Healthcare Life Safety Compliance - HCPro · liaison to NFPA 72, the National Fire Alarm Code. “The typical supervisory device is a device that tells you the control valve for the

October 2007 Vol. 9, No. 10

IN thIs Issue

p. 4 sample formUse our checklist to track your testing methods for a variety of supervisory devices.

p. 5 Monthly vs. 30 daysA Joint Commission official clarifies time references for various frequency-based activities, such as testing.

p. 7 Fire safety citations detailedThe Joint Commission focused on 0.125-inch door gap deficiencies during a summer survey at a Boston hospital.

p. 9 Maintenance MattersAlthough their basic function is similar, smoke alarms differ from smoke detectors.

p. 10 Questions & AnswersIs there a code that requires licensed sprinkler technicians to perform a main drain test, or can it done by in-house personnel?

Under Joint Commission (formerly JCAHO) standard

EC.5.40—which sets a variety of requirements for the

inspection, testing, and maintenance of fire protection

equipment—one of the provisions deals with “supervi-

sory devices.”

What exactly are supervisory devices? In layman’s

terms, a supervisory device emits a signal that indicates

the need for an action, says Lee Richardson, senior

electrical engineer at the NFPA and the association’s staff

liaison to NFPA 72, the National Fire Alarm Code.

“The typical supervisory device is a device that tells

you the control valve for the sprinkler system is not in

the proper position for the sprinkler system to work,”

Richardson says. For example, if the valve remains

closed, water may not flow through the pipes.

Keep up with a key activity

Element of performance 1 of EC.5.40 mandates that

Common supervisory devices bring along plenty of testing

facilities test all supervisory devices quarterly, except for

valve tamper switches. Instead, valve tamper switches

and water flow devices must undergo semiannual testing.

Such activities are critical to protecting occupants

because supervisory devices tie into the fire alarm

panel, says Jason Stoler, vice president at Davis Ulmer

Sprinkler Company, Inc., in Rochester, NY. “Inspection

and testing of a building’s fire alarm system is one of the

most important things you can do,” Stoler says.

> continued on p. 2

Healthcare Life Safety Compliance

The newsletter to assist healthcare facility managers with fire protection and life safety

A complete inventory of supervisory devices that are

subject to testing

Deficiency reports from the testing

Corrective actions for any deficiencies, including any

interim life safety measures that might have been necessary

Staff members who constantly monitor the fire alarm

panel, including during off-hours

Source: Internal Joint Commission (formerly JCAHO) document,

“Life Safety Code: Fundamentals of five environment of care

standards.”

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What surveyors may look for with supervisory devices

Joint Commission surveyors may look at the alarm

panel for any trouble signals and then attempt to iden-

tify how long the signal has been active, according to an

internal commission document that Healthcare Life

Safety Compliance obtained earlier this year.

Note the broad use of supervisory signals

You can find supervisory devices in several areas of

your campus. The following are other examples of equip-

ment that might need supervisory devices:

Wet pipe suppression systems in unheated areas to

monitor for temperature changes

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Page 2 Healthcare Life Safety Compliance October 2007

© 2007 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

The following definitions are taken verbatim from NPFA

72, the National Fire Alarm Code (1999 edition):

supervisory signal—a signal indicating the need for

action in connection with the supervision of guard tours,

the fire suppression systems or equipment, or the mainte-

nance features of related systems

supervisory signal initiating device—an initiating

device, such as a valve supervisory switch, water level

indicator, or low air pressure switch on a dry-pipe sprin-

kler system, in which the change of state signals an off-

normal condition and its restoration to normal of a fire

protection or life safety system

➤

➤

supervisory devices, defined

editorial Advisory Board Healthcare Life Safety Compliance

Group Publisher: Bob Croce, [email protected]

Sr. Managing Editor: scott Wallask, [email protected],

781/639-1872, Ext. 3119

Contributing Technical Editor: James K. Lathrop

Vice President

Koffel Associates, Inc.

Niantic, CT

James R. Ambrose, PePrincipalCode Consultants, Inc. St. Louis, MO

Frederick C. Bradley, PePrincipalFCB Engineering Alpharetta, GA

Michael Crowley, PeSenior Vice President, Engineering ManagerRolf Jensen & Associates, Inc. Houston, TX

Joshua W. elvove, Pe, CsPFire Protection Engineer Aurora, CO

A. Richard FasanoManager, Western OfficeRussell Phillips & Associates, LLC Elk Grove, CA

Burton Klein, Pe PresidentBurton Klein Associates Newton, MA

David MohilePresidentMedical Engineering Services, Inc. Leesburg, VA

Daniel J. O’Connor, PeVice President, EngineeringSchirmer Engineering Corporation Deerfield, IL

thomas salamoneDirector of Safety & SecurityNorwalk Hospital Norwalk, CT

Robert Westenberger, ChFM-MCOConstruction Project Mgr.Atlantic Health System Morristown, NJ

William Wilson, CFPsFire Safety CoordinatorWilliam Beaumont Hospitals Royal Oak, MI

Healthcare Life Safety Compliance (ISSN 1523-7575) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA, 01945. Subscription rate is $279 for one year and includes unlimited telephone assistance. Single copy price is $25. Postmaster: Send address changes to Healthcare Life Safety Compliance, P.O. Box 1168, Marblehead, MA 01945. Copyright 2007 HCPro, Inc. All rights reserved. Printed in the USA. Except where explicitly encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions or for technical support with questions about life safety compliance, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax: 800/639-8511, or e-mail: [email protected]. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. Opinions expressed are not necessarily those of HLSC. Mention of products and services does not constitute endorsement. Advice given is general and based on National Fire Protection Association codes and not based on local building or fire codes. No warranty as to the suitability of the information is expressed or implied. Information should not be construed as engineering advice specific to your facility and should not be acted upon without consulting a licensed engineer, architect, or other suitable professional. Final acceptability of such information and interpretations will always rest with the authority having jurisdiction, which may differ from that offered in the newsletter or otherwise. Advisory Board members are not responsible for information and opinions that are not their own.

Water tanks to monitor outside temperatures and

water levels

Pressure switches to check for low air, water, or gas

pressure in suppression systems

“You want water pressure in your pipes so that when

called upon to fight a fire, [the water] is there,” says

Abhay Nadgir, a detection alarm systems product man-

ager for Kidde-Fenwal in Ashland, MA. For example,

without a supervisory device backing up the sprinkler

system, a water leak could go undetected, Nadgir says.

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➤

Remember, when it comes to Joint Commission

accreditation, if supervisory device signals indicate a life

safety deficiency, you should at least assess the need to

institute interim life safety measures. Also, long-term

fixes may require a plan for improvement under the

Statement of Conditions.

Get out your copy of NFPA 72

Because so many supervisory devices are associated

with sprinkler systems, NFPA 72 is a good starting point

for learning about these items. NFPA 72 sets performance

and maintenance requirements for fire alarm systems.

“It’s what the fire alarm guy will have to deal with,”

Richardson says.

When supervisory devices alert the fire alarm panel,

someone needs to check on the problem and reset the

panel, Nadgir says. “You’ve got to go to the panel . . .

and the device, and figure out why [the device] has had

a change in condition,” he adds.

In some cases, a supervisory signal alert might trigger

the need for an immediate fix of whatever impairment

caused the alert. If facilities can’t complete the fix quick-

ly, the owner or authorities might require a fire watch.

supervisory devices > continued from p. 1

October 2007 Healthcare Life Safety Compliance Page 3

© 2007 HCPro, Inc.


“That’s big picture stuff” that helps illustrate the impor-

tance of supervisory devices, Richardson says.

You’ll bridge between standards

EC.5.40 points you to the 1999 edition of NFPA 72.

Table 7-3.2 in NFPA 72 sets the foundation for testing

supervisory devices that EC.5.40 spells out (see item 15

in Table 7-3.2 for details).

The Life Safety Code® (LSC) refers to fire alarm sys-

tem requirements that stem from NFPA 72 as well.

The LSC “gives the marching orders for a lot of things,”

Richardson says.

Section 9.7 in the LSC talks about existing fire protec-

tion systems and their need to meet supervision require-

ments. Subsequently, the LSC’s healthcare occupancy

chapters refer you back to 9.7, which in turn points to

NFPA 72 (for example, see 19.3.5.1 in the LSC).

An overview of what’s in 72

Broadly speaking, NFPA 72 covers the following provi-

sions for supervisory devices:

The types of signals that supervisory devices must

emit or indicate (see section 2-9)

➤

System requirements for supervisory devices (see

3-8.3.3)

Testing methods for supervisory devices (see 7-2)

Inspection and testing frequencies for supervisory

devices (see 7-3)

See p. 4 for a checklist of methods to inspect supervi-

sory devices.

Other NFPA codes and standards that include refer-

ences to supervisory devices include the following, as

Richardson explains:

NFPA 13, Installation of Sprinkler Systems, includes some

requirements for system supervision

NFPA 20, Installation of Stationary Pumps for Fire Protection,

mandates the monitoring of electrical and diesel fire

pumps (e.g., continuous supervision for the main dis-

connect circuit to the pump’s power supply) n

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Ashe asks the Joint Commission to extend damper testingThe Joint Commission (formerly JCAHO) might for-

mally adopt six-year damper testing frequencies starting

in January.

This news was posted on the American Society for

Healthcare Engineering’s (ASHE) listserv on August 13 by

society Executive Director Dale Woodin.

Currently, facilities need to test dampers every

four years under EC.5.40, which sets various re-

quirements for inspecting and testing fire protection

equipment.

However, a specific provision in the 2007 NFPA 105,

Installation of Smoke Door Assemblies and Other Opening

Protectives, allows damper testing for hospitals only to

occur every six years.

The 2007 NFPA 80, Fire Doors and Fire Windows, also

allows six-year testing for fire dampers in hospitals.

ASHE has asked The Joint Commission to recognize

the six-year frequency, and the commission is in the

process of taking the request through various commit-

tees, Woodin wrote.

Until The Joint Commission adopts the proposal,

though, “the surveyors’ expectation for compliance

remains at testing every four years regardless of what the

NFPA code requirements are,” he added.

ASHE has led the charge for nearly the past three years

to extend damper testing to six-year frequencies. The associ-

ation has argued the damper testing in hospitals has a good

track record that warrants the longer testing intervals. n

In the August 2007 healthcare Life safety

Compliance, dates for the NFPA’s World Safety Conference

and The Joint Commission Perspectives should have listed June

instead of August. We apologize for the mistakes.

Correction

Page � Healthcare Life Safety Compliance October 2007

© 2007 HCPro, Inc.


NFPA 72, the National Fire Alarm Code, outlines methods to test the following supervisory devices:

use these testing methods for certain supervisory devices

Device Q1 Q2 Q3 Q�

Control valve switches

➤ Operate the valve

➤ Verify a signal under one of the following conditions:

– Within the first two revolutions of the hand wheel

– Within one-fifth of the travel distance

– According to manufacturer specifications

high– and low–air pressure switches

➤ Operate the switch

➤ Verify a signal when the required pressure increases or decreases a maximum of 10 lb per

square inch

Room temperature switches


➤ Verify a signal to indicate a decrease in room temperature to 40°F

➤ Verify a signal to indicate a restoration in room temperature to above 40°F

Water level switches


➤ Verify a signal under one of the following conditions:

– The water level raises or lowers 3 inches from the required level within a pressure tank

– The water level raises or lowers 12 inches from the required level within a nonpressure tank

➤ Verify a signal to indicate the restoration of the required water level

Water temperature switches


➤ Verify a signal to indicate a decrease in water temperature to 40°F

➤ Verify a signal to indicate a restoration in water temperature to above 40°F

Water flow devices

Flow water through an inspector’s test connection

Verify a signal under one of the following conditions:

– A flow of water equal to that from a single sprinkler of the smallest orifice size for wet

pipe systems

– An alarm test bypass connection for dry pipe, preaction, or deluge systems

Additional comments: ____________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Source: Based on information from Table 7-2.2 in NFPA 72 (1999 edition).

October 2007 Healthcare Life Safety Compliance Page �

© 2007 HCPro, Inc.


‘Monthly’ doesn’t mean every 30 days, technicallyA Joint Commission official clarifies various time references

A confusing piece of Joint Commission (formerly

JCAHO) compliance stems from various frequency-based

activities, such as inspections, tests, and drills. For exam-

ple, does a requirement for monthly inspections mean

every 30 days or once each calendar month?

George Mills, FASHE, CEM, CHFM, senior engi-

neer at The Joint Commission, helped clear the muddle

at the July American Society for Healthcare Engineering’s

annual conference in New Orleans.

When the EC standards note daily, weekly, monthly,

or quarterly occurrences, they refer to what Mills called

“calendar references.” In other words, monthly refers to

September or October, not a random period of 30 consec-

utive days. Likewise, weekly is Sunday through Saturday,

not a seven-day period that begins on Wednesday.

However, annual and semiannual frequencies refer to

general periods of time.

here’s what the Joint Commission says

Taking the above approaches in mind, the follow-

ing are some hints for frequency-based requirements as

explained by Mills:

Quarterly occurrences can take place on January 1

for Q1 and June 30 for Q2 and remain in Joint Com-

mission compliance

Bimonthly occurrences happen every other month in

the calendar (e.g., April and then June)

Semiannual refers to six months since the last occur-

rence, plus or minus 20 days

Annual refers to one year since the last occurrence,

plus or minus 30 days

These time frames are particularly important for life

safety surveys because the five related EC standards

revolve around calendar references. For example:

The Statement of Conditions, through EC.5.20, offers

plan for improvement grace periods that extend six

months past the original completion date

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➤

➤

➤

EC.5.40 (inspection of fire protection equipment) fea-

tures various time-based requirements (e.g., weekly

fire pump churn tests under no-flow conditions)

The fire pump test frequency has been contentious in

past surveys, said Thomas Salamone, director of safety,

security, fire prevention, and clinical engineering at

Norwalk (CT) Hospital. Salamone spoke during HCPro’s

August 22 Webcast, “The Joint Commission’s Life Safety

Survey.”

Some surveyors have interpreted EC.5.40’s language to

mean every seven days, but that isn’t correct, he added.

the eC requirements differentiate

If you read the EC standards carefully, it’s clear at

what points The Joint Commission makes specific men-

tion of different time frames. For example, EC.7.40

requires generator tests to occur “12 times a year, with

testing intervals not less than 20 days and not more

than 40 days apart.” Note that the standard doesn’t say

“monthly” generator testing.

However, if you space your generator tests at 40-day

intervals, be warned that you might not be able to fit 12

into a year, which would put the facility out of compli-

ance with EC.7.40, said Thomas Huser, MS, CHSP,

safety manager at Clarian Health in Indianapolis.

It may not be worth pushing that limit these days

because “generator testing is going to be a very hot but-

ton” for surveyors, added Huser, who also spoke during

HCPro’s Webcast.

extinguishers often get surveyor attention

On the other hand, EC.5.40 mandates that facilities

inspect portable fire extinguishers monthly, not every 30

days, Huser said.

Surveyors may try to review your extinguisher pro-

gram using the 30-day approach, so be vigilant, he said.

Don’t be afraid to challenge surveyors on this. n

➤


© 2007 HCPro, Inc.


Five tips to keep Joint Commission surveyors happyBelow are five suggestions that will help you stay

compliant with several Joint Commission (formerly

JCAHO) standards:

4 Beef up your knowledge about main drain

tests (eC.�.�0)

Main drain tests programs are lacking in many facili-

ties, and surveyors are aware of the problem. This annual

test helps verify that your water supply is adequate to

meet the sprinkler system’s demand.

During main drain tests, observers should watch for

a noticeable drop in water pressure compared to the

prior test, which could indicate a partially closed valve or

obstruction.

“The key thing surveyors are asking is ‘Do you know

why you [conduct] the main drain test?’ ” said Thomas

Salamone, director of safety, security, fire preven-

tion, and clinical engineering at Norwalk (CT) Hospital.

Incomplete documentation is a big risk here, particularly

if a test shows a problem and there is no written record

of follow-up actions. Ensure that test logs also note static

and residual pressures, Salamone said.

Full details of main drain test procedures are in NFPA

25, Inspection, Testing, and Maintenance of Water-Based Fire

Protection Systems.

4 Keep fire department connections clear

(eC.�.�0)

The Joint Commission requires facilities to inspect

their exterior fire department connections quarterly. A

logical first step in this inspection is to have an up-to-date

inventory of your connection locations, Salamone said.

Take a walk outside and look at the connections. Note

whether you can clearly see the connection from the

street or sidewalk or whether it is hidden or obstructed

by a bush, he added.

If any connection caps are missing, check that no

one has stuffed garbage into the connection port, said

Salamone.

4 stay on top of damper testing (eC.�.�0)

Facilities must fully close all fire and smoke dampers

and remove fusible links, if applicable, every four years.

There has been much talk about the frequency of this test

extending to every six years in hospitals, but as of press-

time four years remains the enforced rule.

The Joint Commission allows you to skip testing on

dampers that are inaccessible (e.g., blocked from reach by

pipes, ductwork, etc.). Make sure you put the dampers as

entries on plans for improvement with a six-year comple-

tion period, said Thomas Huser, MS, CHSP, safety

manager at Clarian Health in Indianapolis.

And remember that your opinion of what constitutes

an inaccessible damper might differ from that of a life

safety specialist. “Be prepared to defend [your position]

with a surveyor,” Huser said.

4 Write up interim steps for emergency power

lapses (eC.7.�0)

If any aspect of an emergency power test fails under

EC.7.40, the standard requires the facility to carry out

interim measures until the necessary repairs are complete.

Ensure that you document what interim steps you take,

particularly because generator testing is so high on sur-

veyors’ minds these days, Huser said. If possible, take pho-

tos of the interim measures too. “It makes the surveyors

happy to see a visual of what you’re doing,” he said.

4 Make medical gas connections staff-friendly

(eC.7.�0)

Review your medical gas outlets to ensure consistency

and clarity, Salamone said. He recalled surveyors asking

staff members at Norwalk Hospital about whether each

outlet had clear labels, he added. n

Editor’s note: Salamone and Huser spoke during HCPro’s

August 22 Webcast, “The Joint Commission’s Life Safety

Survey.” To order a CD-ROM of the Webcast, go to www.


© 2007 HCPro, Inc.


Fire safety takes center stage in a posted survey reportThe Joint Commission focused on 0.125-inch door gap deficiencies

Beth Israel Deaconess Medical Center in Boston took

the unusual step of posting its Joint Commission (former-

ly JCAHO) survey report online in August. The commis-

sion surveyed the facility July 23 through July 27.

Many of the citations noted in the report stem from

the EC standards. Two areas stand out when reviewing

the report: The life safety specialist focused on excessive

gaps and latching problems for smoke and fire doors, and

surveyors also used EC.1.10 (managing safety risks) to

cite fire safety concerns.

Element of performance 4 under EC.1.10 requires

facilities to conduct risk assessments on any hazard that

could negatively affect patients, workers, or the build-

ing. It is an open-ended standard that surveyors are very

aware of these days.

the CeO writes to employees

In regards to the door gap problems, Beth Israel CEO

Paul Levy wrote an e-mail to staff members that said

excessive gaps between doors and door frames are a

“public safety hazard that we will fix.”

Medical gas cylinder storage was also a concern cited

by surveyors. “For example, some gas canisters were

not properly secured,” Levy wrote. “This is a true public

safety hazard. If an unsecured gas canister falls and the

regulator breaks off, the heavy tube can be an uncon-

trolled projectile.”

Levy indicated some of the findings in the report

would likely be appealed. To read the full report and

Levy’s e-mail, go to http://bidmc.harvard.edu and look for

the microscope graphic near the top of the page.

Below is a rundown of the specific fire safety citations,

many of which stem from the Statement of Conditions (SOC).

Citation topic: Fire protection equipment testing

EC reference: EC.5.40.

NFPA reference: NFPA 72, National Fire Alarm Code

(1999 edition), Table 7-3.2; NFPA 96, Ventilation Control

and Fire Protection of Commercial Cooking Operations (1998

edition); NFPA 17A, Wet Chemical Extinguishing Systems

(1998 edition), 5-3.

Deficiencies noted by surveyors: During the third

and fourth quarters of 2006, there was no documenta-

tion that the facility contacted the fire department during

testing of notification transmission equipment. Also, the

facility was unable to produce records for the annual fire

pump test under flow or records for a semiannual inspec-

tion of a kitchen hood.

Citation topic: extinguisher mounting heights


NFPA reference: NFPA 10, Portable Fire Extinguishers

(1998 edition), 1-6.10.

Deficiency noted by surveyors: Staff members

mounted two portable fire extinguishers such that they

exceeded the allowable 5-ft distance from the floor to

the top of the extinguishers (see “Quick tip” on p. 12 for

more details about this requirement).

Citation topic: Medical gas cylinder storage


NFPA reference: NFPA 99, Healthcare Facilities (2002

edition), Chapters 5 and 9.

Deficiency noted by surveyors: In several areas,

surveyors found more than two dozen compressed gas

cylinders that weren’t secured properly in storage rooms.

Citation topic: storage in stairwells


NFPA reference: Life Safety Code® (LSC), 7.2.2.5.3.

Deficiency noted by surveyors: A stairwell had

items stored within it.

Citation topic: Protection of the structure

EC reference: EC.5.20 and SOC, Part 3A, Question 1A

> continued on p. 8


© 2007 HCPro, Inc.


NFPA reference: LSC, 19.1.6.2.

Deficiency noted by surveyors: A structural steel

beam in a sprinkler valve room was missing its fireproofing.

Citation topic: Door latching

EC reference: EC.5.20 and SOC, Part 3A, Question 1C.

NFPA reference: LSC, 8.2.3.2.1.

Deficiency

noted by survey-

ors: A door to an

elevator machine

room didn’t

close and latch as

required for a two-

hour separation.

Citation topic: 0.12�-inch door gaps

EC reference: EC.5.20 and SOC, Part 3A, Questions

1C and 3D.

NFPA reference: LSC, 8.3.4.1 and NFPA 80, Fire

Doors and Fire Windows (1999 edition), 2-4.4.3.

Deficiency noted by surveyors: Rated doors in vari-

ous areas had a greater than 0.125-inch gap between

their meeting edges.

Citation topic: unsealed barrier penetrations

EC reference: EC.5.20 and SOC, Part 3A, Questions

1H and 3C.

NFPA reference: LSC, 8.2.3.2.4.2 and 19.3.7.3.

Deficiency noted by surveyors: Two unsealed pipe

penetrations went through one-hour-rated walls. Also,

several unprotected penetrations were found in various

smoke barriers.

Citation topic: Protection of hazardous areas

EC reference: EC.5.20 and SOC, Part 3A, Question 2K.

NFPA reference: LSC, 19.3.2.

Deficiency noted by surveyors: A conference room

was converted to a storage room, but the new room

wasn’t properly rated to store combustible materials. Also,

an unprotected room was used for medical gas storage

greater than 3,000 cubic feet.

Citation topic: Doors to hazardous areas

EC reference: EC.5.20 and SOC, Part 3A, Question 2L.


Deficiency noted by surveyors: A door’s self-closer

was broken in a soiled utility room.

Citation topic: trash chute doors

EC reference: EC.5.20 and SOC, Part 3A, Question 4B.

NFPA reference: LSC, 8.2.3.2.3.1 and 19.5.4.

Deficiency noted by surveyors: A floor scrubbing

machine held open a trash chute door in one area, and in

another spot a trash exit chute door was missing.

Citation topic: Paths mistaken as exits

EC reference: EC.5.20 and SOC, Part 3A, Question 5I.


Deficiency noted by surveyors: All stairwells in a par-

ticular building that led to the basement level didn’t have

safeguards or signs in place to prevent occupants from inad-

vertently traveling to the basement during an emergency.

Citation topic: Visible exit signs

EC reference: EC.5.20 and SOC, Part 3A, Question 5K.

NFPA reference: LSC, 7.10.5.

Deficiency noted by surveyors: An exit sign in a

stairwell wasn’t illuminated. n

Beth Israel > continued from p. 7

“ If an unsecured gas

canister falls and the

regulator breaks off,

the heavy tube can be an

uncontrolled projectile.”

—Paul Levy

Come to our new boot campThere’s still time to register for the Life Safety Code® Boot

Camp—Hospital Version, which takes place October 8–10

in Elgin, IL (outside of Chicago).

The boot camp will feature two and a half days of inten-

sive, no-frills classroom learning that focuses on healthcare

occupancy requirements. Go to www.hcprobootcamps.com

for full details.


© 2007 HCPro, Inc.


smoke alarm tests verify that smoke enters the deviceEach month in this column,

the staff at Koffel Associates,

Inc., in Elkridge, MD, explain

fire equipment testing and

maintenance concerns. Firm principal Ray Schmid, PE,

authored this installment.

In this article, we’ll review inspection and testing pro-

visions for smoke alarms. Joint Commission (formerly

JCAHO) surveyors look for compliance with the Life

Safety Code® (LSC) and expect facilities to stay current on

fire protection equipment maintenance.

In healthcare facilities, smoke alarms are generally

required in areas used or intended for nonpatient sleep-

ing (e.g., physician on-call rooms and family suites).

You’ll find these provisions in the LSC chapters of the

various residential occupancies, which are considered

residential because they don’t house patients.

Although their basic function is similar, smoke alarms

differ from smoke detectors in two ways:

1. Smoke alarms are typically powered by a 120-volt

circuit that serves other electrical equipment in the

protected area (e.g., a lighting circuit). Smoke alarms

may also have an internal battery backup that will

allow the device to operate upon failure of the electri-

cal power source. Conversely, smoke detectors receive

primary and secondary power from the fire alarm

system, and this power supply is typically monitored

for integrity.

2. Smoke alarms feature an internal audible alarm

that alerts an occupant of the presence of smoke.

Smoke detectors, on the other hand, are typically

arranged to operate fire alarm notification appliances

that are connected to, and powered by, the fire alarm

system.

NFPA 72 sets the stage for inspections

You can find the full requirements for inspection, test-

ing, and maintenance of smoke alarms in NFPA 72, the

National Fire Alarm Code, and in the manufacturer’s litera-

ture for the device.

Although NFPA 72 has no specific requirement for

visual inspections of smoke alarms, it is a good practice to

complete a visual check whenever you perform routine

testing. Visual inspections should verify that the device

hasn’t suffered damage and that smoke entry into the

device isn’t obstructed. Routine cleaning of the device

usually involves carefully blowing compressed air into, or

applying a vacuum to, the detector chamber opening.

test button is useful, but not official

Many smoke alarms have a test button that allows the

user to verify that the internal sounder and electronic cir-

cuitry work properly and that the alarm is loud enough.

Although a useful feature for interim testing, this button

doesn’t act as a true functional test of the device.

Instead, NFPA 72 requires annual testing of smoke

alarms to verify the ability of smoke to enter the device

and initiate the internal alarm. Aerosol smoke is avail-

able from fire alarm service companies that you can use

to carry out a functional test of these devices. Sensitivity

testing is also required to verify that smoke alarms oper-

ate within their listed and marked ranges.

Finally, for those devices equipped with replaceable

batteries, change the batteries frequently. Most local com-

munities provide public service messages when daylight

savings times change, which serve as an effective way of

reminding facility staff members to perform inspections of

smoke alarms and replace any backup batteries. n

Contact senior Managing editor scott Wallask

telephone 7�1/�39-1�72, ext. 3119

e-mail [email protected]

Questions? Comments? Ideas?


© 2007 HCPro, Inc.


&AnswersQuestions

Each month, Jennifer Frecker and James Lathrop of fire

protection consulting firm Koffel Associates, Inc., in Elkridge,

MD, answer your questions about life safety compliance. Our

editorial advisory board also reviews the Q&A column.

Miscellaneous signs in a stairwell

Do you know whether the NFPA says anything

about signs in stairwells? I am not talking about the

directional signs that are required to tell people where

the exit discharge is. Our hospital is starting a well-

ness program for staff members that includes indoor

walking tracks, and organizers want to put signs in the

stairwells to encourage people and also tell them where

the routes are, etc. I told them they couldn’t do this,

and they are fighting me. Do you know whether NFPA

codes specifically address this issue?

There are a few requirements in the Life Safety

Code® (LSC) that discuss decorations and interior

finish, but they don’t specifically state that nothing can

be hung in an exit. The following requirements might

be beneficial, though:

Paragraph 7.1.3.2.3 in the LSC states, “An exit

enclosure shall not be used for any purpose that has

the potential to interfere with its use as an exit and,

if so designated, as an area of refuge.”

7.1.4 states, “The flame spread of interior finish on

walls and ceilings shall be limited to Class A or Class

B in exit enclosures in accordance in Section 10.2.”

7.1.10.2.1 states, “No furnishings, decorations, or

other objects shall obstruct exits, access thereto,

egress therefrom, or visibility thereof.”

As a general rule, we suggest that you limit signs in

exit enclosures to reduce the amount of information

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that people need to review in an emergency. Occupants

shouldn’t need to read several signs in order to get out

of a stairwell.

As long as your wellness program’s signs do not

hinder or confuse occupants, there should not be a

problem. However, securely attach the signs to the

wall to ensure that they do not fall off and cause prob-

lems during egress.

enclosure for an annunciator panel room

A while back, the facility renovated a business

office into a space that houses security, the switch-

board, and a receptionist area. When the room was

a business office, staff members used a rolling metal

curtain to lock the space at night to keep people

out. Now in its current use, an annunciator panel is in

the room. A surveyor cited the facility under EC.5.20

(LSC compliance), feeling that because the room

has an annunciator panel, that the space should be

enclosed in a two-hour wall and that the rolling cur-

tain should also be tied into the fire alarm system.

Does the code require this?

There are requirements under paragraph 11.8.5 of

the LSC for a central control station or fire com-

mand center in high-rise buildings. The requirement

for the enclosure of this type of room in two-hour-

fire-rated construction comes from regional or local

building codes. You can find some discussion of a fire

command center in NFPA 72, the National Fire Alarm

Code, but the two-hour fire rated enclosure is not

required in NFPA 72.

If the facility in question was built meeting the high-

rise requirements of the local building code, then a fire

command center—which would house a fire alarm


© 2007 HCPro, Inc.


If you have a question about life safety compliance,

fire codes and standards, or the environment of care, pass

it along to us, and we’ll include it in one of healthcare

Life safety Compliance’s future Questions & Answers

columns.

Send us your questions in writing by:

Mail to healthcare Life safety Compliance, 200

Hoods Lane, P.O. Box 1168, Marblehead, MA 01945

E-mail to [email protected] (put “Q&A” in the sub-

ject line)

Fax to 781/639-2982 (to the attention of healthcare

Life safety Compliance)

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send us your questions

annunciator panel—most likely requires a two-hour-

fire-rated enclosure.

However, providing a fire alarm annunciator panel

in a specific location doesn’t automatically require a

two-hour enclosure.

As for the surveyor’s action, we would need addi-

tional information to provide a definitive answer about

the validity of the citation.

Classifying intervening rooms from suites

We’ve added a new psychiatric holding area to

our emergency department. The holding area is a

suite. Both access points to the holding area have two

separate doors for security purposes. The patient and

staff member enter the first door, which is then locked

behind them. Next, the second door is unlocked for

them to enter the suite. Would this area between the

doors be classified as an intervening room, and if so,

what travel distance do we need to meet?

The psych holding suite falls under the require-

ments of paragraph 18.2.5.8 in the LSC because it

is new construction. That paragraph allows intervening

rooms from a nonpatient sleeping suite under certain

conditions.

An intervening room occurs when an occupant

must pass through a door into an adjacent space prior

to egressing from a nonpatient sleeping suite. The LSC

doesn’t define the term “intervening room,” and there

are some instances when you can argue that doors

aren’t provided to separate one room from another but

instead are for other purposes, such as infection control.

You can argue the merits of your situation either

way. Your space is a room that occupants must pass

through prior to leaving the suite, but it is only for

security purposes. This may be an opportunity to con-

duct a risk assessment of the situation.

We suggest that you classify your two spaces as

intervening rooms. However, note that under 18.2.5.8,

only two intervening rooms are permitted in nonpa-

tient sleeping suites, and you must observe a travel dis-

tance of 50 ft from the most remote point of the suite

to the corridor.

Main drain test qualifications

Concerning the main drain tests required in EC.5.40

(testing of fire protection equipment), is there a

code that requires licensed sprinkler technicians to per-

form the test, or can it done by in-house personnel?

Under NFPA 25, Inspection, Testing, and Maintenance

of Water-Based Fire Protection Systems, there is no

specific requirement for a licensed person. Rather,

paragraph 4.1.2.3 states that “personnel who have

developed competence through training and experi-

ence” should perform main drain tests.

Generally, you’ll find this level of competency is only

in sprinkler contractors, because they have received

training in the testing and maintenance of sprinkler sys-

tems. If you have in-house employees that can meet this

level of competence, then they can conduct the testing.

If you choose to conduct the main drain tests in-

house, document staff experience. n


© 2007 HCPro, Inc.


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them as housekeepers make their way down a cor-

ridor—then 1-6.8 requires special brackets designed to

withstand the jolting.

Note these height restrictions

NFPA 10 also sets specific conditions for the height of

portable extinguisher installations—see 1-6.10 for the full

rundown.

In brief, observe these height limits for extinguisher

mounting:

If the extinguisher is 40 lb or less, install it so the top

of the canister is no more than 5 ft above the floor.

If the extinguisher is more than 40 lb, install it so the

top of it is no more than 3.5 ft above the floor.

The bottom of an extinguisher must be at least 4 inch-

es from the floor. The intent of this requirement is to

stop someone from simply placing an extinguisher on

the floor as a permanent spot for it.

Be careful with height provisions if you change extin-

guisher brands or types but use the same mounting

brackets or cabinets. For example, a taller replacement

model can exceed the 5-ft limit if the brackets aren’t

readjusted accordingly. n

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Be sure to observe the proper mounting requirements

for your facility’s fire extinguishers. You can find the rel-

evant provisions in NFPA 10, Portable Fire Extinguishers.

Two prime factors figure into how you mount an

extinguisher:

The hanger or bracket used to hold the equipment

How high above the floor the extinguisher goes

Mount extinguishers securely

As mandated in paragraph 1-6.7 of NFPA 10, facili-

ties must securely install extinguishers on the hanger or

bracket supplied

by the vendor or

place the equip-

ment in cabinets

or wall recesses. If

you use a hanger

or bracket, follow the manufacturer’s instructions and

secure it correctly.

Also, note that 1-6.7’s requirements don’t apply to

wheeled fire extinguishers. Instead, you should put

wheeled models in designated locations.

Further, if you find that specific extinguishers fre-

quently get dislodged—perhaps linen carts always hit

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Quick tip

Keep height limits in mind when mounting your portable fire extinguishers

If specific extinguishers

frequently get dislodged,

use special brackets designed

to withstand the jolting.

1. (T) (F) If an extinguisher is 40 lb or less, you must install it so the top of the canister is no more than 5 ft above the floor, according to NFPA 10, Portable Fire Extinguishers.

2. (T) (F) Joint Commission (formerly JCAHO) surveyors may expect to see an inventory of supervisory devices subject to testing.

3. (T) (F) The terms “smoke alarms” and “smoke detectors” are technically interchangeable.

4. (T) (F) A supervisory device emits a signal that indicates the need for an action.

5. (T) (F) As of September 1, The Joint Commission has extended damper testing to every six years.

6. (T) (F) Quarterly testing can take place on January 1 for Q1 and June 30 for Q2, according to a Joint Commission official.

7. (T) (F) NFPA 72, the National Fire Alarm Code, contains all testing provisions for supervisory devices.

8. (T) (F) You can formally test the function of a smoke alarm by pressing the “test” button on the device.

9. (T) (F) If a generator test fails under EC.7.40, the facility must carry out interim measures until the necessary repairs are complete.

10. (T) (F) Doors to soiled utility rooms must have self- or automatic-closing devices.

QuizQuizHealtHcare life Safety complianceThe newsletter to assist healthcare facility managers with fire protection and life safety

Vol. 9 No. 10October 2007

Quiz questions October 2007 (Vol. 9, No. 10)

A supplement to Healthcare Life Safety Compliance

1. True

2. True

3. False. Although their basic function is similar, smoke alarms differ from smoke detectors in two ways, as explained in our “Maintenance Matters” column.

4. True

5. False. Although The Joint Commission is considering the extension, as of September 1 surveyors will still check for damper testing every four years.

6. True

7. False. Although a good place to look for information about supervisory device testing associated with fire alarm systems, NFPA 72 isn’t the only code or standard with information about these devices.

8. False. Although a useful feature for interim testing, this button doesn’t act as a true functional test of a smoke alarm.

9. True

10. True

Quiz answers October 2007 (Vol. 9, No. 10)

Copyright © 2007 HCPro, Inc. Current subscribers to Healthcare Life Safety Compliance may copy this quiz for use at their facilities. Use by others, including those who are no longer subscribers, is a viola-tion of applicable copyright laws. ® Registered trademark, the National Fire Protection Association, Inc.

Documents

Healthcare Life Safety Compliance - HCPro · liaison to NFPA 72, the National Fire Alarm Code. “The typical supervisory device is a device that tells you the control valve for the