By Dean Samet, CHS
In the July 2010 Environment of Care News article Ensuring Effective Fire Alarm and Automatic Sprinkler Systems, The Joint Commission (TJC) reintroduced a manual method of fire alarm transmission policy. This policy is meant to be applied when the four traditional methods of transmitting fire alarm signals to the local fire department cannot be achieved per the 2000 NFPA 101, Life Safety Code® (LSC), Section 9.6.4 Emergency Forces Notification, which in turn references the 1999 NFPA 72, National Fire Alarm Code®.
The four traditional methods consist of:
1. Auxiliary alarm system: Direct connect to servicing fire department (NFPA 72-1999, Chapter16-6)
2. Central station connection: Managing of signals by contracted service (NFPA 72-1999, Chapter 5-2)
3. Proprietary system: Fire alarm systems that serve contiguous and noncontiguous properties under one ownership, with appropriately trained staff (NFPA 72-1999, Chapter 5-3)
4. Remote station connection: Alarm monitoring center that sends signals to the public fire service communications center (NFPA 72-1999, Ch. 5-4)
There may be times and circumstances where a direct-connect to the municipal fire department is not available. This is where TJC’s manual method of transmission may be a viable alternative. Such methods are allowed, with authority having jurisdiction (AHJ) approval, per the Exception to LSC Section 9.6.4.
The following detailed policy information is taken from the March 2008 The Joint Commission Perspectives®, Volume 28, No.3. Before using the TJC alternative manual method, the healthcare organizations must first demonstrate compliance with each of the following requirements:
1. Fire alarm signals must be received at a supervised location in the healthcare facility. Only a single, permanent, central location such as a telecommunications center or a safety/security office may be used. Multiple annunciator panels throughout the facility may also be used. However, the “official” alarm-receiving and -transmitting location must be a single, permanent location.
2. The supervised location must never be left unattended. No staffing requirement is stipulated, but at least one person must be present at all times. If personnel will be performing multiple job functions, it may be necessary to increase staffing. Responding to fire alarms must take precedence over all other assigned job functions.
3. The supervised location must be protected in the same manner as a “hazardous area,” referenced in NFPA 101-2000, Sections 18.3.2.1 and 19.3.2.1. This affords a basic level of protection to both the operators and the equipment at the supervised location. At a minimum, the supervised location must be in a totally enclosed room (or equivalent). If the room is not equipped with sprinklers, all walls, doors, and other penetrations into the room must have a one-hour, fire-resistance rating. If the room is equipped with sprinklers, the walls, doors, and other penetrations into the room may be unrated assemblies but must prevent the transmission of smoke into the room.
4. The supervised location must contain the appropriate equipment to receive fire alarm signals. The equipment may be either the master fire alarm control panel or an auxiliary annunciator panel. Annunciator panels must at least have the capacity to identify the location and type of alarm as the master fire alarm control panel. When a fire alarm signal is received at the supervised location, it must activate both a visual and audible signal at that location. The signal must be clearly distinguishable as the fire alarm signal and must be seen and heard above all other alarms or signals received at that location.
5. A log that records all status changes to the fire alarm system must be maintained in the supervised location. The log may be recorded either manually or with an automatic data recorder integrated with the fire alarm system.
6. Alarm signals received at the supervised location must be immediately transmitted to the fire department. At no time may a transmission of alarms be delayed while other personnel verify or investigate fire alarm signals. Fire alarm signals may be transmitted to the fire department via telephone, two-way radio, master (city) box, or any other means of communication acceptable to the local authority.
7. The supervised location must contain a master copy of the organization-wide fire plan and any other documents, equipment, or records necessary for the operators to implement, coordinate or direct activities related to a fire emergency response.
When each of the seven above-listed requirements is in place, an effective and reliable alternative method of transmitting fire alarm signals to the local fire department should be achievable. The Joint Commission requires that its accredited healthcare organizations be in full compliance with all local, state and federal fire codes and regulations. Organizations that wish to use the aforementioned TJC alternative method of transmitting their fire alarm signals should verify its acceptance with their local fire officials.
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