Jun 04 2018

Addressable Fire Alarm Systems?

Category: BlogBKeyes @ 12:00 am
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Q: Are you aware of any accrediting organization requiring the hospital to have an addressable fire alarm system installed? If so, what organizations? Please explain the rationale and any supporting code behind this decision. Background: A hospital currently has a fully functional zone fire alarm system installed but heard that accrediting organizations are requiring addressable systems. In my review of NFPA 101 2012, I cannot find anything in chapters 18 or 19 that would differ from the 9.6 reference to NFPA 72 2010.

A: There is no NFPA Life Safety Code requirement for you to have an addressable fire alarm system. There is a requirement that the hospital have a fire alarm system that meets the requirements of 19.3.4 of the 2012 LSC, but that does not include being an addressable system. As far as I know, Joint Commission, HFAP, and DNV do not require an addressable fire alarm system, and CMS does not require an addressable fire alarm system.

Now, a state or local law may exceed the NFPA minimum and require an addressable fire alarm system, but you would have to check with your state and local authorities to find that out.

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May 29 2018

Off-Site Monitoring Station for Fire Alarm Systems

Category: BlogBKeyes @ 12:00 am
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Q: I can’t seem to find anything in NFPA 72-2010 that says a facility is required to transmit a fire alarm signal to an off-site supervisory station. Our health care facility currently does not contract with an off-site station, and our procedure is to contact the fire department directly by phone when an alarm is received. Can you comment and provide some insight on this please?

A: Wait… what? This does not sound very good… What kind of healthcare facility are you? A hospital? An Ambulatory Surgical Center? According to the 2012 LSC, section 19.3.4.3.2.1 for hospitals, and section 21.3.4.3.2.1 for ASC, you need to comply with section 9.6.4 in regards to fire department notification. Section 9.6.4.2 requires that you communicate the fire alarm signal to the local fire department in one of the following methods:

  • Auxiliary fire alarm system
  • Central station fire alarm system
  • Proprietary supervising station fire alarm system
  • Remote supervising station fire alarm system

What you described is a manual transmitting system, which is not permitted for hospitals or ASCs. What I’ve observed most hospitals use is the Central Station Fire Alarm System which uses a modem to communicate to a central monitoring station that automatically relays any fire alarm signals to the local fire department. What you have described is a serious violation and one that CMS would consider to be a trigger for an Immediate Jeopardy decision. I suggest you get this resolved ASAP.

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May 18 2018

Fire Alarm System Communication

Category: BlogBKeyes @ 12:00 am
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The answer to this question was provided by my good friend Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL

Q: With the impending discontinuation of the hard copper (POTS) phone lines, and in fact many municipalities already no longer have hard copper pairs from end user to the Central Office, are we, or will we be, in violation of the NFPA code for the primary DACT connection to the CO? Our fire alarm system company is telling us we must upgrade to another form of communication; however we have an IP based phone system in all buildings and the fire alarm company documentation indicates that IP based technology is acceptable, can I simply designate two analog phone lines from our system to the DACT, eliminating the POTS connection?

A: Per NFPA 72 (2010) Chap. 26.6.3.2, Patrick would be code compliant if he continues to use phone lines for a central station connection.  However, if the vendor is saying he must upgrade, it sounds like they’re discontinuing DACT monitoring.  He should verify that with the vendor.  Most central stations have DACT, radio and cellular receivers, but some are discontinuing DACT receiving for the reasons Patrick stated.  If he’s connected to a central station that’s dropping it, he may be able to find a new central station that still has it.  If he’s directly connected to a fire department that’s dropping it, he can see if he’s allowed to use a central station for monitoring.  If they’re not dropping DACT monitoring, he can ride that horse until discontinued by the monitoring agency or the lines die, but I’d advise setting up a new method so he can control the costs before it becomes an emergency.

Switching to IP based phone lines would still use the existing DACT transmitter, but without getting too technical, it comes with a couple of conditions:

  1. There has to be a dial tone on the IP phone lines when the receiver is picked up (loop started).  If you have to dial a number to get a dial tone (ground started), you can’t use it.
  2. The DACT communication out of the fire panel must now be converted into IP packets at the source, then reassembled into digital signals at the receiver.  That means the central station must have an IP converter & the end user must install an IP converter that matches it.
  3. The power for the phone system must be backed up by the emergency generator.

Obviously, bullet #2 is where the costs comes in & it won’t be cheap.  It may seem like it shouldn’t be a big deal, but changing communication methods always involves new equipment.  The costs & legwork involved in staying with phone lines may be more than installing the upgrade, which is probably a radio.

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Mar 30 2018

Fire Alarm Pull Stations

Category: BlogBKeyes @ 12:00 am
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Q: I have a question regarding fire alarm manual pull stations. In our multi-level long term health care facility, we added a new building onto the existing building. At the point where the old building and the new addition connect, there is a 2-hour fire-rated barrier with fire-rated doors that are held-open with magnets. Do we need pull stations within 5-feet of those doors? Both buildings are fully sprinkled and both have a fire alarm system. My reading of the code says that they would have to have pull stations on either side of the building separation wall door assemblies as one should be able to pull a pull station while in the act of leaving one building and going into another. Am I correct?

A: I’m not sure I agree with you, but let’s think this through…. NFPA 72 (2010 edition) section 17.14.6 discusses the location and spacing of fire alarm pull stations. In this section it says pull stations must be located within 5 feet of the exit doorway opening at each floor. So, if the 2-hour separation between the two buildings is in fact a horizontal exit, then I would agree with you that pull stations would have to be mounted within 5 feet of the exit, on both sides of the 2-hour wall. However, if the 2-hour separation between the two buildings is not classified as a horizontal exit, and it is simply a building separation, then I do not see where the standard requires a pull station.

You may ask what is the difference between a building separation and a horizontal exit if they are both 2-hour fire rated, and the answer is a new horizontal exit does not allow any HVAC duct to penetrate the barrier, unless the building on both sides of the barrier is fully protected with automatic sprinklers. Other than that, there really isn’t much difference, other than the name applied to the barrier by the designing architect.

I can see your point that it appears you are ‘exiting’ one building and entering another at this barrier, and a pull station would be required. But if it is not a designated horizontal exit, I think that should be sufficient for an AHJ to not require a pull station. But, what is the cost of adding pull stations at this barrier even if the standard does not require them? If you feel more comfortable, go ahead and add them.

Other pull station location requirements in the standard says the travel distance to the nearest pull station cannot exceed 200 feet, and if you have a group opening (office cubicles) over 40 feet wide, then you need pull stations on each side of the openings. Also, section 18/19.3.4.2.2 in the 2012 edition of the Life Safety Code says a pull station may be mounted at the nurse station in patient sleeping areas in lieu of being mounted within 5 feet of an exit, provided the nurse station is continuously attended by staff, and the 200 foot travel distance is maintained.

So, the conclusion is… go ahead and mount pull stations at the building separation if it makes you more comfortable, but I’m not sure it is needed. I recommend that you consult with your local and state authorities to gain their interpretation.

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Jan 16 2018

Positive Alarm Sequence

Category: BlogBKeyes @ 12:00 am
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I was reviewing some new standards and came across the Positive Alarm Sequence (PAS) issue for fire alarm systems, that the 2012 LSC now permits in fully sprinklered healthcare occupancies (see 18/19.3.4.3 and 9.6.4.3 of the 2012 Life Safety Code), provided it is in accordance with NFPA 72-2010.

The PAS (section 23.8.1.3.1.1 of NFPA 72-2010) is designed to allow the facility a 3-minute delay in annunciation of the fire alarm signal, to allow them time to investigate whether the alarm is a nuisance alarm. The PAS option first became available for use on non-healthcare occupancies in the 2003 edition of the LSC, and then became available for use in healthcare occupancies in the 2006 edition. It is now available to all healthcare occupancies, ambulatory healthcare occupancies, and business occupancies since CMS adopted the 2012 Life Safety Code on July 5, 2016. So, this is something that may be a new concept to many facility managers.

The sequence of operation for the PAS is as follows:

  1. The fire alarm control panel must have the PAS feature an integral part of the programmable control system of the panel. The PAS is not a feature that can be used on older systems that were not originally equipped with it.
  2. To initiate the PAS operation, the signal from an automatic fire detection device selected for PAS operation shall be acknowledged at the fire alarm control unit by trained personnel within 15 seconds of annunciation. Usually any general alarm fire alarm initiating device would activate the PAS operation.  Supervisory or “off normal” conditions wouldn’t activate the PAS.  The only time you wouldn’t have an alarm event activate the PAS would be a general evacuation device, like a key switch monitored by the fire alarm system, that’s intended to signal an immediate evacuation of the hospital.
  3. If the signal is not acknowledged within 15 seconds, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  4. If the PAS operation is initiated in accordance with 23.8.1.3.1.1, trained personnel shall have an alarm investigation phase of up to 3-minutes to evaluate the fire condition and reset the system. The term ‘trained individuals’ means you need to have individuals who are trained to respond properly and immediately. No certifications or licenses are required for this function. The training includes in-house procedures that involve investigation within a certain timeframe, as well as training on use of the fire alarm annunciator and how the PAS is programmed to operate.
  5. If the system is not reset during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  6. If a second automatic fire detection device selected for PAS is actuated during the alarm investigation phase, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  7. If any other fire alarm initiating device is actuated, notification signals in accordance with the building evacuation or relocation plan and remote signals shall be automatically and immediately activated.
  8.  The system shall provide means for bypassing the PAS.

Obviously, in order for the PAS operation to function properly, someone needs to be near the fire alarm control panel or a remote annunciator, so the trained individual who’s monitoring the system may take the appropriate action. If your fire alarm control panel or a remote annunciator is not continuously monitored, then the PAS function would not be suitable for your facility.

The 3-minute phase of investigation to evaluate the alarm condition, can be done with multiple individuals. An example may be one individual at the control panel and one in the field, communicating via walkie-talkies in order to make a decision to reset the panel before the 3-minutes expire, or to allow the alarm annunciation to continue.

Although the PAS function is permitted, caution is recommended before you implement this operation. The PAS can devolve into an automatic reset by the staff to give them more time to investigate, with the intent of pulling a manual station if there is indeed a problem, or worse, to let it go back into alarm as a means of verification.

If you are wondering whether or not CMS allows PAS operation the answer is yes, they do. Although CMS has not officially commented on this issue, they have to allow it since it is permitted by the 2012 LSC. Unless they specifically dis-allow something that is permitted by the LSC, then it is permitted, as long as it applies to the applicable occupancy. Unless they say otherwise, they follow NFPA to the letter. Examples of them saying otherwise involved the 4-inch corridor projection issue (vs. 6-inch what LSC allows); roller latches in certain corridor doors (2012 LSC still allows roller latches in certain corridor doors); and 1 or more patients incapable of self-preservation in Ambulatory Health Care Occupancies (vs. 4 or more). They have published S&C memos or addressed these issues in the Final Rule to adopt the 2012 LSC.

This means your accreditation organizations will allow PAS operations as well, unless of course they specifically have said they dis-allow it. For Joint Commission accredited organizations, their new EP 4 under LS.02.01.34 (2018 CAMH manual) specifically does permit PAS operation, in buildings that are fully protected by sprinklers.

Before you make plans or changes to implement PAS operation, check with your state and local authorities to determine if they have any restrictions on the use of PAS operation.

Gene Rowe, Director of Business Development for Affiliated Fire Systems, Inc., Downers Grove, IL, contributed to this article. You may reach Gene at generowe@affiliatedinc.com

 

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Mar 25 2016

Fire Alarm System in a Business Occupancy?

Category: BlogBKeyes @ 12:00 am
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Q: We have a physician practice that currently has fire extinguishers and a “panic button” that contacts 911. We do not have fire alarms, smoke detectors or a sprinkler system. Are we required to have any of those in the practice?

A: The answer is… maybe yes and maybe no. Sorry; that’s not much of an answer, but not all offsite small business occupancies actually require a fire alarm system.

If the physician practice is truly a business occupancy, meaning there is no procedures being conducted where patients are rendered incapable of self-preservation, then section 39.3.4.1 of the 2000 Life Safety Code says this for existing conditions:

A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following conditions exists:

  • 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 1,000 or more total occupants.

For new construction in business occupancies (meaning new construction or renovation documents approved by local authorities after March 11, 2003), section 38.3.4.1 of the 2000 Life Safety Code says this:

A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following conditions exists: 

  • 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.

 

The occupant capacity is calculated by taking the total gross area of the floor (or building) in square feet, and dividing it by 100 square feet per person. So, a 5,000 square foot story would have an occupant load of 50 persons.

So, as you can see, if the physician practice is a business occupancy and meets the requirements for a new or existing occupancy, then a fire alarm system is not required, according to the Life Safety Code.

Sprinkler systems are not required in business occupancies, whether they are new construction or existing construction.

Now, there may be other codes or standards that you need to comply with, so please check with your local and state authorities to determine what their requirements are.

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Jan 15 2016

Visual Inspection of Fire Alarm Devices

Category: BlogBKeyes @ 12:00 am
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Q: A question came up recently on the NFPA 72 semi-annual visual inspections required for fire alarm system devices. Would the printed records from an intelligent fire alarm system suffice for the visual inspections on devices such as smoke detectors, pull stations and heat detectors?

A: I would say no, the printed records from an intelligent fire alarm system would not suffice for a visual inspection on the fire alarm system devices. Items such as the following must be visually inspected twice a year on a semi-annual basis:

Initiating Devices

  1. Duct Detectors
  2. Electromechanical Releasing Devices
  3. Fire-Extinguishing System(s) or Suppression

System(s) Switches

  1. Fire Alarm Boxes
  2. Heat Detectors
  3. Radiant Energy Fire Detectors
  4. Smoke Detectors

The reasoning for this decision is found in the NFPA 72 handbook, which states: “The visual inspection is made to ensure that there are no changes that effect equipment performance. Equipment performance can be affected by building modifications, occupancy changes, changes in environmental conditions, device location, physical obstructions, device orientation, physical damage, improper installation, degree of cleanliness, or other obvious problems that might not be indicated through electrical supervision.”

It is not uncommon to find ancillary hospital equipment placed or installed in such a way as to affect or obstruct the normal operation of some of these devices. Semi-annual visual inspections will find these issues before they affect the performance of the fire alarm system.

Generally speaking, the printed records from an intelligent fire alarm system would only suffice for documentation on the 2-year sensitivity testing requirement. Everything else would have to be confirmed through direct observation.

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Jan 01 2016

Visual Inspection of Fire Alarm Devices

Category: BlogBKeyes @ 12:00 am
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Q: A question came up recently on the NFPA 72 semi-annual visual inspections required for fire alarm system devices. Would the printed records from an intelligent fire alarm system suffice for the visual inspections on devices such as smoke detectors, pull stations and heat detectors?

A: I would say no, the printed records from an intelligent fire alarm system would not suffice for a visual inspection on the fire alarm system devices. Items such as the following must be visually inspected twice a year on a semi-annual basis:

Initiating Devices

  1. Duct Detectors
  2. Electromechanical Releasing Devices
  3. Fire-Extinguishing System(s) or Suppression

System(s) Switches

  1. Fire Alarm Boxes
  2. Heat Detectors
  3. Radiant Energy Fire Detectors
  4. Smoke Detectors

The reasoning for this decision is found in the NFPA 72 handbook, which states: “The visual inspection is made to ensure that there are no changes that effect equipment performance. Equipment performance can be affected by building modifications, occupancy changes, changes in environmental conditions, device location, physical obstructions, device orientation, physical damage, improper installation, degree of cleanliness, or other obvious problems that might not be indicated through electrical supervision.”

It is not uncommon to find ancillary hospital equipment placed or installed in such a way as to affect or obstruct the normal operation of some of these devices. Semi-annual visual inspections will find these issues before they affect the performance of the fire alarm system.

Generally speaking, the printed records from an intelligent fire alarm system would only suffice for documentation on the 2-year sensitivity testing requirement. Everything else would have to be confirmed through direct observation.

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Sep 23 2015

Heat Detector Spacing From an Air Diffuser

Category: BlogBKeyes @ 12:00 am
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Heat Detector imagesALEXIFM2A reader recently asked me where in NFPA 72 does it say that heat detectors have to be a minimum of 36 inches away from an air diffuser. He could not find the standard reference and asked if I could point him in the right direction.

Well…. I think he had a point, since there is no requirement in NFPA 72 that says heat detectors have to be 36 inches away from air diffusers. Section 2-3.5.1 and section A-2-3.5.1 of NFPA 72-1999 says spacing for detectors from air diffusers (supply and return) must be 3 feet. This section (NFPA 72 2-3) is referring specifically to smoke detectors, and section NFPA 72 2-2 refers specifically to heat detectors and there is no similar language in section 2-2 concerning minimum distance from air diffusers for heat detectors.

Therefore, one can conclude that heat detectors do not have to comply with the 3 foot spacing from air diffusers like smoke detectors. But that is not how all of the AHJs interpret this. The actual spacing (3 feet) for smoke detectors is found in the Annex section of the standard which is explanatory information and not part of the enforceable standard. But AHJs are free to use this information in the Annex section in determining compliance with the standard. Therefore, AHJs can interpret this section how they want, and many of the AHJs interpret that you need to maintain 3 feet from air diffusers for both smoke and heat detectors.

If you get cited, you can fight the finding by pointing out the reference in the Annex section is only for smoke detectors, but ultimately the AHJs get to interpret this the way they want, and you may end up losing anyway.

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Feb 26 2015

Expert Witness

Category: BlogBKeyes @ 5:00 am
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imagesXLH1EQVPI received a telephone call recently from a lawyer that asked me if I would be willing to serve as an expert witness in a pending litigation suit. The situation of the lawsuit is a patient who was admitted to the inpatient psychiatric unit of a hospital busted the protective cover over the fire alarm manual pull station, and activated the fire alarm system. The entrance doors to the psychiatric unit unlocked on the fire alarm, and the patient ran out, climbed to the roof of the facility and jumped off.

Now the family of the patient is suing the hospital and the fire alarm company who installed the interface between the door locks and the fire alarm system. The plaintiff’s lawyer is arguing that the interface should never have been installed and the doors should not have unlocked upon activation of the fire alarm system. I agree with the plaintiff’s lawyer, but the problem is, it was the defense’s lawyer who contacted me.

The two major codes and standards that apply in this situation are the NFPA 72 National Fire Alarm Code (1999 edition), and the NFPA 101 Life Safety Code (2000 edition). The Life Safety Code (LSC) allows clinical needs locks on doors in the path of egress, but only in healthcare occupancies (hospitals). They are not permitted in any other occupancy. These types of locks are permitted where the “clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times”. Clinical needs locks are permitted for Behavioral Health units, such as psychiatric and Alzheimer units, to prevent patients from leaving the unit unauthorized, and potentially harming themselves or others.  Clinical needs locks requires all staff who work on that unit (which includes physicians, nurses, aids, clerical, maintenance, foodservice, housekeeping, etc.) to have a key or device to unlock the door on their person at all times. [Code reference: 19.2.2.2.4, Exception No. 1, 2000 edition of the LSC].

But when it comes to connecting those clinical needs locks to the fire alarm system so they automatically unlock on a fire alarm activation, the codes are not so clear. Other permissible locks, such as delayed egress locks and access control locks, are required by code to be connected to the fire alarm system and automatically unlock the door whenever there is an alarm. However, there is no such similar language for clinical needs locks to unlock on an alarm. In addition, NFPA 72 section 3-9.7.1 and 3-9.7.2 says if you have a lock on an exit door it must be connected to the fire alarm system, and it must unlock the door on a fire alarm. However, the exception to 3-9.7.2 essentially says this is not required if an AHJ says so, or if another code says so. So, we go back to the Life Safety Code, and we see that delayed egress locks and access control locks are required to unlock on an alarm, but the section on clinical needs locks is very silent on the subject. When a code is silent on a subject that means it is open for interpretation. Therefore, section 3-9.7 of NFPA 72 does not apply to clinical needs locks in a hospital, because the interpretation Life Safety Code permits it. It is documented that psychiatric patients are astute enough to actuate a fire alarm to unlock the exit doors. Therefore, the code is available to be interpreted in such a way to not require clinical needs locks to unlock the doors in the path of egress on activation of the fire alarm system provided all staff carry a key to unlock the door in case of an emergency.

But who makes that interpretation? Usually the authorities having jurisdiction (AHJ) makes that interpretation. Section 4.6.1.1 of the 2000 LSC says the AHJ shall determine whether the provisions of the LSC are met. But when the AHJ does not issue an interpretation, then it is up to the individual organization’s to decide. As far as I know, there is no national AHJ for healthcare that has it written in their standards that clinical needs locks should not be connected to the fire alarm system. Therefore, the hospital needs to ask the question: Based on the potential risk to patient safety, is it best to connect the door locks on the psychiatric unit to the fire alarm system so they unlock upon activation of the fire alarm system?

I declined the offer to be an expert witness for the defense, and suggested they settle the lawsuit out of court.

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