Joint Commission Survey: How One Hospital Earned a Perfect Score

By Michael A. Crowley  
OTHER PARTS OF THIS ARTICLEPt. 1: Meeting Health Care Fire/Life Safety Regulations Requires Regular CheckupsPt. 2: Fire Detection, Sprinkler Systems are Key Components of Health Care Fire/Life SafetyPt. 3: Keys to Testing Fire Alarm, Sprinkler Systems in Health Care FacilitiesPt. 4: This PagePt. 5: AHJs: Complications for FMs

NFPA 25 covers many different components of water-based fire-suppression systems. Inspection and testing frequencies vary from component to component. For example, sprinkler valves should be inspected monthly and standpipe valves inspected annually. Inspection personnel should be qualified for the level of inspection or testing being done. More involved inspection and testing of systems will require a fire protection contractor.

The contractor should provide test results after each site visit. For example, information recorded for fire pumps, main drains, dry pipe trip and water flow device tests must be compared to previous testing to determine if there are any changes in the system and water supply. Most contractors are capable of this analysis; however, they fail to bring changes to system performance to the facility owner's attention. Changes in fire pump flow or main drain test could indicate a potential problem developing in the water supply system. This critical analysis of the NFPA 25 test is intended to identify potential problems before they become serious.

Similar to FDAS impairment, NFPA 101 and the International Fire Code require notification of the local AHJ if the automatic sprinkler system is impaired for more than four hours. Also, the building must be evacuated or an approved fire watch must be provided. These impairment agreements vary from area to area. Coordination with the AHJ is needed before automatic sprinkler system impairment occurs. Documentation of this agreement should be retained for other AHJ reviews. Most major property insurance carriers have programs for assisting facility managers with planned or accidental automatic sprinkler impairment.

Michael A. Crowley, PE, FSFPE, SASHE, is a senior vice president and health care practice leader for Rolf Jensen & Associates, providing consulting to architects, facility managers and building owners around the world. He is a Life Safety Code Course instructor for the National Fire Protection Association and has been active in a variety of NFPA technical committees. He can be reached at

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  posted on 11/7/2011   Article Use Policy

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