Jul 18 2018

Fire Extinguishers

Category: BlogBKeyes @ 12:00 am

Q: Are portable fire extinguishers required in business occupancies?

A: Yes… Section 38.3.5 of the 2012 Life Safety Code says portable fire extinguishers must be provided in every business occupancy in accordance with Section references NFPA 10 for installation, inspection, and maintenance of portable fire extinguishers.


Jun 29 2018

Fire Extinguisher Signs

Category: BlogBKeyes @ 12:00 am

Q: I was wondering if there was a specific regulation that states exactly where fire extinguisher signs need to be located. Is there a difference between patient area and staff area? Looking over the new Life Safety Code regulations I have not been able to get a specific answer on where signage location is mandatory.

A: The only thing I can find is section of NFPA 10-2010, which says where visual obstructions of fire extinguishers cannot be completely avoided, means shall be provided to indicate the extinguisher location. The Annex section says acceptable means of identifying the fire extinguisher locations include arrows, lights, signs, or coding of the wall or column.

 So, while there is no direct requirement to install signs over fire extinguishers, you may do so. However, be aware: Some AHJs will expect signs identifying the locations of all extinguishers once you start using signs. Their logic is, if you use signs to identify the location of some extinguishers, then your staff will expect to see signs for all extinguishers.

The AHJs do have the right to interpret the code as they see fit. I suggest you ask your AHJs to see if they would require all of the extinguishers have signs.

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Apr 02 2018

4-Inch Corridor Projection

Category: BlogBKeyes @ 12:00 am

Q: With the adoption of the new 2012 Life Safety Code by CMS, we had a discussion about projections from the corridor wall. Since the LSC only allows projections to be 4 inches, the question that came up was in regards to fire extinguishers mounted to the wall and not recessed as they project out from the wall about 7 inches. Will we be required to recess them or will they be allowed? The same question was raised about wall mounted telephones?

A: Actually, the 2012 LSC allows a 6-inch projection into the corridor [see], but CMS’ Final Rule published May 4, 2016 said they will enforce the more restrictive 4-inch maximum projection into the corridor, based on the Americans with Disabilities Act (ADA). For all healthcare facilities that receive Medicare & Medicaid funds, they must comply with CMS’ exception to the 2012 LSC.

To answer your question, there are no exceptions to the 4-inch maximum projection rule. So, anything projecting more than 4 inches into the corridor, including fire extinguishers and telephones, would likely be cited by a surveyor or inspector.

I read a survey report just the other day where the surveyor cited the hospital for having an ABHR dispenser that projected into the corridor by 4 1/4 inches. So, AHJs are citing anything that projects more than 4-inches into the corridor, including fire extinguishers.

This may be a good opportunity to consider oval-shaped fire extinguishers that do not project more than 4 inches into the corridor. Take a look at these compliant fire extinguishers from Oval brand: http://ovalfireproducts.com/


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Jul 04 2016

New Fire Extinguisher Inspection Frequency

Category: Questions and AnswersBKeyes @ 12:00 am

Q: I could’ve sworn I read somewhere that a monthly fire extinguisher inspection shall be done within 30 days AND that there is to be a 10 day grace period… For example, If the date of a tag showed Jan.31, the next inspection date permitted would be Feb.9th?   You can write down Jan. 31 and then Feb. 1st for the next inspection. Also, If a date is written May 13th, the next date needs to be done BY June 23rd? 10 day grace period from the previous monthly inspected date. Am I wrong or confused on this, I can’t seem to find the language in NFPA 10.


A: Not every AHJ agrees on the Fire Extinguisher monthly inspection issue. Joint Commission will allow the FE to be inspected anytime during the calendar month, which means if it was inspected on January 1 the next inspection could be anytime in February including February 28. However, that also means the FE could be inspected on January 31 and then next on February 1. That is not desirable and will likely receive the attention of a surveyor.

I know CMS does not like the formula used by Joint Commission, and they will follow what the standard requires. NFPA 10-2010, section says extinguishers are required to be inspected manually or by electronic monitoring at a minimum of 30-day intervals. The Annex section for continues to say inspections are performed on extinguishers 12 times per year, once a month.

So, I can see your state agency who surveys on behalf of CMS to require a minimum of 30 days between the monthly inspections, but each extinguisher needs to be inspected monthly. So, this may be a problem for February… If the extinguisher was last inspected on January 31, then 30 days from January 31 is March 2 (or March 1 if it is a leap year). You can’t inspect it less than 30 days but you have to inspect it every month. That’s a Catch-22. Be careful you don’t get caught in that unique trap.

There is no 10-day grace period in NFPA 10.








Apr 01 2016

Fire Extinguisher Cabinet Labeling

Category: BlogBKeyes @ 12:00 am

Q: Our hospital was surveyed recently and one of our deficiencies was that our fire extinguisher cabinets were not labeled. I can find nothing in the Life Safety Code stating this as a requirement. Could you please assist in this matter? Also, if labeling is required would the wall mounted “tent” type placards that are hung on the wall above the cabinets be acceptable?

A: Yes, NFPA 10 (1998 edition), section 1-6.12 says:

Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously.

Sections and of the 2000 Life Safety Code reference NFPA 10 as a requirement for fire extinguishers. So the expectation is you need to comply with NFPA 10.

NFPA 10 does not specify how the fire extinguisher cabinet is to be marked, but it must be marked conspicuously. A 3-deminsional arrow (tent-card style) certainly meets this requirement, but other types of markings do as well, such as painting all extinguisher cabinets red. Most authorities will accept whatever means you choose to use, as long as all the extinguisher cabinets are marked the same way, for continuity.


Feb 26 2016

Certification for Annual FE Maintenance?

Category: BlogBKeyes @ 12:00 am

Q: I read in one of your posts that the annual maintenance service of fire extinguishers does not require to be conducted by a “certified” individual.  I was under the impression that the annual servicing or recharging of a fire extinguisher must be done by a certified individual. I know the monthly can be done by anybody but I thought the annual was different. Was this requirement recently changed?

A: According to NFPA 10 (1998 edition) section 4-1.4, it says annual maintenance, servicing and recharging shall be performed by trained persons having available the appropriate servicing manuals, the proper types of tools, recharge materials, lubricants, and manufacturer’s recommended replacement parts or parts specifically listed for use in the fire extinguisher. Nowhere does it say the person has to be certified.

However, there was a change as you questioned. NFPA 10 (2010 edition) section does say the person performing the annual maintenance and recharging must be certified. So when the 2012 Life Safety Code is finally adopted, that’s when the 2010 edition of NFPA 10 becomes effective and the annual maintenance and recharging must be accomplished by a certified individual.

The Annex section of NFPA 10 (2010 edition) says persons performing annual maintenance and recharging of extinguishes should meet one of the following criteria:

  1. Factory trained and certified for the specific type and brand of portable fire extinguisher being serviced
  2. Certification by an organization acceptable to the authority having jurisdiction
  3. Registration, licensure, or certification by a state or a local authority having jurisdiction

Certification confirms that a person has fulfilled specific requirements as a fire extinguisher service technician and has earned the certification. Supporters of this change wanted the technicians to be certified to ensure the portable fire extinguishers will function properly when needed. Those who opposed this change stated it was championed by a special interest group, to ensure more work would be directed to their constituents.

For whatever reason, the change will be law once the new 2012 LSC is adopted.


Jan 27 2016

Strange Observations – Part 2

Category: BlogBKeyes @ 12:00 am

FE With Blurred InstructionsContinuing in a series of strange things that I have seen while consulting at hospitals….

This is a picture of a fire extinguisher that was located in a laboratory. The staff did a terrific job of cleaning the lab, but the chemicals they used where too harsh on the extinguisher label. Take a close look and you will see the printed instructions were all blurred from the corrosive chemicals in the cleaning agent.

While the extinguisher would still operate correctly in an emergency, it no longer met the requirements of NFPA 10-1998, section 1-6.11 that requires the instructions to be facing outward and be clearly visible.


Feb 05 2015

Fire Extinguisher Documentation

Category: BlogBKeyes @ 6:00 am

fire-extinguisher-sm[1]A surveyor recently cited an organization stating the hospital did not have a document indicating all of the portable fire extinguishers were inspected on a monthly basis. The surveyor asked for a document whereby the organization knows where each portable fire extinguisher is located, and assurance that each extinguisher received its monthly inspection. The hospital did not have such a document and the surveyor cited them for non-compliance with the standard that addresses portable fire extinguishers.

A subsequent conversation with the facility manager of the organization revealed that every portable fire extinguisher that the surveyor inspected did in fact have an annual maintenance tag with the monthly inspections properly identified on each extinguisher. Apparently, the surveyor thought the hospital should have a master list indicating the locations of each portable fire extinguisher, along with documentation that they were inspected monthly. This master list indicating the locations of all the fire extinguishers is a fine idea, but it is not a requirement for compliance with any NFPA code or standard, nor any accreditation organization’s standard. This is what is called “Best Practice” and is not required to be enforced upon the healthcare organizations. Best Practice may be shared with the organization by the surveyor as a suggestion on how they may make improvements, but it is not a requirement. Be assured that NFPA codes and standards do require documentation of the monthly inspections of the fire extinguishers, but they do not stipulate how that inspection is to be documented. Some hospitals like to use the bar-code method to document the inspection, but the most common approach to document this monthly inspection is to mark the date (month and day) along with the initials of the inspector on the annual maintenance tag attached to the extinguisher.

This finding was removed from the survey report during the clarification process.

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Aug 08 2013

Changes with Portable Fire Extinguishers When the New 2012 LSC is Adopted

Category: Blog,Life Safety Code UpdateBKeyes @ 5:00 am

There will be significant changes for facility managers to deal with when the Centers for Medicare & Medicaid Services (CMS) finally adopts the 2012 edition of the Life Safety Code. This excerpt from a new upcoming book by Brad Keyes and published by HCPro, titled “Preparing for the New Life Safety Code” discusses changes involving the life safety equipment.

fire-extinguisher-sm[1]Portable fire extinguishers may be the most over-looked and taken-for-granted component of fire safety in a healthcare facility today. Perhaps it is because for the most part, they are out-of-sight, out-of-mind? No, they are never really out-of-sight, but there are so many of them in a healthcare facility that individuals may tend to over-look them in the same manner as one may overlook the trees in a forest. Other than the security officer or the maintenance technician who is assigned to inspect fire extinguishers on a monthly basis, most people do not give them a second thought, until they are needed.

The 2000 edition of the Life Safety Code (LSC) referenced the 1998 edition of NFPA 10 Standard for Portable Fire Extinguishers, which is one of the oldest referenced standards that healthcare organizations have to comply with. There have been 3 revisions to this standard since then, and the 2012 edition of the LSC references the 2010 edition of NFPA 10.

Once the 2012 edition of the LSC is finally adopted, NFPA 10 will have changes that every facility manager will need to know. While some of the following items may appear to be requirements that organizations must already comply with, they do represent a change in the standard:

  • Other than wheeled extinguishers, portable fire extinguishers must be securely installed on the bracket or hanger provided by the manufacturer, or on a listed bracket for that purpose; or placed in a cabinet; or placed in a wall recess. (Placing the extinguisher on the floor, table, desk or other such item will no longer be permitted.)
  • Extinguishers installed under conditions where they may be subject to physical damage or dislodgement, must be installed in manufacturer’s strap-type bracket designed specifically for protection
  • The extinguisher must be mounted in such a way that the manufacturer’s operating instructions must be located on the front and clearly visible
  • Electronic monitoring of extinguishers is permitted
  • Non-rechargeable fire extinguishers must be removed from service no more than 12 years from the date of manufacture
  • Halogenated agent fire extinguishers (Halon) must be limited to applications where clean agent is necessary to extinguisher a fire without damaging equipment
  • Persons performing maintenance and recharging of fire extinguishers must be certified by one of the following criteria:
    • Factory training and certified
    • Certified by an organization acceptable to the AHJ
    • Licensed, certified or registered by a local or state AHJ

(Persons performing the monthly inspection are not required to be certified.)

  • Discharge hoses on wheeled units must be coiled in such a manner to prevent kinks and allow rapid deployment
  • Hoses on wheeled-type extinguishers must be completely un-coiled and examined for damage during the annual maintenance procedure

Electronic monitoring of fire extinguishers is permitted in lieu of physical monthly inspections. Procedures for monthly inspections have been changed for non-wheeled, rechargeable extinguishers to accommodate electronic monitoring systems, and now only requires:

  • Extinguisher is located in its designated place
  • Access to and visibility of extinguisher is not obstructed
  • Pressure gauge reading is in the proper range
  • Fullness determined by weighing

Dropped from the monthly inspection list is the following:

  • Confirming that the operating instructions are facing outward
  • Ensuring the safety seals and tampers indicators are not broken or missing
  • Examination for obvious physical damage, corrosion, leakage or clogged nozzles.

imagesCAIP9B6BProbably the largest impact of change in fire extinguishers to the average facility is the electronic monitoring that will be permitted once the 2012 edition of the LSC is finally adopted. Manufacturers of these specialized monitoring cabinets have sensors to ensure nothing is parked in front of the cabinets; special listed mounted brackets to determine the weight and presence of the extinguisher; and pressure sensors integrated with the extinguisher to monitor pressure ranges. These specialized monitoring cabinets communicate back to a central monitoring area, and have proven to be very useful in high-theft areas.

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Nov 29 2012

Fire Extinguisher Training

Category: BlogBKeyes @ 5:00 am

Fire extinguisher training… Is it required in healthcare organizations? And what level of training is required? Is hands-on training required where the discharge of the extinguisher is acheived? Or is a simple training module from a computer based learning program all that is required? Well, the answers to those questions depend on which authority having jurisdiction (AHJ) is asked.

Starting with the Joint Commission, they have no standards that specifically state the healthcare organization needs to conduct fire extinguisher training. But that does not mean that they do not require some sort of extinguihser training for the staff. EC.03.01.01, EP 2, says (in part): “The actions required in the event of an environment of care incident can be demonstrated or described by staff.” If a surveyor interviews your staff and concludes that a sampling (how many are a sampling…? 2 or more) cannot describe or demonstrate the proper use of a portable fire extinguihser, then you can expect a finding under this standard.

Likewise, the Centers for Medicare & Medicaid Services(CMS) has very similar language under standard 482.41(b)(7), which says: “The hospital must have written fire control plans that contain provisions for prompt reporting of fire; extinguishing fires; protection of patients, personnel and guests; evacuation; and cooperation with fire fighting authorities.” The survey procedures guideline for this standard requires the inspector to interview staff throughout the facility to verify their knowledge of their responsibilities during a fire. If a staff member cannot adequately describe the proper procedure to operate a fire extinguisher, then that may lead to a finding. This is nearly the same as the Joint Commission standard and process to determine compliance.

OSHA has something to say about fire extinguisher training as well: Section 1910.157(g)(1) says: “Where the employer has provided portabkle fire extinguishers for employee use in the workplace, the employeer shall also provide an educational program to familiarize employees with the general principals of fire extinguisher use and the hazards involved with incipient stage fire fighting.”

While the above AHJs do not require hands-on training, I am aware of at least one other AHJ that does: The College of American Pathologists (CAP) who accredits laboratories, apparaently has a standard whereby all laboratory staff members have to have annual hands-on fire extinguisher training. I am not an expert in CAP standards, but I have been told that this standard does exist in their manual by more than one individual.

Training can be accomplished by a wide range of methods: From the simple and easy-to-adminsiter computer-based learning modules to the more extensive and impressive fires set in the back lot where staff are encouraged to grab an extinguisher and attempt to extinguish the fire. There are also power-point presentations on extinguisher use and safety, along with computer videos where an extinguisher adapted with a laser is pointed at the screen to simulate the use of an extinguisher. Whatever the process you decide to use, you need to customize your training sessions to meet your needs, expectations and resources. There are advantages and disadvantages to these different types of training, and not the least to consider is cost and time required to implement the training. The computer-based learning module is cost affordable and easy to adminster, but it is proven to be the least effective way for people to learn. Hands-on training is usually the most effective way people learn, but getting everyone to the training can be costly and difficult.

If you are interested in a training video for fire extinguisher safety, I learned of an independent company called Compliance and Safety, based out of Middletown, Delaware. They are one of the top suppliers for safety training videos on the market today. While I do not endorse individual products or services, I do find their website informative on a variety of methods for fire extinguisher training. Check then out at: http://complianceandsafety.com/blog/fire-extinguisher-powerpoint/



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