Our health care facility has had a mock survey with joint commission and this is what the surveyor told me.
I would contact the CMS inspector for a list of the current NFPA Standards that is referenced.
Some of the NFPA Standards, such as 13, 25, 72, have handbooks available that explain the reasons for the standards. You will get a discount on the manuals, if you are a member of NFPA. The discount will pay for the membership.
Thanks for the info.
Your fire alarm testing company should be testing the entire circuit. Each smoke head or heat detector that is tested should activate closure of your fire doors that are held open by mag locks. Likewise, if you have air handlers, exhaust venting, elevators, etc. - they should be tied in as well and operate correctly.
Best practices are to ensure your "entire" fire protection systems function properly from point of detection through the automated protective devices and that should be done routinely based on the type of building. Your local fire marshal can tell you the type of building and frequency. When in doubt as to which compliance agency to follow always use the most restrictive.
The Joint Commission surveyor is correct.
The National Fire Alarm Signaling Code, NFPA 72, identifies fire alarm testing requirements performed by the fire alarm testing company. It contains two (2) door-related requirements when the fire alarm is activated:
Delving further into requirements, let's consider fire-rated doors. You don't mention whether the surveyor commented about these doors. The 2012 edition of the Life Safety Code, NFPA 101, was adopted last year and is currently utilized by CMS and TJC. It requires fire doors be inspected per NFPA 80.
Among other requirements, NFPA 80, Section 5.2.6, states automatic closing doors (doors subject to Section 21.8 in NFPA 72) be operationally tested to verify the door assembly will close (and latch) under fire alarm conditions.
Another fire door testing requirement (NFPA 80, 18.104.22.168) is that power operated fire doors be equipped with a releasing device that automatically disconnects power from the operator under fire alarm conditions. So if any fire-rated doors are operated by low energy door operators (offering accessibility for impaired individuals and activated with a "knowing act" wall switch) or high energy door operators (activated by sensor on approach of any individual), these operators must be disconnected from power under fire alarm conditions. And, if these doors are locked, they must unlock as well (NFPA 72, Section 21.9).
In closing, I've commented on more than you asked. But I hope it's obvious the requirements are many and you can see that coordinating fire alarm inspections with requisite annual NFPA 80 fire door inspections will save time, facility inconvenience, and money.
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