind of healthcare facility are you? A hospital? An Ambulatory Surgical Center? According to the 2012 LSC, section 19.3.4.3.2.1 for hospitals, and section 21.3.4.3.2.1 for ASC, you need to comply with section 9.6.4 in regards to fire department notification. Section 9.6.4.2 requires that you communicate the fire alarm signal to the local fire department in one of the following methods:

  • Auxiliary fire alarm system
  • Central station fire alarm system
  • Proprietary supervising station fire alarm system
  • Remote supervising station fire alarm system

What you described is a manual transmitting system, which is not permitted for hospitals or ASCs. What I’ve observed most hospitals use is the Central Station Fire Alarm System which uses a modem to communicate to a central monitoring station that automatically relays any fire alarm signals to the local fire department. What you have described is a serious violation and one that CMS would consider to be a trigger for an Immediate Jeopardy decision. I suggest you get this resolved ASAP.

Fire Alarm System Communication

The answer to this question was provided by my good friend Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL

Q: With the impending discontinuation of the hard copper (POTS) phone lines, and in fact many municipalities already no longer have hard copper pairs from end user to the Central Office, are we, or will we be, in violation of the NFPA code for the primary DACT connection to the CO? Our fire alarm system company is telling us we must upgrade to another form of communication; however we have an IP based phone system in all buildings and the fire alarm company documentation indicates that IP based technology is acceptable, can I simply designate two analog phone lines from our system to the DACT, eliminating the POTS connection?

A: Per NFPA 72 (2010) Chap. 26.6.3.2, Patrick would be code compliant if he continues to use phone lines for a central station connection.  However, if the vendor is saying he must upgrade, it sounds like they’re discontinuing DACT monitoring.  He should verify that with the vendor.  Most central stations have DACT, radio and cellular receivers, but some are discontinuing DACT receiving for the reasons Patrick stated.  If he’s connected to a central station that’s dropping it, he may be able to find a new central station that still has it.  If he’s directly connected to a fire department that’s dropping it, he can see if he’s allowed to use a central station for monitoring.  If they’re not dropping DACT monitoring, he can ride that horse until discontinued by the monitoring agency or the lines die, but I’d advise setting up a new method so he can control the costs before it becomes an emergency.

Switching to IP based phone lines would still use the existing DACT transmitter, but without getting too technical, it comes with a couple of conditions:

  1. There has to be a dial tone on the IP phone lines when the receiver is picked up (loop started).  If you have to dial a number to get a dial tone (ground started), you can’t use it.
  2. The DACT communication out of the fire panel must now be converted into IP packets at the source, then reassembled into digital signals at the receiver.  That means the central station must have an IP converter & the end user must install an IP converter that matches it.
  3. The power for the phone system must be backed up by the emergency generator.

Obviously, bullet #2 is where the costs comes in & it won’t be cheap.  It may seem like it shouldn’t be a big deal, but changing communication methods always involves new equipment.  The costs & legwork involved in staying with phone lines may be more than installing the upgrade, which is probably a radio.

Fire Alarm Pull Stations

Q: I have a question regarding fire alarm manual pull stations. In our multi-level long term health care facility, we added a new building onto the existing building. At the point where the old building and the new addition connect, there is a 2-hour fire-rated barrier with fire-rated doors that are held-open with magnets. Do we need pull stations within 5-feet of those doors? Both buildings are fully sprinkled and both have a fire alarm system. My reading of the code says that they would have to have pull stations on either side of the building separation wall door assemblies as one should be able to pull a pull station while in the act of leaving one building and going into another. Am I correct?

A: I’m not sure I agree with you, but let’s think this through…. NFPA 72 (2010 edition) section 17.14.6 discusses the location and spacing of fire alarm pull stations. In this section it says pull stations must be located within 5 feet of the exit doorway opening at each floor. So, if the 2-hour separation between the two buildings is in fact a horizontal exit, then I would agree with you that pull stations would have to be mounted within 5 feet of the exit, on both sides of the 2-hour wall. However, if the 2-hour separation between the two buildings is not classified as a horizontal exit, and it is simply a building separation, then I do not see where the standard requires a pull station.

You may ask what is the difference between a building separation and a horizontal exit if they are both 2-hour fire rated, and the answer is a new horizontal exit does not allow any HVAC duct to penetrate the barrier, unless the building on both sides of the barrier is fully protected with automatic sprinklers. Other than that, there really isn’t much difference, other than the name applied to the barrier by the designing architect.

I can see your point that it appears you are ‘exiting’ one building and entering another at this barrier, and a pull station would be required. But if it is not a designated horizontal exit, I think that should be sufficient for an AHJ to not require a pull station. But, what is the cost of adding pull stations at this barrier even if the standard does not require them? If you feel more comfortable, go ahead and add them.

Other pull station location requirements in the standard says the travel distance to the nearest pull station cannot exceed 200 feet, and if you have a group opening (office cubicles) over 40 feet wide, then you need pull stations on each side of the openings. Also, section 18/19.3.4.2.2 in the 2012 edition of the Life Safety Code says a pull station may be mounted at the nurse station in patient sleeping areas in lieu of being mounted within 5 feet of an exit, provided the nurse station is continuously attended by staff, and the 200 foot travel distance is maintained.

So, the conclusion is… go ahead and mount pull stations at the building separation if it makes you more comfortable, but I’m not sure it is needed. I recommend that you consult with your local and state authorities to gain their interpretation.

Positive Alarm Sequence

I was reviewing some new standards and came across the Positive Alarm Sequence (PAS) issue for fire alarm systems, that the 2012 LSC now permits in fully sprinklered healthcare occupancies (see 18/19.3.4.3 and 9.6.4.3 of the 2012 Life Safety Code), provided it is in accordance with NFPA 72-2010.

The PAS (section 23.8.1.3.1.1 of NFPA 72-2010) is designed to allow the facility a 3-minute delay in annunciation of the fire alarm signal, to allow them time to investigate whether the alarm is a nuisance alarm. The PAS option first became available for use on non-healthcare occupancies in the 2003 edition of the LSC, and then became available for use in healthcare occupancies in the 2006 edition. It is now available to all healthcare occupancies, ambulatory healthcare occupancies, and business occupancies since CMS adopted the 2012 Life Safety Code on July 5, 2016. So, this is something that may be a new concept to many facility managers.

The sequence of operation for the PAS is as follows:

  1. The fire alarm control panel must have the PAS feature an integral part of the programmable control system of the panel. The PAS is not a feature that can be used on older systems that were not originally equipped with it.
  2. To initiate the PAS operation, the signal from an automatic fire detection device selected for PAS operation shall be acknowledged at the fire alarm control unit by trained personnel within 15 seconds of annunciation. Usually any general alarm fire alarm initiating device would activate the PAS operation.  Supervisory or “off normal” conditions wouldn’t activate the PAS.  The only time you wouldn’t have an alarm event activate the PAS would be a general evacuation device, like a key switch monitored by the fire alarm system, that’s intended to signal an immediate evacuation of the hospital.
  3. If the signal is not acknowledged within 15 seconds, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  4. If the PAS operation is initiated in accordance with 23.8.1.3.1.1, trained personnel shall have an alarm investigation phase of up to 3-minutes to evaluate the fire condition and reset the system. The term ‘trained individuals’ means you need to have individuals who are trained to respond properly and immediately. No certifications or licenses are required for this function. The training includes in-house procedures that involve investigation within a certain timeframe, as well as training on use of the fire alarm annunciator and how the PAS is programmed to operate.
  5. If the system is not reset during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  6. If a second automatic fire detection device selected for PAS is actuated during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  7. If any other fire alarm initiating device is actuated, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  8.  The system shall provide means for bypassing the PAS.

Obviously, in order for the PAS operation to function properly, someone needs to be near the fire alarm control panel or a remote annunciator, so the trained individual who’s monitoring the system may take the appropriate action. If your fire alarm control panel or a remote annunciator is not continuously monitored, then the PAS function would not be suitable for your facility.

The 3-minute phase of investigation to evaluate the alarm condition, can be done with multiple individuals. An example may be one individual at the control panel and one in the field, communicating via walkie-talkies in order to make a decision to reset the panel before the 3-minutes expire, or to allow the alarm annunciation to continue.

Although the PAS function is permitted, caution is recommended before you implement this operation. The PAS can devolve into an automatic reset by the staff to give them more time to investigate, with the intent of pulling a manual station if there is indeed a problem, or worse, to let it go back into alarm as a means of verification.

If you are wondering whether or not CMS allows PAS operation the answer is yes, they do. Although CMS has not officially commented on this issue, they have to allow it since it is permitted by the 2012 LSC. Unless they specifically dis-allow something that is permitted by the LSC, then it is permitted, as long as it applies to the applicable occupancy. Unless they say otherwise, they follow NFPA to the letter. Examples of them saying otherwise involved the 4-inch corridor projection issue (vs. 6-inch what LSC allows); roller latches in certain corridor doors (2012 LSC still allows roller latches in certain corridor doors); and 1 or more patients incapable of self-preservation in Ambulatory Health Care Occupancies (vs. 4 or more). They have published S&C memos or addressed these issues in the Final Rule to adopt the 2012 LSC.

This means your accreditation organizations will allow PAS operations as well, unless of course they specifically have said they dis-allow it. For Joint Commission accredited organizations, their new EP 4 under LS.02.01.34 (2018 CAMH manual) specifically does permit PAS operation, in buildings that are fully protected by sprinklers.

Before you make plans or changes to implement PAS operation, check with your state and local authorities to determine if they have any restrictions on the use of PAS operation.

Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL, contributed to this article. You may reach Gene at generowe@affiliatedinc.com

 

AEM Program for Fire Alarm and Sprinklers

Q: Are sprinklers, smoke detectors, etc. considered to be operating components of the utility systems? If so, our inspections are based on the pertinent NFPA references. I think that the fire system inspections could be considered preventive maintenance or at least the means to determine what maintenance needs to be completed. Can we use the CMS AEM program to alter our PM activities on the fire alarm and sprinkler systems?

A: You cannot use the CMS AEM program for Fire Alarm inspection and testing requirements. The CMS S&C letter 14-07 that describes the AEM program says the following regarding when the AEM program is not appropriate: “Other CoPs require adherence to manufacturer’s recommendations and/or set specific standards. For example: The National Fire Protection Association Life Safety Code (LSC) requirements incorporated by reference at 42 CFR 482.41(b) has some provisions that are pertinent to equipment maintenance, and compliance with these requirements are assessed on Federal surveys.”

So… you must follow the NFPA requirements specified for sprinkler and fire alarm testing and inspection, and the AEM program is not applicable.

Batteries for Fire Alarm Systems

Q: Can you tell me where I could find the code reference for how often batteries serving fire alarm panels (booster panels, control panels, etc.) need to be replaced based on how old they are?

A: Currently, we are on the 2010 edition of NFPA 72, and Table 14.4.5 (6) (d) says sealed lead acid type batteries used on fire alarm systems need to be replaced 5 years after date of manufacturer, or more often as needed.

So, for now it is every 5 years after date of manufacturer.