Fire Alarm System Communication

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., 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.

Joint Commission Clarification of Findings

Q: We recently had a survey which resulted in multiple Life Safety findings. We want to clarify away some of these findings, and were told we can only clarify the ‘C’ category findings. Is this true?

A: No, I would not say that statement is true. Any finding may be clarified after the survey as long as the organization provides sufficient evidence that they were in compliance with the standard at the time of the survey. All ‘A’ and ‘C’ listed elements of performance that received a finding from the surveyor may be appealed to the accreditor with an explanation as to why the hospital believes they were compliant. This is called the clarification process, and organizations have ten (10) days to submit their clarifications once the survey report has been posted.

However, standards with ‘C’ elements of performance do have the additional advantage of clarification if the organization can prove they were compliant with at least 90% of the items covered under the standard prior to the survey. Take the example that corridor doors are required to latch (LS.02.01.30, EP 11); If the hospital regularly examines their corridor doors and has documentation that demonstrates at least 90% of the corridor doors did latch, then that information may be used in a written clarification and any finding of a corridor door not latching would eventually be vacated if the accreditor accepts the clarification.

In order to take advantage of this additional ‘C’ EP clarification process, the documented evidence of compliance must be gathered prior to the survey. This would require the organization to have a monitoring program in place that evaluates various features of life safety on a routine basis. That is why the old Building Maintenance Program (BMP), which is optional, is so important as it provides a documented history of compliance at any given time.  Many hospitals choose not to implement a BMP because it no longer provides any direct relief of a finding during the survey, but the program still provides the historical evidence needed for a clarification. And, it is a very good self-assessment program of your features of life safety.

The clarification process seems to be hit and miss, at times. It is dependent on a well-crafted written response with the evidence needed to vacate the finding. The staff in the Standards Interpretation Group at the accreditation organization does not always approve the clarifications the same way. It may depend on who is actually reviewing the clarification.

Clarification on Oxygen Cylinder Finding


images[5] (2)My good friend Gloria Legere shared the following clarification that she wrote for a client hospital. The finding by the surveyor read:


There were full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock.

Gloria’s clarification read:

The report of survey findings cited that at the xxx location, “there were full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock”.

NFPA 99-1999 section 4-, which parallels the accreditation organization  standard, requires that gas cylinders should be stored in such a way that staff retrieving them in a hurry will not have to make a decision about which cylinders are full and which are not.  The accreditation organization published an article that cautioned hospitals to make sure full and partial or empty cylinders are physically separated to prevent staff confusion when retrieving a cylinder during an emergency.

The Hospital’s policy on storage of medical gas cylinders follows the requirements set forth by the NFPA and the accreditation organization for the storage of medical gas cylinders, however, the requirements of both the NFPA and the wording from the accreditor’s article cited, stress that the delineated storage requirements are to “prevent staff confusion when retrieving a cylinder during an emergency”.

The findings cited from our triennial survey indicate “full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock”.  The cylinders located on the loading dock are not ‘in storage’ for patient use.  The cylinders, located on the loading dock area, are in a state of flux of shipping and receiving; either being delivered or retrieved by the delivery company or are overflow of product that exceeds the storage capabilities within the hospital. The cylinders are not accessible by staff caring for patients and patient care is never delivered in this area. Once the cylinders are brought into the hospital for use, the cylinders are appropriately stored in the designated racks in the patient care areas which differentiate by both location and signage separating the full cylinders from in-use/empty cylinders so that there would never be confusion by staff when retrieving oxygen cylinders for use in emergency situations or daily need.

The reply from the accreditor:

The clarifying evidence was accepted for observation 1 based on the cylinders being located on the loading dock and not interior to the building 


So the lesson learned here is to know and understand the codes and standards you are being surveyed against. Surveyors try and do the best job that they can, but they are not the final authority on the interpretation of the standards. It would have been interesting to know what the surveyor would have done if the above documentation was presented during the survey. Would the surveyor accepted the issue on the spot or would the surveyor have continued to document the finding?

Communication With Nurses

imagesCAATJSWMThe key to life safety compliance is education. Relating better to caregivers will open their eyes about the important of Life Safety Code® (LSC) requirements.

The situation with nurses not observing LSC provisions is near universal in hospitals. The solution has to start with safety and accreditation professionals because the nurse’s main focus is often on patient care. The LSC isn’t a regulation that nurses generally worry about—there are plenty of issues in their jobs that are more immediately pressing.

For example, nurses like to keep patient care items nearby (e.g., parking blood pressure cuff machines in corridors outside patient rooms) instead of having them stored 30 feet away in a utility room. Although items parked in corridors is generally a legitimate violation of the LSC and Joint Commission standards, if you voice your objection nurses may nonetheless feel you are policing them. Rather than taking a hard-line stand on compliance, a more open approach will get the desired results. 

Steps to Open Lines of Communication

Use the following tips to win over nurses:

  • Go onto the units and job-shadow nurses for a few hours. Tell them, “I want to get to know what you do better.” You’ll learn nurses may need to take all of their patients’ blood pressure every two hours, which is why they want the blood pressure cuff devices nearby.
  • Schedule times to sit down and talk to the nurses, either individually or in group meetings. This approach is time-consuming because the goal is to reach every nurse in the facility. Years ago, I carried out a similar effort as a safety officer at the hospital where I used to work, and it took a total of six months to talk to all the nurses. This involved coming to the hospital on weekends and at 2 a.m. on the overnight shift.
  • When you talk to nurses, don’t wear a suit. Appearance plays a large part in the success of the interaction. You don’t want to dress like you’re someone’s boss.
  • Avoid mentioning LSC terms and related jargon. Words such as “Life Safety Code,” “standards,” “laws,” and “rules” will drown out your message. Don’t use these buzzwords because caregivers will tune you out right away.
  • Relate life safety to nursing work. After learning what activities nurses undertake as part of patient care, explain that life safety compliance has a similar goal. Tell them, “I want you to consider other examples in the environment that keep your patients safe.”
  • Use visual examples to drive the point about life safety provisions home. For example, explain that an 8-foot corridor needs to remain clear because in a fire, nurses may need to push 40-inch-wide hospital beds down that corridor. Those beds almost never roll straight and could occupy up to 6 feet of the corridor, especially if IV pumps, heart monitors, and other equipment are attached to the patient. The remaining width of the corridor needs to stay clear for other nurses, security officers, and firefighters who are trying to get onto the unit to assist. As a nurse moves a bed, if he or she encounters an item blocking the corridor, that item will need to be moved out of the way and stored somewhere. This could take 30–60 seconds to accomplish and may mean the difference between life and death for the last person trying to get out.
  • Show nurses the closest locations of portable fire extinguishers and fire alarm pull stations. There’s a good chance caregivers will pass by the closest location for these items and delay response because they simply don’t realize the devices are there. Encourage nurses to talk to each other about the locations of extinguishers and pull stations to maintain awareness.
  • Confirm that nurses know where to relocate patients during an evacuation. Sure, most nurses understand that if an alarm goes off in their unit, they may need to move patients to the nearest safe smoke compartment, which begins after a double set of smoke barrier doors. But not all double doors that close on alarm are smoke barrier doors. Show nurses the exact locations of adjacent smoke compartments so they know where to relocate patients.
  • Ask nurses whether they’ve ever been involved with a fire. If you’re talking to a group of nurses and you encounter one who has responded to a blaze, that nurse’s recounting of the event will support your cause.

Time Is the Major Investment

The above approach will take time but shouldn’t cost you much money. Getting leadership support is important, particularly if you run into a nurse who butts heads with you about efforts such as keeping egress corridors clear. You can further convince nurses to help you with LSC compliance by assisting them with nagging projects, such as hanging a bulletin board that’s been lying around for weeks. By fixing little things, you can buy trust.