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Fire Extinguisher Inspections at Health Care Facilities
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by Stan Oman, NAFED Technical Training Manager

Tags and Documentation

The completion dates for each monthly inspection have to be documented. Some surveyors ask that the tag have the day, month, and year recorded. But, usually the surveyor allows the year to be omitted as long as the tag has the year pre-printed on it.

Other AHJs may not be as lenient. Many state agency surveyors for the Centers for Medicare and Medicaid Services (CMS) are asking to see month/day/year for every monthly and annual inspection (even if the tag has the year pre-printed) and a signature of the individual performing the service.

Many of us like to use a rubber stamp in lieu of the actual signature on the tag for the individual performing the annual maintenance on portable fire extinguishers. There are many state agency surveyors for CMS who do not accept the rubber stamp and want a signature of the individual performing the service on each tag (any service, not just fire extinguishers).

My advice is to discontinue using the rubber stamp and have the service technician sign the tags. This will avoid any potential disagreement. Each individual surveyor could have a different point of view.

Monthly Inspections

Who at the health care facility is carrying out the monthly inspection? There are differences between the monthly inspection and the annual maintenance. Whoever is doing the inspection, do they know what they need to do when carrying it out? Do they carry it out at the same time every month? Do they know what to check?

According to NFPA 10, 2010 edition, section 7.2.2, a monthly inspection should confirm the following:
  1. Located in designated place
  2. No obstruction to access or visibility
  3. Pressure gauge reading or indicator in the operable range
  4. Fullness as determined by weighing or hefting for self-expelling type extinguishers, cartridge-operated extinguishers, and pump tanks
  5. Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
  6. Indicator for non-rechargeable extinguishers using push-to-test pressure indicators
Is it possible that the person conducting the annual maintenance can also do the first monthly inspection? Yes, but that would have to be documented. Typically it would be documented on the tag on the fire extinguisher. The surveyor could say if it was not documented then it did not happen.

In addition, the Joint Commission’s standard EC.02.03.05, EP 15 requirement reads:
  At least monthly, the hospital inspects portable fire extinguishers. The results and completion dates are documented.
  Note 1: There are many ways to document the inspections, such as using bar-coding equipment, using check marks on a tag, or using an inventory.
  Note 2: Inspections involve a visual check to determine correct type of and clear and unobstructed access to a fire extinguisher, in addition to a check for broken parts and full charge.
  Note 3: For additional guidance on inspection of fire extinguishers, see NFPA 10-2010 7.2.2; 7.2.4.


Copyright NAFED 2017. Do not reuse without permission.

See also:
So You Want to Service Health Care Facilities
Health Care Facilities and NFPA Standards: What’s New
more Calendar

8/29/2017
Fire Extinguisher Training Seminar

8/30/2017
Pre-Engineered Systems Seminar

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