Jun 14 2017

Annual Test on Fire Rated Door Assemblies

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: In regards to the new annual fire rated door assembly inspection, are we to inspect every door that has a fire rating or the doors that are located in fire-rated walls? I have noticed that not all fire doors in the building are located in fire rated walls, according to my Life Safety drawings. What do you say?

A: It is not uncommon for fire-rated door assemblies to be found in walls and barriers that are not fire-rated. This is often due to conflicting building codes that require 20-minute fire rated doors in all corridors, or a misunderstanding by the design professional. But make no mistake: You are required to test and inspect those doors on an annual basis.

My interpretation is based on section 7.2.1.15.2 of the 2012 LSC which says: “Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80…” This section of the LSC does not have any exceptions for fire-rated door assemblies that are located in walls and barriers that are not fire-rated.

Therefore, all fire-rated door assemblies must be inspected and tested in accordance with NFPA 80 on an annual basis, regardless where they are located.

Another way of looking at this issue is to review section 4.6.12.3 of the 2012 LSC which says existing life safety features that are obvious to the public, if not required by the LSC, must be either maintained or removed. The interpretation of what’s ‘obvious to the public’ is certainly open for discussion, but most fire-rated door assemblies can be determined by looking at a fire rating label on the hinge-side edge of the door, and that is viewable by the public. Whether it is obvious or not is a matter of opinion, but if you take the hardline on that, then all fire-rated doors (with a fire rating label) have to be maintained even if they are not located in a fire-rated barrier.

Either way… I think the LSC is pretty clear… you need to test and inspect all fire rated door assemblies regardless if they are located in a fire rated barrier. And by the way, the first test of the side-hinged swinging fire doors is due in a couple weeks: July 5, 2017. Better have it completed by then.


May 03 2017

Annual Fire Pump Test

Category: Fire Pump,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: I read where the annual fire pump test requires a 30-minute churn test but does not differentiate between a diesel or electric pump (as in the weekly test). NFPA 25, 2011 edition requires only a 10-minute churn for the annual test on an electric pump. What happened to the 30-minute churn test?

A: NFPA 25-1998 did require the annual fire pump flow-test for both electric-motor driven fire pumps and engine-driven fire pumps to have a 30-minute churn test at no-flow conditions to begin the test. This was to ensure the pressure relief valve opened to allow circulating water to cool the pump when operating at standby (i.e. no-flow) conditions.

Since CMS adopted the new 2012 LSC, we are now on NFPA 25-2011. Section 8.3.3.2(1) of NFPA 25-2011 dropped the requirement for a 30-minute churn test for the annual fire pump flow-test, but still requires the churn test; it just doesn’t specify how long the churn test must be. I can only surmise that the industry figured a churn test for 30 minutes to ensure the relief valve opens is no longer required.

However, section 8.3.3.2(3) says “For electric motor-driven pumps, the pump shall not be shut down until the pump has run for 10 minutes.” This statement is in reference to the pump operating at flow conditions, and is not a reference to how long the pump must run at no-flow conditions.

The new 2012 LSC is now being enforced by accreditation organizations and by CMS. For annual fire pump flow tests from now on, you may run the churn test portion long enough to ensure the relief valve opens and dumps water. You no longer have to run the churn test for any given length of time.


Feb 09 2017

Life Safety Inspections at Offsite Locations

Category: Documentation,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher inspections required? We have several off-site laboratories and other services in buildings that we do not own.

A: Yes… you must maintain all of the features of Life Safety at the offsite locations, even those that you do not own; the same as you would at the main hospital. Just because you do not own the fire extinguishers, fire alarm system, sprinkler system, fire dampers, exit signs, generator, elevators, medical gas systems, and fire doors does not give you a pass on not properly maintaining them. I understand that landlords rarely conduct the same level of testing and inspection of their building’s fire safety features as you would at the hospital, but the rules for testing and inspection apply evenly across all facilities where you have staff and patients, regardless who owns it. Your survey team may not always ask to see the documentation for testing and inspecting these systems at the offsite locations, but it is a requirement found in the core chapters and occupancy chapters of the Life Safety Code.


May 23 2016

ASC Fire Alarm Testing

Q: What section of NFPA 72 (the National Fire Alarm Code) requires ambulatory surgery centers to perform testing of their fire alarm system on a quarterly basis? Do devices that require annual testing have to be divided and have the service contractor do 25% of them each quarter? My organization would like to know the specific identifier so that the requirement may be referred to.

A: The quick answer is there is no requirement in NFPA 72 (or any other NFPA standard) that requires quarterly testing of the fire alarm system for ASC classified as ambulatory care occupancies. Section 20.3.4.1 of the 2000 edition of the LSC requires compliance with section 9.6. Section 9.6.1.4 requires compliance with NFPA 72 (1999 edition) for testing and maintenance. NFPA 72, Table 7-3.2 discusses the frequency of testing and inspection for each component and device of the fire alarm system. While there are a few items that require quarterly testing (such as water-flow switches on sprinklers system, which actually comes from NFPA 25, and off-premises emergency notification transmission equipment), for the most part, annual testing is required on all initiating devices, notification devices, and interface devices. You do not have to divide the components that require annual testing into four groups and have your service contractor perform testing on 25% of the devices on a quarterly basis. Actually, this can be troublesome for larger organizations if the service contractor fails to test the devices during the same quarter each year. Most accreditation organizations require the annual test to be performed 12 months from the previous test, plus or minus 30 days.


Apr 18 2016

Weekly Fire Pump Testing

Category: Fire Pump,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: The Joint Commission standard for weekly testing of the fire pump only requires us to record the test date of the inspection. We were cited for not recording the suction and discharge pressures. Is this a requirement?

A: Yes, recording the suction and discharge pressures, along with the amount of time required to start the weekly test (by lowering the water pressure) are required documentation for each weekly fire pump test. Even though these requirements are not specifically identified in the EC standards, they are identified in the NFPA 25 (1998 edition) which is referenced by the Joint Commission standards.

Get a copy and read the NFPA 25 (1998 edition) as it has a lot of testing requirements of the sprinkler system which are not identified in the Joint Commission standards, but are required.


Apr 04 2016

Fire Alarm Test Report

Category: Fire Alarm,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: Does NFPA 72-1999 edition specifically state that annual fire system inspection documentation include an itemized inventory of each system device as passed or fail? Does a report stating that (i.e. 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed) satisfy the requirement?

A: Specifically? I would say it does, but if you want to see the words: “Every annual fire alarm system documentation must include an itemized inventory of each device as passed or failed” … you will not find those words in NFPA 72, 1999 edition.

What it does say is this: Section 7-5.2.2 requires documentation of the fire alarm test to comply with all the applicable information found in Figure 7-5.2.2. On page 3 (of 4) of figure 7-5.2.2, the documentation required by NFPA 72 includes:

    • Location of the device
    • Serial number of device
    • Device type
    • Visual check
    • Functional test
    • Factory setting
    • Measured setting
    • Pass of Fail

In addition to that requirement for annual testing, section 7-1.6.2.1 requires all components affected by a change to the system to be 100% tested. This is in regards to a change to the system, like the addition of an initiating device all the devices on the circuit for the new device must be tested.

So, I would say NFPA 72 (1999 edition) does specifically require the documentation of whether or not each device passed or failed its test. Also, it is now an interpretation by many of the national AHJs for healthcare organizations that each test report has this information documented. The logic for this requirement is solid; how does the facility manager know that the fire alarm testing technician actually tested each and every device in their building, if you do not know where they are, and document the results of each test?

A report stating that 20 pull stations passed, 72 smoke detectors passed, 19 duct detectors passed their inspection would NOT satisfy the reporting requirement, as I understand it. There needs to be an inventory list showing each device location and whether or not it passed or failed its test.

 

It makes good sense.

 


Oct 23 2015

Quarterly Testing and Inspection Challenges

Category: Joint Commission,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not always able to schedule us within the tight 20-day window each quarter that Joint Commission will now require. So by definition our schedule will now be in flux, depending on the completion date of the last inspection, rather than set on the same month each quarter. I realize they do not want people to schedule inspections in back to back months, which we do not do, but this seems like it will cause more instability than anything. 

A: I see your dilemma and understand the difficulty in the logistics of your situation. Scheduling a contractor to be onsite within the new 20-day window each quarter will be a challenge to large organizations like yours.

For the record, the Engineering department at the Joint Commission was not in favor of the requirement that quarterly testing and inspections to be performed 3 months from the previous test/inspection, plus or minus 10 days. But the power-that-be above them made that decision.

To answer your question: I do not know what other organizations are doing in regard to challenges with the new quarterly testing requirements. However, I think there is a way you can deal with this issue.

I suggest you contact the Standards Interpretation Group at the Joint Commission and discuss your options concerning the challenges in meeting the quarterly test/inspection window. Ask them if you can have some leeway that would allow you a wider window each quarter for the testing/inspection frequency other than the plus or minus 10 day window. My guess is they will allow it as long as you can demonstrate the hardship in meeting this requirement.


Oct 05 2015

Business Occupancy Testing

Category: Business Occupancy,Questions and Answers,TestingBKeyes @ 12:00 am
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Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual fire drill but what about the testing of fire alarm system and sprinkler system?

A: Assuming the two-story office building that you refer to is classified as a business occupancy, the requirements for testing, inspection and maintenance are found in section 39.3.4.1 of the 2000 Life Safety Code, which refers to section 9.6. Section 9.6.1.4 requires the fire alarm system to be tested, inspected and maintained in accordance with NFPA 72 (1999 edition). Likewise, section 9.7.5 requires required sprinkler systems to be maintained in accordance with NFPA 25 (1998 edition). If your sprinkler system is not a ‘required system’, you still need to maintain it, according to 4.6.12.2. The testing, inspection and maintenance requirements found in NFPA 72 and NFPA 25 are the very same requirements that healthcare occupancies need to comply with. The bottom line is: You need to test, inspect and maintain the fire alarm system and the sprinkler system in a business occupancy at the very same frequency and level as you would in a hospital.


Jul 07 2014

Main Drain Tests

Category: Main Drain,Questions and Answers,Sprinklers,TestingBKeyes @ 5:00 am
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Q: Where are main drain tests required to be done? This is a large medical facility with nine story towers. Several fire mains feed the various campus buildings. Is the main drain test required to be done only where the fire mains supply the system risers, or does it also need to be done on each floor at the riser as well? Would you please supply your rationale for your answer?

A: According to the 2000 edition of the Life Safety Code, main drain tests are regulated by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition. Section 1-5 of NFPA 25 defines a main drain as the primary drain connection on the system riser and also is utilized as a flow test connection. Section 9-2.6 requires a main drain test must be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply and control valves. NFPA 25 does not adequately define what a ‘system riser’ is, so we turn to the Handbook for NFPA 13 Standard for the Installation of Sprinkler Systems which identifies a ‘system riser’ as the above ground horizontal or vertical pipe between the water supply and the mains (cross or feed) that contains a control valve (either directly or within its supply pipe) and a waterflow alarm device. A system riser is more than just a subset of the term riser, which is broadly defined as any vertical piping within the sprinkler system. As indicated by the definition, a system riser can be any aboveground pipe in a vertical or horizontal orientation installed between the water supply and the system mains that contain specific devices. By this definition it appears one could loosely define the locations of a main drain test to be conducted wherever there is a control valve and waterflow alarm switch. In a large multi-story facility such as yours, that would most likely require a main drain test at least on every floor, possibly more. The Accreditation Organizations (AOs, such as Joint Commission, HFAP and DNV) typically do not seek this level of compliance. Most of the AOs only expect main drain tests to be conducted at the base of the risers of the sprinkler system, not at every floor. However, depending on your state agency surveyors who conduct CMS validation surveys, it is very reasonable and possible that they will expect the main drain tests to be conducted at every floor. To continue with additional information, the purpose of a main drain test is covered in the Annex section A-9-2.6, which says main drain tests are used to determine whether there is a major reduction in waterflow to the system, such as might be caused by a major obstruction, a dropped gate, a valve that is almost fully closed, or a check valve clapper stuck to the valve seat. A large drop in the full flow pressure of the main drain (as compared to a previous test) normally is indicative of a dangerously reduced water supply caused by a valve in an almost fully closed position or other type of severe obstruction. After closing the drain, a slow return to normal static pressure is confirmation of the suspicion of a major obstruction in the waterway and should be considered sufficient reason to determine the cause of the variation. A satisfactory drain test (i.e., one that reflects the results of previous tests) does not necessarily indicate an unobstructed passage, nor does it prove that all valves in the upstream flow of water are fully opened. The performance of drain tests is not a substitute for a valve check on 100 percent of the fire protection valving. The main drain test is conducted in the following manner:

  1. Record the pressure indicated by the supply water gauge [Static Pressure]
  2. Close the alarm control valve on alarm valves
  3. Fully open the main drain valve
  4. After the flow has stabilized, record the residual (flowing) pressure indicated by the water supply gauge
  5. Close the main drain valve slowly
  6. Record the time taken for the supply water pressure to return to the original static (nonflowing) pressure
  7. Open the alarm control valve


Feb 10 2014

Fire Alarm Control Panel Batteries

Category: Fire Alarm,Questions and Answers,TestingBKeyes @ 6:00 am
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Q: What are the testing frequencies for fire alarm panel batteries and where do you find this requirement?

A: The testing frequencies for batteries for fire alarm control panels (including notification appliance circuit extender panels, or ‘NAC panels’) are found in Table 7-3.2 of NFPA 72 (1999 edition). For years, batteries used in fire alarm systems have been sealed lead-acid type, and there are three (3) tests that need to be conducted:

  • Charger Test                     (Annually)
  • Discharge Test                  (Annually)
  • Load Voltage Test           (Semi-Annually)

The Load Voltage test is usually what trips up the fire alarm testing contractor, as they do not always return on a semi-annual basis to perform the load voltage test. This is not always the fault of the testing contractor, but more of a contract issue with the healthcare organization. Make sure you check the language of your contract to ensure the vendor is performing these tests at the allocated time frequencies.  If you’re scoring this as a Joint Commission deficiency, non-compliant with Table 7-3.2 battery testing could be scored under one of the following:

  • EC.02.05.05,    EP 3
  • EC.02.06.01,    EP 26
  • LS.02.01.34,     EP 4

Be aware that Joint Commission, and many other authorities, will expect the semi-annual test conducted 6 months from the previous test, plus or minus 20 days. The annual tests must be conducted 12 months from the previous test, plus or minus 30 days. Make sure your contract stipulates these requirements and monitor their activity to confirm it.


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