Fire alarm systems play an important part in any healthcare facility’s compliance with the Joint Commission and the Centers for Medicare & Medicaid Services (CMS) requirements for accreditation. Maintaining and inspecting the fire alarm system is required by NFPA 101, the Life Safety Code, which also is the referenced code both the CMS and Joint Commission use in determining life safety compliance. The Joint Commission’s focus on Life Safety Code compliance doesn’t look to be subsiding, as evidenced by fire safety provisions topping the latest list of most-cited standards in hospitals.
Fire safety is so important in a healthcare setting that in 2009, the Joint Commission established its own Environment of Care (EC) standard, which is devoted to “life safety” and based on the NFPA Life Safety Code. This chapter allows hospitals and other healthcare institutions to become more aware of the code requirements they must meet in order to maintain their accreditation with the Joint Commission. In addition to compliance with the Life Safety Code, the Joint Commission expects all accredited healthcare institutions to be in full compliance with state and local fire codes.
Because accredited institutions must maintain their fire alarm systems and because a Joint Commission surveyor can inspect them at anytime, the electrical contractor has the opportunity to provide fire alarm services on a regular basis.
In addition, hospitals are now under a new level of scrutiny. The Joint Commission’s Life Safety Surveyor will review the hospital’s statement of conditions and review any plan for improvement activity. Typically, the surveyor will ask to see inspection and maintenance documentation on the fire alarm system equipment as well as the emergency power systems maintenance, test and inspection records.
Also, the surveyor will ask to see the hospital’s Interim Life Safety Management (ILSM) plans to demonstrate that the hospital develops and implements plans to ensure the safety of occupants during times when the building may have a Life Safety Code deficiency or a temporary change in life safety systems or plans due to construction activities.
NFPA 101 is not normally adopted by jurisdictions that have already adopted a building code, so many contractors are unaware of its requirements as they apply to healthcare institutions. The Life Safety Code states in section 188.8.131.52 “To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.” And as with any fire alarm system, but especially with healthcare institutions, the records of conducted maintenance and testing and a copy of the certificate of compliance must be maintained.
Additionally, when contractors perform maintenance and testing activities, they will need to take extra care to ensure they comply with the hospital’s ILSM plan to compensate for the period of time the fire alarm system is temporarily out of service. The Life Safety Code requires that, where a required fire alarm system is out of service for more than four hours in a 24-hour period, the authority having jurisdiction must be notified. Also, the building must be evacuated, or an approved fire watch must be provided for all parties left unprotected by the shutdown, until the fire alarm system has been returned to service. As it is used in the code, the term “out of service” is intended to imply that a significant portion of the fire alarm system is not in operation, such as an entire initiating device, signaling line or notification appliance circuit. It is not the intent of the code to require notification of the authority having jurisdiction, or evacuation of the portion of the building affected, for a single nonoperating device or appliance.
The ILSM plan may already have an outline of what must be done. Typically, a fire watch will involve some special action beyond normal staffing, such as assigning an additional security guard or guards to walk the areas affected. The code recommends that such individuals be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.
But you as a contractor must understand that the testing of a fire alarm system also impairs that system’s operation during the testing. NFPA 72 states in the annex that “Impairments can be limited to specific initiating devices and/or functions (e.g., disconnecting the supervising station connection during system testing), or they can involve taking entire systems or portions of systems out of service.”
Prior to any scheduled inspection or testing, NFPA 72 recommends that the service company consult with the building or system owner or the owner’s designated representative. Issues of advance notification, including advance notification time, building posting, systems interruption and restoration, evacuation procedures, accommodation for evacuees, and other related issues, should be agreed on by all parties prior to any inspection or testing. This is especially true in healthcare institutions where testing must be coordinated with on-going treatments, coordination to prevent interruption of critical building systems or equipment or operations in the facility. NFPA 72 also requires that before proceeding with any testing, all people and facilities receiving alarm, supervisory or trouble signals and all building occupants shall be notified of the testing to prevent unnecessary response. And, of course, at the conclusion of testing, those previously notified and others, as necessary, shall be notified that all testing has been concluded.
Another service you can provide when marketing to healthcare institutions is to offer to audit the fire alarm system to ensure that it meets both the requirements of NFPA 101 and NFPA 72. For example, unlike other building occupancies, healthcare institutions practice a defend-in-place concept. It is, therefore, very important that the master fire alarm control panel be adequately protected to ensure the integrity of the fire alarm system. The 2009 Hospital Accreditation Standards of The Joint Commission mandate in LS.02.01.34 Element of Performance 2, “The master fire alarm panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and -hour fire-rated doors) that is continuously occupied or in an area with a smoke detector.”
NFPA 72-2010 now requires that in areas that are not continuously occupied, automatic smoke detection must be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location. There is no longer an exemption for the smoke detector requirement if the building is protected by an automatic sprinkler system installed in accordance with NFPA 13. There is an exception if ambient conditions prohibit installation of automatic smoke detection; in that case, automatic heat detection is permitted. However, it should be obvious that, if ambient conditions are not suitable for smoke detection, the location should be evaluated as to whether the area is suitable for the control unit.
NFPA 72-2010 also states that, “Where the area or room containing the control unit is provided with total smoke--detection coverage, additional smoke detection is not required to protect the control unit. Where total smoke-detection coverage is not provided, the Code intends that only one smoke detector is required at the control unit even when the area of the room would require more than one detector if installed according to the spacing rules in Chapter 17. The intent of selective coverage is to address the specific location of the equipment.”
As a professional contractor, you certainly can offer more services than simply testing and maintaining a fire alarm system for a healthcare institution. You can review and learn the requirements of NFPA 101 and NFPA 72 so that you will better understand the healthcare institution’s needs as they relate to compliance with the Joint Commission and CMS requirements. That knowledge will make you and your services invaluable to the healthcare institution you are serving.
MOORE, a licensed fire protection engineer, frequent speaker and an expert in the life safety field, is a co-editor of the current National Fire Alarm Code Handbook. Moore is a principal with Hughes Associates Inc. at the Warwick, R.I., office.