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.

Annual Test on Fire Rated Door Assemblies

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.

Annual Fire Pump Test

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.

Life Safety Inspections at Offsite Locations

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.

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.

Weekly Fire Pump Testing

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.

Fire Alarm Test Report

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.

 

Joint Commission Quarterly Testing Requirements

Q: Do you find that TJC only enforces the quarterly plus or minus 10 days from the MONTH of last test on quarterly inspections (instead of the day)? This is what others are learning at the JCR base camps evidently, and they showed me a page from their training book, which appears to show that TJC is using the ‘month of testing’ as the basis unlike we thought when first discussed.

A: You have touched on an issue that is very interesting. The Joint Commission standards say one thing, but the Joint Commission Engineering Department says something different.

To be sure, Joint Commission has always said that their official position is only found in their standards, in their Frequently Asked Questions and in their Perspectives magazine. No other Joint Commission or Joint Commission Resources publication is official. Therefore, when referencing their ‘official’ position on quarterly testing, we must look at their Hospital Accreditation Standards.

On page EC-3 of the Joint Commission 2015 Hospital Accreditation Standards (HAS) manual, it states: “Quarterly/every quarter = every three months, plus or minus 10 days”. This implies that if the last activity was March 15, then the next activity is due June 15, plus or minus 10 days. So the window for the next activity is June 5 to June 25, or 20 days.

There is no reference in the HAS manual that the “every three months” is from the month of the last activity, just the date of the last activity. Now, representatives from the Joint Commission Engineering department have stated at various times that they are interpreting the above requirement for quarterly testing to be 3 months from the month of the last activity (not the date of the last activity), plus or minus 10 days. This means if the last activity was March 15, then 3 months from March is June, so plus ten days is July 10 and minus ten days is May 21. So, based on this interpretation, you have an open window of 50 days instead of the tighter window of 20 days.

I believe the Joint Commission Engineering Department is honestly trying to help hospitals by making an interpretation that is easier for their clients to have larger window of opportunity for quarterly testing. And who can say that is wrong? But the basic premise is the HAS standards do not clearly state that this is the official interpretation. Since the Engineering Department’s interpretation is not cited in Perspectives, the Frequently Asked Questions, or in the Standards, then it is not official.

As long as the surveyors stick with the Engineering Department’s interpretation you should not have any problems. But what happens when a surveyor holds you accountable to what their HAS standards say? Then you have no recourse since the other interpretations are not official.

Quarterly Testing and Inspection Challenges

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.

Business Occupancy Testing

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.