By Healthcare Facilities Today

In the second part of a series on the FacilityCare website focusing on navigating fire safety codes, the authors take a closer look at the segment of the Environment of Care Standard which addresses the requirements for duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes and smoke detectors.

According to the article, when reviewing supervisory signal devices, creating a complete inventory of all initiating devices is a mandatory requirement and an essential first step in the process. 

For addressable fire alarm panels, this can be done by generating a complete points list report through the fire alarm panel, converting this report into an editable format and filtering/grouping each device by device type, the article said. For non-addressable fire alarm systems, the zones on the main fire alarm panel should be reviewed to identify dedicated zones for initiating devices and then consulting approved fire alarm drawings to create a complete list of initiating devices.

Even though the requirement to create a complete inventory is not spelled out in the standard EC.02.03.05, the Joint Commission requires a complete inventory as a baseline to demonstrate that every device has been tested and any deficiencies identified as an outcome of the testing have been resolved, the article said. 

The following best practices are suggested:

• Create your own internal gap analysis to identify any potential areas of noncompliance (EC.04.01.01). 

• Conduct a risk assessment to evaluate the effectiveness of your current program and identify next steps for potential improvements.

• Coordinate and align the timing of the fire alarm system testing with the testing of the premise security system.

To ensure proper and efficient testing, inspection and maintenance of the fire alarm and interfaced equipment, a coordinated effort between the hospital departments as well as any vendors involved will be required. The development of a test plan should be considered to ensure that the testing of these features is accomplished in a coordinated and timely manner, the article said.

Read the article.

Read part one of the series.