Fire Protection Documentation Survey trends, requirements and documentation for EC.02.03.05.

Introductions Kyle Phipps Steve Konze kphipps@koetterfireprotection.com (512) 563-4529 Steve Konze SKonze@koetterfireprotection.com (512) 541-5971

DEVICE TOTAL: 15 PASSED: 6 FAILED: 1 UNTESTED: 8 EP 28 Building: Sample Hospital Pull Station EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors Manual fire alarm boxes shall be operated per the manufacturer's published instructions. Key-operated presignal and general alarm manual fire alarm boxes shall both be tested. (2010 ed.) (NFPA 72 Table 14.4.2.2 (14e)) DEVICE TOTAL: 15 PASSED: 6 FAILED: 1 UNTESTED: 8 Address ScanID Location Date/Time Pass/Fail Notes 1-L1M06 01821571 1st Stair A 07/16/2018 7:00:01 PM Passed   1-L1M05 01821572 1st Stair B 1-L1M04 01821573 1st Emergency Room 1-L1M03 01821574 1st Loading Dock Inspection Performed By Company: Koetter Fire Protection of Austin, LLC Inspector: John Doe Address: 16069 Central Commerce Drive Phone: 555-555-5555 Address: Fax: City/State/Zip: Pflugerville, TX 78660 Mobile: Country: United States of America Email: jdoe@sampleorg.com Inspection Completion Date: Jul 16, 2018 Building: Sample Hospital EC 02.03.05 EP 03 Annual testing of duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors Devices Total Quantity Duct Detector 11 Heat Detector 5 Pull Station 15 Smoke Detector 20 Total Device Count: 51

Timeframes 3 year= +/- 45 Days 1 year= +/- 30 Days Semi-annual= +/- 20 Days Quarterly= +/- 10 Days Monthly = Once a month Weekly = Once per calendar week This Photo by Unknown Author is licensed under CC BY-NC

Documentation Flow Certificate, inspection documentation, etc. Inventories, results, etc. Deficiency report (If applicable) ILSM, solution summary, repair documentation Close out documentation. Complete the circle. This Photo by Unknown Author is licensed under CC BY-NC-ND

EP 1 Quarterly All supervisory signals except tampers. Surveyors may want to see what pressure the low air signal comes in at.

EP2 Semi-annual (WMG are quarterly)

EP3 Annual Accurate inventory is essential

DEVICE TOTAL: 6 PASSED: 6 FAILED: 0 UNTESTED: 0 EP4 Building: Sample Hospital The Inspection & Testing section lists all of the items inspected in your building, which are then categorized by the applicable code reference. Horn/Strobe EC 02.03.05 EP 04 Annual test of visual and audible fire alarms, including speakers and door-releasing devices. NFPA 72-2010 Table 14.4.5 Audibles: Periodic Testing shall comply with the following: Sound pressure levels shall be measured with a sound level meter meeting ANSI S1.4a, Specifications for Sound Level Meters, Type 2 requirements. Sound pressure levels throughout the protected area shall be measured to confirm that they are in compliance with Chapter 18. Visibles: Test shall be performed in accordance with the manufacturer's published instructions. (2010 ed.) (NFPA 72 Table 14.4.2.2 (15a,c)) DEVICE TOTAL: 6 PASSED: 6 FAILED: 0 UNTESTED: 0 Address ScanID Location Date/Time Pass/Fail Notes 1 01821523 1st Main Corridor 07/16/2018 10:55:23 AM Passed   01821521 2nd Main Corridor 07/16/2018 10:55:17 AM 01821518 3rd Main Corridor 07/16/2018 10:55:10 AM 01821516 4th Main Corridor 07/16/2018 10:55:05 AM 01821513 5th Main Corridor 07/16/2018 10:55:01 AM 01821512 Penthouse Elevator Machine Room 07/16/2018 10:54:59 AM

EP5 Sometimes overlooked on inventory. Documentation of the delay to offsite monitoring.

EP6 Electric pumps are monthly. Diesel pumps are weekly.

EP7 and EP8 Semi-annual high and low level alarms. Every month during cold weather.

EP9 Classification and inventories of main drains. Annually Documentation of main drain pressure reading.

EP10 Quarterly

EP11 Annual flow test*. Documentation of comparison between previous years. * If the pump is not equipped with a test header, NFPA 25 (2011 ed) 8.3.3.1.2.3-8.3.3.1.4.2 does address using the bypass flow meter.

EP12 5 year hydrostatic and waterflow test on standpipes. NFPA 25 (2011 ed.) 6.3.1.1 states the flow test is on an automatic wet standpipe. NFPA 25 (2011 ed) 6.3.2.1 states that the hydrostatic test shall be conducted on manual standpipes and semi-automatic dry standpipes.

EP13 Semi-annually

EP14 Annually AHJ report is semi-annual Documentation of tanks weights.

EP15 & 16 Monthly Annual Inventories are critical to documentation.

EP17 Occupant hoses 5 years after install and every 3 years after that. Several hospitals have gone away from these.

EP18 Dampers. One year after install and every 6 years after that.

EP19 Air handler shutdowns will typically be done in conjunction with the duct detectors in EP3.

EP20 Rolling and sliding doors.

EP25

This Photo by Unknown Author is licensed under CC BY-NC

Thank you Kyle Phipps kphipps@koetterfireprotection.com (512) 563-4529 Steve Konze SKonze@koetterfireprotection.com (512) 541-5971

References The Joint Commission (2019). 2019 Hospital Accreditation Standards: Standards Elements of Performance. Environment of Care. ISBN: 978- 1-63585-070-3. NFPA 25- 2011 Ed. NFPA 72- 2010 Ed. NFPA 10- 2010 Ed. NFPA 96- 2011 Ed.