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Fire Watch Needed

by Brad Keyes, CHSP, on Oct 14, 2020 1:00:17 AM

Q: We have to replace our fire alarm panel. The change-out will affect the supervisory devices for the sprinkler valve tamper switches and the waterflow switches as well. Unfortunately, we cannot keep the old panel up and running while we bring up the new one. Per our ILSM policy and the Life Safety Code, we will have to institute a fire watch. My Administration has challenged me and said that we are going over-the-top placing the entire hospital on a fire watch and providing fire watch coverage based upon our risk assessments for the assigned areas. They say this is for construction projects. I have informed them that the fire alarm panel replacement is a construction project that my local AHJ had to approve and issue a permit. The Administration has challenged me stating they don't think it is needed or needed to they level I have recommended as the safety officer. They want examples of the codes and standards that say we need a fire watch. Do you think I am right?

A: You are absolutely correct. Whenever any impairment of the fire alarm system or the sprinkler system is made, you must conduct a fire watch. Here are some code and/or standard references to support this position:

  • NFPA 101-2012 Life Safety Code: Section 9.6.1.6 says where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the AHJ must be notified, and the building must be evacuated or an approved fire watch must be provided for all impaired areas. This applies to all fire alarm system impairment, not just those associated with construction or renovation. So this means you must notify the local fire department, the state agency in charge of hospital design and construction, the hospital’s insurance company on liability, and you must conduct a continuous fire watch for the entire building. According to the CMS Final Rule to adopt the 2012 Life Safety Code (published May 4, 2016), an approved fire watch is a dedicated individual (or individuals) who has no other responsibility who walks the entire impaired area looking for fire and conditions that could promote fire, and have a communication device with them to call for the fire department if necessary. This person (or persons) cannot leave the impaired areas until the fire watch is discontinued or they are relieved by other dedicated fire watch persons. If it takes more than 30-minutes to walk the impaired area, then additional dedicated fire watch people need to be deployed. NOTE: This can cost big $$$ real quick depending on the length of the fire watch and the area where the fire watch applies.

  • NFPA 101-2012 Life Safety Code: Section 9.7.6 says sprinkler impairments procedures must comply with NFPA 25-2011 (see below).

  • NFPA 25-2011, Water-Based Fire Protection Systems: Section 15.5.2 (4) says where a required fire protection system is out of service for more than 10 hours in a 24-hour period, you must evacuate the building, or perform an approved fire watch, and you need to notify the local fire department, the insurance carrier, and any other AHJs. If the waterflow switches and tamper switches are impaired, that constitutes the sprinkler system being impaired.

  • Joint Commission standard LS.01.02.01, EP 2 says essentially the same thing as the above.

I suggest you contact your local fire marshal, your state fire marshal, your state agency responsible for licensing of hospitals, your state agency responsible for design and construction, your accreditation organization, and your CMS Regional Office and ask each of them what procedures you must follow to comply with an impaired fire alarm system and an impaired sprinkler system. I would expect they would say the same thing I have said above.

Topics:Fire Watch

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