The Life Safety Surveyor

The Life Safety Surveyor

Healthcare Engineering Consultants

How Should I Prepare for the Life Safety Surveyor Documentation Session?

The LSS Document Review


Documents likely to be reviewed include:

Fire system detection and extinguishing test documents

Electrical system test documentation including emergency

generators, battery lights and SEPPS units

Medical gas and vacuum system test results and new

installation certifications

Interim life safety measures policy and documentation

Pre-Construction Risk Assessment (PCRA) policy and

documentation

Statement of Conditions (SOC), unless already reviewed

during the Preliminary Planning Session

The Life Safety Surveyor (LSS)

It is likely that the LSS will arrive with the team on the first or second day, less likely later in the survey

The LSS will be scheduled for at least two days “on-site”, with extra days for >1.5 million square feet and three or more surveyable healthcare occupancy buildings (could be up to 5 days “on-site”!)

The LSS will spend several hours on dedicated documentation review, but much more time on the facility tour

Other responsibilities assigned to the LSS will depend on the survey team member preferences and responsibilities – they will probably conduct the Physical Environment Interview and Emergency Management review

The other survey team members will also observe life safety issues, but not as detailed as the LSS – it is not likely that the nurse and physician will request a ladder and flashlight!

If the LSS observes deficiencies outside of their defined responsibility (example: medical records privacy or medication security), they will report it to the other team members


Fire System Tests


Points to Remember:

Every fire system device must be individually inventoried, with each test result documented as “PASS” or “FAIL”

Test records should be sorted by device type, not as a combination of devices, and placed in a binder that is tabbed by each device type

Written test procedures and references to the NFPA standards should be readily available

Documentation should be available to indicate the resolution of all identified deficiencies

A method should be used to track when fire system tests are scheduled and when they have been completed, such as a monitoring grid or “dashboard”

Fire System Tests


Points to Remember

The chart on the right indicates the probable order in which the surveyor will review the documentation – put the test records in this order, either in a binder or in folders

The test interval may vary (example: flow devices, fire pump churn tests), depending upon adoption of the CMS “Categorical Waivers”

Be sure to indicate on the documentation (or chart) the NFPA code reference for each test, as required in standard EC.02.03.05, EP 25

Fire System Component Test Schedule

Standard Element of Performance Scoring Category

Test Interval

NFPA Reference

EC. 02.03.05

Fire Component Tests

1 Supervisory switches

C Q NFPA 72

2 Tamper switches, flow devices

C S/A NFPA 72

3 Duct detectors, door releasing devices

C A NFPA 72

3 Smoke and heat detectors, pull boxes

C

A NFPA 72

4 Audible and visual alarms

C A NFPA 72

5 Off-premises transmission equipment

A Q NFPA 72

6 Fire pump churn test

C W NFPA 25

7 Water tank level alarms

C S/A NFPA 25

8 Water tank level alarms (cold weather only)

C M NFPA 25

9 Main drain tests on system risers

C A NFPA 25

10 Fire department connections

A Q NFPA 25

11 Fire pumps (flow test)

A A NFPA 25

12

Standpipe test C 5 yr NFPA 25

13 Kitchen extinguishing systems

A S/A NFPA 96

14 Carbon dioxide/ gaseous extinguishing systems

A A NFPA 2001

15 Portable fire extinguishers (visual check)

C M

NFPA 10

16

Portable fire extinguishers (preventive maintenance)

C A NFPA 10

17 Occupant hoses

C 3 yr–hydro 5 yr–new

NFPA 25, 1962

18 Smoke/ fire dampers

C 6 years NFPA 80, 105

19 HVAC smoke detectors w/ shutdown

A A NFPA 90A

20 Horizontal/ vertical fire doors

C A NFPA 80

Fire System Test Descriptions


Supervisory Devices

Test interval: Quarterly

Be prepared to explain which devices are considered “supervisory” (not including tamper switches!)

Supervisory signals are defined in the 2000 Life Safety Code in section 9.7.2 as:

“…monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves”

Typically, the surveyor will ask about documented test results for power off and phase loss conditions for the fire pump and low air pressure on dry sprinkler systems

Code Reference: NFPA 72, 1999 edition, Table 7.3.2



Waterflow Devices

Test interval: Quarterly, unless the CMS “Categorical Waiver” has been adopted, which then requires semi-annual tests

Time delay documentation on device activation recommended

“Categorical Waiver” applies to vane-type and pressure switch-type waterflow alarm devices

Code References: NFPA 25, 1998 edition, section 2-3.3 without the waiver; NFPA 25, 2011 edition, sections 5.3 and 8.3 with the waiver



Duct Detectors

Test interval: Annually

Must be tested to ensure that the device will sample the airstream

Tests must be in accordance with the manufacturer’s instructions

Physical verification of damper closure and/ or air handler shutdown must performed (EC.02.03.05, EP19) and is required by NFPA 90A, 1999 edition, section 4-4.1

Failure to test and document the damper closure and/ or air handler shutdown will result in a Direct Impact finding

Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2, and NFPA 90A



Smoke Detectors

Test interval: Annually; Sensitivity: AHJ

Must be tested in place to ensure smoke entry into the sensing chamber and alarm activation

Tests must be in accordance with the manufacturer’s instructions, including type of test smoke and/ or aerosol

Smoke detector sensitivity tests must use a calibrated test method, manufacturer’s approved instrument, or other test method acceptable to the AHJ

Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2



Off-Premises Transmission Equipment


Two tests required:

1. Receipt of signal by off-site “responders” (local fire

department) – Joint Commission requirement

2. Receipt of signal by “receiving station” (can be off-site

stations such as ADT, Simplex, etc. or fire department)

within 90 seconds (reference to NFPA 72)

Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2



Fire Pumps

Test interval: Annual flow test; weekly churn test

Weekly churn test unless CMS “Categorical Waiver” is

accepted, which requires a monthly test (electric pumps)

Churn test must be activated by dropping water pressure

Electric pump: 10 minute test; Diesel pump: 30 minutes

Annual flow test should include a graph of test results

Code References: NFPA 25, 1998 edition, sections 5-3.2.1, 5-3.2.2; with CMS waiver, NFPA 25, 2011 edition



Main Drain Test

Test interval: Annual

Either test the system low point or all system risers

Perform the test using the following steps:

1. Record the initial static pressure

2. Open the main drain valve, record residual pressure

3. Slowly close the main drain valve

4. Record the time to return to initial static pressure

Changes in the return time indicate possible obstructions

Code References: NFPA 25, 1998 edition, sections 9-2.6 and Appendix A-9.2.6



Fire Department Connections


Perform and document the following checks:

1. Connections and ID signs are visible and accessible

2. Couplings and swivels rotate smoothly

3. Plugs, gaskets and caps are in place and undamaged

4. Check valve is not leaking

5. Automatic drain valve operates properly

Intended to be outside fire department connections

Code Reference: NFPA 25, 1998 edition, section 9-7.1



Standpipe Waterflow Test

Test interval: Every Five Years


1. Flow the system at the highest design pressure to the

hydraulically most remote or highest hose connection

of each standpipe system

2. Consult the local AHJ for the appropriate test location

Code Reference: NFPA 25, 1998 edition, section 3-3.1.1



Kitchen Extinguishing Systems

Test interval: Semi-annually


1. Inspect the extinguishing system and hoods

2. Test all actuation components (pull stations, detectors,

dampers, mechanical and electrical devices, etc.)

3. Replace fusible links and sprinkler heads annually

4. Service and/ or replace detection according to

manufacturer recommendations

Discharge of the system is not required

Code Reference: NFPA 96, 1998 edition, section 8-2



Gaseous Extinguishing Systems



1. Inspection and tests (4-1)

2. Clean agent containers (4-2)

3. System hose inspection (1-year), test (5-years) (4-3)

4. System maintenance (4-5)

5. Training of staff who inspect (4-6)

Discharge of the system is not required

Code Reference: NFPA 2001, 1996 edition, section 4-1



Portable Fire Extinguishers

Test intervals: Monthly, Annual and 6-Year

Monthly checks require the following:

1. Proper location, no restriction to access or visibility

2. Instructions for use legible and seals/ indicators OK

3. Fullness determined by “hefting” or weighing

4. Evidence of physical damage and gauge reading

5. Documentation with date/ month/ year/ initials

Annual preventive maintenance required

6-Year extinguisher recharge

Code Reference: NFPA 10, 1998 edition, sections 4-3 and 4-4



Smoke and Fire Dampers

Test intervals: Initially, 1-year and 6 years thereafter

All smoke and fire dampers must be tested initially and

one year after installation

Re-testing is every four years except 6 years for hospitals

Inaccessible dampers should be placed on a PFI with a

6-year timeframe for re-evaluation (document ILSM!)

The 1-year test after installation only applies to dampers

installed after January 1, 2008

Code References: NFPA 80, 2007 edition, section 19.4.1.1; NFPA 105, 2007 edition, section 6.5.2



Sliding and Rolling Fire Doors


Test must include proper operation and full closure

Re-setting the release mechanism must be done

according to manufacturer specifications

Fusible links and other release devices must not be

painted or prevented from operating by sealing gaps with

intumescent materials

Code Reference: NFPA 80, 1999 edition, section 15-2.4

Fire System Test Monitoring


Regulatory Compliance Dashboard for Fire System Tests

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments Supervisory Devices

1/15 X X X

Tamper Switches

1/15 X X X

Water Flow Devices

1/15 X X X

Duct Detectors

1/22

Door Releasing Devices

X

Smoke Detectors

X

Pull Boxes

1/18 X

Audible Alarms

X

Visual Alarms

X

Signal Time to FD

1/6 X X X

Fire Pump Churn Test

4, 11 25

W W W W W W W W W W W

Fire Pump Flow Test

X

Water Tank Level Alarms

N/A X X X X X X X

Main Drain Riser Test

X

Fire Dept. Connections

1/12 X X X

Standpipe Test

X 5 yr

Kitchen Systems

X X

Best Practice for Monitoring Compliance

Fire System Test Monitoring


Regulatory Compliance Dashboard for Fire System Tests (continued)

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments CO2/ Gaseous Systems

X

Portable Extinguishers

1/23 X X X X X X X X X X X

Portable Extinguishers

X

Occupant Hoses

X 3 yr

Smoke/ Fire Dampers

X 6 yr

HVAC Shutdown

1/25 X

Horiz/ Vertical Fire Doors

X

Key to dashboard symbols: X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required A/R – Indicates that action is required when applicable Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).

Emergency Power Systems


EC.02.05.07: Emergency Generators

Perform and document weekly generator visual checks Code reference: NFPA 110, 2005 edition, section 8.4.1

Perform and document monthly generator tests with at least 30% of the rated load for 30 minutes

Document that all automatic transfer switches are exercised monthly

Conduct 2-hour annual load bank tests if the 30% load is not achieved and manifold temperatures are not sufficient

If the CMS “Categorical Waiver” is adopted by the hospital, then the 2010 edition of NFPA 110 will require a 1.5 hour annual load bank test with a 50% load for 30 minutes, and a 75% load for 60 minutes



EC.02.05.07: Emergency Generators Combining the annual and trienniel tests can be performed by starting the load at 30% of nameplate for the first 30 minutes of the test, then continuing with: 50% of load for 30 minutes; 75% load for 60 minutes, and; any load greater than 30% for the remaining 2 hours

Note: If the CMS “Categorical Waiver” is adopted, then the combined tests require a 50% load for 30 minutes, a 75% load for 1.5 hours and any load greater than 30% for the remaining 2.5 hours

Document the static or dynamic 4-hour trienniel test for all generators

Test fuel oil quality annually per ASTM D-975, unless fuel is consumed from the entire tank over the course of 12 months

Code Reference: NFPA 110, 2005 edition, section 8.3.8

Utilize “Interim Emergency Power Measures” (IEPM) when necessary



EC.02.05.07: Emergency Battery Lights Required in all anesthetizing locations (NFPA 70: 517.63 )

“administration of nonflammable inhalation anesthetic agents

in the course of examination or treatment”

Note: Grandfathering usually permitted in existing OR’s w/o lights

Required in “Level 1 or Level 2 EPS equipment locations”, which is normally interpreted as transfer switch locations (NFPA 110: 7.3.1)

Required in some business occupancies for egress lighting where emergency power is not required or not available (NFPA 101: 7.9.1.1)

Monthly 30-second push-to-test and annual 90-minute discharge test required for all battery installations, whether for task or egress lighting

Annual battery replacement is acceptable in lieu of 90-minute discharge test, but 10% of lights must be tested for 90 minutes annually, even if the batteries are changed



EC.02.05.07: Stored Emergency Power Supply Systems (SEPSS)

Standard applies to Level 1 systems (NFPA 111: 4.5.1)

Level 1: “failure of the equipment to perform could result in

loss of human life or serious injuries”

Testing requires:

1. Quarterly functional test (5 minutes or class specification)

2. Annual full-load test for 60% of SEPSS class duration

Note 1: NFPA 111 requires a monthly inspection, quarterly functional test and annual full load test for full class duration for Level 1 systems

Note 2: The Joint Commission references exit lighting, life support ventilation, fire detection and alarm systems, and public communications systems as Level 1 systems, but most are not SEPSS systems, since they are backed up with emergency generators; non-SEPSS UPS systems should be tested per manufacturer specifications

The LSS Documentation Review


EC.02.05.09: Medical Gas and Vacuum Systems

Medical gas and vacuum system preventive maintenance

program is required (facility must define PM) and must include:

- Bulk medical gas and vacuum system components and source valve

- Master signal panels and area alarms

- Automatic pressure switches and shutoff valves

- Flexible connectors and outlets




Testing per NFPA 99 is required for new installation,

modification or repair (cross-connections, purity, pressure)

Main supply valves and area shut-off valves must be

accessible and clearly labeled

Utilize “Interim Medical Gas Measures” (IMGM) when

necessary

Note: Significant changes for testing have been included in NFPA 99, the 2012 edition, but it has not yet been adopted by CMS or the Joint Commission, except for the “Categorical Waiver” tht permits one master alarm monitor location to be a computer




Certification of installers and verifiers per ASSE 6000 series is

required

Medical air quality must meet NFPA 99 requirements below:

Parameter Limit Value

Pressure dew point 39 degrees F

Carbon monoxide 10 ppm

Carbon dioxide 500 ppm

Gaseous hydrocarbons 25 ppm (as methane)

Halogenated hydrocarbons 2 ppm



Medical Gas and Vacuum System PM Recommendations

Component Description

Recommended Test Frequency

Gas cylinder manifold pressure

Daily

Gas cylinder manifold changeover signal

Daily

Liquid cylinder manifold pressure

Daily

Liquid cylinder manifold changeover signal

Daily

Liquid cylinder reserve/ in-use signal

Annually

Bulk liquid system contents gauge

Daily

Bulk system pressure gauges

“Regularly” (weekly)

Bulk system master signal

“Periodically” (monthly)

Main line vacuum system gauge

Daily

Medical air intake location

Quarterly

Medical air pressure gauge

Annually

Medical air high level water sensor

Annually

Medical air receiver drain

Daily

Medical compressed air alarms

Annually

Medical air compressors/ vacuum pumps

Per manufacturer specifications

Dew point sensor/ CO monitor

Annually

Warning system components

Annually

Audible/ visual alarms

Monthly

Shut-off valve leak test

“Periodically” (annually)

Outlet leakage and flow

“Periodically” (annually)

Medical air purity

As determined by facility

Note 1: The recommendations provided in the chart to the right are from NFPA 99, the 2005 edition, Appendix C, section 5.2. Tests that are required due to new system installations, renovations or repair are listed in Chapter 5 of NFPA 99

Note 2: Significant changes for medical gas system tests have been added to NFPA 99, the 2012 edition, but have not yet been adopted by either CMS or the Joint Commission, except for the single master alarm panel “Categorical Waiver”



Interim Utility System Measures Interim Utility System Measures

Project Number: _________________ Date: ____________________ Affected System: Fire System: _____ Emergency Power _____ Medical Gas: _____ Description of Project: ______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Interim Measures Required: _____ Affected staff notified Comments: ______________________________________ _____ Additional Equipment Required Specify: _________________________________ _____ Back-up Procedures in Place Specify: ___________________________________ _____ Emergency Procedures Reviewed Comments: ____________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ _____ Other: ______________________________________________________________ Additional Comments: ______________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Date Project Completed: ___________________ Reviewed By: ____________________

Best Practice!

Strongly recommended to document that interim measures have been implemented to compensate for utility systems that are taken out of service

Interim Life Safety Measures


Interim Life Safety Measures Requirement

Standard LS.01.02.01 from the Joint Commission Accreditation Manual:

“The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction”



The Interim Life Safety Measures Process Includes the Following Steps:

1. Is an ILSM evaluation required? Y or N

2. If Yes, does the ILSM evaluation require the implementation of ILSM? Y or N

3. If Yes, which interim measures apply?

4. Implement and document the required measures

Note: An interim life safety measures policy must be written and address each of the four steps listed above



Step 1: Is an ILSM evaluation required?

The need for an interim life safety measure evaluation is normally required whenever there is a life safety deficiency that is found, or renovation or construction activities create life safety deficiencies.

Be sure to do an ILSM evaluation for PFI’s!

Include in the ILSM policy “exclusions” for evaluations, such as “routine work orders” or “superficial projects”



Example Interim Life Safety Measures Policy Purpose The purpose of this interim life safety measures (ILSM) policy is to address situations during periods of construction or renovation, or whenever Life Safety deficiencies exist and cannot be immediately corrected, so that an equivalent level of Life Safety is maintained. This policy also includes criteria for evaluating when and to what extent the hospital follows special, temporary measures to compensate for increased life safety risk. Policy This policy provides information and guidelines for evaluating and implementing interim life safety measures during times when a Life Safety deficiency is present due to construction or whenever an existing building deficiency is identified. Procedure When the hospital identifies Life Safety deficiencies during surveillance rounds, during periods of construction or renovation, or through other means, and the deficiency cannot be immediately corrected, the hospital performs an analysis to determine whether the implementation of interim life safety measures is necessary. This analysis is documented using the Interim Life Safety Applicability Form (ILSAF) attached to Appendix A of this policy. Completion of the ILSAF form is not required for routine work orders, or superficial projects that do not impact life safety in the hospital. If the completion of the ILSAF indicates that interim life safety measures are not required, then the completed form is maintained in a document file for reference purposes. If the ILSAF indicates that interim life safety measures are required to be implemented, then the Interim Life Safety Measures Chart (ILSMC) form is completed (refer to Appendix B) to determine which interim measures must be implemented and documented. The ILSMC form should be completed by referring to the following “Typical Triggers” for each of the possible interim measures listed below. Note: The following list of “Typical Triggers” are suggestions only and may be revised on the ILSAF form based on the judgment of hospital personnel. Measure 1: Notify the fire department, and initiate and document a fire watch. Typical Trigger Criteria: When the fire alarm or sprinkler system is out of service for more than 4 hours in a 24-hour period in an occupied building, as defined by the fire watch decision grid in Appendix C. Measure 2: Inspect exits in affected areas on a daily basis and document the inspection.

Interim life safety measures evaluation exception for “routine work orders or superficial projects that do not impact life safety”



Step 2: Are interim life safety measures necessary, based on the evaluation?

Interim life safety measure “trigger points” include the following:

Egress is compromised, and alternative exits are necessary

Compartmentation is breached,and is considered serious

Part or all of the fire detection or extinguishing system has been taken out of service

“Hot Work” is being performed

Large quantities of combustible materials are present

Other conditions determined by the organization


Interim Life Safety MeasuresAppendix A - Interim Life Safety Applicability Form

Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location: ________________________________________________________________ Instructions: Determine whether any of the “ILSM Triggers” listed in the chart below apply to or will occur during this project. Description of ILSM Trigger

Applicable?

Hot work

Y N

Blocked exit

Y N

Alternate egress

Y N

Excessive combustible materials

Y N

Removal of part or all of the fire detection system

Y N

Removal of part or all of the extinguishing system

Y N

Significant breach of smoke or fire wall

Y N

Significant breach of smoke or fire door

Y N

Y N

Y N

Y N

If one or more of the ILSM triggers listed above are marked “Yes”, then interim life safety measures apply and must be evaluated using Appendix B, Interim Life Safety Measures Chart ______ ILSM measures do not apply ______ ILSM measures do apply _____________________________ _________________________ ______________ Signed Title Date

Check which “triggers” (if any) apply for the project

Add other “triggers, as desired

If none of the “triggers” are marked “Yes”, then no additional action is required



Step 3: Which interim life safety measures apply?

The use of an ILSM “applicability matrix” that helps to determine which interim measures apply is helpful. The matrix can either be “pre-filled” for specific conditions or left blank until the evaluation process occurs. The ILSM policy should describe how the interim measures are selected, based on criteria developed by the hospital



Possible Interim Life Safety Measures Include:

Fire watch

Alternative exit signage

Daily inspection of exits

Temporary, but equivalent fire alarm and detection systems

Additional fire fighting equipment

Temporary, smoke-tight, noncombustible partitions

Increased surveillance of buildings, grounds and equipment

Storage, housekeeping and debris removal practices

Additional staff training for staff who use fire equipment



Possible Interim Life Safety Measures Include (continued):

Additional fire drills

Inspect and test temporary systems monthly

Additional staff training related to the interim measures

Additional training to compensate for impaired fire or building features

Note: Implementation of any or all of the interim life safety measures noted in the list above are based on criteria developed by the hospital and should be listed in the hospital interim life safety measures policy

Interim Life Safety Measures (ILSM)


Applicability Grid Example for Interim Life Safety Measures

Compromise egress X X X X X X

Breach compartmentation

X X X X X X X X X

Impair fire detection, alarm, suppression

X X X X X X X X

Hot work X X

Large quantities of combustibles

X X X X X X X X

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Example for Interim Life Safety Measures Chart

Appendix B - Interim Life Safety Measures Chart

Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location: ________________________________________________________________ Instructions: Based on the project or deficiency described above, determine and document which of the following interim life safety measures apply in the chart below. Description of Interim Measure

Applicable?

Fire watch (see Appendix C)

Y N

Signage signifying alternative exits

Y N

Daily inspections in affected area

Y N

Temporary and equivalent fire alarm and detection systems

Y N

Additional portable fire extinguishers

Y N

Temporary construction partitions (non- or limited combustibility)

Y N

Increased surveillance of buildings, grounds or equipment

Y N

Additional storage, housekeeping and debris removal

Y N

Additional staff training for portable fire extinguishers

Y N

Additional fire drills

Y N

Monthly tests and inspections of temporary systems

Y N

Additional staff training for construction hazards, temporary measures

Y N

Additional staff training for impaired fire safety features

Y N

Additional comments related to required measures: ____________________________ ______________________________________________________________________ _____________________________ _________________________ ______________ Signed Title Date

One or more of the interim measures listed on the chart may be selected, based on the scope of the project and the type of deficiency that exists



Step 4: Implement and document the required measures

Whichever interim measures are selected must be implemented and documented

Remember: Failure to implement or document interim life safety measures, when required, can result Contingent Accreditation from the Joint Commission!



Fire Watch Requirements


LS.01.02.01: EP 1

“The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented”

Question: What constitutes when “a fire alarm or sprinkler system is out of service”?

Fire Watch “Decision Grid”


Appendix C – Fire Watch Decision Grid

Description of Project or Deficiency: _________________________________________ ________________________________________________________________________ Location of Project or Deficiency: ____________________________________________ Fire Watch Notification: ______ Fire Department ______ Other Responders ______ Insurance Company ______ Internal Hospital Staff ______ Other Instructions: Based on the “Out of Service” description listed in the chart below, the requirement for a fire watch is indicated. Circle each “Yes” below, as applicable. Description of Fire Alarm or Sprinkler System “Out of Service” Condition

Fire Watch Required?

Multiple fire alarm or sprinkler system components out-of- service for less than 4 hours in a 24-hour period

No

Fewer than 6 smoke detectors in the same area out-of- service for more than 4 hours in a 24-hour period

No

Extinguishing system in less than a single smoke compart- ment out-of-service for more than 4 hours in a 24-hour period

No

Fire alarm system in “bypass” mode due to testing

No

More than 5 smoke detectors in the same area out-of-service for more than 4 hours in a 24-hour period

Yes

Extinguishing system in more than a single smoke compart- ment out-of-service for more than 4 hours in a 24-hour period

Yes

Any combination of fire detection and extinguishing devices out of service > 4 hours in a 24-hour period at the same time

Yes

Failure of the fire alarm annunciator panel (any time period)

Yes

Failure of the entire fire detection system (any time period)

Yes

Failure of the entire extinguishing system (any time period)

Yes

Failure of the fire pump (any time period)

Yes

Y N

Y N

_____________________________ _________________________ ______________ Signed Title Date

The requirement for a fire watch is determined by the hospital staff. NFPA 101, section A.9.6.1.6 states: “it is not the intent of the Code to require notification of the AHJ for a single non-operating device or appliance”

Functional Environment


Issue: Pre-Construction Risk Assessment (PCRA)

Biggest Pitfall: Only ICRA and ILSM are evaluated

Best Practice: Include all seven of the items listed below in the PCRA evaluation

● Noise ● Emergency procedures

● Vibration ● Utility failures

● Air quality ● Interim life safety measures

● Infection control

Infection Control Risk Assessment (ICRA) – Best Practice Grid


Risk Criteria for Infection Control

Type A Type B Type C Type D

Group 1 (lowest) I II II III

Group 2 (medium) I II III IV

Group 3 (medium high) II III III IV

Group 4 (highest)

III

IV IV IV

Construction TypePatient

Risk



Issue: Documentation of PCRA

Achieving Compliance:

• Evaluate measures to reduce risk and minimize the impact of the construction activities

• Perform daily monitoring in all construction areas

• Use a monitoring checklist

• Post required permits, such as hot work, ICRA, above-the-ceiling work, ILSM, etc. on door entrance to construction area



Issue: Pre-Construction Risk Assessment (PCRA)

Best Practice: Include MCRA changes during the project

Pre-Construction Risk Assessment Timeline Chart

Project number: __________________________ Date: _____________________ Completed by: ____________________________

PCRA Category

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Comments

Noise

Vibration

Air Quality

Infection Control Risk Assessment (ICRA)

Interim Life Safety Measures (ILSM)

Emergency Procedures

Utility Failures

The Life Safety Surveyor Document Review

Questions?
