Q: I work in a 420 bed Hospital and during a recent survey we got cited for our yearly inspection dates on our fire extinguishers, which I understand. But on the monthly inspection dates, does the inspector put the date they do the inspection or the date of the next month?
A: For monthly inspections of portable fire extinguishers, NFPA 10 (2010 edition) section 184.108.40.206 says at a minimum of 30 day intervals, the date the inspection was performed and the initials of the person performing the inspection must be recorded. So each month, the person making the inspection must record the date that the inspection is made, on the extinguisher tag. Most authorities want to see an actual date, written in a month/day format provided the year is clearly identified on the tag. Initials of the individual conducting the inspection are usually accepted over actual signatures.
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Q: During a recent survey, we were cited for not having monthly inspections on our extinguishers during the month of the annual inspection. We have never run into this before. Doesn’t the annual service include and go beyond a monthly check?
A: You would think so, wouldn’t you… But, technically speaking, no the annual maintenance does not include and go beyond the monthly inspection. There are differences between the monthly inspection and the annual maintenance, which are:
Monthly inspection (per NFPA 10):
Confirm the following:
- Location in designated place;
- No obstruction to access or visibility;
- Operating instructions on nameplate legible and facing outward;
- Safety seals and tamper indicators not broken or missing;
- Fullness determined by hefting;
- Examination for obvious physical damage, corrosion, leakage, or clogged nozzle;
- Pressure gauge reading or indicator in the operable range;
- Condition of tires, wheels, carriage, hose, and nozzle;
- HMIS label is in place.
Annual Maintenance (per NFPA 10):
Perform the following:
- Examine all mechanical parts;
- External examination;
- Pull pin and replace tamper seal.
So, you can see that the annual maintenance activities are entirely different than the monthly inspection activities. It is entirely possible that the person conducting the annual maintenance can also do the first monthly inspection, but that would have to be documented. Typically it would be documented on the tag on the fire extinguisher. If that was not documented then it did not happen.It appears to me that the surveyor who made that citation was very astute.
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Q: Brad, how does the date need to be recorded on the fire extinguisher tags for the monthly inspection? Does the year need to be included on the inspection tag of the portable fire extinguisher along with the month and day for each inspection?
A: Depending on which authority having jurisdiction (AHJ) is inspecting your facility, yes the year needs to be recorded along with the month and day for every monthly inspection. Joint Commission’s standard EC.02.03.05, EP 15 requires the completion dates for each monthly inspection to be documented. According to Webster’s Dictionary, the phrase ‘date’ means “Time stated in terms of the day, month, and year.” So, technically, Joint Commission is asking that the tag have the day, month and year recorded. But, usually the accreditor allows the year to be omitted as long as the tag has the year pre-printed on it.
Other AHJs may not be as lenient. Many state agency surveyors for the Centers for Medicare & Medicaid Services (CMS) are asking to see month/day/year for every monthly and annual inspection (even if the tag has the year pre-printed), and a signature of the individual performing the service.
Many fire extinguisher service companies like to use a rubber stamp in lieu of the actual signature on the tag for the individual performing the annual maintenance, which is compliant with NFPA 10 (both 1998 edition and 2010 edition) on portable fire extinguishers. However, I have heard of many state agency surveyors for CMS who do not accept the rubber stamp and want a signature of the individual performing the service on each tag.
My advice is to inform the fire extinguisher service company to discontinue using the rubber stamp and have the service technician sign the tags. This will avoid any potential disagreement and squabble about what’s right and what’s wrong later when the surveyors come snooping around. It’s really all dependent on the individual surveyor.
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Q: I have a question regarding fire extinguishers. We have our extinguishers located in cabinets that are flush with the wall. Is it required to have signage above the extinguisher?
A: No, it is not. The 2000 Life Safety Code requires you to be in compliance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, and section 1-6.12 of NFPA 10 requires fire extinguishers that are mounted inside a cabinet or wall recesses, must be marked conspicuously. A sign mounted on the wall above the fire extinguisher cabinet is certainly a conspicuous marking, but it is not the only marking that meets the requirements of 1-6.12. A red dot on the floor or on the ceiling is also a conspicuous marking as well. If the fire extinguisher cabinet is lettered with the words “Fire Extinguisher”, then that qualifies as a conspicuous marking. If the authority having jurisdiction does not believe that lettering on the outside of the cabinet that says “Fire Extinguisher” meets the requirements of 1-6.12, then you need to negotiate with them and try to get them to understand that it does meet the requirements of NFPA 10. Otherwise, you need to comply with what the AHJ interprets.
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Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital?
A: The monthly inspection and annual maintenance requirements for the portable fire extinguisher is the same for all occupancies, and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:
- Make sure extinguisher is in its designated place
- Make sure the access to the extinguisher is not obstructed
- Make sure the operating instructions on the nameplate is legible and facing outward
- Make sure the safety seals and tamper indicators are not broken or missing
- ‘Heft’ the extinguisher to determine fullness (pick it up and hold it)
- Examine the extinguisher for obvious damage, corrosion, leakage or clogged nozzle
- Make sure the pressure gauge (if so equipped) is in the normal operating range
- For wheeled units, check the condition of the tires, wheels, carriage, hose, and nozzle
- Make sure the HMIS label is in place
This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable) and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. An annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection is required. A 12 year hydro-test of the extinguisher is also required.
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Q: Our administration wants us to discontinue applying bar-code labels on each extinguisher in our facility, and begin applying the labels on the cabinets and walls where the extinguishers are located. Do you see this being an issue for us down the road?
A: It would be interesting to understand why your administration wants this change made. I have seen bar-coding done both ways: label the extinguisher vs. label the location of the extinguisher. I don’t see it as a problem, either way. NFPA 10 (1998 edition) section 4-3.4.3 says records of the monthly inspection must be kept on a tag or label attached to the extinguisher; on an inspection checklist maintained on file; or in an electronic system (e.g. bar coding) that provides a permanent record. The standard does not say the bar-code label has to be on the extinguisher, so logic says it can be located near the extinguisher. This is subject to state and local authorities’ interpretation of the standard, as they may want the label in a specific location. I personally would want to label the asset rather than the asset location.
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Q: Do we have to have a special placard on our fire extinguishers in our kitchen, alerting people to activate the cooking hood fire suppression system first, before using the fire extinguishers? We received a citation from a surveyor on this issue.
A: The answer is yes, but I admit I was not aware of this requirement until recently. A hospital-client of mine was cited by their state surveyor for not having a placard near the Class K fire extinguishers informing the staff not to use the fire extinguisher until the cooking hood fire suppression system had been activated. I had never heard of this, so I contacted the surveyor at the state agency and asked what code or standard required this. He said it was in NFPA 96 (1998 edition), and sure enough, there it was in section 7-2.1.1: “A placard identifying the use of the extinguisher as a secondary means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.” Now, the standard says ‘each portable fire extinguisher in the cooking area’, but the state surveyor cited just the Class K extinguishers. I learned something new that day, so I considered it a successful day. If you don’t have those placards near all of your extinguishers in the cooking areas of your establishment, then I suggest you consider them, before you get cited.
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Q: During a recent survey we were almost cited because one of the fire extinguisher signs was on the front of the fire extinguisher cabinet and the rest were above the cabinets. The surveyor warned us that all of the signs needed to be the same. Is that true?
A: Well, I’m glad the surveyor did not cite you for this. If he/she had, you could have easily appealed this away after the survey. The 2000 edition of the LSC requires compliance with NFPA 10 Standard for Portable Fire Extinguishers (1998 edition). Section 1-6.12 of NFPA 10 says fire extinguishers mounted in cabinets or wall recesses must be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers must be marked conspicuously. Section 1-6.6 says extinguishers should not be obstructed, but if they are then ‘means shall be provided to indicate the location’ and the Annex portion of 1-6.6 describes acceptable means, such as arrows, lights, signs, or coding of the wall or column. Nowhere does it say all of the fire extinguishers have to be marked the same way or method. Now, I’ll admit that it is obvious to me that they all should be marked the same way for continuity purposes, but I do not see where the standard requires that. Therefore, based on your comment that the surveyor ‘almost’ cited you but did not, indicates to me that he/she felt the same way that I do that the extinguishers should be marked the same way, but it is not a standard requirement, therefore no citation was made. So, no the extinguisher cabinets don’t have to be marked the same way, but it sure makes sense to do so. I suggest you have someone correct this so they all are marked the same way.
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Q: Are we required to have portable fire extinguishers in our parking garages?
A: No. The placement of portable fire extinguishers is dependent on the requirements for that particular occupancy requirement. A parking garage is regulated under NFPA 88A Standard for Parking Structures, (1998 edition) and nowhere in that standard does it require the placement of portable fire extinguishers. It does address whether or not a sprinkler system or a fire alarm system is required, but it does not address portable fire extinguishers. As always, check with your local and state authorities to determine if they have any requirements for extinguishers.
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Q: Is the hospital responsible for the fire extinguishers supplied by the contractors while they are performing work in our hospital? We had a surveyor cite us for not performing monthly inspections on a fire extinguisher that did not belong to us, but was on a construction site in the hospital.
A: Yes, the hospital is responsible for all fire extinguishers in your facility or on your property, regardless who owns the first-aid devices. According to section 220.127.116.11 of the 2000 edition of the LSC, compliance with section 18.104.22.168 is required. Section 22.214.171.124 in turn requires compliance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition for installation, inspections and maintenance. Section 1-2 states that NFPA 10 is prepared for the use and guidance of persons charged with selecting, purchasing, installing, approving, listing, designing and maintaining portable fire extinguishers. The Annex section of 1-2 continues to say that the owner or occupant of a property in which a fire extinguisher is located has an obligation for the care and use of the extinguishers at all times. This standard does not differentiate as to who owns the extinguishers, it simply states the owner of the building is responsible. When an accreditation organization surveys the hospital for compliance with the LSC, they are surveying the hospital, not the contractors. The actions and operations of contractors are your responsibility as long as they are on your property, therefore you are responsible for the extinguishers. This is why I always prohibited contractors from bringing their own extinguishers into the hospital where I worked. I insisted that the hospital provide adequate extinguisher coverage, and I supervised where they were located and when they were inspected. My advice is to never rely on a contractor to comply with a LSC requirement.
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