Fire Safety Inspections

Q: Can testing and inspections of features of life safety be completed in-house or does a third party need to complete them? I would like to know which areas need to be inspected by a third party and which areas can be inspected by our own maintenance staff.

A: My first response to your question is there are no NFPA or accreditation standards or regulations that require you to have an outside contractor (third party) perform any of the fire-safety testing and inspection requirements. But, the reality of it is, it is not likely that you can do all of this with your own staff. Take the fire alarm testing requirements. The technicians performing inspections, testing, maintenance and service on the fire alarm system must be certified or licensed to do so, or they need to be employed by an organization that is certified or licensed. This is a NFPA requirement, and is frequently enforced by the CMS and accreditation surveyors. However, certified and licensed fire alarm technicians are not very common among hospital facilities departments, so this is usually contracted out.

For other features of life safety that need to be tested and inspected, NFPA and the accreditation organizations do not require a certification or license for the technicians performing the task. But the technician does need to have knowledge and experience in order to perform the task, and again, it is not likely that a typical hospital facilities department will have staff with all of this knowledge. And besides, given all that is required, does your staff even have the time to test and inspect all of the features of life safety if they did have the knowledge?

So, the reality is, hospitals typically contract out most of the testing and inspection, but they frequently do perform some of the more routine (and mundane) items like quarterly Fire Department Connection inspections. Now, in contrast to this last statement, I have a couple of clients who are huge, and they do have the resources to hire certified technicians and perform all of the testing and inspection of features of life safety themselves. But my observation is the facilities department must be well-funded in order to achieve this level of self-testing and inspection. As always, please check with your state and local authorities to see if they have more restrictive requirements.

Emergency Response Plan

Q: We are going to prepare an action card for fire safety as part of our major emergency response plan. What information regarding fire safety would you suggest we include on the Emergency Response job action card?

A: Emergency response preparedness (i.e. Emergency Preparedness) involves many different aspects, including fire safety. In order to write a job action sheet (or job action card) for fire safety, I would suggest that you utilize your basic fire response plan for the internal portion of emergency preparedness. Many hospitals utilize the familiar acronym RACE to help remind their staff as to the organization’s fire response plan:

  • R = Rescue anyone in harm’s way of the fire
  • A = Activate the alarm by pulling the manual fire alarm station and dialing______
  • C = Contain the fire by closing all the doors
  • E = Extinguish the fire with portable extinguishers, OR Evacuate patients from the scene of the fire

For external fires, a job action sheet may include some (or all) of the following:

  • Shutting down all of the fresh-air intakes for the hospital’s ventilation system.
  • Placing boards on windows
  • Taking pro-active action and wetting-down combustible portions of the facilities or grounds
  • Possible relocating patients from one wing or area to another
  • Emptying parking lots and garages which are close to the hospital
  • Possible evacuation of hospital
  • Re-directing traffic away from the hospital
  • Controlling access to the Emergency Department
  • Suspending shift change and proceeding to a 12 hour on/12 hour off rotation