Recording the Monthly Fire Extinguisher Inspections

Q: Brad, how does the date need to be recorded on the fire extinguisher tags for the monthly inspection? Does the year need to be included on the inspection tag of the portable fire extinguisher along with the month and day for each inspection?

A: Depending on which authority having jurisdiction (AHJ) is inspecting your facility, yes the year needs to be recorded along with the month and day for every monthly inspection. Joint Commission’s standard EC.02.03.05, EP 15 requires the completion dates for each monthly inspection to be documented. According to Webster’s Dictionary, the phrase ‘date’ means “Time stated in terms of the day, month, and year.” So, technically, Joint Commission is asking that the tag have the day, month and year recorded. But, usually the accreditor allows the year to be omitted as long as the tag has the year pre-printed on it.

Other AHJs may not be as lenient. Many state agency surveyors for the Centers for Medicare & Medicaid Services (CMS) are asking to see month/day/year for every monthly and annual inspection (even if the tag has the year pre-printed), and a signature of the individual performing the service.

Many fire extinguisher service companies like to use a rubber stamp in lieu of the actual signature on the tag for the individual performing the annual maintenance, which is compliant with NFPA 10 (both 1998 edition and 2010 edition) on portable fire extinguishers. However, I have heard of many state agency surveyors for CMS who do not accept the rubber stamp and want a signature of the individual performing the service on each tag.

My advice is to inform the fire extinguisher service company to discontinue using the rubber stamp and have the service technician sign the tags. This will avoid any potential disagreement and squabble about what’s right and what’s wrong later when the surveyors come snooping around. It’s really all dependent on the individual surveyor.

Fire Extinguisher Signage

Q: I have a question regarding fire extinguishers. We have our extinguishers located in cabinets that are flush with the wall. Is it required to have signage above the extinguisher?

A: No, it is not. The 2000 Life Safety Code requires you to be in compliance with NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition, and section 1-6.12 of NFPA 10 requires fire extinguishers that are mounted inside a cabinet or wall recesses, must be marked conspicuously. A sign mounted on the wall above the fire extinguisher cabinet is certainly a conspicuous marking, but it is not the only marking that meets the requirements of 1-6.12. A red dot on the floor or on the ceiling is also a conspicuous marking as well. If the fire extinguisher cabinet is lettered with the words “Fire Extinguisher”, then that qualifies as a conspicuous marking. If the authority having jurisdiction does not believe that lettering on the outside of the cabinet that says “Fire Extinguisher”  meets the requirements of 1-6.12, then you need to negotiate with them and try to get them to understand that it does meet the requirements of NFPA 10. Otherwise, you need to comply with what the AHJ interprets.

Fire Extinguisher Documentation

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.

Portable Fire Extinguishers

Q: What is the requirement for inspecting fire extinguishers in our medical office building? Is it different than what is expected in our hospital?

A: The monthly inspection and annual maintenance requirements for the portable fire extinguisher is the same for all occupancies, and does not change from facility to facility. NFPA 10, section 4-3.1 (1998 edition) requires monthly inspections for the following items:

  • Make sure extinguisher is in its designated place
  • Make sure the access to the extinguisher is not obstructed
  • Make sure the operating instructions on the nameplate is legible and facing outward
  • Make sure the safety seals and tamper indicators are not broken or missing
  • ‘Heft’ the extinguisher to determine fullness (pick it up and hold it)
  • Examine the extinguisher for obvious damage, corrosion, leakage or clogged nozzle
  • Make sure the pressure gauge (if so equipped) is in the normal operating range
  • For wheeled units, check the condition of the tires, wheels, carriage, hose, and nozzle
  • Make sure the HMIS label is in place

This inspection needs to be recorded, preferably on the maintenance tag, with name (initials are acceptable) and date (month/day/year). This monthly inspection may be performed by anyone who has been trained and educated on how to inspect a fire extinguisher. An annual maintenance is required on all extinguishers by a certified and trained individual. Six-year maintenance includes emptying the contents of the extinguisher and an internal inspection is required. A 12 year hydro-test of the extinguisher is also required.

Fire Extinguisher Bar-Code Labels

Q:  Our administration wants us to discontinue applying bar-code labels on each extinguisher in our facility, and begin applying the labels on the cabinets and walls where the extinguishers are located. Do you see this being an issue for us down the road?

A: It would be interesting to understand why your administration wants this change made. I have seen bar-coding done both ways: label the extinguisher vs. label the location of the extinguisher. I don’t see it as a problem, either way. NFPA 10 (1998 edition) section 4-3.4.3 says records of the monthly inspection must be kept on a tag or label attached to the extinguisher; on an inspection checklist maintained on file; or in an electronic system (e.g. bar coding) that provides a permanent record. The standard does not say the bar-code label has to be on the extinguisher, so logic says it can be located near the extinguisher. This is subject to state and local authorities’ interpretation of the standard, as they may want the label in a specific location. I personally would want to label the asset rather than the asset location.

Special Fire Extinguisher Placard

Q: Do we have to have a special placard on our fire extinguishers in our kitchen, alerting people to activate the cooking hood fire suppression system first, before using the fire extinguishers? We received a citation from a surveyor on this issue.

 A:  The answer is yes, but I admit I was not aware of this requirement until recently. A hospital-client of mine was cited by their state surveyor for not having a placard near the Class K fire extinguishers informing the staff not to use the fire extinguisher until the cooking hood fire suppression system had been activated. I had never heard of this, so I contacted the surveyor at the state agency and asked what code or standard required this. He said it was in NFPA 96 (1998 edition), and sure enough, there it was in section 7-2.1.1: “A placard identifying the use of the extinguisher as a secondary means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.” Now, the standard says ‘each portable fire extinguisher in the cooking area’, but the state surveyor cited just the Class K extinguishers. I learned something new that day, so I considered it a successful day. If you don’t have those placards near all of your extinguishers in the cooking areas of your establishment, then I suggest you consider them, before you get cited.


Fire Extinguisher Signs

Q: During a recent survey we were almost cited because one of the fire extinguisher signs was on the front of the fire extinguisher cabinet and the rest were above the cabinets. The surveyor warned us that all of the signs needed to be the same. Is that true?

A: Well, I’m glad the surveyor did not cite you for this. If he/she had, you could have easily appealed this away after the survey. The 2000 edition of the LSC requires compliance with NFPA 10 Standard for Portable Fire Extinguishers (1998 edition). Section 1-6.12 of NFPA 10 says fire extinguishers mounted in cabinets or wall recesses must be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers must be marked conspicuously. Section 1-6.6 says extinguishers should not be obstructed, but if they are then ‘means shall be provided to indicate the location’ and the Annex portion of 1-6.6 describes acceptable means, such as arrows, lights, signs, or coding of the wall or column. Nowhere does it say all of the fire extinguishers have to be marked the same way or method. Now, I’ll admit that it is obvious to me that they all should be marked the same way for continuity purposes, but I do not see where the standard requires that. Therefore, based on your comment that the surveyor ‘almost’ cited you but did not, indicates to me that he/she felt the same way that I do that the extinguishers should be marked the same way, but it is not a standard requirement, therefore no citation was made. So, no the extinguisher cabinets don’t have to be marked the same way, but it sure makes sense to do so. I suggest you have someone correct this so they all are marked the same way.

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

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.

Fire Extinguishers in Parking Garage

Q: Are we required to have portable fire extinguishers in our parking garages?

A: No. The placement of portable fire extinguishers is dependent on the requirements for that particular occupancy requirement. A parking garage is regulated under NFPA 88A Standard for Parking Structures, (1998 edition) and nowhere in that standard does it require the placement of portable fire extinguishers. It does address whether or not a sprinkler system or a fire alarm system is required, but it does not address portable fire extinguishers. As always, check with your local and state authorities to determine if they have any requirements for extinguishers.

Fire Extinguisher Training

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: