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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Dec 23 2015

Joint Commission Quarterly Testing Requirements

Category: BlogBKeyes @ 12:00 am
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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.

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Oct 16 2014

Fire Alarm System Interface Relays

Category: BlogBKeyes @ 6:00 am
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Fire Alarm Interface RelayOut of sight is out of mind. It is the master illusionist’s greatest asset. He gets you looking at something that is distracting your attention away from the object at hand, and before you know it he makes it seem that through a magical intervention, something appears. Or disappears. Or… whatever. The point is, while your attention is located elsewhere, something else happened that you did not notice.

When I was a kid they called that a trick. Actually, it still is a trick, but now they call it something else, like an illusion. Harry Houdini was first called a magician before he was called an escape artist. But I don’t remember seeing anything in print where they called him an illusionist. The word “illusionist” sounds so much nicer and professional for today’s environment than “magician”. But, I digress… That seems to have very little to do with what I want to share today.

A review of the survey deficiency reports indicates surveyors are looking for documentation that the hospital has tested the interface relays and modules on the fire alarm system. I guess that’s the bridge between the illusions and the interface relays: You can’t see them. The interface relays are “out-of-sight and out-of-mind”. If you can’t see them, you tend to forget they are there, and then they are not included in the fire alarm testing report.

Many facility managers rely on the fire alarm contractor to provide a complete test report without actually checking what was tested. This is a grave mistake. No offense to fire alarm testing contractors, but you should never rely on their advice or opinion on the level of testing. You (as the facility manager) have to be smarter than the fire alarm testing contractor to ensure they did everything correctly. They don’t necessarily know what codes and standards (or what editions) you need to comply with, but you should know. That makes you the expert.

Not long ago I was consulting in a hospital and reviewing their fire alarm test report. The report failed to indicate that they tested their interface relays. I asked the facility manager about it and he called the sales representative from the fire alarm testing contractor who happened to be nearby. He stopped in while I was there and I asked him why they did not test the interface relays. He said he knew they were supposed to be tested, but told me (and this is a direct quote): “The hospital would not let me test them”. This surprised the facility manager and myself, and the sales rep explained further.

“We had to bid our services to the hospital based on a request for proposal. Nothing in the request indicated that the interface relays were included. We submitted a bid strictly based on what was requested in the proposal. Had we added anything that was not requested, we would not have been awarded with the contract.”

Some would say that the fire alarm testing contractor was unethical for not informing the hospital of all the items that needed to be tested that were not included in the RFP. I don’t know if that is unethical or not, but I will tell you this: That hospital got exactly what it asked for in the RFP. Unfortunately.

So, back to the point: Get those fire alarm interface relays included in the fire alarm testing process and document each one individually, with a “Pass” or a “Fail” notation. Here is a list of the most common interface relays used in hospital fire alarm systems:

  • Magnetic hold-open devices
  • Air handler shutdown
  • Kitchen hood suppression system
  • Elevator recall
  • Magnetic locks
  • Fire pump
  • Smoke dampers
  • Clean agent suppression systems
  • Sprinkler dry pipe/pre-action systems
  • Overhead rolling fire doors

Take a look at your latest fire alarm test report. Does it include interface relays? If not… better get on the phone to the company or individual conducting the testing for you.

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Oct 02 2014

Private Fire Service Mains

Category: BlogBKeyes @ 6:00 am
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imagesS9VJZMEONFPA 25 (1998 edition), section 4-3.1 has a requirement listed to test the Private Fire Service Mains once every 5 years. The standard says the test must be performed on exposed fire service mains and underground fire service mains. The handbook that accompanies the NFPA 25 standard explains this water-flow test on the private fire service mains applies to only private exposed and underground fire service mains that are outside the facility, such as piping to a private fire hydrant. The piping inside the facility is covered under a different section of the NFPA 25 standard.

The Annex section A-4-3.1 of NFPA 25 says this flow test can be performed through yard fire hydrants; a fire department connection (once the check-valve is removed); and other connections. Typically, the test is conducted at a fire hydrant that is connected to the private fire service mains due to it accessibility. The test must be able to measure flow in gallons per minute (GPM), and the results are measured against the original acceptance data. The key thing to understand at your facility is whether or not you own the fire hydrants that are close to your building, or if they are owned by the city or municipality. Surprisingly, many facility managers simply do not know. If they are privately owned, then you need to conduct the 5-year private fire service main flow test.

Nat all surveyors are asking to see this documentation during a survey, but it is becoming a more frequent request. Remember: The 2000 Life Safety Code, section 9.7.5 requires compliance with the entire NFPA 25, so everything in the standard must be followed as long as you have the equipment.

Not all accreditation organizations are consistent in reviewing this documentation, but as time progresses, you will see more and more surveyors ask to review this test report. This 5-year private fire service main water-flow test should not be confused with the annual water-flow of the private fire hydrants and the 5-year internal inspection of sprinkler piping.

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Jul 17 2014

Follow-Up on Documentation

Category: BlogBKeyes @ 5:00 am
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imagesIDI1GACXMy recent series of articles on Documentation created quite a bit of response. One individual had this question:

“What is your opinion of documentation being kept electronically rather than in hard copy format?  We will have things organized and easy to find and search, but I don’t want to go through the process of electronic files if a surveyor is going to request hard copies.”

My understanding is most authorities will accept electronic documentation provided it meets all of the requirements for documentation. Many AHJs have specific requirements concerning what’s included in the documentation, such as:

Testing & Inspection- Documentation.

Unless otherwise stated, testing, inspection and maintenance documentation must include, at the minimum, the following information:

  1. Name of individual performing the activity
  2. Affiliation of the individual performing the activity
  3. The signature of the individual performing the activity
  4. Activity name
  5. Date(s) (month/day/year) that activity was performed
  6. The frequency that is required of the activity
  7. The NFPA code or standard which requires the activity to be performed
  8. The results of the activity, such as ‘Pass’ or ‘Fail’

An electronic signature typically would be acceptable in lieu of a hand-written signature. That usually means the technician performing the work would have to enter the data in order to create the electronic signature. Most authorities would not accept an electronic signature from a data-entry person in lieu of the technician performing the work. Most authorities also would not accept a data-entry person issuing an electronic signature of another individual, such as a jpg picture of a signature. However, pdf copies of documentation with all of the above requirements is acceptable. Essentially, it would be similar to a photo-copy of a report.

There are stories of the data-entry person not being present during the survey and they were the only one with the passcodes to access the data, or with the knowledge on how to retrieve the data. I also witnessed a situation where weekly reports were turned into a clerical person to enter the data into the computer. The clerical person allowed the reports to accumulate and the data was not entered during the week that the test/inspection was performed. The data-entry person used the ‘default’ date stamp provided by the software platform when the data was entered, which effectively said the test/inspection was not performed during the required time-period.

It is difficult to attach follow-up reports to electronic copies, such as ILSM assessments or repair work orders to a particular LSC deficiency. With paper files, they can easily be inserted into a binder or a folder.

Bottom line: Electronic documentation is permitted, but most hospitals realize the risks do not out-weigh the rewards. I am not a fan of electronic documentation because I have witnessed the problems with using them. But as with all technology, time is needed to work out the problems and make improvements. I’m an old man, and perhaps the younger generation has already implemented solutions to this problem.

I welcome your feedback on the use of electronic documentation.

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Jul 03 2014

Smoke Dampers

Category: BlogBKeyes @ 5:00 am
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imagesW9BNC02CWhat do we do with smoke dampers now that the hospital is fully protected with sprinklers? That question is asked many times by facility managers who are looking to cut back on what they believe are unnecessary maintenance costs. For new construction purposes, chapter 18 in the Life Safety Code does not require the installation of smoke dampers in smoke compartment barriers provided the HVAC ductwork that penetrates the smoke compartment barrier is fully ducted (no open return air plenum ceilings), and both smoke compartments served by the smoke compartment barrier are fully protected with quick-response automatic sprinklers. But sprinklers were not always required for healthcare occupancies and only became a rule for new construction in the 1991 edition of the LSC.

Until then, sprinklers were an option (unless state or local laws required it, and the construction type required it), and not all hospitals choose to invest in the systems when the building was constructed. That means smoke dampers had to be installed in the smoke compartment barriers. After the facility became fully protected with sprinklers, many hospitals believed they could remove the smoke dampers (or disable them in place), since new construction specifications did not require the smoke dampers. Section 4.6.7 of the 2000 LSC says whenever alterations or renovations are made, the requirements of new construction must apply. Since new construction (chapter 18) requirements for hospitals did not require smoke dampers where both smoke compartments are protected with sprinklers, facility managers thought they had good ground to stand on.

While this may be acceptable for NFPA, it is not for the International Code Council which publishes the International Building Code (IBC). The organization needs to request permission from their local and state authorities before they remove them. Usually, permission will not be granted because the IBC does not recognize the removal of existing fire safety equipment. I’ve also been told that in those jurisdictions where the smoke dampers were installed prior to the adoption of the IBC, there is a chance that the authorities may permit it.

Bottom line… Don’t be in a hurry to remove the smoke dampers even if you believe they are no longer required. Check with the state and local AHJs and seek their permission. It will save you a lot of work of re-installing them if you don’t ask for permission, and they find out later.

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Jun 05 2014

Inaccessible Fire Dampers

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Many of you may be familiar with the Joint Commission’s standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose to insert the damper into the Statement of Conditions Plan for Improvement (PFI) list with a 6-year projected completion date. Then the hospital does not have to resolve the inaccessible fire damper, and they will not be cited for not performing the required testing.

Well, no other accreditation organization (AO) or state agency surveying on behalf of CMS has that luxury. CMS has been very clear to all AOs: If you observe a deficiency, then you must cite it. AOs and state agency surveyors are not permitted to not cite a deficiency if they are presented evidence that a feature of the Life Safety Code is non-compliant. And an inaccessible fire damper on a PFI list is clear evidence that it has not been tested.

So, why does Joint Commission continue to allow their hospital clients to not test inaccessible fire dampers and permit them to place them on the PFI list if CMS does not allow this practice? It is my observation that the reason is mainly due to the fact Joint Commission has been operating as an independent authority since 1965 without having to meet CMS’s rules and regulations, until just recently (2009).

For the record, I like the Joint Commission PFI list and think it is a very good deal for hospitals. It provides the hospital an incentive to get out and find their deficiencies before a survey and manage a solution to them through the PFI list. Then a TJC surveyor will not cite them for the deficiency. It’s a win-win situation. Hospitals are motivated to conduct self-examinations of their facilities and find all the LSC deficiencies they can, which results in a safer environment for their patients. I wish all AOs and state agencies had that option. However, CMS is threatening to remove the feature from Joint Commission and if they succeed, then the fear is hospitals will not be pro-active and look for their own deficiencies, and sit back and wait to see if the surveyors will find them during the triennial survey.

Even if Joint Commission allows you to manage the inaccessible fire damper through the PFI list, that’s only good for a Joint Commission survey. You still need to make the damper accessible and then test it for all the other AHJs.

So, when a fire damper cannot be tested because it is inaccessible… you have little choice but to make the fire damper accessible and then test it. There is another option though; you may request a waiver during the Plan of Correction process, provided it is a significant hardship to the hospital. Waivers are much more difficult to get approved lately through CMS but it is the only other option to you.

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May 22 2014

Sprinkler Riser Main Drain Tests

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sprinkler_class2pg8pic1[1]NFPA 25 (1998 edition) section 9-2.6 says main drain tests are to be conducted annually at each sprinkler system riser to determine if there has been a change in the water supply, piping or control valves. The original purpose for main drains on sprinkler risers is to drain water from the overhead piping after the system is shut off.

 But the added value of the main drains is to perform the test to determine whether there is a major reduction in water-flow to the system, such as might be caused by the an obstruction from a dropped gate on a valve, a partially closed valve, a check valve stuck on its seat, or a foreign object like a rock or a tool left in the pipe from a recent service.

 The Annex section of 9-2.6 does allow standpipe risers to have their main drain tests performed at the low point drain where the water enters the building, but that option is not permitted for the sprinkler system risers.

 A large drop in the full pressure of the main drain test when compared to previous tests normally indicates a dangerously reduced water supply. After closing the main drain test valve, a slow return to normal static pressure is confirmation of the suspicion of a major obstruction, and is just cause to investigate why the water supply is reduced. A main drain test is considered satisfactory when the pressures and time to restore to static pressure are nearly the same as previous main drain tests.

Please remember that sprinkler riser main drain tests are performed at the sprinkler riser – not at the location where the main water supply enters the building. It is not unusual that the older hospitals are not outfitted with the main drain test valve and pressure gauge on each riser, but that is what NFPA 25 requires. Since each sprinkler riser is supposed to have a main drain test conducted, that means you need to have the same number of main drain test results. Whatever number of risers you have, that’s how many main drain tests you should have documented each year.

 Main drain tests are required annually at each system riser, and downstream of any valve that is shut-off, then re-opened. The main drain tests should be coordinated to be performed just after the annual sprinkler control valve exercise. Here is the procedure to conduct a main drain test:

With the fire pump off, but the jockey pump on:

1.     Record the static pressure.

2.     Open the main drain valve slowly.

3.     After the pressure gauge has stabilized, record the residual pressure.

4.     Slowly close the main drain valve.

5.     Record the time it takes to return the residual pressure back to static pressure.

 This main drain test should provide the following findings on the test sheet:

  • Static pressure
  • Residual pressure
  • Time to restore back to static pressure

These findings should be compared to previous main drain test findings to determine if they were consistent. If they are not consistent with previous main drain tests, then an investigation should be conducted to determine if there is an obstruction in the sprinkler water supply.

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May 15 2014

Fire Alarm Test Reports

Category: BlogBKeyes @ 5:00 am
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fire-alarm-system-detects-protects-24-x-7-250x250[1]Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings and citations, mainly because there are so many devices connected to the fire alarm system. A typical 200 bed hospital may have over 2,000 devices connected to the fire alarm system that need to be tested.

Nearly all of the requirements for the frequency of the tests performed on fire alarm systems can be found under NFPA 72 (1999 edition), section 7-3.2. The one exception would be the requirement for the water-flow switch testing which is found under NFPA 25 (1998 edition), section 2-3.3. (NOTE: This does not take into consideration the recent CMS categorical waivers.)

Often times a contractor performing the fire alarm testing will not test all of the devices listed below, even if your hospital has them in your system. The reasons may differ but the bottom line is the hospital facility manager must review the contract and determine what is actually required. Many times the standard contract (or signed proposal) will state something to the effect the fire alarm system will be tested in accordance with NFPA 72, although it doesn’t always refer to the proper edition (most hospitals are on the 1999 edition of NFPA 72). If the contract says it will test to NFPA 72, then you must hold them accountable for testing everything on the list below.

Make sure the test report lists the complete inventory of each and every device connected to the fire alarm system. All of the initiating devices, all of the occupant notification devices and all of the interface relays must be listed in an inventory complete with their location and whether they passed or failed their test. And don’t forget all of the batteries in the fire alarm system, not just those in the fire alarm control panel. There may be other batteries involved such as those in a remote panel or a Notification Appliance Circuit (NAC) extender panel.

Here is a list of devices that could be connected to the typical fire alarm system in a hospital:

Device/Test

Frequency

Initiating   Devices

Water-flow switches

Quarterly

Smoke detectors

Annually

Heat detectors

Annually

Duct detectors

Annually

Manual pull stations

Annually

Supervisory   Signal Devices

Low air pressure switches

Quarterly

Low water level switches

Quarterly

Tamper switches

Semi-annually

Notification   Devices

Strobes

Annually

Horns

Annually

Bells

Annually

Chimes

Annually

Interface   relays and modules

Magnetic hold-open

Annually

Air handler shut-down

Annually

Kitchen hood suppression sys

Annually

Elevator recall

Annually

Magnetic locks

Annually

Fire pump

Annually

Smoke dampers

Annually

CO2/Clean agent suppression

Annually

Sprinkler dry-pipe/pre-action

Annually

Overhead rolling fire doors

Annually

Control   panel batteries

Charger test

Annually

Discharge test

Annually

Load voltage test

Semi-annually

Smoke   detector sensitivity test

2-years

Off-premises   monitoring transmission equipment

Quarterly

Here are some basic requirements about the fire alarm test report:

  • Make sure the report is dated and signed by the service technician and you (the owner’s representative)
  • Make sure all the devices connected to the fire alarm system are accounted for and inventoried in the report
  • Make sure resettable heat detectors are ‘tested’ rather than ‘inspected’. Lazy technicians may not want to get out the hot-air guns to test the heat detectors so they just ‘inspect’ them
  • Make sure the heat detectors are tested with heat, and not with magnets. Only the one-shot non-resettable heat detectors are permitted to be tested with magnets.
  • When items on the report are identified as having ‘failed’ their test, make sure there is follow-up action to resolve the issue
  • Don’t forget to assesse the failed devices for Interim Life Safety Measures (ILSM)
  • Resolve all deficiencies and staple copies of the paperwork that demonstrates the repair was completed, along with a re-test, to the test report
  • Ensure that the technician performing the fire alarm testing, service and repairs meets the qualifications for certification or licensing. This applies to in-house staff or contracted staff. Have the qualifying documents on file.

Maintain your fire alarm test report at this level of documentation and you should not have any troubles with the surveyors.

 

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