Joint Commission Flashcards
EC.02.03.05, EP1
Annual (Supervisory Signal Devices)
What is a Superisory Signal Device?
A device that sends a signal back to the main fire alarm panel
Examples of a Supervisory Signal Device
‒ Sprinkler system pressure
‒ Pressure tank
‒ Dry pipe pressure (High & Low)
‒ Steam pressure
‒ Water level
‒ Water temperature
‒ Room temperature
‒ Wired, powered, or controlled by FA panel
EC.02.03.05, EP 2
Semi-annual (Water Flow & Valve Tamper Switches)
What is a water flow switch?
‒ These devices alarm when the flow of water is detected in the sprinkler system (i.e., possibly a sprinkler head activated)
‒ Vane and pressure type only
‒ Water gongs are included if they are present
What are Tamper Switches
‒ Monitor sprinkler zone valves; a signal is sent to main fire alarm panel if attempt to close
‒ Must be tested semi-annually
‒ Some AHJs also require the valve to be locked in the open position
Tamper Switches
‒ Monitor sprinkler zone valves; a signal is sent to main fire alarm panel if attempt to close
‒ Must be tested semi-annually
‒ Some AHJs also require the valve to be locked in the open position
EC.02.03.05, EP 3
Annual (Detectors and Door Release Devices)
What are Duct Detectors?
The hospital tests duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors on the inventory.
EC.02.03.05, EP 4
Annual (Fire Alarm Audio/Video Devices, Speakers, and Door Releases)
EC.02.03.05, EP 5
Every 12 months, (Off-Site Transmission)
-The hospital tests fire alarm equipment on the inventory for notifying off-site fire responders.
- The results and completion dates are documented.
EC.02.03.05, EP 6
Monthly (FIre Pump No Flow), For automatic sprinkler systems:
- The hospital tests electric motor–driven fire pumps monthly and diesel engine–driven fire pumps every week under no-flow conditions.
- The results and completion dates are documented.
Fire Pump Testing (Churn Test) EP6
‒ Purpose of test is to verify pump is in operating condition
‒ Water flow is not required
‒ Electric – monthly, 10 min.
‒ Diesel – weekly, 30 min.
‒ Pump System
‒ Pump starting pressure
‒ Suction and discharge pressure gauge readings
‒ Electrical System
‒ Time controller is on first step (for reduced voltage or reduced current
starting)
‒ Amount of time to ramp to full speed
‒ Time pump runs after starting (for automatic stop controllers)
EC.02.03.05, EP 7
(Removed July 1, 2022) For automatic sprinkler systems: Every six months, the hospital tests water-storage tank high- and low-water level alarms. The
results and completion dates are documented.
EC.02.03.05, EP 8
(Removed July 1, 2022)
For automatic sprinkler systems: Every month during cold weather, the hospital tests water-storage tank temperature alarms. The results and completion dates are documented.
EC.02.03.05, EP 9
Annual (Main Drain Test),
- The hospital tests main drains at system low point or at all system risers.
-The results and completion dates are documented.
Main Drain Test
‒ Conducted to determine a change in the condition of water supply piping or control valves
‒ Will reveal if there has been any deterioration of the water supply by comparing test results to previous test results
‒ Document both static and residual pressures
‒ When there is a 10% or more reduction in flow from previous test, the cause shall be identified and corrected per NFPA 25.
EC.02.03.05, EP 10
Quarterly (Fire Department Connections), For automatic sprinkler systems: – Every quarter, the hospital inspects all fire department water supply connections.
- The results and completion dates are documented.
Fire Department Connections
‒ These are connections through which the fire department can pump supplemental water into the building sprinkler system or standpipe system
‒ Visible and Accessible
‒ Caps in place
‒ Must be inspected quarterly
EC.02.03.05, EP 11
Annual (Fire Pump Under Flow), For automatic sprinkler systems:
- Every 12 months, the hospital tests fire pumps under flow.
-Fire pump supervisory signals for “pump running” and “pump power loss” are tested annually.
-The results and completion dates are documented.
Fire Annual Flow Test, EP11
‒ Purpose of test is to verify that pump can provide the needed amount of water
‒ Length of pump test time is based upon pump’s rating
‒ Evaluate against previous test and design flow
‒ For installations having an automatic transfer switch , simulate a power failure condition while the pump is operating at peak load
‒ Alarm conditions shall be simulated by activating alarm circuits at alarm sensor locations, and all such local or remote alarm indicating devices (visual and audible) shall be observed for operation
‒ Test results are not less than 95% of either the pressure at rated speed and flow of the initial field acceptance test or the performance on the nameplate
‒ Degradation of more than 5% is investigated and corrected
‒ Test data Volts x Amps is not greater than the rated Volts x rated Amps x permitted motor service (power) factor
‒ Test data voltage is within 5% below and 10% above the rated voltage
Pump Room Tour (Part of EP11)
‒ Controller in auto
‒ ATS in auto
‒ Make sure all service valves are open and labeled
‒ Record (take a picture) pump data pressure and flow at:
‒ Churn
‒ 100%
‒ 150%
‒ Packing dripping
‒ 1 drop per second
‒ Make sure equipment isaccessible
EC.02.03.05, EP 12
5 years (Standpipe Water Flow)
- The hospital conducts hydrostatic and water-flow
tests for standpipe systems.
- The results and completion dates
are documented.
5-Year Standpipe Test (EP12)
‒ Purpose of flow test is to verify the water supply provides design pressure at the required flow
‒ Hydrostatic test required on dry standpipes for two hours
‒ Document gallons per minute flow data
EC.02.03.05, EP 13
Semi-annual (Kitchen Automatic Extinguishment)
- Every 6 months, the hospital inspects any automatic fireextinguishing
system in a kitchen.
- The results and completion dates are documented.
Note 1: Discharge of the fire-extinguishing systems is not
required.
Kitchen Automatic Extinguishment (EP13)
‒ Shuts off fuel source automatically
‒ Connected to fire alarm panel
‒ Must be inspected every 6 months
‒ Actual discharge is not required
‒ NFPA 96 -2011:
‒ 10.4.1 Upon activation of any fire-extinguishing system for a
cooking operation, all sources of fuel and electrical power that
produce heat to all equipment requiring protection by that
system shall automatically shut off.
EC.02.03.05, EP 14
Annual (Gaseous Automatic Extinguishment System)
The hospital tests automatic fire-extinguishing systems as follows:
- Carbon dioxide systems every 12 months
- Halon systems every 6 months
- Other special systems per National Fire Protection Association standards and manufacturers’ recommendations.
- The results and completion dates are documented.
Note 1: Discharge of the fire-extinguishing systems is not required.
Note 2: For full text, refer to NFPA 12-2011: 4.8.3.2 (for carbon dioxide
systems) and NFPA 12A-2009: 6.1 (for halon systems).
Note 3: For full text, refer to NFPA 11-2010; NFPA 16-2011; NFPA 17-2009;
NFPA 17A-2009 for other extinguishing systems.
Carbon Dioxide & Other Gaseous Systems (EP14)
‒ Must be inspected annually
‒ Actual discharge is not required
EC.02.03.05, EP 15
Monthly (Portable Fire Extinguishers)
- At least monthly, the hospital inspects portable fire extinguishers.
- The results and completion dates are documented.
Note 1: There are many ways to document the inspections, such as using bar-coding equipment, using check marks on a tag, or using an inventory.
Note 2: Inspections involve a visual check to determine correct type of and clear and unobstructed access to a fire extinguisher, in addition to a check for broken parts and full charge.
Note 3: For additional guidance on inspection of fire extinguishers, see NFPA 10-2010: 7.2.2; 7.2.4.
EC.02.03.05, EP 16
Annual (Portable Fire Extinguishers)
- Every 12 months, the hospital performs maintenance on portable fire extinguishers, including recharging. Individuals performing annual maintenance on extinguishers are certified.
- The results and completion dates are documented.
Note 1: There are many ways to document the maintenance, such as using bar-coding equipment, using check marks on a tag, or using an inventory.
Note 2: For additional guidance on maintaining fire extinguishers, see NFPA 10-2010: 7.1.2; 7.2.2; 7.2.4; 7.3.1.
Portable Fire Extinguishers (EP 15 & EP16)
‒ Monthly visual inspection
‒ Accessible
‒ Fully charged
‒ Any parts broken
‒ Correct type
‒ Annual maintenance by a licensed fire protection service
company
Portable Fire Extinguisher Inspections
‒ Month, day and year of inspection per NFPA 10-2010:
‒ 7.2.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action
‒ 7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded
‒ 7.2.4.4 Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method
‒ 7.2.4.5 Records shall be kept to determine that at least the last 12 monthly inspection have been performed
