Fire Alarm Testing Frequencies

Q: What is the testing requirement for a fire alarm system in a nursing home? Is it annual or semiannual?

A: The testing frequencies for a fire alarm system differ based on the components of the fire alarm system, not where it is installed. A fire alarm system has to be tested at the same frequency regardless of where it is installed: A hospital, a nursing home, a surgical center, a medical office building, a school, etc. Take a look at Table 14.4.5 of NFPA 72-2010 for testing frequencies of different components of the fire alarm system. A quick summary of testing frequencies is:

Quarterly: Supervisory signal devices (i.e. low air pressure switches on dry-pipe systems)

Semi-annually: Waterflow switches, tamper switches, load voltage test on batteries

Annually: Smoke detectors, heat detectors, duct detectors, manual pull stations, occupant notification devices (i.e. strobes, horns, chines), interface relays and modules, charger test on batteries, discharge test on batteries, off-premises monitoring transmission equipment

Every 2 Years: Smoke detector sensitivity test

The time-frame to complete these tests is different for fire alarm systems than it is for other features of life safety. According to section 3.3.106 of NFPA 72-2010, the minimum and maximum times between testing/inspection events are as follows:

  • Weekly: Fifty-two times per year, once per calendar week.
  • Monthly: Twelve times per year, once per calendar month.
  • Quarterly: Four times per year with a minimum of 2 months and a maximum of 4 months.
  • Semi-annually: Twice per year, with a minimum of 4 months, and a maximum of 8 months.
  • Annually: Once per year with a minimum of 9 months and a maximum of 15 months.

I have confirmation from CMS that they will comply with these definitions of frequency for fire alarm testing/inspection, but it does not apply to features of life safety that are not fire alarm systems. The accreditation organizations should also accept these frequency definitions, but to be sure, check with them before implementation.

Smoke Detector Sensitivity Testing

Q: In regards to the sensitivity testing of smoke detectors, I believe my fire alarm system is capable of complying with NFPA 72 for the sensitivity testing of smoke/heat initiating devices. For example: If we have a smoke detector that exceeds the expected sensitivity range it will send a trouble signal and the panel will show “dirty photo detector” and it will tell the device location. Additionally, we can run a complete report on all devices to show the current sensitivity value of each detector, this could be done on the alternating year frequency dictated by the code. I believe this meets NFPA 72-2010 requirements for sensitivity testing. Your thoughts, please.

A: I would agree with you. But when the surveyor asks for evidence that your smoke detector sensitivity was checked, what report do you show him? If you don’t print out a sensitivity report at least once every two years, you would have little to nothing to show them.

ASC Smoke Detector Sensitivity

Q: We are a service contractor that is attempting to obtain a contract with a new client that is an Ambulatory Surgery Center. The ASC told us they never had their smoke detector sensitivity checked. We told them it was a CMS requirement to have the smoke detector sensitivity checked every 2 years, but they tell us they want us to check it every 5-years as that is what their current service contractor is telling them. How can they be in business for over 12 years and no one ever checked their smoke detector sensitivity? Have the NFPA standards changed regarding smoke detector sensitivity testing?

A: Ignorance, and a lack of understanding of the codes and standards. And a lack of enforcement by their AHJs…that’s how it could be missed for 12 years. This is not surprising. But to answer your last question: No, testing intervals have not changed in NFPA 72. Sensitivity of the smoke detectors has to be checked one year after installation, and then every other year thereafter. After the second required calibration test, frequency may extend to every 5 years provided the sensitivity tests indicate the devices have remained within its listed and marked sensitivity range.

Smoke Detectors

Q: Do you have to have smoke detectors in emergency electrical rooms or electrical rooms?

A: In a hospital? Only if you have an FSES equivalency that requires it, or the room is located inside an area under Specialized Protective Measure locks as described in section 19.2.2.2.5.2 of the 2012 LSC. Otherwise, there are no NFPA codes or standards that require it. But check with your state and local authorities to see if they have regulations that require it.

Often times smoke detectors are placed in locations based on designer preference.

Smoke Detectors

Q: Are smoke detectors required in individual hospital patient rooms, and what are the exemptions to not have a detector in individual rooms?

A: There is no Life Safety Code or NFPA 72-2010 requirement to have smoke detectors in hospital patient sleeping rooms or treatment areas. There may be other standards or regulations that could require them, so check with your state and local authorities.

Typically, the only areas that are required to have smoke detectors in a hospital are:

  • Elevator lobbies and elevator mechanical rooms
  • Near doors that are held-open by magnets
  • In the same room with fire alarm control panels that are not constantly supervised
  • In areas open to the corridor that are not constantly supervised
  • Inside locked areas that use the Specialized Protective Measure locking arrangement identified by 19.2.2.2.5.2
  • Patient sleeping suites that do not provide direct supervision
  • Smoke compartments containing patient sleeping suites over 5,000 square feet but not exceeding 7,500 square feet and are not equipped with Quick Response (QR) sprinklers
  • Patient sleeping suites over 7,500 square feet but not exceeding 10,000 square feet

Additionally, smoke detectors may be required in patient sleeping rooms if an Equivalency was submitted and approved.

Perforated Ceiling Tiles

Q: My facility is installing perforated ceiling tiles because it looks “modern” and does not look like the old healthcare setting. With the perforation in the ceiling tiles, does this mean I have to install sprinklers and fire alarm smoke detectors above and below the ceiling since the dropped ceiling is no longer a smoke-resistant barrier? I believe I have to also take the smoke compartment barrier walls to the deck… is that correct?

A: First of all, do you need smoke detectors in the area where the new ceiling tiles are being installed? If yes, then we need to address this issue, but the NFPA codes and standards do not require that many smoke detectors in a hospital. Unless you are employing Specialized Protective Measure locks (see section 19.2.2.2.5.2 of the 2012 Life Safety Code), or have specific requirements from a state or local authority that exceed what NFPA requires, smoke detectors are only mandatory in the following locations of a hospital:

  • In areas open to the corridor that are not directly supervised by a person (see section 19.3.6.1 of the 2012 LSC)
  • Near doors that are held open by devices that release on a fire alarm activation (see section 17.7.5.6.5.1 of NFPA 72-2010)
  • In elevator lobbies and elevator equipment rooms (see section 9.4.3.2 of the 2012 LSC)
  • In rooms where fire alarm panels (including NAC panels and off-premises monitoring transmission equipment) are located without direct supervision by a person (see section 9.6.1.8.1 of the 2012 LSC)

You may want to revisit why the smoke detectors are there in the first place. Check with your state and local authorities to see if they have requirements for smoke detectors to be there.

But assuming you do want to maintain the smoke detection level in this area where the new ceiling tiles are located, NFPA 72-2010 does address this issue. Let’s look at section 17.5.3.1.3 which discusses the requirements for an open grid ceiling. It says smoke detectors are not required below an open grid ceiling if the openings in the ceiling are ¼-inch or larger in the least dimension, and the openings constitute at least 70% of the surface area of the ceiling. So, what this means, smoke detectors are not required above the ceiling if the openings are less than ¼-inch and the accumulative area of the openings is 30% of the total surface area of the ceiling. But this section only applies if smoke detectors are required in the general area where these new ceiling tiles are being installed. But keep in mind, if you install smoke detectors where they are not required, they still must be installed in compliance with NFPA 72-2010.

Here are the requirements found in NFPA 13-2010, at section 8.15.13 for an approved open-grid ceiling. Open-grid ceiling must be installed below the sprinklers where all of the following apply:

  1. The openings of the open-grid ceiling must be at least ¼ inch or larger in the least dimension.
  2. The thickness or the depth of the material does not exceed the least dimension of the opening.
  3. The openings must constitute 70 percent of the area of the ceiling material.

If your ceiling tile openings are less than ¼-inch and the openings in the ceiling tile equal less than 70% of the ceiling area, then I conclude sprinklers would not be required above the ceiling.

There is one issue you need to be aware of… Most surveyors will cite you for having gaps in ceiling tiles greater than 1/8-inch as that would allow heat and smoke to filter up through the ceiling and would cause the sprinklers or smoke detectors to delay activation. Make sure these ceiling tiles do not have openings greater than 1/8-inch.

Smoke compartment barrier walls always have to extend from the floor to the deck above regardless whether or not the ceiling tiles have openings in them.

Staff Sleeping Room

Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that these staff sleeping rooms are required to have single-station smoke alarms since they are considered a different occupancy (Lodging & Rooming House) and must meet section 26.3.4.5.1 of the 2012 LSC. But can I use the hospital smoke detector system in lieu of installing a battery-operated smoke alarm in these rooms?

A: Yes… According to section 9.6.2.10 of the 2012 LSC, smoke detectors connected to the building’s NFPA 72-2010 approved fire alarm system are permitted instead of installing the battery-operated smoke alarms. However, section 9.6.2.10.1.4 does say these system smoke detectors must be arranged to function in the same manner as single-station or multiple-station smoke alarms. The typical building system smoke detectors are detectors only and do not provide any occupant notification.

But the single-station smoke alarms provide both functions: Detection and occupant notification. Therefore, on a technical standpoint, the basic fire alarm system smoke detectors are not enough and some sort of occupant notification system must be provided. Now, having said that, I do know that some accreditation organizations are simply accepting a smoke detector in the on-call sleeping room without the inclusion of an occupant notification device. But, I am aware that some state agencies surveying on behalf of CMS do enforce the letter of the code and will cite you if you do not have an occupant notification device in the room.

ILSM for Fire Alarm System in Test Mode

Q: If we put the fire alarm system in test by-pass but we are still monitoring the alarms so we can troubleshoot or test the system so we avoid nuisance FA activation do we need an ILSM (Fire watch)?

A: Well… How long do you have it in test mode? More than 4 hours? If so, then I can see where an ILSM assessment is required, but the assessment would identify that the fire alarm system is impaired since it is in test mode, but you have a Fire Watch in effect because you would have someone at the panel constantly until the panel is off test mode.

So… an ILSM assessment would be required after you reach the 4-hour mark, but the assessment should identify that you are doing a Fire Watch my posting a responsible individual at the panel.

Sounds like a paper documentation issue, as you are already doing the Fire Watch.

Smoke Detectors During Construction

Q: We are seeking to eliminate accidental activation of existing smoke heads in healthcare spaces that are taken over for renovation/construction work while maintaining fire protection coverage in the space that does not involve the use of a fire watch. We are looking at multiple sensor detectors, but the initial comment we received from our vendor is that they are sometimes triggered by dust. In your opinion, would changing the smoke detectors to heat detectors be an acceptable solution in a construction space? If the space has an active sprinkler system, in your opinion, would it be acceptable to simply remove these smoke heads? Any thoughts you can provide would be greatly appreciated.

A: Changing the smokes to heats is not an acceptable solution to prevent a fire watch, because heats do not sense the presence of smoke. But perhaps you are making this more difficult than it has to be. The code only requires a fire watch for required fire alarm devices that are impaired. Are the smoke detectors in the construction area required? If so, then you need to do the fire watch if you remove the detectors, or suffer through many false alarms.

But if they are not required devices, then you can remove the smoke detectors and not have to do a fire watch. Section 9.6.1.6 of the 2012 LSC specifically says a fire watch is for required fire alarm systems out of service.

One may be surprised to learn that in the typical hospital, there are very few locations that a smoke detector is required to be installed:

  • In areas open to the corridor as described in section 19.3.6.1 of the 2012 LSC
  • In areas containing fire alarm control panels (including NAC panels) that are not continuously occupied as described in 9.6.1.8.1 of the 2012 LSC
  • Near doors that are held open that must close on a fire alarm activation as described in NFPA 72-2010, section 17.7.5.6.5.1
  • Elevator recall for fire-fighter’s service as described in NFPA 72-2010, section 21.3

There are other situations where smoke detectors may be required, but those requirements are stipulated on optional design factors, such as on-call sleeping rooms, specialized protective measure locks, and equivalencies.

Therefore, if you have smoke detectors in an area that is under construction, and these smoke detectors are not required, then you may remove the detectors without having to perform a fire watch.

Strobe Synchronization

Q: My fire alarm installer tells me that NFPA 72 does not require strobe synchronization of two (only two) devices. The sync is required if there are more than two. I read NFPA 72 2010 18.4.3.2 (4) and it is not clear if he is correct. Can you comment on it, please?

A: The installer is technically correct in that, since 1996, all manufacturers’ strobe flash rates were lowered so that viewing two non-synched devices would not produce an overall flash rate considered to be dangerous.  As far as code requirements, the NFPA 72-2010 requirement for strobe synchronization is actually found in Chapter 18.5.4.3.2 (for rooms) and 18.5.4.4.5 & 7 (corridors).  If this question is being asked for a room, then the intent is to achieve a minimum light output.  If achieving that output requires ‘…more than 2 visual appliances…’, then they must be synched.  In a corridor, “when more than 2 visible notification devices are in any field of view, they shall flash in synchronization.”  So technically, if just two strobes are in the overall field of view (including non-direct viewing), they don’t need to be synched to meet NFPA 72 requirements.

That’s in a vacuum.  However, in the real world, these devices are generally on circuits that have additional visual devices that serve other areas where more than two devices are in the direct or non-direct field of view, or the circuit may need be expanded in the future where synchronization is required.  Another important real world consideration is the expectation of the facility’s reviewing AHJ (CMS, State Agency, Joint Commission, etc.).  Unless the strobes were installed prior to 1999, the expectation of every AHJ I’ve dealt with since that time is that every strobe in line of sight will be synched.  If in response to a citation, the chief engineer of a healthcare facility wants to pull out the code book and cite specific code application of strobe synchronization to their reviewer, he may eventually win that battle (or not), but in doing so he may be opening the door to a more ‘letter of the code’ enforcement regarding other areas of concern.

NOTE: Gene Rowe from Affiliated Fire Systems provided the answer to this question.