LIFE SAFETY TRAINING Nebraska Health Care Association Chris Moran - - PDF document

LIFE SAFETY TRAINING Nebraska Health Care Association

Chris Moran November 1, 2017

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WHO WE ARE

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We are a global company offering specialty engineering and consulting services for the built environment. We have nearly 1,200 engineers, consultants, scientists and professionals focused on evaluating risks and developing practical, cost effective solutions for our clients’ protection, safety and security needs. 36+ years of specialty engineering and consulting services experience Our global clients include numerous Fortune 500 companies that encompass architects, designers, general contractors, developers, building owners and facility operators.

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Learning Outcomes:

• Top 10 k-tags
• Inspection, testing, and maintenance (ITM)

requirements

• Fire extinguishers
• Sprinkler systems
• Fire alarm systems
• Fire doors
• Facility personnel vs. licensed contractor ITM

Agenda

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Purpose:

• Identify ways to avoid common deficiencies
• Identify importance of fixing deficiencies
• Understand what regular ITM applies to your facility
• Discuss specific requirements for different life safety

systems in the facility

• Understand level of expertise required to perform

ITM

Overview

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• This is a discussion, not a speech
• Need input from you
• Helps me help you better
• Identify issues to follow-up on
• Ask questions

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Discussions

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Important Information

• FSES – S&C 17-15
• 5 year waiver
• Emergency Preparedness Rule
• 11/15/17
• S&C 17-29
• Electrical Breaker Testing
• Not recommended by manufacturers
• Fire Door Inspections – S&C 17-38
• Full compliance by 1/1/18
• Cited under K211
• Non-rated doors as part of facility maintenance program

CMS Updates

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Important Information

• K-tags with additional criteria
• K224 – ‘No hazards’ for manual horizontal doors
• K325 – ABHR inappropriate access protection
• K712 – Quals for planning/conducting drills
• K712 – Fire drill regularity
• K900 – Quals for risk assessment
• K912 – Reference error
• K918 – Circuit breaker testing not available from

manufacturers

CMS Updates

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Important Information

• Extent of CMS Survey
• Customary Access
• Fire Alarm DACT
• Minimum of 1 POTS line
• Risk Assessments
• New construction

CMS Updates

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PruittHealth – Palymra, 6-9-15

100 residents evacuated Fire in bathroom, mainly water and smoke damage No life threatening injuries Two of 4 wings closed indefinitely

NURSING HOME FIRES

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Albany Herald

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NHC Health Care Center, Nashville, 09-25-03

8 women dead, ages 76 to 96 20 critically injured Fire on 2nd floor (cause undetermined) No sprinklers in residential area “The smoke was so thick you could cut it with a knife”

NURSING HOME FIRES

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King’s Manor Nursing Home, 1-27-14

60 displaced residents Fire in storage closet (ruled accidental) Extensive damage

NURSING HOME FIRES

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Amarillo Globe News

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Henan Province (China) Nursing Home Fire, 5-25-15

38 residents killed, 6 injured Cause of fire not known Home completely destroyed Not anticipated that sprinklers provided

NURSING HOME FIRES

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Bbc.com

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Health Care Data

Civilian deaths in health care facilities

• 2004-2008: 6 deaths
• 2009-2013: 4 deaths

Nursing home data

Civilian deaths in nursing home facilities

• 2009-2013: 3 deaths

88% of fires were confined to the object of origin 3% of fires spread beyond the room of origin

1Richard Campbell, (2016). Structure Fires in Health Care Facilities. NFPA, Quincy, MA.

NFPA HEALTH CARE FIRE DATA1

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NFPA HEALTH CARE FIRE DATA1

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• Structure fires in health care facilities have followed

a steady downward trend over past decade

• Fire departments responded to 5,650 structure fires

in health care properties per year in 2009-2013

• $45 million in direct property damage
• 2009 – 2013 cooking was the leading cause of fires

(65%)

1Richard Campbell, (2016). Structure Fires in Health Care Facilities. NFPA, Quincy, MA.

NFPA HEALTH CARE FIRE DATA1

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NFPA HEALTH CARE FIRE DATA1

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NFPA HEALTH CARE FIRE DATA1

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1Richard Campbell, (2016). Structure Fires in Health Care Facilities. NFPA, Quincy, MA.

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Importance of resolving deficiencies

• Safety of patients
• Safety of employees
• Continuity of operations
• Liability

Health Care Facilities Maintenance

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Top 10 Life Safety Deficiencies 1. K353 – Sprinkler System Maintenance (32.1%) 2. K363 – Corridors - Doors (22.7%) 3. K321 – Hazardous Areas Separations (21%) 4. K372 – Smoke Barrier Construction (18.8%) 5. K511 – Gas and Electric Utilities (18.7%) 6. K712 – Fire Drills (15.4%) 7. K345 – Testing of Fire Alarm System (13.6%) 8. K324 – Cooking Facilities (11.6%) 9. K920 – Power Cords and Extension Cords (11.1%)

• 10. K351 – Sprinkler System Installation (10.7%)

Top 10 Deficiencies

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K353 – Automatic Sprinkler System Maintenance

LSC 4.6.12, 9.7.5, 9.7.7, 9.7.8 18.7.6, 19.7.6 NFPA 25 provides requirements for regular inspection, testing and maintenance (ITM) Up-to-date records

• Date sprinkler system last checked
• Who provided system test
• Water system supply source
• Provide in remarks info on coverage for any non-required or partial

system

CMS Top 10 Citations

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K353 – Automatic Sprinkler System Maintenance How to avoid?

CMS Top 10 Citations

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K353 – Automatic Sprinkler System Maintenance How to avoid?

• Keep records on-site
• 2 staff member knowledge
• Review changes in occupancy/use

CMS Top 10 Citations

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K353 – Automatic Sprinkler System Maintenance

CMS Top 10 Citations

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Component Inspection Testing Maintenance Control Valves Monthly Annually Annually Alarm Device Quarterly Semi-Annually N/A Sprinklers Annually 50 Years* N/A Pipe/Fittings Annually N/A N/A Fire Dept. Conn. Quarterly N/A N/A Main Drain N/A Annually N/A Alarm Valve 5 Years Annually N/A Check Valve 5 Years N/A N/A Dry-Pipe Valve Annually Quarterly/Annually Annually Backflow Preventer Monthly Annually N/A

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K353 – Automatic Sprinkler System Maintenance

CMS Top 10 Citations

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Zone Control Assembly Alarm Check Valve

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K353 – Automatic Sprinkler System Maintenance

CMS Top 10 Citations

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Backflow Preventer Dry Pipe Valve Check Valve

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K363 – Corridors - Doors

LSC 18.3.6.3 / 19.3.6.3 Substantial construction or 20-min fire rated, resist smoke

CMS Top 10 Citations

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K363 – Corridors - Doors

Roller latches prohibited S&C 07-18 – Permitted door gaps

• ¼” gap in not fully sprinklered smoke compartments
• ½” gap in gully sprinklered smoke compartments

No impediment Positive latching hardware Auto/ self- closing on exits, smoke barriers, etc. Unlimited height protective plates permitted Powered doors permitted

CMS Top 10 Citations

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CMS Top 10 Citations

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K363 – Corridors - Doors How to avoid?

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K363 – Corridors - Doors

CMS Top 10 Citations

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No Latching Door unable to close

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CMS Top 10 Citations

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K363 – Corridors - Doors How to avoid?

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CMS Top 10 Citations

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K363 – Corridors - Doors How to avoid?

• Keep records on-site
• Repairs breaks or damage immediately
• Visual inspections

– Labels – Damage – Hardware

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K321 – Hazardous Areas Separated by Construction

LSC 18.3.2.1 / 19.3.2.1 Self / auto-closing doors New construction: 1-hr fire barrier, 45 minute fire door Existing Construction: 1-hr fire barrier or sprinkler protection with smoke partition

CMS Top 10 Citations

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K321 – Hazardous Areas Separated by Construction

Hazardous areas include:

CMS Top 10 Citations

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Boiler Room Fuel Fired Heater Room

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K321 – Hazardous Areas Separated by Construction

Hazardous areas include:

CMS Top 10 Citations

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Laundries > 100 ft2 Repair, Maint. & Paint Shops

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K321 – Hazardous Areas Separated by Construction

Hazardous areas include:

CMS Top 10 Citations

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Laboratories Combustible Storage > 100 ft2

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K321 – Hazardous Areas Separated by Construction

Hazardous areas include:

CMS Top 10 Citations

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Trash Collection Rooms Soiled Linen Rooms

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K321 – Hazardous Areas Separated by Construction

CMS Top 10 Citations

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CMS Top 10 Citations

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K321 – Hazardous Areas Separated by Construction How to avoid?

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CMS Top 10 Citations

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K321 – Hazardous Areas Separated by Construction How to avoid?

• Check functionality of doors

– Self-closing or automatic-closing – Field applied protective plates limited to 48” from floor

• Check for unprotected penetrations in walls

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K372– Subdivision of Building Spaces: Smoke Barrier Construction

LSC 18.3.7, 18.1.6 / 19.3.7, 19.1.6 Fire resistance in accordance with LSC 8.5 Windows protected by fire-rated glazing or wired glass panels Minimum of 2 compartments per floor

CMS Top 10 Citations

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NFPA 101 NFPA 101

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K372– Subdivision of Building Spaces: Smoke Barrier Construction

Buildings subdivided as follows:

• In-patient sleeping/ treatment rooms divided into at least 2

compartments

• Stories with occupant load > 50 divided into at least 2

compartments

• Compartments cannot exceed 22,500 ft2
• Limit travel distance to 200 ft

CMS Top 10 Citations

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K372– Smoke Barrier Construction

CMS Top 10 Citations

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Typical smoke barrier penetrations

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K372– Smoke Barrier Construction

CMS Top 10 Citations

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NEW EXISTING

NFPA 101 NFPA 101

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CMS Top 10 Citations

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K372 – Smoke Barrier Construction How to avoid?

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CMS Top 10 Citations

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K372 – Smoke Barrier Construction How to avoid?

• Check for unprotected penetrations
• Verify functionality of door-closing device
• Doors are not required to be tested per NFPA 105

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K511– Gas and Electric Utilities

LSC 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 Equipment using gas or related gas piping complies with NFPA 54 Electrical wiring and equipment complies with NFPA 70 Existing installations can continue in service as long as there is no hazard to life

CMS Top 10 Citations

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CMS Top 10 Citations

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K511 – Gas and Electric Utilities How to avoid?

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CMS Top 10 Citations

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K511 – Gas and Electric Utilities How to avoid?

• Keep on-site records
• Verify hazard of existing conditions

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K712 – Fire Drills

LSC 18.7.1.2 / 19.7.1.2 Held quarterly on each shift Shift change drills only count for 1 shift Coded announcement permitted when drills conducted between 9 pm and 6 am Documented and records maintained

CMS Top 10 Citations

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today.duke.edu

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K712 – Fire Drills

Employees periodically instructed on their duties during a drill Employee response includes:

• Removal of all occupants directly involved with fire emergency
• Transmission of fire alarm signal to warn building occupants
• Confining fire by closing doors
• Relocation of patients as detailed in fire safety plan

Bedridden patients not required to evacuate

CMS Top 10 Citations

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CMS Top 10 Citations

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K712 – Fire Drills How to avoid?

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CMS Top 10 Citations

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K712 – Fire Drills How to avoid?

• Keep on-site records
• Ensure staff is familiar with routines and procedures
• Ensure staff competent and responsible

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K345 – Testing of Fire Alarm

LSC 9.6.1.4 Up-to-date records 2 staff member minimum knowledge ITM requirements in NFPA 72

CMS Top 10 Citations

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K345 – Testing of Fire Alarm

CMS Top 10 Citations

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Device Visual Inspection Testing Smoke/Heat Detector Semi-Annual Annual Pull Station Semi-Annual Annual Duct Detector Semi-Annual Annual Tamper Switch Quarterly Semi-Annual Flow Switch Quarterly Semi-Annual Horns/Strobes Semi-Annual Annual DACT Semi-Annual Annual Remote Annunciator Semi-Annual Annual Control Equipment Annual Annual Battery* Semi-Annual/Monthly Annual/Semi-Annual

*Frequency dependent on battery type

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CMS Top 10 Citations

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K345 – Testing of Fire Alarm How to avoid?

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CMS Top 10 Citations

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K345 – Testing of Fire Alarm How to avoid?

• Keep on-site, up-to-date records
• 2 staff member minimum knowledge
• Check devices for visual damage

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K324 – Cooking Facilities

LSC 9.2.3 / 18.3.2.5.1 / 19.3.2.5.1 9.2.3 – Commercial cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection

• f Commercial Cooking Equipment

CMS Top 10 Citations

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K324 – Cooking Facilities

Residential cooking equipment (small appliances) permitted to be used for food warming or limited cooking Cooking facilities protected according to NFPA 96 are not required to be enclosed as hazardous areas, but shall not be

• pen to corridor

CMS Top 10 Citations

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K324 – Cooking Facilities 18.3.2.5.3 / 19.3.2.5.3 Cooking facilities open to the corridor in smoke compartments with 30 or fewer patients shall comply with the following:

Cook top has a suppression system (UL 300A), grease collection, and 500 cfm minimum exhaust Interlocks to shut down fuel and electrical power Smoke zone limited to 30 beds Two smoke alarms located 20 – 25 feet away Smoke detectors not located within 20 ft

CMS Top 10 Citations

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CMS Top 10 Citations

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K324 – Cooking Facilities

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K324 – Cooking Facilities TIA 12-2

Applies to cooking facilities in new and existing healthcare

• cc. (Ch. 18/19)

Permits smoke alarm to be located outside of kitchen area to meet distance requirements Smoke detector permitted to be used in lieu of smoke alarm

• Can emit local signal without activating building fire alarm
• Local silencing of the audible notification is permitted

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CMS Top 10 Citations

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CMS Top 10 Citations

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K324 – Cooking Facilities How to avoid?

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CMS Top 10 Citations

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K324 – Cooking Facilities How to avoid?

• Compliance with NFPA 96
• Ensure proper use of equipment

– Small equipment used for limited cooking and heating

• Ensure proper separations to the corridor unless

exceptions met

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K920 – Power Cords and Electric Cords

LSC 9.1.2 Used only for components of movable patient care related equipment (PCREE) that meet the conditions of 10.2.3.6 Power strips may be used for computers, monitors, and printers outside patient care vicinity MEDICAL DEVICES allowed within limitations

CMS Top 10 Citations

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K920 – Power Cords and Electric Cords

Power strips for PCREE meet UL 1363A or UL 60601-1 Power strips for non-PCREE in the patient care rooms (outside

• f vicinity) meet UL 1363

Extension cords are not used as a substitute for fixed wiring of a structure Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4

CMS Top 10 Citations

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CMS Top 10 Citations

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K920 – Power Cords and Electric Cords How to avoid?

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CMS Top 10 Citations

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K920 – Power Cords and Electric Cords How to avoid?

• Ensure proper use

– Computers, monitors outside patient vicinity – Components of movable patient care equipment – Extension cords not used as substitution for fixed wiring

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K351 – Sprinkler System Installation

LSC 18.3.5 / 19.3.5 Sprinkler protection required in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems In Type I & II construction, alternative protection measures permitted in lieu of sprinkler system in specific areas where AHJ prohibits sprinklers

CMS Top 10 Citations

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K351 – Sprinkler System Installation

Sprinkler devices connected to FA panel Closets, built-in wardrobes and bathrooms require sprinklers Exterior combustible canopies > 4’

CMS Top 10 Citations

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K351 – Sprinkler System Installation

CMS Top 10 Citations

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NFPA 101

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CMS Top 10 Citations

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K351 – Sprinkler System Installation How to avoid?

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CMS Top 10 Citations

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K351 – Sprinkler System Installation How to avoid?

• Ensure sprinklers installed in all rooms, especially

when walls are relocated

• Listed quick-response sprinklers or listed residential

sprinklers are used throughout smoke compartments with patient sleeping rooms in new facilities

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923 (Gas Cylinder/Equip Storage) – 10.6% 918 (Essential Electrical ITM) – 9.9% 521 (HVAC) – 9.6% 271 (Exit Discharge) – 9.5% 211 (Means of Egress Requirements) – 9.3%

OTHER CITATIONS

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SUMMARY OF K-TAGS

Majority of citations concern regular maintenance or drills Keep track of maintenance and records Ensure sprinkler protection provided throughout Maintain exits, doors and walls in working order

CONCLUSION

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OPEN DISCUSSION

Survey Trends Recent Experiences

RECENT SURVEY DISCUSSION

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OPEN DISCUSSION

What can your facility do to minimize deficiencies? What are the benefits of keeping up with facility maintenance?

DISCUSSION

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Inspection, Testing, and Maintenance Service: A service program provided by a qualified contractor or qualified property owner’s representative where all system components are inspected and tested at the required frequency and necessary maintenance is provided

What is ITM

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Qualified

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A competent and capable person or company that has met the requirements and training for a given field acceptable to the authority having jurisdiction.

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THE OWNER IS RESPONSIBLE FOR ITM

International Fire Code NFPA 101 and Referenced Standards (excerpt from NFPA 25)

Who is Responsible for ITM?

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• It is REQUIRED by code
• NFPA 101 – 2012 Edition (CMS) adopts:
• NFPA 10 – 2010 Edition
• NFPA 25 – 2011 Edition
• NFPA 72 – 2010 Edition
• NFPA 110 – 2010 Edition
• State Fire Code Adopts:
• NFPA 101 – 2000 Edition
• NFPA 10 – 2002 Edition
• NFPA 25 – 2002 Edition
• NFPA 72 – 2002 Edition
• NFPA 110 – 2002 Edition
• Mitigate the owner’s liability
• Stay on top of deficiencies

ITM – Why Test & Inspect?

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• Continuity of building
• perations
• General life safety
• Liability associated with not

performing ITM

ITM – Why Test & Inspect?

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NFPA 10, 2010 Edition

Standard for Portable Fire Extinguishers

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• LSC 18/19.3.5.12 – portable fire extinguishers shall

be provided in all health care occupancies in accordance with 9.7.4.1

• LSC 9.7.4.1 - where required by the provisions of another

section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10

• K355

ITM: Fire Extinguishers

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Fire Extinguisher Symbol Marking

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• Internal examination at intervals based on type of

extinguisher (varies from 1-6 years)

• Maintenance, servicing, and recharging performed

by certified persons

• Technician must be “certified by an organization with

a certification program acceptable to the AHJ” and “have the proper tools, listed parts, and appropriate manufacturer’s service manual.”

ITM: Fire Extinguishers

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• 7.1.1. The owner or designated occupant is

responsible for ITM

• 7.1.2. Personnel
• Certification required
• Persons training for certification permitted to perform

maintenance under direct supervision of a certified person

• Persons passing the testing process issued a certificate
• Persons performing 30-day inspections not required to be

certified

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.1.4 Tags or labels
• Tags for recording

inspections not placed on front of fire extinguisher

• Labels indicating

use or classification placed on front of fire extinguisher

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.2 Inspection
• Manually inspected when initially placed in service
• Inspected manually at a maximum of 30-day intervals

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.2.2 Procedures check list

1. Location in designated place 2. No obstruction to access or visibility 3. Pressure gauge reading or indicator in the operable range

• r position

4. Fullness determined by weighting or hefting for self- expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks 5. Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers 6. Indicator for non-rechargeable extinguishers using push- to-test pressure indicators

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.2.2.1 Additional visual inspection required where

the following conditions exist

1. High frequency of fires in the past 2. Severe hazards 3. Locations that make fire extinguishers susceptible to mechanical injury or physical damage 4. Exposure to abnormal temperatures or corrosive atmospheres

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.2.2.2 Additional inspection

procedures

1. Verify that operating instructions on nameplates are legible and face outward 2. Check for broken or missing safety seals and tamper indicators 3. Examine for obvious physical damage, corrosion, leakage, or clogged nozzle

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.2.4 Inspection record

keeping

• Records kept for all fire

extinguishers inspected

• Date of inspections and

initials of inspector recorded

• Inspection records kept
• n tag attached to

extinguisher, on inspection checklist maintained on file, or by an electronic method

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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• 7.4 Recharging
• Extinguishers recharged after any use, as indicated by

inspection, or when maintenance is performed

• Amount of recharge agent verified by weighing
• Recharged gross weight required to be the same as the

gross weight marked on the nameplate

• Where a gross weight is not provided on nameplate, a

permanent label indicated gross weight shall be provided

Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers

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Frequency of Internal Maintenance of Fire Extinguishers

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Frequency of Internal Maintenance and Hydrostatic Testing of Fire Extinguishers

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• What are the procedures for inspection?
• What information must be recorded during ITM?
• Benefits of fire extinguisher ITM?
• Common deficiencies?

Discussion

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• Visual Inspection required at a minimum of 12 times

per year

• Follow inspection procedure checklist
• Keep detailed records of inspections

Summary of Fire Extinguisher ITM

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NFPA 25, 2011 Edition

Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems

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ITM: Sprinkler Systems

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• LSC 9.7.5 Maintenance and Testing
• All automatic sprinkler systems and standpipe systems

required by this code inspected, tested, and maintained in accordance with NFPA 25

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• Property owner or designated representative

responsible for proper maintenance

• Building owner responsible for ensuring all areas of

the building containing water-filled piping maintained at a minimum temperature of 40° F

• Property owner must notify AHJ, the fire department,

and alarm-receiving facility before testing or shutting down a system or supply

4.1 Responsibility of the Property Owner or Designated Representative

100

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• 4.1.8 Information sign
• Permanently marked metal or rigid plastic information sign

placed at the system control riser supplying antifreeze loop, dry system, preaction system, or auxiliary system control valve

• Sign secured with corrosion-resistant wire or chain

providing the following information:

• 1. Location of area served by system
• 2. Location of auxiliary drains and low-point drains for dry pipe

and preaction systems

• 3. Presence and location of antifreeze or other auxiliary systems
• 4. Presence and location(s) of heat trace

4.1 Responsibility of the Property Owner or Designated Representative

101

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• Where an impairment occurs, compliance with

Chapter 15 required

• Tag used to indicate a system or part thereof has been

removed from service

• Tag posted at each system control valve
• Emergency impairments
• System leakage
• Interruption of water supply
• Frozen or ruptured piping
• Equipment failure

4.1.9 Impairments

102

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Sample Impairment Tag

103

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• Impairment coordinator shall verify the following

procedures have been implemented:

1. Any necessary inspections and tests have been conducted to verify affected systems are operational 2. The following have been advised that protection is restored:

• Supervisors, fire department, property owner or designated

representative, insurance carrier, alarm company, other AHJ

3. Impairment tag removed

Restoring Systems to Service

104

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• Records made for all ITM readily available to AHJ

upon request

• Indicate procedure performed, organization that

performed work, results, date

4.3 Records

105

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• What gets a visual inspection?
• Sprinkler riser components
• Control & alarm check valves
• Gauges
• Sprinklers
• Piping
• Fire department connection
• Dry pipe valves

5.2 Inspection

106

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5.2 Inspection

107

• Why should you perform ITM?

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• Why inspect?

5.2 Inspection

108

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5.2 Inspection

109

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• Inspect sprinkler system Backflow Preventer (NFPA

25 §13.7)

Physical damage Leakage Isolation valves in the open position

Sprinkler System Weekly Inspection

110

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• Inspect gauges on dry sprinkler

systems [NFPA 25 § 13.2.7.1.3]

• If not supervised by the fire alarm system,

confirm normal air and water pressures are being maintained

• Where air pressure supervision is

connected to a constantly attended location can be quarterly [13.2.7.1.3.2]

• If you are in a freezing climate,

conduct the following inspections:

• Enclosures around dry-pipe, preaction or

deluge valves maintaining a minimum of 40° F (4° C)

Sprinkler System Monthly Inspection

111

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• Inspect locked or supervised sprinkler system

valves (NFPA 25 §13.3.2.1.1 & 13.3.2.2)

• Normal position (open or closed - Critical on dry and preaction

systems)

• Properly sealed, locked, and/or supervised
• Accessible
• Appropriate wrenches when required for operation
• No external leaks
• Appropriate identification

Sprinkler System Quarterly Inspection

112

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• Inspect sprinkler system

Alarm Check Valves (NFPA 25 § 13.4.1.1)

• Valve trim valves are correct

position (i.e., open or closed)

• Is free of leakage from the

retarding chamber or alarm drains

Sprinkler System Quarterly Inspection

113

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• Fire department connections

[FDC] (NFPA 25 § 13.8.1):

• Visible and accessible
• Couplings and swivels not damaged

and rotate smoothly

• Plugs or caps in place and

undamaged

• Gaskets in place and in good

condition

• Identification sign(s) in place
• Check valve is not leaking
• Automatic drain valve in place and
• perating properly
• Interior of the connection is inspected

for obstructions

• Visible piping supplying the fire

department connection is undamaged

Sprinkler System Quarterly Inspection

114

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• Inspect sprinkler system gauges monitoring water

pressure (NFPA 25 § 13.2.7.1.2):

• Being in good condition and free of physical damage
• Indicating normal water supply pressure is being maintained

Sprinkler System Quarterly Inspection

115

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• Freezing climate: perform these inspections before freezing

weather.

• What are we looking for:
• Adequate heat to areas where wet sprinkler piping is

located? (NFPA 25 § 4.1.2)

• Check low temperature alarms, if installed in heated valve

enclosures (NFPA 25 § 13.4.3.1.2, 13.4.4.1.2, 13.4.5.1.1.2)

• Check unit heater locations to prevent sprinkler activation

Sprinkler System Annual Inspections

116

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• 5.2.1 Sprinklers
• Inspected annually from floor level
• Replace sprinklers if any of the following conditions exist:
• 1. Leakage
• 2. Corrosion
• 3. Physical damage
• 4. Loss of fluid in the glass bulb heat responsive element
• 5. Loaded with dust
• 6. Painting unless done by manufacturer
• 7. Installed at incorrect orientation

5.2 Inspection

117

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• 5.2.1 Sprinklers

5.2 Inspection

118

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• 5.2.1 Sprinklers

5.2 Inspection

119

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• 5.2.2 Pipe and Fittings
• Inspected annually from floor

level

• What to look for:
• Piping and fittings in good condition
• Mechanical damage
• Leaks
• External condition
• Mechanical couplings properly

aligned

• Nothing hung or resting on pipes
• Pipes and fittings installed in

concealed spaces do not required inspection

5.2 Inspection

120

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• 5.2.2 Pipe and Fittings

5.2 Inspection

121

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• 5.2.3 Hangers and Seismic Braces
• Inspected annually from floor level
• Replace/refasten if damaged or loose
• Hangers and seismic braces installed in concealed spaces

do not require inspection

5.2 Inspection

122

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• 5.2.4 Gauges
• Inspected monthly on wet pipe systems
• Inspected weekly on dry, preaction, and deluge systems
• Monthly inspection permitted where air pressure supervision is

connected to a constantly attended location

• When gauge near compressor reads higher than gauge

near dry pipe valve, take air line out of service

• Open alternate air line to equalize pressure
• Internally inspect air line taken out of service and reassemble

for future use

5.2 Inspection

123

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• Waterflow Alarm and Supervisory Devices
• Inspected quarterly for physical damage
• Hydraulic Design Information Sign
• Inspected quarterly to verify secure attachment and legibility
• Inspected annually for standpipe systems
• Heat Tape
• Inspected per manufacturer’s requirements

5.2 Inspection

124

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Sample Hydraulic Design Information Sign

125

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• What tests can be performed by personnel on

automatic fire sprinkler systems:

• All required, some may be better performed by contractors:
• Main Drain Test
• Inspector’s Test
• Alarm Test
• Dry Pipe Trip Test
• Pump Test

5.3 Testing

126

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Owner’s Section on Inspection Report

127

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• Purpose
• Confirm water supply condition

(pressure drop, unobstructed, clean)

• Frequency
• Annually [NFPA 25, 13.2.5]
• Any time a riser main control

valve is closed

• Quarterly, if backflow

preventer present [NFPA 25, 13.2.5.2]

Main Drain Test

128

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Main Drain Test Procedures

129

Step 1 Step 2 Step 3 Call the fire alarm system out of service and notify occupants (i.e., controllers, etc.). Visually inspect the discharge location.

12

Note system pressure

• n both sides of the

alarm check valve.

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Main Drain Test Procedures

130

Step 4 Step 5 Step 6 Open main drain valve. Visually inspect the discharged water.

• Clean? Clear? No debris?

130

Note system pressure on both sides of the alarm check valve.

• excessive drops from

previous tests or as-builts?

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Main Drain Test Procedures (cont’d)

131

Step 7 Step 8 Step 9 Confirm outside water motor gong

• peration, if present.

Close main drain valve. Remove bypasses and call system back into service. DONE!

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• Purpose
• Simulate sprinkler activation
• Confirm operation of flow

switches, water motor gong, etc.

• Confirm water delivery time

for Dry Pipe System

• Frequency
• Every 6-months for paddle-

type water flow switch [NFPA 25, 13.2.6.2.2]

Inspector’s Test

132

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Inspector’s Test Procedures

133

Step 1 Step 2 Step 3 Call the FA system out of service and notify occupants. Visually inspect the discharge location. Open the Inspector’s Test valve.

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Inspector’s Test Procedures (cont’d)

134

Step 4 Step 5 Step 6 Visually inspect the discharge. Re-close the inspectors test valve. Call system back into service. Finally Confirm water motor gong

• peration, if present. (must

ring within 5 minutes) Note: May be an electric bell activated by a flow switch.

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• Special testing

considerations?

• Often installed because

freezing is anticipated!

• Must be drained after

testing!

• Test Types &

Frequency

• Partial trip - Annual [NFPA

25, 13.4.5.2.2]

• Full Trip - Every 3 years

[NFPA 25, 13.4.5.2.2.2]

Dry Sprinkler Systems

135

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Dry System Full Trip Test Procedures

136

Step 1 Step 2 Step 3 Call the FA system out of service and notify

• ccupants.

Visually inspect the discharge location. Open the Inspector’s Test valve.

• Note the time!

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Dry System Full Trip Test Procedures (cont’d)

137

Step 4 Step 5 A Visually inspect the discharged water.

• Clean? Clear? No debris?

Confirm waterflow and fire alarm activation within 60 seconds and… Confirm water motor gong operation, if

• present. (must ring

within 5 minutes) Step 5 B

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Dry System Full Trip Test Procedures (cont’d)

138

Step 6 Reset dry pipe valve. Remove bypasses and call system back into service. Re-close the inspectors test valve. Step 7

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• Special testing

considerations?

• Valve will trip so be prepared

to reset

Dry Sprinkler System Partial Trip Test Procedures

139

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Dry Sprinkler System Partial Trip Test Procedures

140

Step 1 Step 2 Call the FA system out of service and notify occupants. Partially close the main water control valve located under the dry valve.

• Ensures the riser does

not flood.

• Will introduce a

supervisory on the Fire Alarm system

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Dry Sprinkler System Partial Trip Test Procedures (cont’d)

141

Open the Inspector’s Test valve. Step 4 Listen for the dry valve clapper to open. Step 3 Step 5

1

Reset dry pipe valve. Remove bypasses and call system back into service. Re-close the inspectors test valve. Step 6 e clapper to open. Re-close the inspectors test valve. Once the valve trips, fully close the control valve.

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• Purpose
• Confirm water motor gong or Electric Bell operation
• Frequency
• Quarterly [NFPA 25, 13.2.6.1.2]
• Can be included as part of dry sprinkler trip tests

Dry System Alarm Test

142

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Dry System Alarm Test Procedures

143

Step 1 Step 2 Step 3 Call the FA system out of service and notify occupants (i.e., controllers, etc.). Locate the pressure switch trim piping and associated valve. Open the trim piping alarm valve.

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Dry System Alarm Test Procedures (cont’d)

144

Step 4 Step 5 Step 6 Confirm water motor gong or electric horn is

• perating. (Must ring within 5 minutes)

Close alarm line trim piping. Remove bypasses and call system back into service.

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• Annual
• Must flow pump at minimum, rated

and peak flows [NFPA 25, 8.3.3.1]

• Monthly
• Electric pump run for minimum of 10

minutes [NFPA 25, 8.3.1.2.2 & 8.3.2.3]

• Weekly
• Diesel pump run for minimum of 30

minutes [NFPA 25, 8.3.1.1.1 & 8.3.2.4]

• Automatically started
• Run without flowing water
• Who should perform
• Contractor
• Equipment and labor intense

Fire Pump Tests

145

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• 5.3.1 Sprinklers
• Replaced if in service more than 50 years, or

representative samples tested

• Test procedures repeated at 10-year intervals
• Replaced if manufactured prior to 1920

5.3 Testing

146

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• 5.3.1 Sprinklers
• Sprinklers using fast-response elements in service for 20

years shall be replaced or representative samples shall be tested and re-tested every 10 years

• Representative samples: 4+ sprinklers or 1% of sprinklers in

sample, whichever greater

• Sprinklers tested on 5-year basis where subjected to harsh

environments

• Manufacturers permitted to make modifications in the field

that restore original performance where acceptable by AHJ

5.3 Testing

147

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Sprinkler Operating Element Identification

148

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• 5.3.2 Gauges
• Replaced every 5 years or tested every 5 years by

comparison with calibrated gauge

• Replace or recalibrate gauges not accurate to within 3% of

the full scale

5.3 Testing

149

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• 5.3.3 Waterflow Alarm Devices
• Vane-type and pressure switch-type tested semiannually
• Testing devices on wet pipe systems shall include opening

inspector’s test connection

• Bypass connection used where freezing weather conditions

exist

5.3 Testing

150

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• 5.3.4 Antifreeze Systems
• Freezing point tested annually
• Measure specific gravity with a hydrometer or refractometer
• Listed CPVC sprinkler pipe and fittings protected from

freezing with glycerin only (new to 2011 edition)

• Use of antifreeze systems in accordance with state or local

health regulations

• If test results indicate incorrect freeze point at any point in

the system:

• 1. Drain system
• 2. Solution adjusted
• 3. System refilled

5.3 Testing

151

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5.3 Testing

152

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5.3 Testing

153

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• Maintenance to be performed to

keep the system equipment

• perable (§4.8).
• Sprinklers (§5.4.1):

Sprinklers removed for any reason not reinstalled Characteristics for replacement sprinklers

• Dry pipe systems (§5.4.2):

Dry pipe systems kept dry at all times Air driers and compressors maintained

Sprinkler System Maintenance

154

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• Standpipe and hose systems (NFPA

25, 6.4 & 6.2.3):

• Replace missing or damaged valve caps
• Repair damaged fire hose connections
• Replace missing or damaged valve handles
• Replace missing or deteriorated cap gaskets
• Repair leaking valves
• Remove visible and physical obstructions to

hose connections

• Repair valves that do not operate smoothly
• Replace valve where threads are damaged

Sprinkler System Maintenance

155

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• 5.4.1 Sprinklers
• Replacement sprinklers shall have the proper

characteristics for intended application, including:

• 1. Style
• 2. Orifice size and k-factor
• 3. Temperature rating
• 4. Coating
• 5. Deflector type
• 6. Design requirements

Sprinkler System Maintenance

156

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• Dry-pipe systems being

maintained in dry condition? (NFPA 25, 5.4.2)

• Interior of dry-pipe, preaction and

deluge valves cleaned? (NFPA 25, 13.4.4.3.2)

• Low points drained in dry-pipe,

preaction and deluge systems prior to the onset of freezing weather? (NFPA 25, 13.4.4.3.3)

• Air leaks in dry-pipe system

resulting in pressure loss significant to sound warning alarms located and repaired

Dry Systems Maintenance

157

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• Conducted every 5 years at a minimum
• For the presence of foreign organic & inorganic

material

• If tubercules or slime is found required to be tested

for microbiologically influenced corrosion (MIC)

• Performed at the following minimum four points:
• System valve; Riser
• Cross main; Branch line

Internal Piping Condition Obstruction Investigation

158

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Facility

• Visual inspections
• Information signs
• Corrosion
• Damage
• Obvious deficiencies
• Leakage
• Record keeping

Facility ITM vs. Contractor ITM

159

Contractor

• Quarterly, monthly, and

annual tests

• Main drain test
• Inspector’s test
• Alarm test
• Dry pipe trip test
• Pump test
• Restoring systems to service
• System replacements

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• Importance of ITM?
• Steps to take to make sure ITM runs smooth and is

done properly?

• Questions?

Sprinkler System ITM Discussion

160

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NFPA 72, 2010 Edition

161

National Fire Alarm and Signaling Code

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• LSC 9.6.1.5
• 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 Electric Code, and NFPA 72, National Fire Alarm and Signaling Code

ITM: Fire Alarm Systems

162

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• Improve fire alarm system reliability
• Reduce false / nuisance alarms

Why Test & Inspect?

163

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• Lack of inspection, testing, and maintenance is a

leading reason for fire alarm system failure

Why Test & Inspect?

164

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Why Test & Inspect?

165

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Why Test & Inspect?

166

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Why Test & Inspect?

167

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CONTINUITY OF BUILDING OPERATIONS – AVOID SYSTEM FAILURES

Importance of ITM

168

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• NFPA 72 Section 14.2.2.1 states that the property or

building owner or the owner’s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to the system

• NFPA 72 Section 14.2.2.5 states that service

personnel shall be qualified and experienced in accordance with the requirements of 10.4.3

Who is Responsible for ITM?

169

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• NFPA 72 Section 10.4.3 states that qualified ITM

personnel shall include:

• Personnel who are factory trained or certified for the

specific type and brand of system being services

• Personnel who are certified by a nationally recognized

certification organization acceptable to the AHJ

• Personnel who are registered, licensed or certified by a

state or local authority to perform service on systems addressed within the scope of this Code

• Personnel who are employed and qualified by an
• rganization listed by a national recognized testing

laboratory for the servicing systems within the scope of this Code.

Who is Responsible for ITM?

170

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Visual Inspection

171

Device Visual Inspection Testing

Smoke/Heat Detector Semi-Annual Annual Pull Station Semi-Annual Annual Duct Detector Semi-Annual Annual Tamper Switch Quarterly Semi-Annual Flow Switch Quarterly Semi-Annual Horns/Strobes Semi-Annual Annual DACT Semi-Annual Annual Remote Annunciator Semi-Annual Annual Control Equipment Annual Annual Battery* Semi-Annual/Monthly Annual/Semi-Annual *Assume sealed lead acid battery www.jensenhughes.com www.jensenhughes.com

• Start at control panel
• Check for the obvious
• Start testing after successful completion of visual

inspection

Visual Inspection

172

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Visual Inspection

173

• Visual Inspections and Testing
• Smoke detectors are required to be tested

with smoke

• All notification appliances must be operated

annually and proper operation must be verified

• Periodically verify system is “normal”

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The panel should indicate “normal”

Visual Inspection

174

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Should NOT indicate trouble

Visual Inspection

175

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Visual Inspection

176

Should not indicate “Alarm” Should not indicate “Fault” or “Supervisory”

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• No obvious wire breaks, corrosion, or other damage

to connections

Visual Inspection

177

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• Look for the obvious and take action

Visual Inspection

178

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Visual Inspection

179

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Visual Inspection

180

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• Devices and

appliances properly mounted and oriented

Visual Inspection

181

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Visual Inspection

182

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• Will this duct detector operate?

Visual Inspection

183

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• Will this duct detector operate?

Visual Inspection

184

Not with the dust cover on!

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• Will this duct detector operate?

Visual Inspection

185

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• Will this duct detector operate?

Visual Inspection

186

Not with the sampling ports blocked!

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• Will this bell work?

Visual Inspection

187

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• Will this bell work?

Visual Inspection

188

Not without the gong!

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• What is wrong with these arrangements?

Visual Inspection

189

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• What is wrong with these arrangements?

Visual Inspection

190

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Testing

191

Device Visual Inspection Testing

Smoke/Heat Detector Semi-Annual Annual Pull Station Semi-Annual Annual Duct Detector Semi-Annual Annual Tamper Switch Quarterly Semi-Annual Flow Switch Quarterly Semi-Annual Horns/Strobes Semi-Annual Annual DACT Semi-Annual Annual Remote Annunciator Semi-Annual Annual Control Equipment Annual Annual Battery* Semi-Annual/Monthly Annual* *Dependent on battery type. Sealed lead acid shown www.jensenhughes.com www.jensenhughes.com

LSC 18.3.4.3 / 19.3.4.3 – Positive alarm sequence permitted

Trained personnel have 15 seconds to acknowledge alarm 180 seconds then provided to investigate the alarm and reset the system

9.6.1.8 – Smoke detector required at location of control equipment

Testing

192

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• NFPA 72 Section 14.4
• Before beginning testing, notify:
• 1. Building occupants – place signs on exit doors, send emails,

signs in lobby, bulletin boards

• 2. Fire department
• 3. AHJ
• 4. Monitoring company

Testing

193

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• Minimize disruption of

services

• Limit testing to distinct areas
• Restore systems promptly
• Follow manufacturer's

instructions for the specific device being tested

Testing

194

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• 14.4.1.2 Reacceptance test done after changes are

made to the system

• Initiating device, notification appliance, or control relay is

added - functionally tested

• Initiating device, notification appliance, or control relay

deleted – another device, appliance, or control relay on the circuit is functionally tested

• 10% Re-test

Reacceptance Testing

195

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• 10.18.2.2 After any

change, revise the Record of Completion

Testing

196

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• Control equipment
• Tested to verify correct receipt of alarm, supervisory,

trouble signals; circuit supervision; operation of evacuation signals

• Integrity of single or multiple circuits providing interface

between two or more control units verified

• Lamps and LEDs illuminated
• Secondary power disconnected and tested under

maximum load

Test Methods – Table 14.2.2

197

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• Engine-driven generator
• If used, operation verified by owner in accordance with

NFPA 110, Standard for Emergency and Standby Power Systems

• Uninterrupted Power Supply
• If used, operation verified by building owner in accordance

with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems

Test Methods – Table 14.2.2

198

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• Secondary (standby) power supply
• All main power disconnected and occurrence of required

trouble indication for loss of primary power verified

• Standby and alarm current demand measured
• General alarm systems operated for ≥ 5 minutes
• Emergency voice communication systems operated for

≥ 15 minutes

• Main power supply reconnected at end of test

Test Methods – Table 14.2.2

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• Batteries – general tests

a) Visual inspection

• Inspect for corrosion, leakage, tightness of connections,

electrolyte levels

b) Battery replacement

• When current falls below manufacturer’s recommendations

c) Charger test

• Operation checked in accordance with appropriate charger

test for battery type

d) Discharge Test

• Load tested with battery charger disconnected

e) Load voltage test

• Terminal voltage measured with battery charge disconnected

Test Methods – Table 14.2.2

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• Batteries – general tests

Test Methods – Table 14.2.2

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• Fire alarm control unit trouble signals
• Audible and visual
• Disconnect switches
• Ground-fault monitoring circuit
• Transmission of signals off-premises location
• Remoted annunciators verified

Test Methods – Table 14.2.2

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• Initiating devices
• Correct operation of electromechanical releasing device

verified

• Fire extinguishing system/ suppression system/ alarm

switch verified

• Heat detectors
• Manual fire alarm boxes
• Smoke detectors

Test Methods – Table 14.2.2

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• Fixed-temperature, rate-of-rise, rate of

compensation, restorable line, spot type heat detectors

• Heat test performed with listed and labeled heat source
• Assure test method does not damage the nonrestorable

fixed-temperature element of a combination rate-of- rise/fixed-temperature element detector

Test Methods – Table 14.2.2

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Careful not to damage / melt detector

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• Fixed-temperature heat detectors

Test Methods – Table 14.2.2

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• Fixed-temperature, nonrestorable spot type heat

detectors

• Do not perform heat test
• Test functionality mechanically and electrically
• Measure and record loop resistance
• After 15 years from initial installation, replace all devices or

have 2 detectors per 100 laboratory tested

• If a failure occurs on any of the detectors removed, remove

and test additional detectors

Test Methods – Table 14.2.2

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• Fixed-temperature nonrestorable heat detectors

Test Methods – Table 14.2.2

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• Smoke detectors
• Tested in place to ensure smoke entry into the sensing

chamber and an alarm response

• Use smoke or listed and labeled product acceptable to the

manufacturer or in accordance with published instructions

• Magnet testing NOT acceptable

Test Methods – Table 14.2.2

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• Smoke detector functionality test
• Conducted annually (minimum)
• Aerosol smoke acceptable
• This is NOT a sensitivity test

Test Methods – Table 14.2.2

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• Duct smoke detectors
• Tested for smoke entry
• Those utilizing sample tubes must be tested to ensure they

will properly sample the airstream in duct

• Magnet/key-switch is NOT acceptable

Test Methods – Table 14.2.2

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• Waterflow switches
• Functionally tested
• Water required to be flowed through an inspector’s test

connection

Test Methods – Table 14.2.2

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• Supervisory devices
• Control valve switch functionally operated
• Signal receipt verified to be within first two revolutions of

hand wheel or one-fifth of the travel distance

• High or low-air pressure switch operated
• Signal receipt verified where the required pressure is

increased or decreased 10 psi (70 kPa) from required pressure level

Test Methods – Table 14.2.2

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Test Methods – Table 14.2.2 – Sprinkler System Devices

213

Fire Alarm Signaling Systems Handbook

Vane type waterflow indicator switch.

Roll Paddle to Insert Into Pipe Through Hole SPDT Switches Retard Adjustment Dial Reset Adjustment Direction of Flow Arrow Polyethylene Vane Pipe Saddle

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• Audible/Visible notification appliances
• Strobes
• Horns
• Combination horn/strobes
• Evacuation speakers
• Combination speaker/strobes
• Chimes
• Textual visual appliances

Test Methods – Table 14.2.2

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• Visual notification

appliances

• Test performed in accordance

with manufacturer’s instructions

• Appliance locations verified to

approved layout

• Verify candela rating marking

agrees with approved drawing

• Confirm each appliance

flashes

Test Methods – Table 14.2.2

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• 10.18.3.1 After tests

are satisfactorily finished, complete Inspection and Testing Form

• Retain form in a safe

place

• Recommend retaining

at least 3 years

Test Records

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• Generally follows manufacturer's published

instructions

• Maintenance frequency dependent on type of

equipment and ambient conditions

• Equipment cleaning frequency dependent on type of

equipment and ambient conditions

• Records required for all maintenance

Maintenance – Section 14.5

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• What visual inspections can you complete to ensure

performance of devices/appliances?

• Obvious things to look for when performing visual

inspections?

• Questions?

Fire Alarm ITM Discussion

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Standard for Fire Doors and Other Protective Openings NFPA 80, 2010 Edition

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• Integral part of buildings passive fire protection

system and overall fire protection

• Properly operating fire door is key component to

compartmentalization

• Limit spread of fire
• Restrict movement of smoke

ITM: Fire Doors

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• Components of a fire door:
• Frame
• Fire exit hardware
• Door closers
• Hinges
• Locks
• Door bolts
• Glazing
• Labels

ITM: Fire Doors

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• Categories of fire doors:
• Horizontal sliding
• Fire shutters
• Swinging
• Vertically sliding
• Chutes
• Overhead rolling fire doors
• Service counter fire doors

ITM: Fire Doors

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• NFPA 101 Section 7.2.1.15.2 - compliance with:
• NFPA 80, Standard for Fire Doors and Other Opening

Protectives – 2010 Edition

ITM: Fire Doors

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• Fire door assemblies

inspected and tested annually by a qualified individual

• Operation
• Door clearance
• Coordinator
• Latch
• Closer
• Written record signed and

kept for AHJ

5.2 Inspection

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• Fire-rated door assembly visual inspection includes:
• Labels are present and legible
• No holes or breaks of door or frame
• Glazing in tact (if provided)
• No signs of damage to door, frame, hinges, hardware
• No parts missing or broken
• Door clearances are appropriate
• Self-closing device operating properly
• Coordinator working properly (if installed)
• Latching hardware operates
• No auxiliary hardware present that would interfere w/
• peration
• No field modifications that would void label

5.2.4 Visual Inspection

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• Performed by individuals with proper knowledge and

understanding of operating components of door

• Prior to testing, perform visual inspection to identify
• bvious deficiencies, missing parts, etc. that could

create a hazard during testing or affect operation

5.2.3 Functional Testing

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• Swinging doors normally held open shall be
• perated at frequent intervals to ensure operation
• Horizontal or vertical sliding and rolling fire doors

tested annually for full closure

• When annually tested, rolling steel fire doors drop-

tested twice

• First test to check proper operation and full closure
• Second test to verify automatic-closing device properly

reset

• Cannot paint fusible links or other heat-actuated

devices

5.2.14 Maintenance of Closing Mechanisms

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• Damaged glazing replaced with labeled glazing
• Any breaks in face covering of doors repaired

immediately

• Where a door, frame, or other part is damaged:

1. Repair with parts obtained from original manufacturer 2. Test door to ensure emergency operation and closing upon repair completion

5.2.15 Repair of Fire Doors

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Fire Door Assembly

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Fire Door Parts and Functions

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• Fire rated permanent label attached and legible

Fire Door Label

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• NFPA 101 Section 8.3.3.1
• Hardware must match the capabilities of the door and

frame used

• Check hardware is UL listed and tested for rating to match

fire door

Fire Door Hardware Labeling

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• Where fire doors require fire exit hardware, ensure

labels on hardware match label on the door

Fire Exit Hardware

233

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• What visual inspections can you perform to ensure

doors are code complaint?

• What should you do if you notice

damages/improperly functioning doors?

• Questions?

Fire Door ITM Summary

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Standard for Emergency Power and Standby Systems NFPA 110, 2010 Edition

235

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• 8.1.1 Routine maintenance and operational testing

program based on the following:

1. Manufacturer’s recommendations 2. Instruction manuals 3. Minimum requirements of this chapter 4. Authority having jurisdiction

Chapter 8 – Routine Maintenance and Operational Testing

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• 8.3 Maintenance and Operational Testing
• EPSS maintained to ensure to a reasonable degree that

system is capable of supplying service within time specified for the type and time duration specified for the class

• Routine maintenance and operational testing program

initiated immediately after EPSS passes acceptance test

• Written schedule established

Chapter 8 – Routine Maintenance and Operational Testing

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• 8.3 Maintenance and Operational Testing
• Permanent record maintained and readily available

including the following:

• 1. Date of maintenance report
• 2. Identification of servicing personnel
• 3. Notation of any unsatisfactory condition and corrective action

taken, including parts replaces

• 4. Testing of any repair for the time as recommended by

manufacturer

Chapter 8 – Routine Maintenance and Operational Testing

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• 8.3 Maintenance and Operational Testing
• Transfer switches and paralleling gear subjected to ITM

program that includes the following operations:

• 1. Checking of connections
• 2. Inspection or testing for evidence of overheating and excessive

contact erosion

• 3. Removal of dust and dirt
• 4. Replacement of contacts when required

Chapter 8 – Routine Maintenance and Operational Testing

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• 8.4 Operational Inspection and Testing
• EPSSs inspected weekly and exercised under load at least

monthly

• EPS test initiated by simulating a power outage using test

switches on ATSs or by opening a normal breaker

• Transfer switches operated monthly
• Routine maintenance and operational testing program

shall be overseen by a properly instructed individual

• Full EPSS system tested at least once every 36 months for

duration of its assigned class

Chapter 8 – Routine Maintenance and Operational Testing

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• 8.4 Diesel GenSet Testing
• Exercise monthly for 30 minutes by:
• Loading that maintains minimum exhaust temps recommended

by manufacturer

• Under operating temperature conditions and at not less than

30% of EPS nameplate kW rating.

OR

• Exercise monthly at available EPSS load and annually with
• At not less than 50% of nameplate rating for 30 min
• At not less than 75% of nameplate rating for 1 hour

Chapter 8 – Routine Maintenance and Operational Testing

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• 8.4 Natural Gas GenSet Testing
• Exercise monthly with available EPSS load for 30 minutes
• r until water temp and oil pressure stabilize

Chapter 8 – Routine Maintenance and Operational Testing

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NFPA 99 – 2012 Edition

243

Health Care Facilities Codes

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• 6.3.4.1 Maintenance and Testing of Electrical

Systems

• Where hospital grade receptacles are required at patient

bed locations, testing performed after initial installation, replacement, or servicing of device

• Non hospital grade receptacles tested annually

Chapter 6 – Electrical Systems

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• 6.3.4.1 Maintenance and Testing of Electrical

Systems

• Record maintained of tests required by this chapter and

associated repairs or modifications

• Record shall contain the following:
• 1. Date
• 2. Rooms or areas tested
• 3. Indication of which items have met or failed to meet

performance requirements

Chapter 6 – Electrical Systems

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• 10.3 Testing Requirements
• Confirm physical integrity by visual inspection
• Verify resistance of appliances in patient car vicinity with

grounding pin

• Power cords connected in accordance with conventions of

a grounded system

Chapter 10 – Electrical Equipment

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• 10.5.2.1 Testing Intervals
• Facility shall establish policies and protocol for type of test

and intervals of testing for patient care-related electrical equipment

• Maintain records of ITM for several years
• Extension cord / multitap adapter wiring tested for:
• 1. Physical integrity
• 2. Polarity
• 3. Continuity of grounding at time of assembly and periodically

thereafter

Chapter 10 – Electrical Equipment

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• 10.5.3 Servicing and Maintenance of Equipment
• Manufacturer of appliance shall furnish documents

containing the following:

• 1. Technical description
• 2. Instructions for use
• 3. Means of contacting manufacturer
• Electrical equipment safety labels and condensed
• perating instructions on appliance are legible
• Personnel responsible for testing, maintenance and use

receive continuing training

Chapter 10 – Electrical Equipment

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• 10.5.3 Servicing and Maintenance of Equipment
• Manufacturer’s document shall include the following:
• 1. Illustrations that show locations of controls
• 2. Explanations of the function of each control
• 3. Illustrations of proper connection to the patient or other

equipment, or both

• 4. Step-by-step procedures for testing and proper use of the

appliance

• 5. Safety considerations in use and servicing of the appliance
• 6. Precautions to be taken if the appliance is used on a patient

simultaneously with other electric appliances

Chapter 10 – Electrical Equipment

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• 10.5.3 Servicing and Maintenance of Equipment

(cont.)

• 7. Schematics, wiring diagrams, mechanical layouts, parts list,
• ther pertinent appliance data
• 8. Instructions for cleaning, disinfection, sterilization
• 9. Utility supply requirements (electrical, gas, ventilation, heating,

cooling, etc.) 10.Explanation of figures, symbols, abbreviations on appliance 11.Technical performance specifations 12.Instructions for unpacking, inspection, installation, adjustment, alignment 13.Preventive and corrective maintenance and repair procedures

Chapter 10 – Electrical Equipment

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• I contract out my testing and maintenance, what am

I responsible for?

Who is responsible for ITM?

251

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• Visual inspection
• Physical damage
• Abnormal conditions
• Obvious deficiencies

ITM: Facility Personnel

252

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ITM: Facility Personnel

253

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ITM: Facility Personnel

254

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ITM: Facility Personnel

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ITM: Facility Personnel

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ITM: Facility Personnel

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ITM: Facility Personnel

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ITM: Facility Personnel

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ITM: Facility Personnel

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• Factory trained and certified
• Certified by nationally

recognized certification

• rganization
• Registered, licensed, certified

by state of local authority

• Employed and qualified by an
• rganization listed by

nationally recognized testing laboratory

ITM: Licensed Contractor

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• Documentation – hard copy and electronic copy of

ALL reports

• Keep in a safe, secure location
• Obtain copies of as-built drawings
• Keep one copy current, as occupancy or system changes
• ccur
• Obtain copies of NFPA Standards applicable to your

systems

Best Practice for all Systems

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• Perform all annual testing at the same time
• Hire qualified service providers to make repairs
• Your plumber is NOT qualified
• Your electrician is qualified in system wiring, NOT

system programming

Best Practice for all Systems

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• Ignoring deficiencies will make them WORSE

Best Practice for all Systems

264

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• Ignoring deficiencies will make them WORSE

Best Practice for all Systems

265

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• Ignoring deficiencies will make them WORSE

Best Practice for all Systems

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• Know all of your fire protection systems as well as

you know your other building systems

• These are LIFE SAFETY systems
• Set up inspection and documentation procedures
• Designate and train personnel
• Prioritize and repair deficiencies in a timely manner

ITM Conclusion

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“A conclusion is the place where you got tired

• f thinking.”
• - Steven Wright, comedian

CONCLUSION

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QUESTIONS?

269

Contact

Chris Moran +1 410-737-8677 cmoran@jensenhughes.com For More Information Visit www.jensenhughes.com