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The Joint Commission, Fire Protection & YOU: Everything You Need to Know about Fire Protection in your Healthcare Facility

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Keeping your healthcare facility in constant preparedness for Fire and Life Safety surveys can be a challenge. It’s important that you be ready, but it can be easy to get overwhelmed.

The Joint Commission accreditation is the gold standard in healthcare certification, and as a facility professional, the responsibility for Fire and Life Safety Code compliance falls to you. That means that you’re on the spot when The Joint Commission surveyors, including a Life Safety Code surveyor, arrive unannounced.

It’s important for hospitals to demonstrate their dedication to safe, effective, and comprehensive patient care. While they can display this in their day-to-day operations, most choose to take things a step further by earning accreditation from The Joint Commission (JCAHO) or another accrediting organization. 

Accrediting organizations have applied for and received “deeming authority” from the Centers for Medicaid and Medicare Services (CMS). This means they can determine which healthcare facilities meet Medicare and Medicaid certification requirements. However, each of them goes about determining that in their own way, with a different set of standards. 

In the United States, nearly 23,000 health care organizations are evaluated and accredited through the Joint Commission, one of the few accreditation organizations accepted by the Centers for Medicare and Medicaid Services (CMS).

At A P Fire we will help you understand and tackle JCAHO and the standards it uses to determine fire safety in hospitals – large and small.

What Is the Joint Commission?

The Joint Commission is an accreditation body that focuses on quality care for the American public through a voluntary and independent evaluation process. It is governed by a 21-member Board of Commissioners that includes physicians, administrators, nurses, employers, quality experts, a consumer advocate and educators. They also employ approximately 1,000 people in its surveyor force.

All of these people work together to influence national healthcare policy, funding priorities, performance measurement, and future legislation. In addition, they establish standards for safe, effective, and comprehensive patient care. 

What Are jcaho Standards?

The Joint Commission performs on-site surveys once every three years, but hospitals must also perform annual self-assessments.  These standards are all focused on setting hospital performance expectations that are reasonable, achievable, and surveyable. Together they are aimed at holding healthcare facilities responsible for high-quality care.

Over the years, JCAHO has established hundreds of standards, with categories, or chapters, ranging from Document and Process Control (DC), to Infection Prevention and Control (IC), to Medication Management (MM), and many more. When it comes to fire safety in hospitals, these standards are found in The Joint Commission’s Life Safety (LS) Chapter. 

GENERAL BUILDING REQUIREMENTS – LS.02.01.10 (HOSPITALS) AND LS.03.01.10 (AMBULATORY CARE FACILITIES) The elements of performance: Unprotected openings in fire rated walls and floors Fire doors hardware and gaps Openings in 2-hour fire rated walls for 1½ hours MEANS OF EGRESS REQUIREMENTS – LS.02.01.20 (HOSPITALS) The elements of performance: Corridor clutter Doors unlocked in the direction of egress PROTECTION – LS.02.01.30 (HOSPITALS) The elements of performance: Hazardous storage area issues Corridor doors Smoke barriers do not have unsealed penetrations FIRE PROTECTION – EC.02.03.05 (HOSPITALS) The elements of performance: Lack of documentation related to the maintaining, inspecting, and testing Annual testing of smoke detectors, duct detectors, etc. Automatic air handling unit shutdown Annual testing of visual and audible fire alarms Water flow device testing Quarterly testing of fire alarm notification to off-site fire responders

How The Joint Commission Evaluates Facilities for Fire Safety

JCAHO standards provide the basis for an evaluation process to measure, assess, and improve hospital performance. They conduct surveys for a given facility every three years to determine if they are in compliance with CMS requirements.

Between surveys, health care facilities are required to conduct ongoing self-assessments and make improvements based on their results. This requirement encourages continuous improvement, which – where fire and life safety are concerned – directly contributes to improved occupant safety.

There are two groups of The Joint Commission Standards that pertain specifically to fire and life safety:

The Joint Commission Environment of Care (EC) Standards

These standards address a number of safety and security risks within the facility’s building or space, including fire safety.

The Joint Commission Life Safety (LS) Standards

These standards address all of The Joint Commission requirements in the National Fire Protection Association (NFPA) 101 Life Safety Code for construction and operational conditions to minimize fire hazards and provide safe fire protection systems.

How Joint Commission Standards relate to the National Fire Protection Association Standards

The Joint Commission standards related to fire safety are based on National Fire Protection Association (NFPA) codes. Most of the codes specific to hospitals and ambulatory care facilities come from NFPA 101 Life Safety Code. Furthermore, there are a number of different NFPA codes that are applicable to all health care occupancies. The table below provides a comparison between The Joint Commission Standards and their corresponding NFPA Codes.

If you work in a hospital or healthcare setting that’s accredited by The Joint Commission, it’s important to know what these standard updates mean for your facility. In order to pass your annual self-assessment or triennial survey from The Joint Commission, you need to ensure full compliance with protocol. 

The Joint Commission helps hospitals become reliable organizations for delivering safe and effective care. A large component of that is adhering to their standards on effective fire protection.

Maintaining accreditation is critically important for any facility that provides services to Medicare and/or Medicaid patients. And, any facility found to have critical violations can find itself on a 90-day termination track toward losing CMS reimbursement.

Fire safety continues to be a significant challenge for health care facilities in their Joint Commission surveys. According to the results of The Joint Commission surveys in 2018, almost half of the top compliance issues for hospitals and ambulatory facilities were related to fire safety.

Top Fire Safety-Related Compliance Challenges

Here are the top fire safety-related deficiencies that The Joint Commission identified in 2018 with the applicable standard noted in parentheses:

  • Only 35 percent of hospitals were adequately maintaining their fire safety equipment and the fire safety features of their buildings (EC.02.03.05).
  • The building and fire protection features of more than 55 percent of the ambulatory care facilities (LS.03.01.10) and 68 percent of hospitals (LS.02.01.10) evaluated did not adequately protect occupants from the effects of fire, smoke, and heat.
  • In fewer than 28 percent of the hospitals (LS.02.01.30) evaluated, the buildings either did not provide the necessary features to protect occupants from the hazards of fire and smoke, or they had the necessary features but were not being properly maintained.
  • Almost 89 percent of rural hospitals designated as critical access hospitals were lacking the required equipment for extinguishing fires. And, in the other hospitals evaluated, that number jumped to 90 percent. More than 55 percent of outpatient facilities did not meet these standards (LS.03.01.35).
  • Another common area of non-compliance was in the Means of Egress provided by hospitals (LS.02.01.20) with half of those evaluated failing to meet The Joint Commission standards.

APFP Can Help You Meet The JCAHO and NFPA Standards

A P Fire Protection is one of the few fire protection companies in Arizona that can provide total protection from one source. If your facility is accredited by The Joint Commission, our team of NICET-certified and factory-trained engineers and technicians can provide the knowledge and expertise you need to ensure that your employees and patients are safe – and your facility is compliant with both The JCAHO and NFPA standards.

Fire protection Services for Healthcare Accreditation

Keeping your healthcare facility in constant preparedness for Fire and Life Safety surveys can be a challenge. It’s important that you be ready, but it can be easy to get overwhelmed.

The Joint Commission accreditation is the gold standard in healthcare certification, and as a facility professional, the responsibility for Fire and Life Safety Code compliance falls to you. That means that you’re on the spot when The Joint Commission surveyors, including a Life Safety Code surveyor, arrive unannounced.

With the overwhelming number of operating challenges you face on any given day, it’s unlikely you have time to continually think about Fire and Life Safety documentation. APFP services for The Joint Commission accreditation are designed to give you the peace of mind knowing that a sudden visit is never a cause for alarm.

Leave the documentation management to us

The Joint Commission’s accreditation program requires that you maintain an extensive set of Fire and Life Safety documentation, properly completed, appropriately organized and easily accessible. Missing paperwork or incomplete entries are more than embarrassing; they can trigger non-compliance requiring corrective action.

 A P Fire Protection Fire Services for The JCAHO Accreditation ensure proper documentation of all inspection and test reports related to Fire and Life Safety systems in your buildings and are designed to simplify and streamline the survey process. The program provides you with an annual delivery schedule to ensure no test is overlooked. Regular review meetings will be included to familiarize your staff members with all related documentation and paperwork as well as prepare them to speak knowledgeably with surveyors during a survey.

Our goal is to help you avoid unpleasant surprises, and free you up to devote more of your resources to daily operations.

Our highly trained professionals speak “The Joint Commission” language.

You can depend on A P Fire Protection testing, inspection and documentation to mirror the very latest requirements including The Joint Commission Environment of Care and Life Safety requirements. The APFP team maintains in-depth knowledge of The Joint Commission standards, as well as National Fire Protection Association codes as it relates to healthcare.

Make A P Fire Protection your single source for Fire and Life Safety

When A P Fire Protection partners with your facility, you can end the hassle of managing multiple life-safety vendors. With one service agreement, you can consolidate testing and maintenance processes, scheduling and documentation for all your Fire and Life Safety systems.

Testing and maintenance services can include fire alarm systems, sprinklers, kitchen hoods, portable extinguishers, fire pumps, fire suppression systems and more. Learn more about A P Fire Protection Fire Services.

A P Fire Protection services for The Joint Commission Accreditation Program can be tailored to your exact needs:

• Testing of Fire and Life Safety systems to The Joint Commission and other regulatory standards

• Easy-to-read, customized test reports, created per each applicable Element of Performance standard established by The Joint Commission

• Comprehensive inspection management in the form of a detailed inspection schedule, structured around The Joint Commission Elements of Performance standards

• Deficiencies tracking and repairs in full accordance with applicable standards and deadlines of The Joint Commission

• Account management services including frequent review meetings to discuss present and future needs

• Assistance with interpretation of The Joint Commission standards and requirements

If you’d like to know more about The Joint Commission’s Standards, check out these publications: Joint Commission resources2023 Environment of Care® Essentials for Health Care,  Life Safety Made Easy: Your Key to Understanding Fire Safety in Health Care Facilities and The Joint Commission Big Book of EC, EM, and LS Checklists

At A P Fire Protection, we’re experts on The Joint Commission’s standards. We can help you ensure you’re always in compliance. Contact us to learn more.

Schedule Now!

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Authority Having Jurisdiction (AHJ) and Fire Protection

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The authority having jurisdiction, or AHJ, plays a crucial role in ensuring fire/life safety in buildings, and it’s essential that facility managers understand what the AHJ is and the role it plays throughout the life of a building.

The concept of an authority having jurisdiction (AHJ) has been included in safety standards for years. The first thing to understand about an AHJ is that it is not a single entity. Depending on the jurisdiction your facility is in, the type of facility you’re in, and who owns your facility, you may be visited not only by the fire marshal, but by a variety of individuals, referred to as “the authority having jurisdiction”, who ensure your fire and life safety programs are within their standards of operation.

Defining the Authority Having Jurisdiction

The National Fire Protection Association (NFPA) 701 codes define the AHJ as “an organization, office, or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation, or a procedure.” Specifically, under the NFPA 701 annexes, it is distinguished that “where public safety is primary, the AHJ may be a federal, state, local, or other regional department or individual such as a fire chief; fire marshal; chief of a fire prevention bureau, labor department, or health department; building official; electrical inspector; or others having statutory authority.  For insurance purposes, an insurance inspection department, rating bureau, or other insurance company representative may be the AHJ.”

Essentially, this means that the AHJ serves primarily as an official responsible for code interpretation, enforcement, and implementation. It also means your AHJ is most likely more than a single person, office, or entity. The requirements your AHJ is employed to enforce depend mostly on the type of building or property. Their main objective is to evaluate the overall condition of the fire and life safety performance on your property and to confirm or request that it meets those up-to-date expectations. For example these could include:

Local Government

  • Building Department
  • Fire Departments & the Fire Chief
  • Zoning Departments

State Government

  • State Fire Marshal
  • State Health Department

Federal Government

  • Government Service Administration
  • Federal Programs
    • OSHA
    • JCAHO
    • BIA

Private Sector

  • Insurance Company
  • Third-party Certification & Accreditation Organizations

The United States’ codes and standards development process can be confusing. Unlike many other countries, there is no federal government code, so your AHJ requirements may differ depending on where your building is located. Furthermore, the codes your AHJ is employed to enforce can differ depending on which edition of the code your jurisdiction has adopted. It’s essential to recognize that once a code is adopted by a jurisdiction, it essentially should be noted as law for that jurisdiction.

With each of these sectors, various disciplines, or AHJs with unique or specialized areas of focus, might be present. An AHJ with overall knowledge of building and fire code issues, or one with special knowledge of plumbing systems and electrical systems, are a few examples of whom you might encounter.

International Code Council and National Fire Protection Association Code Books
Examples of Code Books Enforced by AHJS

Understanding Codes Enforced By AHJS

The codes and standards development process in the United States is managed almost entirely within the private sector. While the processes used to develop the code-based provisions have some differences, the NFPA code development process uses the principles of the American National Standards Institute (ANSI). These principles include:

  • Consensus must be reached by representatives from materially affected and interested parties.
  • Standards are required to undergo public reviews when any member of the public may submit comments.
  • Comments from the consensus body and public review commenters must be responded to in good faith.
  • An appeals process is required.

Transparency, openness, and inclusion are at the center of this process. NFPA uses a model of balanced committees; a mix of materially affected, interested parties derive requirements and develop the standards. In regard to the building, those who have to do the enforcing (the AHJ), pay for the building (the building owners), maintain it (the owners/contractors), install it (the contractors), design it (the architects/engineers), and insure it (the insurance company), all have a perspective on what the “requirement” should be, and they work together to find that balance.

Code Adoption

Once a code is adopted by a jurisdiction, the Authority Having Jurisdiction and the building owner are obligated to follow and it is what the AHJ is obligated to enforce. Finding out which code is applicable can be a bit tricky. A state or local jurisdiction may be several editions behind in adopting the most current code. For instance, the current edition of NFPA 101, Life Safety Code, is from 2021. Although this code is updated every three years, some jurisdictions may be using a 2015 edition or even a 2009 edition. Furthermore, a particular edition may be adopted at the state level but Home Rule (where county or municipal governments implement principles of a local self-government) may allow the code to be adopted at the local level.

The AHJ is the best person to ask to learn which edition and what local amendments are in effect. This approach is also a great way to strike up a relationship with the AHJ. Doing so can give you a better understanding of expectations and requirements.

A Critical Role

On occasion, there are stories about the fire marshal controlling or setting limits on the way a building can be used. Contrary to some popular myths, fire marshals and other Authorities Having Jurisdiction do not make up their own rules. One of their primary jobs is to enforce the locally adopted codes and standards in the jurisdiction. The restrictions, limits, or changes in your building that the AHJ has identified are there to protect the owner, the building occupants, first responders, and the community at large.

It might be helpful to think of AHJs as customer service representatives. They help with carrying out the “policy” (adopted code) for the jurisdiction. During construction or renovations, they are also allies of the building owner. The AHJ is usually involved in the plan review process. This process helps ensure that the building and its related systems meet the requirements of the adopted code or standard and that the building’s construction features, systems, and architectural features are in compliance, thereby assuring the building owner that he or she is paying for a code-complying structure.

AZ Department of Forestry and Fire Management logo
The Fire Marshal in AZ is under the Department of Forestry & Fire Management

It is their duty to verify your building is safe for everyone. In case of an emergency, any requested modifications also benefit the first responders. For instance, if a fire starts in your building, first responders are going to assume your life safety systems are up to date. If you have failed to follow AHJ instructions, a first responders’ ability to take control of a possibly dangerous situation could be compromised. Not only is this a disservice in respect to overall safety, but potential legal ramifications may follow.

Your Responsibility

However, even with a government AHJ responsible for the initial installation and an assigned facility AHJ for subsequent facility installations, there is an obligation for an employer to verify that maintenance, repair, or modification of the initial equipment does not create unsafe conditions. 

Tips for Working with the Authority Having Jurisdiction

When it comes to your fire code and safety inspection services, the AHJ plays a vital role in certifying that the fire and life safety systems in your building are up to date and up to the NFPA codes standards. Many of us generally don’t know who their AHJ is, let alone what fire codes and standards apply to our buildings.

The NFPA requires fire inspections primarily where public safety is at potential risk. Inspections are not to assign blame. They confirm that equipment is installed and maintained in a manner that safeguards persons and property from hazards arising from everyday use of the facility as well as in emergency situations. Without verifying compliance, employees, customers and anyone else who enters your building are at risk. 

At A P Fire Protection we believe it is our responsibility to make sure you know what to do when the AHJ for your business comes into the picture. The following tips will help you know what to expect and prepare for so that you can go in feeling confident and comfortable with the fire inspection process.

Get to Know Your AHJ 

In the most general sense, if you’re a building owner, your AHJ is an ally, so it’s important to treat them as such and take them seriously when they perform inspections. Keeping an open mind and providing the upmost transparency when relaying information pertaining to the building is crucial in maintaining a positive relationship with your AHJ, as well as the safety of anyone who goes into your building.

Sustaining a positive relationship with your AHJ(s) additionally provides you the opportunity to know your building inside and out in a way that will help you to conserve the integrity of the building and therefore your business. It will also help you in case something goes wrong, you’ll be able to effectively communicate where the issue is so as to provide the persons in charge of fixing or inspecting the issue all of the facts. Good for you, but also good for your AHJ to know too.

Remember, your AHJ isn’t your enemy, your AHJ is your friend! It’s up to you to maintain a good rapport, no matter the condition of your building(s), a good relationship with the AHJ can only improve the situation.

Document Inspections/Correspondences and Follow Up

It is as beneficial for you as it is the AHJ when you both are on (literally) the same page. Take notes during inspections, save all paperwork, and don’t be afraid to ask questions.

Chances are, if you lack the knowledge, you’ll be left wondering what to do when your Authority Having Jurisdiction shows up. At APFP, we don’t want that to happen. After all, your success is our success, and we all can agree a safe building is the best kind of building.

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Fire Protection for Schools & Universities

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The first step in keeping students, faculty, and visitors protected in the event of a fire involves fire protection systems and fire safety protocols for schools and universities. Fire protection systems can help to extinguish a fire and provide building occupants the time they need to evacuate safely, but only when they are well-maintained and functioning. It is extremely important to uphold established fire safety protocols to keep everyone informed and prepared so that they know what to do and where to go in the event of a fire.

Fire Protection Systems

Authorities Having Jurisdiction (AHJ), code officials, field inspectors, and school districts have the responsibility to ensure each school building is built and maintained properly. Set your year up for success by ensuring your fire protection systems are up to code and ready to deploy in the event of an emergency. Each level of your fire protection systems is a critical component of fire safety on your campuses. Be sure to have your  inspections and maintenance items scheduled early and A P Fire Protection can work with your school calendar to have your fire protection in tip-top shape.

Fire Alarms

The International Building Code (IBC) and International Fire Code (IFC) provide minimum requirements for fire alarm systems such as automatic detection and manual fire alarm boxes throughout a school. A school fire alarm system can be set off in one of two ways: a system will automatically sound if smoke or high heat is detected, or it can also be manually started through a pull lever.

Smoke detectors are constantly testing for combustion particles in the air, while heat detectors measure air temperature. Depending on the installation areas and code requirements, each type could be installed on your campuses to reduce nuisance alarms while still providing reliable early detection. Early detection and notification also offer ample time to locate and extinguish a fire before it spreads.

The control panel is typically located in the front office, but not always.The panel is programmed to be able to tell the staff where the fire is happening, whether a fire alarm lever was pulled or automatically activated by the presence of heat or smoke.

Fire Extinguishers

Portable fire extinguishers should be located in accessible locations in accordance with the AHJ requirements for your region. Staff should know where the closest extinguisher is located at all times and how to operate it. APFP offers onsite training courses and certification where staff can operate a real extinguisher to put out a live flame. Trained personnel can use fire extinguishers to quickly stop a small fire from spreading or to create a path for escape. 

Fire Sprinklers

Quick response (QR) fire sprinklers are preferred in systems for facilities with high occupancies like school buildings and dormitories. Their smaller bulb size speeds up thermal responsiveness. Additionally, quick response sprinkler deflectors discharge water higher on the walls to keep the fire from climbing and maintain lower ceiling temperatures (heat rises!). Cooler ceilings reduce the likelihood of flashover and slow a fire’s rise within a building, improving the odds for survivability. These elements give occupants time to evacuate. 

Fire Damage at School

Fire Safety Plans

Unfortunately, statistics indicate that most school fires are started while school is in session, meaning the occupants are responsible for most school fires. Staff training and fire drills are essential in educating our children about fires and keeping them safe. Even with the best fire protection systems in place, it is important to have emergency operation plans that are organized to provide quick and orderly evacuation. These plans should be reviewed frequently and updated to reflect any building modifications or changes in occupancy.

Mass Notification System

Depending on one form of emergency communication, such as a PA system or text messages, can be incredibly unreliable during an emergency. NFPA 72 recommends using at least two of the four layers of communication – indoor, outdoor, personal, and public alerting. A mass notification system allows building occupants to be promptly and clearly alerted to a variety of emergency situations. This includes fires, severe weather, active shooters, or any other emergency requiring immediate communication to many people. Internal speakers, outdoor blast speaker systems, mass text messages, and e-mails can all be utilized to alert everyone to the specific danger and provide instructions on how to remain safe.

An egress map showing evacuation routes and fire protection unit locations held down by a detector.
Emergency Action Plan: Example Egress Map

Fire and Evacuation Drills

Fire and evacuation drills are the most important fire safety exercise you can do. Conduct drills on a regular basis to learn and maintain awareness of exit routes and best efficiency practices. An egress map should be posted in each classroom and near each building exit. Each egress map should designate two assembly areas that are at least 500 feet away from the building where students and staff should assemble upon evacuation as a “Main Assembly Area” and an “Alternate Assembly Area”, in the event the Main Area cannot be used. 

Drills can be used as an opportunity to identify problem areas and egress choke points and to ensure occupants understand any directions given by the fire alarm or mass notification system. In addition, it is important that all employees be aware of the locations of alternate exits and keep exit routes free and clear of obstructions. Drills should be used to update plans as needed to account for new or renovated buildings, student growth, and other changes that might affect emergency egress.

Dormitory Checks

September is Campus Fire Safety Month, and that’s a great time to review best practices for fire safety in dormitories. According to the National Fire Protection Association (NFPA), from 2015-2019, U.S. fire departments responded to an estimated annual average of 3,840 structure fires in dorms, fraternities, sororities, and other related properties, resulting in annual averages of 29 civilian injuries and $11 million in direct property damage. Most campus fires happen in dormitories between the hours of 5-11 p.m. Of these incidents, 6 out of 7 are related to cooking. While it is important to enforce policies that reduce risks including unattended cooking, candles, and the disabling of smoke alarms, it is vital to ensure that all dormitories are fully sprinklered and have an operable fire alarm system that has been inspected in accordance with local fire codes.

Fire Protection Services 

Working with APFP

Whether you need smoke detectors, fire extinguishers, or an automatic sprinkler system installed at your school facilities, A P Fire Protection is here for you. We have been protecting Arizona from fire damage since 2008 and we have over a century of combined experience! Known for our superb customer service, our expertise, and our reliability, we understand as school systems it is imperative to complete most maintenance while students and staff are off campus and will do everything in our power to schedule around your breaks and holidays.

Schedule Now!

In preparation for your services, you should check in with a couple of departments so you are ready to go. Facility directors/managers should be able to tell you if their monthly inspections have detected any problem areas or changes to structures or occupancies. If this is your first time partnering with APFP, we encourage you to reach out to your previous fire protection company to see what reports they can provide you with, or at the very least, collate your campus maps in preparation for a walkthrough where we will mark each device location. Working with the procurement office ahead of time can also save you time when it comes to getting purchase orders after an estimate has been approved. You can also check out our list of common

Typical school Fire Code Violations

System Reports

We will do our best to provide our customers with job reports containing device counts and placement, outlining deficiencies and needed repairs and compiling previous repairs and notations. Not only does this make you more aware of your fire protection capabilities and needs, but it also sets you up for success by establishing verifiable numbers needed to project more accurate pricing for upcoming maintenance.

Fire alarm systems in schools, like other buildings, generally are not mandated to be updated or replaced to meet current code requirements unless the system is no longer operational or if buildings are being modernized. Although codes are developed to improve safety, these modified codes also have increased the cost of building and installing systems.

These cost restraints are the primary reasons that many school districts simply have not been able to budget for new or upgraded fire alarm systems. While school administrators would like to upgrade or replace obsolete fire alarm systems, often funding is not available to do so. Sadly, this fact could result in a school having an obsolete and possibly non-operational fire alarm system, which is unacceptable when the protection of our children is at stake.

School fire protection systems do not need to have all new top of the line equipment; however, it should be stressed that obsolete and out of date equipment that does not meet applicable code requirements puts lives in danger. First and foremost, we should be able to keep our children safe from fire while they are in school. 

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Fire Protection Monthly Inspection Checklist

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Fire Protection Readiness

One of the most costly and devastating events for a company or organization is a fire. Scheduling regular fire protection monthly inspection and tests overseen by you or someone in your business can help ensure that your fire prevention systems are ready when needed. Conducting preventive maintenance tasks can also help make sure your fire protection systems are in good working order and make yearly testing and inspections a breeze!

Every business should establish its testing schedule to comply with external regulations or internal procedures. A fire protection monthly inspection checklist is a form used by property owners or managers to verify the operational reliability of fire protection devices installed in their properties. It aims to ensure national fire safety code standards are observed.

Download yours here!

Visual inspections are part of the inspection, testing, and maintenance required by the National Fire Protection Association (NFPA) and each area within your system has different guidelines and timelines. NFPA defines an inspection as “a visual examination of a system or portion there of to verify that it appears to be in operating condition and is free of physical damage.” As a general rule, make sure all fire protection equipment is unobstructed and accessible. A fire protection expert from A P Fire Protection can help point out what else you need to look for in a monthly inspection. However, for annual, semi‑annual, or quarterly inspection requirements, we will need to send out an experienced, certified technician to your business.

Training Panel: Fire Alarm Panel, Smoke/Heat Detectors, Horn Strobe, Pull Stations, Duct Detectors & Alarm Bell

Pulls Detectors, Notifiers & Emergency Lights

Often your first line of defense, pulls, detectors, notifiers (horns, strobes & sounders)  and emergency lights are the first to know when a fire has ignited. Pulls or detectors send a signal to your fire panel which raises the alarm, sending an internal signal to your alarm system and an external signal to first responders and your monitoring company. When these devices are obstructed, dirty or not working properly, this could cost you valuable seconds in response, creating more time for the fire to spread. at each monthly inspection you should take the steps below to provide the quickest response possible.

Testing

Schedule tests of smoke detectors, fire alarms and emergency lights at least once a month per the U.S Fire Administration. Set a calendar reminder to check the performance of these items on a day or week when you are generally less busy. By scheduling in your downtime, you can negate any potential to put off your testing because another task is demanding your attention.

To test, hold the test button on each device and wait for the signal. If the light is weak/does not illuminate or you do not hear anything after a few seconds, take note of the location on your report. Batteries must be replaced every 6 months in smoke detectors not connected to a fire alarm panel. It is important to make sure the new batteries inserted are fresh, so it is always important to test a smoke detector once the batteries are replaced. It is also important to note that emergency lights are required to be equipped with a battery backup, however, these will need to be tested by a professional during an annual inspection.

Cleaning

In addition, detectors, notifiers and emergency lights should be cleaned at least quarterly to prevent dirt and dust build-up and obstructions moved out of the way. This will help ensure the quickest detection and warning in case of a fire. Be sure to use only a soft cloth and light pressure when cleaning to avoid damaging your equipment. Dampen the cloth with warm water when needed.

Follow up

Lastly, confirm that fire departments and your monitoring company are properly receiving notifications when your fire alarm system is being tested. After you’ve completed these steps, schedule work as needed with the fire protection professionals at A P Fire Protection for further testing and troubleshooting, maintenance and repairs to ensure sensors and wiring are all functioning correctly. 

Butterfly Valves on a Fire Riser

Fire Sprinkler Systems

Visual Inspection

NFPA 25 provides the criteria for the routine activities that must be conducted to ensure that water-based fire protection systems, such as automatic sprinklers systems, can be relied upon in the event of a fire. It also outlines the required areas for visual inspections on sprinkler systems as valves, backflows, gauges, standpipes, fire pumps and sprinklers. During your monthly inspection you should be looking for:

Corrosion on Sprinkler System
  • • Leakage
  • • Corrosion detrimental to sprinkler performance
  • • Physical damage
  • • Loss of fluid in the glass bulb heat-responsive element
  • • Loading (dust and other environmental debris) detrimental to sprinkler performance 
  • • Paint other than that applied by the sprinkler manufacturer
  • • Sprinklers installed in the incorrect orientation
  • • Minimum clearance to storage is maintained 

Any signs of physical damage or noncompliance could affect the effectiveness of your system. Monthly visual inspections should be carried out on all parts of the system you can access and/or see from the floor. This means that typically there should be no special equipment needed for these routine inspections such as ladders or lifts. Furthermore, NFPA 25 clearly states that sprinklers located in concealed spaces such as above suspended ceilings do not require inspection though any sprinklers that cannot be accessed for inspection should be noted on inspection reports. On the other hand, make sure escutcheons (sprinkler covers) are flush to the ceiling (they serve a purpose beyond looking pretty!). 

Cleaning

In most instances, loading on fire sprinkler components can be cleaned using a dry soft cloth or one dampened by warm water. Nonetheless, you may want to leave this step to the professionals as sprinkler head bulbs can be easily damaged when appropriate care is not taken.

Kitchen Hood Nozzles with Caps Removed

Kitchen Hoods

Visual Inspection

Kitchen fire suppression system inspections are vital to safety. In any size kitchen, the restaurant hood fire suppression systems acquire a grease and grime build-up. This build-up, when not cleaned regularly, will eventually clog the nozzles meant to disperse wet chemicals over the source of a stove, fryer, or grill fire to put the fire out. This causes a serious fire hazard in commercial kitchens. During your visual inspection, make sure caps are in place, check system pressure and note any build up on nozzles and hood filters. You should also verify that no appliances have moved or changed positions, as the nozzles installed are designed for use over specific appliances and determined area. Depending on use, you may need to perform a weekly visual inspection.

Maintenance & Cleaning

Likewise, maintenance and cleaning schedules are also determined by frequency of use; every six months is typical for most facilities, every three months for heavy use, annually for low use (e.g., event spaces, seasonal facilities, etc.). APFP does not provide cleaning services for kitchen hoods, but we do provide other maintenance services. Cooking equipment is the leading cause of fires, accounting for three out of five structure fires.

Different Use Fire Extinguishers

Fire Extinguishers

OSHA regulations mandate that commercial businesses must inspect their portable fire extinguishers monthly. Sometimes referred to as a visual inspection, monthly inspections can be executed by employees who have received proper training. Every month, you should complete a visual check of your fire extinguishers to make sure that they are still functional in the following areas – 

Location & Accessibility

Example: Fire Extinguisher Signage

All portable fire extinguishers should be unobstructed, easy to see, and easy to reach. If the extinguisher is blocked or unreachable, any obstructions should be moved or the extinguisher itself should be relocated where it will be more accessible. 

Gauge Pressure Reading

A disposable fire extinguisher has a plastic head with a gauge that reads “full” or “empty”. Rechargeable extinguishers have a metal head with a gauge that shows the level of charge.

For a rechargeable extinguisher, the needle of the pressure gauge should be pointing to the green indicator, known as the operating zone. If the needle is below the operating zone, the extinguisher has lost pressure and needs to be recharged by a professional. If the needle is above the operating zone, it has too much pressure and is at risk of a leak or a cylinder failure (read: explosion). Call us right away if the pressure gauge is outside of the operating zone in either direction for service.

Fire Extinguisher Gauge Reading Low Pressure

Inspection Tag

Extinguisher Inspection Tag – Front & Back

Check the inspection tag to see when the last annual inspection took place. If your inspection date is getting close, make a note to call and schedule this year’s maintenance and inspection. If there is no tag, the extinguisher should be inspected to avoid any issues. After your inspection is complete, our technician will attach an updated inspection tag punched with the month, year, the type of extinguisher and the service performed.

Finally, the exterior of the extinguisher needs to be checked thoroughly for damage or corrosion. Check that the instruction label is present and easy to read. The serial number should also be legible. Look for dents and punctures, as well as paint removal and rust. The hose should be unobstructed, securely fastened to the side of the extinguisher and free of cracks or other damage. Tamper seals are required and indicate if anyone has attempted to use or discharge the unit. Tamper seals are placed around the locking pin and secured around the handle. They may look similar to a zip tie, but they break easily with a little bit of force. You cannot secure an extinguisher with a zip tie!  If any extinguishers are damaged or tampered with, have them inspected immediately.

Document Your Findings

Most inspection tags provided space to record monthly inspections. Sign your name or initials and date of inspection to confirm that it has been done. After you’ve completed your inspection and signed off, write a report detailing any issues and whether any actions have been taken to remedy them. Your report should include your name, date, and location of the extinguisher that needs service.

Example: Egress Map

Egress & Evacuation

OSHA strongly recommends (and in some cases requires) businesses to have an emergency action plan in place. EAPs designate roles and responsibilities to employees during emergencies, and are designed to help organizations facilitate safe evacuations.  If you have more than 10 employees your plan must be written, kept in the workplace, and available for employee review. In certain instances OSHA standard also requires that an egress map be posted throughout your facility,

If an evacuation from your building is required due to an emergency such as a fire alarm, gas leak, natural disaster or any other reason, occupants should always remember to stay calm, do not rush, and do not panic. The best way to achieve this is to practice. Fire alarm drills should be implemented on at least a monthly basis. 

Furthermore, it is recommended that each department/business unit in a building identify a few department members who will act as evacuation coordinators. These evacuation coordinators should:

  • • Assist other department members, including those needing assistance, in evacuating the building, including – if safe to do so – checking restrooms as they are exiting; and
  • • Be able to do a “head-count” of evacuated personnel and identify to Emergency Personnel any individuals who do not appear to be present at the evacuation assembly area.

In addition, it is important that all employees be aware of the locations of alternate exits and keep exit routes free and clear of obstructions. Each egress map should designate two assembly areas that are at least 500 feet away from the building where employees and others should assemble upon evacuation as a “Main Assembly Area” and an “Alternate Assembly Area”, in the event the Main Area cannot be used. 

Preventing Fire Damage with a monthly inspection

You can prevent fire damage, injury and death with these maintenance tips. Contact A P Fire Protection to discuss these services. A representative will work with you to schedule services to meet the code requirements, the requirements of the local authority having jurisdiction (AHJ), and your facilities’ particular needs. 

If your business has been damaged by fire or smoke, contact APFP for reliable service to replace damaged or deployed fire protection units. Our emergency response technician can be reached 24/7 at 623-772-5344 and we can be onsite within two hours to help mitigate any damage and work towards a smooth recovery.

Whether you own a business or manage a building, maintaining the safety of employees, clients and all other occupants is paramount. Having a network of fire detection and prevention equipment is key, but they must work properly in order to do so. Make a monthly check-in with your fire prevention systems a to-do and be one step ahead when disaster strikes.

Fire Extinguisher with APFP Tag

Fire Extinguishers: Lifecycle & Expiration

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Fire Extinguisher Expiration

Fire extinguishers don’t last forever, and while all fire extinguishers do expire at some point, there is not always a set expiration date. As your first line of defense during a fire, it is important that your extinguishers are functional and well maintained.

How Long Do Fire Extinguishers Last?

Do fire extinguishers expire? All fire extinguishers should be installed, inspected and maintained in accordance with the National Fire Protection Association standard titled “Portable Fire Extinguishers“, NFPA-10 and the requirements of local authorities having jurisdiction.

Fire Extinguisher Manufacture Date

The lifespan of a fire extinguisher varies based on a few factors including:

  • Type of fire extinguisher
  • Whether the extinguisher is disposable or rechargeable
  • How well the extinguisher is maintained
  • The date it was manufactured
  • Manufacturer recommendations

When to Replace Your Fire Extinguisher

According to NFPA standards, disposable fire extinguishers need to be replaced every 12 years and rechargeable fire extinguishers must be recharged every 6 years. 

Some manufacturers set recommended expiration dates for their fire extinguishers. However, there are many extinguishers without expiration dates which can make it hard to tell when it should be replaced. 

In short, fire extinguishers expire. Certain types of fire extinguishers are now considered obsolete as regulations change or technology advances. NFPA guidelines dictate which types of extinguishers should be removed from service. If you have an older fire extinguisher, one of our experienced technicians can help you to determine whether it needs to be replaced.

Do Fire Extinguishers Expire?

Monthly Extinguisher Inspection

Occupational Safety and Health Administration (OSHA) regulations mandate that commercial businesses must inspect their portable fire extinguishers monthly. Sometimes referred to as a visual inspection, monthly inspections can be executed by employees who have received proper training. Every month, you should complete a visual check of your fire extinguishers to make sure that they are still functional in the following areas – 

Location & Accessibility

All portable fire extinguishers should be unobstructed, easy to see, and easy to reach. If the extinguisher is blocked or unreachable, any obstructions should be moved or the extinguisher itself should be relocated where it will be more accessible. 

Low Pressure Fire Extinguisher Gage: Do Fire Extinguishers Expire
Low Pressure Gauge Reading

Gauge Pressure Reading

A disposable fire extinguisher has a plastic head with a gauge that reads “full” or “empty”. Rechargeable extinguishers have a metal head with a gauge that shows the level of charge.

For a rechargeable extinguisher, the needle of the pressure gauge should be pointing to the green indicator, known as the operating zone. If the needle is below the operating zone, the extinguisher has lost pressure and needs to be recharged by a professional. If the needle is above the operating zone, it has too much pressure and is at risk of a leak or a cylinder failure (read: explosion). Call us right away if the pressure gauge is outside of the operating zone in either direction for service.

Inspection Tag: Do Fire Extinguishers Expire
Inspection Tag Example: Front and Back

Inspection Tag

Check the inspection tag to see when the last annual inspection took place. If your inspection date is getting close, make a note to call and schedule this year’s maintenance and inspection. If there is no tag, the extinguisher should be inspected to avoid any issues. After your inspection is complete, our technician will attach an updated inspection tag punched with the month, year, the type of extinguisher and the service performed.

Corrosion: Do Fire Extinguishers Expire
Corroded Fire Extinguisher

Visual Damage

Additionally, the exterior of the extinguisher needs to be checked thoroughly for damage or corrosion. Check that the instruction label is present and easy to read. The serial number should also be legible. Look for dents and punctures, as well as paint removal and rust. The hose should be unobstructed, securely fastened to the side of the extinguisher and free of cracks or other damage. Tamper seals are required and indicate if anyone has attempted to use or discharge the unit. Tamper seals are placed around the locking pin and secured around the handle. They may look similar to a zip tie, but they break easily with a little bit of force. You cannot secure an extinguisher with a zip tie!  If any extinguishers are damaged or tampered with, have them inspected immediately.

Document Your Findings

Finally, most inspection tags provided space to record monthly inspections; sign your name or initials and date of inspection to confirm that it has been done. After you’ve completed your inspection and signed off, write a report detailing any issues and whether any actions have been taken to remedy them. Your report should include your name, date, and location of the extinguisher that needs service.

Internal Fire Extinguisher Components: Do Fire Extinguishers Expire
Internal Extinguisher Components

Regular Maintenance 

Regular inspections, testing, and maintenance according to NFPA and manufacturer recommendations can help to extend the lifespan of your fire extinguishers. Hiring the experienced professionals at A P Fire can help to keep your extinguishers functional and code compliant. 

Annual Inspections

Fire Extinguisher Inspection
Annual Inspection

While on site, our annual inspection of fire extinguishers shall include a check of at least the following items: 

1. Location in designated place. 

2. No obstruction to access or visibility. 

3. Pressure gauge reading or indicator in the operable range or position. 

4. Fullness determined by weighing or hefting for self-expelling-type extinguishers, Cartridge-operated extinguishers, and pump tanks. 

5. Operating instructions on nameplate and facing outward. 

6. Safety seals and tamper indicators not broken or missing. 

7. Examination for obvious physical damage, corrosion, leakage, or clogged nozzle

Maintenance on Expired Fire Extinguishers

Six & Twelve Year Maintenance

Every six years, additional testing is required to ensure your extinguisher is in optimal operating condition. At this stage of maintenance, the unit must be completely dismantled so inspections can be completed on all internal components including a check of at least the following items:

1. Discharge chemical and pressure into a “closed” dry chemical recovery system making sure that the extinguisher is completely empty and depressurized. 

2. Clean extinguisher to remove dirt, grease or foreign material. Check to make sure that the instruction nameplate is securely fastened and legible. Inspect the cylinder for corrosion, abrasion, dents or weld damage. 

3. Inspect the extinguisher for damaged, missing or substitute parts. Only factory replacement parts are approved for use. 

4. Check the date of manufacture on the extinguisher label.

5. (12 year only) Hydrostatically test to factory test pressure marked on the label, using the proof pressure method, in accordance with CGA C-1 and NFPA 10. 

6. Visually inspect the pressure gauge – if bent, damaged or improper type or pressure – replace. 

7. Check ring pin for freedom of movement. Replace if bent or if removal appears difficult. 

8. Inspect discharge lever for any dirt or corrosion which might impair freedom of movement. Inspect carrying handle for proper installation. If lever, handle or rivets are damaged, replace. 

9. Remove nozzle or hose and horn assembly and visually inspect threads on nozzle or hose coupling, horn and hose for damage, and replace as necessary. Blow air through nozzle or hose and horn to ensure passage is clear of foreign material. 

10. Inspect the valve assembly for corrosion or damage to nozzle or hose thread connection. Replace valve assembly or component parts as necessary. 

11. Remove and disassemble valve assembly by removing downtube, spring and valve stem assembly. Install a new valve stem and collar o-ring after lightly lubricating. 

 12. Recharge the extinguisher.

13. Complete maintenance by issuing a new inspection tag and service collar.

We perform annual inspections, six year maintenance, twelve year hydrostatic testing and we will recharge your extinguisher in the event it has been discharged. As of 2022, we are distributors for Amerex and Badger brand extinguishers. We service school districts, healthcare facilities, municipalities and other commercial buildings. If you have a small business or home extinguisher, we also accept walk-ins at our office location. In the end, there is no hard and fast rule of when fire extinguishers expire. If you are worried about your fire extinguishers expiring and would like to request service for your fire extinguishers, contact us!

Fire Extinguisher Service request
A P Fire Protection Extinguisher

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