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Joint Commission expectations for Testing Fire Alarm and Sprinkler Systems
Washington Society for Healthcare Engineering October 22, 2011 Yakima, Washington
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Managing the Process
Documentation management . Electronic . Notebook . Open files . Signed? . Follow up on failed tests . Back up for survey
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What buildings do you inspect?
What is in your E.S.O.C.? What about condos? What about leased buildings? Contracted or in-house? Managing the contracts.
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EC.02.03.05 EP 25
Start at the end with the beginning in mind. New requirements for the testing identified in EC. 02.03.05 elements of performance are required. The standards change almost makes you re-design the entire process of documenting tests. They include;
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Element of Performance 25
Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following;
Name of Activity Date of Activity Required frequency of activity Name and contact info of testor NFPA standard used Results of the activity
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EC.02.03.05 EP 1
Quarterly Test “A” standard Requirement for documentation What are supervisory alarm devices? Inventory needed EP 25
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EC. 02.03.05 EP 2
New This July “A” Standard Documentation required Quarterly test water-flow devices Every 6 months test valve tamper
switches. Inventory, EP 25
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EC.02.03.05 EP 3
Every 12 months test duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.
“C” Standard Requirement for documentation Inventory, EP 25
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EC.02.03.05 EP 4
Every 12 months, the hospital tests visual and audible fire alarms, including speakers.
“C” Standard Requirement for documentation Direct impact score Is an inventory required?
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EC.02.03.05 EP 5
Off site notification to fire responders “A” standard Requirement or documentation Quarterly What about off site buildings you own? Contract or in-house Fire drills could accomplish this
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EC.02.03.05 EP 6
Weekly fire pump churn test “C” standard Requirement for documentation Requirement for Measure of success Recommend verifying test meets NFPA
25, 1998
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EC.02.03.05 EP 7
Water storage tank inspection. “A” standard Documentation required High and Low level alarms tested Every 6 Months
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EC.02.03.05 EP 8
Water Storage tank temperature test “C” standard Documentation required Measure of success Monthly during cold weather
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EC.02.03.05 EP 9
Sprinkler system main drain test “A” standard Documentation required At low point or on each riser Inventory, EP 25
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EC. 02.03.05 EP 10
Fire department water connections “A” standard Documentation required Quarterly Inventory, EP 25
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EC.02.03.05 EP 11
Fire pump flow test “A” Standard Annual requirement Documentation required Direct impact score NFPA 25 has the test requirements Use it as a tool, compare tests
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EC.02.03.05 EP 12
Water flow test for standpipe systems. “A” standard Documentation required 5 year test Both Wet and Dry systems Compare to last tests NFPA 25 for reference on test
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EC.02.03.05 EP 13
Kitchen Fire system Test “A” standard Documentation required 6 months Don’t forget EP 25
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EC.02.03.05 EP 14
Carbon dioxide and other gaseous fire extinguishing system testing
“A” standard Documentation required Annual test requirement EP 25 Inventory
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EC 02.03.05 EP 15
Portable Fire Extinguisher inspection “C” standard Documentation required Measure of success required Many ways to get there Don’t forget, Day/Month/Year Not sure how this one will match to EP
25?
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EC.02.03.05 EP 16
Annual Fire Extinguisher inspection “A” standard Documentation required Needs to be a certified person Need inventory NFPA 10 (1998) edition
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EC. 02.03.05 EP 17
Standpipe hoses “A” standard Documentation required 5 years after installation 3 years after that Inventory
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EC.02.03.05 EP 18
Fire and Smoke Dampers “C” standard Documentation required 1 year after install 6 years after that “I occupancy” 4 years after that “B occupancy” Don’t forget the outlying buildings
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EC. 02.03.05 EP 19
Automatic shutdown devices for air handlers
“A” standard Documentation required Direct impact score Inventory Not the relay but actual shutdown
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EC.02.03.05 EP 20
Sliding and roll down doors “A” standard Documentation required Annual Inventory “Stuff under roll down doors” Smoke curtains?
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Managing failures in LS systems
What do you do when you have a failure of a life safety system component?
I.L.S.M Fire Watch Policies Records for review.
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Questions?
Contact information [email protected] 208-367-2726 Or, use the force, use the force!!!