CMS Top 10 Citations K321 – Hazardous Areas Separated by Construction � Hazardous areas include: � Laboratories � Combustible Storage > 100 ft 2 www.jensenhughes.com www.jensenhughes.com 35 CMS Top 10 Citations K321 – Hazardous Areas Separated by Construction � Hazardous areas include: � Trash Collection Rooms � Soiled Linen Rooms www.jensenhughes.com 36 www.jensenhughes.com
CMS Top 10 Citations K321 – Hazardous Areas Separated by Construction www.jensenhughes.com www.jensenhughes.com 37 CMS Top 10 Citations K321 – Hazardous Areas Separated by Construction � How to avoid? www.jensenhughes.com 38 www.jensenhughes.com
CMS Top 10 Citations 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 www.jensenhughes.com www.jensenhughes.com 39 CMS Top 10 Citations 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 NFPA 101 NFPA 101 www.jensenhughes.com 40 www.jensenhughes.com
CMS Top 10 Citations 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 ft 2 • Limit travel distance to 200 ft www.jensenhughes.com www.jensenhughes.com 41 CMS Top 10 Citations K372 – Smoke Barrier Construction Typical smoke barrier penetrations www.jensenhughes.com 42 www.jensenhughes.com
CMS Top 10 Citations K372 – Smoke Barrier Construction NFPA 101 NFPA 101 NEW EXISTING www.jensenhughes.com www.jensenhughes.com 43 CMS Top 10 Citations K372 – Smoke Barrier Construction � How to avoid? www.jensenhughes.com 44 www.jensenhughes.com
CMS Top 10 Citations 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 www.jensenhughes.com www.jensenhughes.com 45 CMS Top 10 Citations 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 www.jensenhughes.com 46 www.jensenhughes.com
CMS Top 10 Citations K511 – Gas and Electric Utilities � How to avoid? www.jensenhughes.com www.jensenhughes.com 47 CMS Top 10 Citations K511 – Gas and Electric Utilities � How to avoid? • Keep on-site records • Verify hazard of existing conditions www.jensenhughes.com 48 www.jensenhughes.com
CMS Top 10 Citations 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 today.duke.edu www.jensenhughes.com www.jensenhughes.com 49 CMS Top 10 Citations 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 www.jensenhughes.com 50 www.jensenhughes.com
CMS Top 10 Citations K712 – Fire Drills � How to avoid? www.jensenhughes.com www.jensenhughes.com 51 CMS Top 10 Citations K712 – Fire Drills � How to avoid? • Keep on-site records • Ensure staff is familiar with routines and procedures • Ensure staff competent and responsible www.jensenhughes.com 52 www.jensenhughes.com
CMS Top 10 Citations K345 – Testing of Fire Alarm � LSC 9.6.1.4 � Up-to-date records � 2 staff member minimum knowledge � ITM requirements in NFPA 72 www.jensenhughes.com www.jensenhughes.com 53 CMS Top 10 Citations K345 – Testing of Fire Alarm 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 www.jensenhughes.com 54 www.jensenhughes.com
CMS Top 10 Citations K345 – Testing of Fire Alarm � How to avoid? www.jensenhughes.com www.jensenhughes.com 55 CMS Top 10 Citations 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 www.jensenhughes.com 56 www.jensenhughes.com
CMS Top 10 Citations 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 of Commercial Cooking Equipment www.jensenhughes.com www.jensenhughes.com 57 CMS Top 10 Citations 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 open to corridor www.jensenhughes.com 58 www.jensenhughes.com
CMS Top 10 Citations 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 www.jensenhughes.com www.jensenhughes.com 59 CMS Top 10 Citations K324 – Cooking Facilities www.jensenhughes.com 60 www.jensenhughes.com
CMS Top 10 Citations K324 – Cooking Facilities TIA 12-2 � Applies to cooking facilities in new and existing healthcare occ. (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 www.jensenhughes.com www.jensenhughes.com 61 CMS Top 10 Citations K324 – Cooking Facilities � How to avoid? www.jensenhughes.com 62 www.jensenhughes.com
CMS Top 10 Citations 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 www.jensenhughes.com www.jensenhughes.com 63 CMS Top 10 Citations 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 www.jensenhughes.com 64 www.jensenhughes.com
CMS Top 10 Citations 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 of 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 www.jensenhughes.com www.jensenhughes.com 65 CMS Top 10 Citations K920 – Power Cords and Electric Cords � How to avoid? www.jensenhughes.com 66 www.jensenhughes.com
CMS Top 10 Citations 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 www.jensenhughes.com www.jensenhughes.com 67 CMS Top 10 Citations 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 www.jensenhughes.com 68 www.jensenhughes.com
CMS Top 10 Citations K351 – Sprinkler System Installation � Sprinkler devices connected to FA panel � Closets, built-in wardrobes and bathrooms require sprinklers � Exterior combustible canopies > 4 ’ www.jensenhughes.com www.jensenhughes.com 69 CMS Top 10 Citations K351 – Sprinkler System Installation NFPA 101 www.jensenhughes.com 70 www.jensenhughes.com
CMS Top 10 Citations K351 – Sprinkler System Installation � How to avoid? www.jensenhughes.com www.jensenhughes.com 71 CMS Top 10 Citations 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 www.jensenhughes.com 72 www.jensenhughes.com
OTHER CITATIONS � 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% www.jensenhughes.com www.jensenhughes.com 73 CONCLUSION 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 www.jensenhughes.com 74 www.jensenhughes.com
RECENT SURVEY DISCUSSION OPEN DISCUSSION � Survey Trends � Recent Experiences www.jensenhughes.com www.jensenhughes.com 75 DISCUSSION OPEN DISCUSSION � What can your facility do to minimize deficiencies? � What are the benefits of keeping up with facility maintenance? www.jensenhughes.com 76 www.jensenhughes.com
What is ITM 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 www.jensenhughes.com www.jensenhughes.com 77 Qualified A competent and capable person or company that has met the requirements and training for a given field acceptable to the authority having jurisdiction. www.jensenhughes.com 78 www.jensenhughes.com
Who is Responsible for ITM? THE OWNER IS RESPONSIBLE FOR ITM � International Fire Code � NFPA 101 and Referenced Standards (excerpt from NFPA 25) www.jensenhughes.com www.jensenhughes.com 79 ITM – Why Test & Inspect? • 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 www.jensenhughes.com 80 www.jensenhughes.com
ITM – Why Test & Inspect? • Continuity of building operations • General life safety • Liability associated with not performing ITM www.jensenhughes.com www.jensenhughes.com 81 NFPA 10, 2010 Edition Standard for Portable Fire Extinguishers www.jensenhughes.com 82 www.jensenhughes.com
ITM: Fire Extinguishers • 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 www.jensenhughes.com www.jensenhughes.com 83 Fire Extinguisher Symbol Marking www.jensenhughes.com 84 www.jensenhughes.com
ITM: Fire Extinguishers • 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.” www.jensenhughes.com www.jensenhughes.com 85 Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 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 www.jensenhughes.com 86 www.jensenhughes.com
Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 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 www.jensenhughes.com www.jensenhughes.com 87 Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 7.2 Inspection • Manually inspected when initially placed in service • Inspected manually at a maximum of 30-day intervals www.jensenhughes.com 88 www.jensenhughes.com
Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 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 or 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 www.jensenhughes.com www.jensenhughes.com 89 Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 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 www.jensenhughes.com 90 www.jensenhughes.com
Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 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 www.jensenhughes.com www.jensenhughes.com 91 Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 7.2.4 Inspection record keeping • Records kept for all fire extinguishers inspected • Date of inspections and initials of inspector recorded • Inspection records kept on tag attached to extinguisher, on inspection checklist maintained on file, or by an electronic method www.jensenhughes.com 92 www.jensenhughes.com
Chapter 7: Inspection, Maintenance, and Recharging of Portable Fire Extinguishers • 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 www.jensenhughes.com www.jensenhughes.com 93 Frequency of Internal Maintenance of Fire Extinguishers www.jensenhughes.com 94 www.jensenhughes.com
Frequency of Internal Maintenance and Hydrostatic Testing of Fire Extinguishers www.jensenhughes.com www.jensenhughes.com 95 Discussion • What are the procedures for inspection? • What information must be recorded during ITM? • Benefits of fire extinguisher ITM? • Common deficiencies? www.jensenhughes.com 96 www.jensenhughes.com
Summary of Fire Extinguisher ITM • Visual Inspection required at a minimum of 12 times per year • Follow inspection procedure checklist • Keep detailed records of inspections www.jensenhughes.com www.jensenhughes.com 97 NFPA 25, 2011 Edition Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems www.jensenhughes.com 98 www.jensenhughes.com
ITM: Sprinkler Systems • 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 www.jensenhughes.com www.jensenhughes.com 99 4.1 Responsibility of the Property Owner or Designated Representative • 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 www.jensenhughes.com 100 www.jensenhughes.com
4.1 Responsibility of the Property Owner or Designated Representative • 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 www.jensenhughes.com www.jensenhughes.com 101 4.1.9 Impairments • 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 www.jensenhughes.com 102 www.jensenhughes.com
Sample Impairment Tag www.jensenhughes.com www.jensenhughes.com 103 Restoring Systems to Service • 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 www.jensenhughes.com 104 www.jensenhughes.com
4.3 Records • Records made for all ITM readily available to AHJ upon request • Indicate procedure performed, organization that performed work, results, date www.jensenhughes.com www.jensenhughes.com 105 5.2 Inspection • What gets a visual inspection? • Sprinkler riser components • Control & alarm check valves • Gauges • Sprinklers • Piping • Fire department connection • Dry pipe valves www.jensenhughes.com 106 www.jensenhughes.com
5.2 Inspection • Why should you perform ITM? www.jensenhughes.com www.jensenhughes.com 107 5.2 Inspection • Why inspect? www.jensenhughes.com 108 www.jensenhughes.com
5.2 Inspection www.jensenhughes.com www.jensenhughes.com 109 Sprinkler System Weekly Inspection • Inspect sprinkler system Backflow Preventer (NFPA 25 § 13.7) � Physical damage � Leakage � Isolation valves in the open position www.jensenhughes.com 110 www.jensenhughes.com
Sprinkler System Monthly Inspection • 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) www.jensenhughes.com www.jensenhughes.com 111 Sprinkler System Quarterly Inspection • 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 www.jensenhughes.com 112 www.jensenhughes.com
Sprinkler System Quarterly Inspection • 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 www.jensenhughes.com www.jensenhughes.com 113 Sprinkler System Quarterly Inspection • 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 operating properly • Interior of the connection is inspected for obstructions • Visible piping supplying the fire department connection is undamaged www.jensenhughes.com 114 www.jensenhughes.com
Sprinkler System Quarterly Inspection • 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 www.jensenhughes.com www.jensenhughes.com 115 Sprinkler System Annual Inspections • 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 www.jensenhughes.com 116 www.jensenhughes.com
5.2 Inspection • 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 www.jensenhughes.com www.jensenhughes.com 117 5.2 Inspection • 5.2.1 Sprinklers www.jensenhughes.com 118 www.jensenhughes.com
5.2 Inspection • 5.2.1 Sprinklers www.jensenhughes.com www.jensenhughes.com 119 5.2 Inspection • 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 www.jensenhughes.com 120 www.jensenhughes.com
5.2 Inspection • 5.2.2 Pipe and Fittings www.jensenhughes.com www.jensenhughes.com 121 5.2 Inspection • 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 www.jensenhughes.com 122 www.jensenhughes.com
5.2 Inspection • 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 www.jensenhughes.com www.jensenhughes.com 123 5.2 Inspection • 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 www.jensenhughes.com 124 www.jensenhughes.com
Sample Hydraulic Design Information Sign www.jensenhughes.com www.jensenhughes.com 125 5.3 Testing • 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 www.jensenhughes.com 126 www.jensenhughes.com
Owner’s Section on Inspection Report www.jensenhughes.com www.jensenhughes.com 127 Main Drain Test • 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] www.jensenhughes.com 128 www.jensenhughes.com
Main Drain Test Procedures Call the fire alarm system out of service and Step 1 notify occupants (i.e., controllers, etc.). Visually inspect the discharge Step 2 location. Note system pressure Step 3 on both sides of the alarm check valve. www.jensenhughes.com www.jensenhughes.com 12 129 Main Drain Test Procedures Step 4 Open main drain valve. Visually inspect the Step 5 discharged water. -Clean? Clear? No debris? Note system pressure on both sides of the alarm check Step 6 valve. - excessive drops from previous tests or as-builts? www.jensenhughes.com 130 130 www.jensenhughes.com
Main Drain Test Procedures (cont’d) Confirm outside water motor gong Step 7 operation, if present. Close main drain valve. Step 8 Remove bypasses Step 9 and call system back into service. www.jensenhughes.com www.jensenhughes.com 131 DONE! Inspector’s Test • 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] www.jensenhughes.com 132 www.jensenhughes.com
Inspector’s Test Procedures Call the FA system out of service Step 1 and notify occupants. Visually inspect the Step 2 discharge location. Open the Inspector’s Test valve. Step 3 www.jensenhughes.com www.jensenhughes.com 133 Inspector’s Test Procedures (cont’d) Visually inspect the discharge. Step 4 Confirm water motor gong operation, if present. (must ring within 5 minutes) Step 5 Note: May be an electric bell activated by a flow switch. Re-close the inspectors test Step 6 valve. Call system back into Finally service. www.jensenhughes.com 134 www.jensenhughes.com
Dry Sprinkler Systems • 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] www.jensenhughes.com www.jensenhughes.com 135 Dry System Full Trip Test Procedures Call the FA system out of service and notify Step 1 occupants. Visually inspect the Step 2 discharge location. Open the Inspector’s Step 3 Test valve. -Note the time! www.jensenhughes.com 136 www.jensenhughes.com
Dry System Full Trip Test Procedures (cont’d) Visually inspect the discharged water. Step 4 -Clean? Clear? No debris? Confirm waterflow and fire Step 5 alarm activation within 60 A seconds and… Confirm water motor gong operation, if Step 5 present. (must ring B within 5 minutes) www.jensenhughes.com www.jensenhughes.com 137 Dry System Full Trip Test Procedures (cont’d) Re-close the inspectors test valve. Step 6 Reset dry pipe valve. Remove Step 7 bypasses and call system back into service. www.jensenhughes.com 138 www.jensenhughes.com
Dry Sprinkler System Partial Trip Test Procedures • Special testing considerations? • Valve will trip so be prepared to reset www.jensenhughes.com www.jensenhughes.com 139 Dry Sprinkler System Partial Trip Test Procedures Call the FA system out of service Step 1 and notify occupants. Step 2 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 www.jensenhughes.com 140 www.jensenhughes.com
Dry Sprinkler System Partial Trip Test Procedures (cont’d) Open the Inspector’s Test valve. Step 3 Step 4 Listen for the dry valve clapper to open. e clapper to open. Once the valve trips, fully close the control valve. Step 5 Re-close the inspectors test valve. Re-close the inspectors test valve. Reset dry pipe valve. Remove bypasses and call system back into Step 6 service. www.jensenhughes.com www.jensenhughes.com 1 141 Dry System Alarm Test • 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 www.jensenhughes.com 142 www.jensenhughes.com
Dry System Alarm Test Procedures Call the FA system out of Step 1 service and notify occupants (i.e., controllers, etc.). Locate the pressure switch trim piping and associated valve. Step 2 Open the trim Step 3 piping alarm valve. www.jensenhughes.com www.jensenhughes.com 143 Dry System Alarm Test Procedures (cont’d) Step 4 Confirm water motor gong or electric horn is operating. (Must ring within 5 minutes) Step 5 Close alarm line trim piping. Remove bypasses Step 6 and call system back into service. www.jensenhughes.com 144 www.jensenhughes.com
Fire Pump Tests • 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 www.jensenhughes.com www.jensenhughes.com 145 5.3 Testing • 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 www.jensenhughes.com 146 www.jensenhughes.com
5.3 Testing • 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 www.jensenhughes.com www.jensenhughes.com 147 Sprinkler Operating Element Identification www.jensenhughes.com 148 www.jensenhughes.com
5.3 Testing • 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 www.jensenhughes.com www.jensenhughes.com 149 5.3 Testing • 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 www.jensenhughes.com 150 www.jensenhughes.com
5.3 Testing • 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 www.jensenhughes.com www.jensenhughes.com 151 5.3 Testing www.jensenhughes.com 152 www.jensenhughes.com
5.3 Testing www.jensenhughes.com www.jensenhughes.com 153 Sprinkler System Maintenance • Maintenance to be performed to keep the system equipment operable ( § 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 www.jensenhughes.com 154 www.jensenhughes.com
Sprinkler System Maintenance • 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 www.jensenhughes.com www.jensenhughes.com 155 Sprinkler System Maintenance • 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 www.jensenhughes.com 156 www.jensenhughes.com
Dry Systems Maintenance • 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 www.jensenhughes.com www.jensenhughes.com 157 Internal Piping Condition Obstruction Investigation • 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 www.jensenhughes.com 158 www.jensenhughes.com
Facility ITM vs. Contractor ITM Facility Contractor • Visual inspections • Quarterly, monthly, and annual tests • Information signs • Corrosion • Main drain test • Damage • Inspector’s test • Obvious deficiencies • Alarm test • Leakage • Dry pipe trip test • Pump test • Record keeping • Restoring systems to service • System replacements www.jensenhughes.com www.jensenhughes.com 159 Sprinkler System ITM Discussion • Importance of ITM? • Steps to take to make sure ITM runs smooth and is done properly? • Questions? www.jensenhughes.com 160 www.jensenhughes.com
NFPA 72, 2010 Edition National Fire Alarm and Signaling Code www.jensenhughes.com www.jensenhughes.com 161 ITM: Fire Alarm Systems • 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 www.jensenhughes.com 162 www.jensenhughes.com
Why Test & Inspect? • Improve fire alarm system reliability • Reduce false / nuisance alarms www.jensenhughes.com www.jensenhughes.com 163 Why Test & Inspect? • Lack of inspection, testing, and maintenance is a leading reason for fire alarm system failure www.jensenhughes.com 164 www.jensenhughes.com
Why Test & Inspect? www.jensenhughes.com www.jensenhughes.com 165 Why Test & Inspect? www.jensenhughes.com 166 www.jensenhughes.com
Why Test & Inspect? www.jensenhughes.com www.jensenhughes.com 167 Importance of ITM CONTINUITY OF BUILDING OPERATIONS – AVOID SYSTEM FAILURES www.jensenhughes.com 168 www.jensenhughes.com
Who is Responsible for ITM? • 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 www.jensenhughes.com www.jensenhughes.com 169 Who is Responsible for ITM? • 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 organization listed by a national recognized testing laboratory for the servicing systems within the scope of this Code. www.jensenhughes.com 170 www.jensenhughes.com
Visual Inspection 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 171 Visual Inspection • Start at control panel • Check for the obvious • Start testing after successful completion of visual inspection www.jensenhughes.com 172 www.jensenhughes.com
Visual Inspection • 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” www.jensenhughes.com www.jensenhughes.com 173 Visual Inspection The panel should indicate “normal” www.jensenhughes.com 174 www.jensenhughes.com
Visual Inspection Should NOT indicate trouble www.jensenhughes.com www.jensenhughes.com 175 Visual Inspection Should not indicate “Alarm” Should not indicate “Fault” or “Supervisory” www.jensenhughes.com 176 www.jensenhughes.com
Visual Inspection • No obvious wire breaks, corrosion, or other damage to connections www.jensenhughes.com www.jensenhughes.com 177 Visual Inspection • Look for the obvious and take action www.jensenhughes.com 178 www.jensenhughes.com
Visual Inspection www.jensenhughes.com www.jensenhughes.com 179 Visual Inspection www.jensenhughes.com 180 www.jensenhughes.com
Visual Inspection • Devices and appliances properly mounted and oriented www.jensenhughes.com www.jensenhughes.com 181 Visual Inspection www.jensenhughes.com 182 www.jensenhughes.com
Visual Inspection • Will this duct detector operate? www.jensenhughes.com www.jensenhughes.com 183 Visual Inspection • Will this duct detector operate? Not with the dust cover on! www.jensenhughes.com 184 www.jensenhughes.com
Visual Inspection • Will this duct detector operate? www.jensenhughes.com www.jensenhughes.com 185 Visual Inspection • Will this duct detector operate? Not with the sampling ports blocked! www.jensenhughes.com 186 www.jensenhughes.com
Visual Inspection • Will this bell work? www.jensenhughes.com www.jensenhughes.com 187 Visual Inspection • Will this bell work? Not without the gong! www.jensenhughes.com 188 www.jensenhughes.com
Visual Inspection • What is wrong with these arrangements? www.jensenhughes.com www.jensenhughes.com 189 Visual Inspection • What is wrong with these arrangements? www.jensenhughes.com 190 www.jensenhughes.com
Testing 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 191 Testing � 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 www.jensenhughes.com 192 www.jensenhughes.com
Testing • 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 www.jensenhughes.com www.jensenhughes.com 193 Testing • Minimize disruption of services • Limit testing to distinct areas • Restore systems promptly • Follow manufacturer's instructions for the specific device being tested www.jensenhughes.com 194 www.jensenhughes.com
Reacceptance Testing • 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 www.jensenhughes.com www.jensenhughes.com 195 Testing • 10.18.2.2 After any change, revise the Record of Completion www.jensenhughes.com 196 www.jensenhughes.com
Test Methods – Table 14.2.2 • 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 www.jensenhughes.com www.jensenhughes.com 197 Test Methods – Table 14.2.2 • 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 www.jensenhughes.com 198 www.jensenhughes.com
Test Methods – Table 14.2.2 • 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 www.jensenhughes.com www.jensenhughes.com 199 Test Methods – Table 14.2.2 • 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 www.jensenhughes.com 200 www.jensenhughes.com
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