© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Joint Commission expectations for Testing Fire Alarm and Sprinkler Systems

Washington Society for Healthcare Engineering October 22, 2011 Yakima, Washington

Client name/ Presentation Name/ 12pt - 2

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Managing the Process

Documentation management . Electronic . Notebook . Open files . Signed? . Follow up on failed tests . Back up for survey

Client name/ Presentation Name/ 12pt - 3

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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.

Client name/ Presentation Name/ 12pt - 4

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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;

Client name/ Presentation Name/ 12pt - 5

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 6

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05 EP 1

Quarterly Test “A” standard Requirement for documentation What are supervisory alarm devices? Inventory needed EP 25

Client name/ Presentation Name/ 12pt - 7

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 8

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 9

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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?

Client name/ Presentation Name/ 12pt - 10

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 11

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 12

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05 EP 7

Water storage tank inspection. “A” standard Documentation required High and Low level alarms tested Every 6 Months

Client name/ Presentation Name/ 12pt - 13

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05 EP 8

Water Storage tank temperature test “C” standard Documentation required Measure of success Monthly during cold weather

Client name/ Presentation Name/ 12pt - 14

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 15

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC. 02.03.05 EP 10

Fire department water connections “A” standard Documentation required Quarterly Inventory, EP 25

Client name/ Presentation Name/ 12pt - 16

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 17

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 18

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05 EP 13

Kitchen Fire system Test “A” standard Documentation required 6 months Don’t forget EP 25

Client name/ Presentation Name/ 12pt - 19

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 20

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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?

Client name/ Presentation Name/ 12pt - 21

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 22

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC. 02.03.05 EP 17

Standpipe hoses “A” standard Documentation required 5 years after installation 3 years after that Inventory

Client name/ Presentation Name/ 12pt - 23

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 24

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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

Client name/ Presentation Name/ 12pt - 25

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

EC.02.03.05 EP 20

Sliding and roll down doors “A” standard Documentation required Annual Inventory “Stuff under roll down doors” Smoke curtains?

Client name/ Presentation Name/ 12pt - 26

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

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.

Client name/ Presentation Name/ 12pt - 27

© C

opyr

ight

, The

Joi

nt C

omm

issi

on

Questions?

Contact information Willmorg@sarmc.org 208-367-2726 Or, use the force, use the force!!!