The purpose of a building’s life safety system is to reduce the potential risks to life as well as the property from various threats. For that reason, the National Fire Protection Association (NFPA) has developed life safety codes to protect people’s lives based on the building’s construction, protection, and occupancy features. However, systems that are found deficient and out of compliance will lead to expensive fines or even loss of accreditation! But as a facility manager, trying to keep up with every update to the code’s standards isn’t always easy. Not to mention, trying to figure out what is in compliance versus out of compliance can be stressful. So, to help ease your stress, we created a list of 5 ways to help you avoid a citation.
1. Make Sure You Have Up-To-Date Life Safety Drawings
A facility’s life safety drawings serve as a map to the building’s fire and life safety systems. So, keeping them up-to-date and readily accessible is not only important for inspectors but for those who utilize them on a daily basis. Unfortunately, too often during inspections, facilities will have an older, outdated set life safety drawings. This could be due to a recent building renovation, or there may be inaccuracies in the original or existing documents that were never corrected. Therefore, it is important for Healthcare Facilities to supply an accurate, up-to-date set of life safety drawings, which are required by:
- Joint Commission
- Centers for Medicare and Medicaid Services (CMS)
- State Health Department
- Local AHJ’s
2. Setup Annual Fire Door Inspections
If kept shut, fire doors help compartmentalize a facility by containing fire and smoke to its origin. However, they are complex devices and have hundreds of tiny parts that go into making them work. That’s why NFPA has required door assemblies to be maintained in working condition throughout the life of their installation. In fact, The U.S. CMS adoption of the 2012 edition of NFPA 101: Life Safety Code® requires that healthcare facility operators conduct a yearly inspection of fire door assemblies in accordance with NFPA 80: Standard for Fire Doors and Other Opening Protectives.
NFPA 80 – “Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ”.
3. Setup Fire/Smoke Dampers Inspections
Fire dampers are designed to prevent the spread of flames within the ductwork, while smoke dampers are used in the ductwork and air transfer openings that are designed to resist the passage of air and smoke. However, dampers have a tendency to fail and because they are hidden in the ductwork, they are out of sight, which means they could be out of compliance. As a result, NFPA 80 & 105 requires that, “The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every 6 years”.
*NOTE: NFPA requires that each damper in a facility should be tested and inspected 1 year after the initial installation.
4. Routine Maintenance of Fire Barrier Walls
Fire walls, partitions, and smoke barriers are designed to help prevent the spread of both fire and smoke in the event of a fire. However, gaps from penetrating items such as pipes and wires are common, which allows both fire and smoke to spread. This is why both the International Building and Fire Code requires that firestop materials are used to seal off any holes surrounding penetrating items in those particular walls, floors and ceilings.
IBC and IFC – “Openings made therein for the passage of pipes, electrical conduit, wires, ducts, air transfer opening and holes made for any reason shall be protect with approved methods capable of resisting the passage of smoke and fire”.
5. Setup Above Ceiling Inspection
Above ceiling issues are out of sight, which means you may not be aware that they are there. Faulty wiring is one of the top reasons a fire could start. Once the fire has started, having unsealed holes above the ceiling allows easy access for both fire and smoke to spread quickly through the building. This ultimately puts your building and everyone inside in terrible danger.
*Fire safety above ceiling is one of the most common inspections that is required by your Authority Having Jurisdiction (AHJ)
The bottom line is, you can’t afford to not have effective passive fire protection in your building. Life safety should be your number one concern, and keeping your fire-protection systems well maintained will go a long way in preventing fires and saving lives.
