In a June 2009 The Joint Commission Perspectives® article titled “Conducting the Fire Watch of Standard LS.01.02.01,” TJC clarified when a “fire watch” is required during both scheduled and unscheduled outages.
Background: Standard LS.01.02.01, EP1 states, “The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is ‘out of service’ more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. (For full text and any exceptions, refer to NFPA 101®-2000: 9.6.1.8 and 9.7.6.1).” See also Life Safety Code® Annex A.9.6.1.8 and A.9.7.6. At a minimum, TJC expects the organization to:
• Notify the fire department, fire marshal, or other appropriate emergency response group, and document when that notification occurs; and
• Conduct rounds of the area(s) affected by the outage, and document those rounds.
It is mandated that the fire watch be enforced until the fire alarm or sprinkler system has been returned to service, is stable, and is fully functioning.
Fire Watch Defined: Per the NFPA 101®-2000: Annex A.9.6.1.8, “A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.” The Health Care Interpretations Task Force (see NFPA website for HITF info) agreed in 1998 that the clinical staff in an area affected by a fire alarm or sprinkler system impairment could be used to satisfy the requirements for a fire watch, provided there would be adequate staffing to continuously patrol the affected area(s), and staff would have the means to make proper notification to building occupants in the event of a fire.
Per the aforementioned Perspectives article, a “scheduled activity” (planned) would be an event known to and under the control of the organization’s staff, e.g., a new installation or servicing or upgrading an existing fire alarm or sprinkler system. All other outages would typically be considered “unscheduled activities” (unplanned).
A table is provided in the June 2009 The Joint Commission Perspectives article defining “Out of Service” responsibilities, showing different service situations, whether a fire watch is required, and whether an interim life safety measure (ILSM) evaluation is required. It is intended only to provide guidance regarding the phrase “out of service.” Organizations still need to assess each outage or activity to determine the need for a fire watch and if ILSM procedures should be implemented per their written ILSM policies.
Out of Service Situations:
• Putting a shield over one smoke detector to prevent dust/false alarms for more than four hours - No fire watch required; ILSM evaluation recommended.
• Covering all smoke detectors during a “controlled” event, such as only during the time the contractors are working in an affected area, although after hours, the entire area is fully operational - No fire watch required; ILSM evaluation required.
• Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than four hours as part of a:
1. “Scheduled” event, e.g., working on, servicing, or upgrading the fire alarm or sprinkler system - Fire watch not required in all cases; ILSM evaluation required with emphasis on occupant notification.
2. “Unscheduled” event, e.g., shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than four hours in response to a system failure - Fire watch required; ILSM evaluation required.
Further clarification was provided recently by TJC’s senior engineer, George Mills, at a June 2009 NFPA conference in Chicago where George talked about “planned” vs. “unplanned” outages of the fire alarm or sprinkler system. He said that if the outage was planned and only covered one alarm zone at a time, a fire watch would probably not be needed. However, if the outage was not planned and resulted from an indeterminate cause, then it would be a good idea to set up a fire watch and appropriate ILSMs. George also suggested that your ILSM policy not be overly restrictive and be matched to the hazard(s) being addressed.
In order to ensure as safe an environment as possible during any potential outages of the fire alarm system or automatic sprinkler system, whether scheduled or unscheduled, planned or unplanned, it is imperative that the above listed criteria be followed. Failure to do so could result in an adverse accreditation decision of either Conditional Accreditation or Preliminary Denial of Accreditation per the 2009 “criticality model” of scoring and Accreditation Decision Rules.
For questions about conducting a fire watch, you may contact The Joint Commission’s Standards Interpretation Group (SIG) at 630-792-5900 or on-line at SIGInquiries@jointcommission.org.
