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.

Documentation- Part 3: Sprinkler System

imagesJ0Z09XQXThis is the third in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Last week I talked about the fire alarm system testing documentation. There are potentially over 25 different devices that a typical hospital fire alarm system may have, and some hospitals tend to over-look the occupant notification devices and the interface relays. Make sure your reports include these devices.

Sprinkler systems have many different components, most of which are hidden from view to the general public. If you haven’t already, take the time to investigate whether or not you have these devices in your facility. It is unlikely that any hospital would have every device listed below, but all of these devices have been observed in one healthcare institution or another.



NFPA   Standard

Fire pump churn test


25-1998; 5-3.2.1

Control valve inspection


25-1998; 9-3.3.1

Fire department connections


25-1998; 9-7.1

Pre-action/Dry pipe valve priming   water test


25-1998; 9-

Sprinkler inspection


25-1998; 2-2.1.1

Piping & hanger inspection


25-1998; 2-2.2

Pre-action/Dry pipe valve trip test


25-1998; 9-

Main drain test


25-1998; 9-2.6

Control valve exercise


25-1998; 9-3.4.1

Backflow preventer


25-1998; 9-6.2

Anti-freeze test


25-1998; 2-3.4

Private service fire hydrants


25-1998; 4-3.2

Fire pump flow test


25-1998; 5-3.3.1

Occupant use fire hose – inspection


1962-1998; 2-3.3

Occupant use fire hose – pressure   test

5-Years after installation; then   every 3-Years

1962-1998; 2-3.2

Check valve inspection


25-1998; 9-4.2.1

Pressure gauge calibration


25-1998; 2-3.2

Standpipe waterflow test


25-1998; 3-3.1

Private fire service mains


25-1998; 4-3.1

Internal inspection of system piping   (if obstruction conditions)


25-1998; 10-2.2

QR sprinkler head replacement


25-1998; 2-3.1.1

SR sprinkler head replacement


25-1998; 2-3.1.1

If you contract your sprinkler system testing and inspection activities, take this list and sit down with your contractor and review with them if they are performing these functions. The above list does not take into consideration any alternative frequencies based on the CMS categorical waivers.

If you want to download a copy of the complete list of requirements for the document review session, go to “Tools” page, and click on “Acute Care Hospital Documentation Requirements”. You will find the file under the Life Safety Document Review heading.

Next week we will look at the final installment and rest of the list of items needed for the document review session.