February 16, 2021 | | Comments 3
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Are you transmitting? Late night fire drills and alarm signals…

I think we can safely say that sometimes it is tough to pinpoint specifics when it comes down to what performance elements are cited during regulatory surveys, be they virtual or actual. In this regard, I really couldn’t say to what extent this particular item is being cited, but I know that it happens and often that happening results in some level of consternation of the “How am I supposed to do that?” variety.

The Life Safety Code® (LSC) NFPA 101-2012 requires that: “(f)ire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.” Section 19.7 (section, to be precise) goes on to indicate that “(w)hen drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.” I suspect that, over time, a lot of folks have ended up equating the transmission of a fire alarm signal and the use of a coded announcement as being equivalent, but that really isn’t the case. allows you to conduct a fire drill without disturbing patients, etc., but, as it turns out, you still have to include the transmission of the fire alarm signal (that’s the signal that actually “leaves” the building and goes to the central monitoring service, 911 call center, etc.). If you need further indication, I submit to you the “opinion” (or you could call it an interpretation) of one of our favorite AHJs. I think this gives you a good sense of the separation of what happen inside your facility versus making sure that pesky alarm signal finds its way outside.

But the question then becomes, how does one accomplish this if one has a fire alarm system that doesn’t provide an easy way of turning off the internal signals and still allowing for the transmission of the signal? This question bounced my way recently and I decided to do some poking around to see if there were any scholarly works, etc., and I came across some guidance published back in 2016 (the document is dated June 2016, so it would precede the official adoption of the 2012 LSC by CMS), that outlines some of the particulars of fire drills to be conducted in Minnesota.

One of the interesting elements is a note that deals with today’s discussion: “Note: When a coded announcement is used instead of audible alarms on the night shift, the fire alarm should be sounded first thing in the morning the following day to meet the requirement that each drill include ‘transmission of a fire alarm signal.’” Now I recognize that AHJ interpretations are many and varied (to an almost frightening degree), but I was wondering if anyone had been able to negotiate this type of process with their AHJ. It certainly makes sense to me that you could “extend” completion of the fire drill a few hours to ensure proper operation of the fire alarm system, but I also suspect that you’d probably be reticent to go that route without getting some sort of permission and you’d probably need to write it in to your policy or management plan as a standard practice or procedure, but it seems a rather elegant solution to me ( as a non-AHJ). What say you all?

Hoping this finds you well and staying safe; I figure every week brings us closer to whatever’s coming next, so let’s get there together!

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Filed Under: Life Safety Code


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Steve,
    We’ve had this discussion with our AHJ and he told us that as long as the fire alarm system was activated within 24 hours (prior to or after) of the fire drill, they would accept that as meeting the code. We document what time the fire drill was conducted and what time the system was actually activated. Not sure that every Fire Marshal would be ok with that, but wanted to relay what ours has told us. Thanks!

  2. We do a paper drill between 9PM an 6AM and sound our alarms first thing in the morning after the paper drill before 9AM looking for strobes and alarms and doors closing and we receive our report from our monitoring company that it connected.

  3. Due to a very strict Joint Commission Life Safety Surveyor, our night shift fire drills at a state psychiatric hospital abruptly changed from a longstanding simulated emergency scenario, to widely varying actual practices that luckily did not aggravate acute psychiatric patients committed per court orders. Having a nursing staff go find the nearest fire alarm and extinguisher and then verbally explain how to use them, was no longer sufficient, per that JC LS surveyor. Fire alarms had to get quickly key-activated, then immediately silenced, so that the strobe lights remained flashing while the alarm signal transmitted to the fire department via the central station monitoring service. Changing times. Two staff (clinical and non-clinical) had to grab the nearest, and next nearest, fire extinguishers and then take them outdoors to discharge on a nearby bush, representing extinguishing a patient bed fire, a staff breakroom microwave oven fire, etc.

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