Fire Alarm Test Reports

fire-alarm-system-detects-protects-24-x-7-250x250[1]Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings and citations, mainly because there are so many devices connected to the fire alarm system. A typical 200 bed hospital may have over 2,000 devices connected to the fire alarm system that need to be tested.

Nearly all of the requirements for the frequency of the tests performed on fire alarm systems can be found under NFPA 72 (1999 edition), section 7-3.2. The one exception would be the requirement for the water-flow switch testing which is found under NFPA 25 (1998 edition), section 2-3.3. (NOTE: This does not take into consideration the recent CMS categorical waivers.)

Often times a contractor performing the fire alarm testing will not test all of the devices listed below, even if your hospital has them in your system. The reasons may differ but the bottom line is the hospital facility manager must review the contract and determine what is actually required. Many times the standard contract (or signed proposal) will state something to the effect the fire alarm system will be tested in accordance with NFPA 72, although it doesn’t always refer to the proper edition (most hospitals are on the 1999 edition of NFPA 72). If the contract says it will test to NFPA 72, then you must hold them accountable for testing everything on the list below.

Make sure the test report lists the complete inventory of each and every device connected to the fire alarm system. All of the initiating devices, all of the occupant notification devices and all of the interface relays must be listed in an inventory complete with their location and whether they passed or failed their test. And don’t forget all of the batteries in the fire alarm system, not just those in the fire alarm control panel. There may be other batteries involved such as those in a remote panel or a Notification Appliance Circuit (NAC) extender panel.

Here is a list of devices that could be connected to the typical fire alarm system in a hospital:

Device/Test

Frequency

Initiating   Devices

Water-flow switches

Quarterly

Smoke detectors

Annually

Heat detectors

Annually

Duct detectors

Annually

Manual pull stations

Annually

Supervisory   Signal Devices

Low air pressure switches

Quarterly

Low water level switches

Quarterly

Tamper switches

Semi-annually

Notification   Devices

Strobes

Annually

Horns

Annually

Bells

Annually

Chimes

Annually

Interface   relays and modules

Magnetic hold-open

Annually

Air handler shut-down

Annually

Kitchen hood suppression sys

Annually

Elevator recall

Annually

Magnetic locks

Annually

Fire pump

Annually

Smoke dampers

Annually

CO2/Clean agent suppression

Annually

Sprinkler dry-pipe/pre-action

Annually

Overhead rolling fire doors

Annually

Control   panel batteries

Charger test

Annually

Discharge test

Annually

Load voltage test

Semi-annually

Smoke   detector sensitivity test

2-years

Off-premises   monitoring transmission equipment

Quarterly

Here are some basic requirements about the fire alarm test report:

  • Make sure the report is dated and signed by the service technician and you (the owner’s representative)
  • Make sure all the devices connected to the fire alarm system are accounted for and inventoried in the report
  • Make sure resettable heat detectors are ‘tested’ rather than ‘inspected’. Lazy technicians may not want to get out the hot-air guns to test the heat detectors so they just ‘inspect’ them
  • Make sure the heat detectors are tested with heat, and not with magnets. Only the one-shot non-resettable heat detectors are permitted to be tested with magnets.
  • When items on the report are identified as having ‘failed’ their test, make sure there is follow-up action to resolve the issue
  • Don’t forget to assesse the failed devices for Interim Life Safety Measures (ILSM)
  • Resolve all deficiencies and staple copies of the paperwork that demonstrates the repair was completed, along with a re-test, to the test report
  • Ensure that the technician performing the fire alarm testing, service and repairs meets the qualifications for certification or licensing. This applies to in-house staff or contracted staff. Have the qualifying documents on file.

Maintain your fire alarm test report at this level of documentation and you should not have any troubles with the surveyors.

 

Documentation- Part 2: Fire Alarm System

imagesT4IH0BMLThis is the second in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Last week I presented some general suggestions on how to improve your documentation for easier retrieval during a survey. I suggested placing the test and inspection reports in 3-ring binders and separating them by categories. Use tabs to separate the categories so you can access the reports easier and faster.

The different categories that I present below are based on the Joint Commission Environment of Care standard EC.02.03.05; HFAP chapter 13 on Life Safety;  DNV PE.1, SR.2; and CMS Conditions of Participation. Here are the categories of the different test/inspection reports that you will likely need:

  • Fire alarm test reports
  • Sprinkler system inspection/test reports
  • Fire pump test reports
  • Alternative fire suppression test reports
  • Generator test reports
  • ATS test reports
  • Medical gas & vacuum system test reports
  • Interim Life Safety Measures assessments
  • Fire & smoke damper test reports
  • Fire door test reports
  • Exit sign inspection reports
  • Elevator recall test reports
  • Fire drills

Today I will identify what you need to have for a valid fire alarm test report.

Fire Alarm System

With the exception of the sprinkler water-flow switches, all of the other devices connected to the fire alarm system must be tested according to the frequency specified in NFPA 72 (1999 edition), section 7-3.2.  Water-flow switches must be tested according to the frequency specified in NFAP 25 (1998 edition), section 2-3.3. This list does not take into consideration any changes to testing frequency based on acceptance of the CMS Categorical waivers.

 

Device

Frequency

Initiating devices

Water-flow switches

Quarterly

Smoke detectors

Annually

Heat detectors

Annually

Duct detectors

Annually

Manual pull stations

Annually

Supervisory signal devices

Low air pressure   switches

Quarterly

Low water level   switches

Quarterly

Tamper switches

Semi-annually

Notification devices

Strobes

Annually

Horns

Annually

Bells

Annually

Chimes

Annually

Interface relays and   modules

Magnetic hold-open

Annually

Air handler shutdown

Annually

Kitchen hood   suppression

Annually

Elevator recall

Annually

Magnetic locks

Annually

Fire pump

Annually

Smoke dampers

Annually

Clean agent suppression

Annually

Sprinkler dry pipe

Annually

Sprinkler pre-action

Annually

Overhead rolling fire doors

Annually

Control panel batteries

Charger test

Annually

Discharge test

Annually

Load voltage test

Semi-annually

Smoke detector sensitivity test

2-years

Off-premises monitoring transmission equipment

Quarterly

 If you have these devices connected to your fire alarm system, then you need to have evidenced that each individual device was tested. That means you also need an accurate inventory of every device, complete with a description as to where it is located. The test report needs to list each and every individual device, a description of where it is located, and whether it passed or failed its test. This means there may be over 50 pages to an average test report since a typical 200 bed hospital may have over 2,000 devices connected to its fire alarm system.

Next week we will look at the sprinkler system.