Aug 04 2017

Sprinkler Testing Certification

Category: Questions and Answers,Sprinklers,TestingBKeyes @ 12:00 am
Share

Q: I reside in California. Do I need a special license or certificate to perform monthly and quarterly sprinkler systems tests and/or inspections? Primarily, I am interested in main drain tests. I am the fire alarm, technician at a large hospital, and have NICET Level II certification. I have over 20 years of hospital fire experience and I have a State of California weekly fire pump test certificate. From a NFPA standpoint, do I need a license or certificate to perform testing and inspections on water based fire protection equipment (sprinklers)?

A: No. NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems only requires ‘qualified’ people to perform the inspections and testing activities, and ‘qualified’ means being competent and capable, and having met any requirements and training that are acceptable to the AHJ. So, if the state of California has additional requirements for training, such as licensing and/or certification, then you would have to comply with that. But NFPA 25 does not require license or a certificate to perform inspections and testing.


Jul 27 2017

AHJ on Fire Door Inspections

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
Share

Q:  Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections?

A: Yes they do. Take a look at 4.6.1.1 of the 2012 LSC “The authority having jurisdiction shall determine whether the provisions of this Code are met.” That means the AHJ decides if the organization is compliant with the applicable NFPA codes and standards. But, keep in mind the typical hospital has 5 or 6 different AHJs that inspect their facility for compliance with the LSC:

  • CMS
  • Accreditation organization
  • State health department
  • State agency with over-sight on hospital construction
  • State fire marshal
  • Local fire inspector
  • Liability insurance company

Not one AHJ can over-ride another AHJ’s decision. All AHJs are equal… but different. If 5 AHJs say the qualifications of the person performing the fire door inspections are fine, but 1 AHJ says no, then the hospital must comply with the most restrictive requirements and comply with the latter AHJ’s desires. An AHJ may have rules and requirements that exceed NFPA standards, as well they should. NFPA standards are minimal standards, and most hospitals exceed the NFPA standards in some capacity, often due to local ordinances or state regulations (and sometimes at the whim of the design professional). But, if the AHJ decides to have standards that exceed the minimal NFPA requirements, they need to be able to justify that decision.

It is not at all uncommon for a healthcare organization to seek permission from a state or local AHJ (i.e. state fire marshal) to install a particular device or have a particular feature, only to find out later that their accreditation organization does not agree, and cites the issue. Both the state or local AHJ and the accreditation organization are correct; they are interpreting the Life Safety Code as they see fit. Whatever was approved by the state or local AHJ is just an approval for the state or local regulations. What was cited by the accreditation organization was cited based on the accreditation organization’s regulations and understanding of the Life Safety Code.

This is why healthcare organizations need to obtain permission and interpretations from all of their AHJs… not just one or two.


Jul 20 2017

Fire Door Inspection Qualifications

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
Share

Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection?

A: NFPA 80-2010, section 5.2.3.1 says fire doors must be tested by individuals with knowledge and understating of the operating components of the door assembly, but NFPA 80 does not identify or describe what ‘knowledge and understanding’ actually means. The word ‘qualified’ is not found in this context of describing the individual who performs this inspection. When the codes or standards are vague (as they often are), then it is up to the authorities having jurisdiction to decide how to interpret the code or standard (see 4.6.1.1 of the 2012 LSC). When the AHJ does not make an interpretation of the code or standard, then it is up to the individual facility to decide what’s right.

In this case, no national AHJ has published an interpretation for hospitals on what ‘knowledge and understanding’ is required to test and inspect fire door assemblies. Therefore, hospitals and other healthcare organizations have the right to decide what that means. However, during a survey or an inspection, the AHJ surveyor has the right to question how the hospital determined their individual has the ‘knowledge and understanding’ and if it is not satisfactory to the AHJ surveyor, then a citing may be in order.

My advice to healthcare organizations on this issue is to document why they believe their individual has the ‘knowledge and understanding’ to perform the inspections. If their maintenance person has worked on fire doors for 20 years then that may be sufficient evidence.

I also recommend healthcare organizations to sign their people up for an online course on fire door inspections, by using the link and coupon code located at the right-hand side of this web-page, to the International Fire Door Inspector Association (IFDIA).


Jul 19 2017

Maintaining Testing/Inspection Documents

Category: Documentation,Questions and Answers,TestingBKeyes @ 12:00 am
Share

Q: Our organization is accredited by Joint Commission. I know for inspection purposes we need to have the current year plus that past three years of documentation for LS and EC standards such as fire extinguisher, emergency lights, emergency generator, med gas testing etc. We currently have years and years of documentation being stored. Can these be disposed of or do we need to keep it because we need to keep records of all devices? I hope I’m explaining myself well.

A: I fully understand what you’re saying and you explained yourself well. Your questions is, can you dispose of testing/inspection documents older than 3 years? Well…. I guess you could, but I certainly would not recommend it.

A couple of years ago, during a Joint Commission survey, a surveyor asked a client of mine to produce a document to ensure a particular item was replaced and retested from seven (7) years prior. Fortunately, the client was able to produce that document, but it surprised the client (and me) that a surveyor would want to look at a document that was seven years old.

I understand that Joint Commission surveyors can and often do ask for documentation that goes back 3 years, so obviously having 3-years’ worth of documentation available is a necessity. But there are other reasons to maintain testing/inspection document, such as evidence for litigation cases. While one hopes they never have to utilize documents for that reason, it is a real possibility.

When I was Safety officer at the hospital where I worked, I found strategic storage areas where I kept my old testing/inspection documents. But if you’re asking if there are NFPA codes or standards, or Joint Commission standards that require maintaining these documents for any particular length of time, I would say no… I’m not aware of that.


Jul 17 2017

Generator Testing at Business Occupancies

Q: Does a diesel generator that is located in a business occupancy require the same testing frequencies as the one at our hospital requires?

A: It depends if the generator is required by the Life Safety Code. Sections 38/39.5.1 of the 2012 Life Safety Code says utilities in business occupancies must comply with section 9.1. Section 9.1.3 says emergency generators, where required for compliance with the Life Safety code, must be tested and maintained in accordance with NFPA 110, which is the same standard requirement for healthcare occupancies.

So, the question now becomes, is the generator in your business occupancy required by the LSC? Business occupancies do not automatically require emergency power like healthcare occupancies do. For business occupancies, it depends on a variety of issues.

For new business occupancies, emergency lighting is required where any one of the following is met:

  • The building is two or more stories in height above the level of exit discharge;
  • The occupancy is subject to 50 or more occupants above or below the level of exit discharge;
  • The occupancy is subject to 300 or more total occupants.

For existing business occupancies, emergency lighting is required where any one of the following is met:

  • The building is two or more stories in height above the level of exit discharge;
  • The occupancy is subject to 100 or more occupants above or below the level of exit discharge;
  • The occupancy is subject to 1000 or more total occupants.

When emergency lighting is required it must meet the requirements of section 7.9 of the 2012 Life Safety Code. Section 7.9 does not mandate that emergency lighting be powered by a generator, but section 7.9.2.4 does say if the emergency lighting is powered by generators, then the generators must be tested and maintained in accordance with NFPA 110.

So, if your business occupancies are required to provide emergency lighting, and the emergency lighting is powered by generators, then the generator must be tested and maintained in accordance with NFPA 110, which is the same requirement as hospitals.


Jun 14 2017

Annual Test on Fire Rated Door Assemblies

Category: Fire Doors,Questions and Answers,TestingBKeyes @ 12:00 am
Share

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
Share

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
Share

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
Share

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.


Next Page »