Healthcare Facility Fire Protection Requirements

By Jackie Berens

Healthcare Facility Fire Protection Requirements

This isn’t Grey’s Anatomy- Avoid the unnecessary drama and ensure you have proper fire protection in place

Paging Dr. Grey. Code Red. A fire has broken out in Grey-Sloan Hospital and all the patients and doctors are at risk. We know… you’re glued to your television. This is some intense drama. While yes, a fire in a hospital makes for a drama-filled, intense episode of Grey’s Anatomy, we don’t want that to become a reality for your healthcare facility. 

Healthcare facilities have greater requirements than most other facilities because they are governed by the Joint Commission. Because of these stringent requirements, hospitals need to be better equipped to withstand a sudden fire. You all hold lives in your hands every day and documentation is critical in your facilities to validate that you are upholding critical safety measures required by governing agencies such as NFPA and Joint Commission. 

Here are a few of the requirements needed for your healthcare facility.

Compartmentation in medical facilities

Compartmentation typically utilizes a passive fire protection system that prevents or slows the spread of fire by blocking it off. Fire-resistant walls, doors, and corridors should be in place to protect patient rooms, operating areas, special hazard space, and egress paths. 

Fire Sprinklers

Sprinkler systems must be installed throughout healthcare occupancies. These systems must be inspected, tested, and maintained regularly. Major components should be inspected quarterly, semi-annually, and annually. Each of these inspections requires specific components to be maintained. 

Fire extinguishers and special hazard fire suppression systems

Any facility with a commercial kitchen or cooking facility requires hood and fire suppression systems to ensure fires don’t spread throughout the rest of the building. Fire extinguishers must be selected, placed, inspected, tested, and maintained following NFPA 10.

Kitchen hood and fire suppression systems

Any commercial kitchen and cooking facilities in a medical facility must be protected with a hood and fire suppression system, which requires semi-annual inspections, testing, and maintenance. Additionally, the filters and exhaust ductwork that make up the hood system require regular cleaning—the frequency of which is based on the amount of grease that is used in the cooking process. These specific requirements are outlined in NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

Fire Alarm Systems

NFPA requires a fire alarm system throughout the facility. NFPA 72: National Fire Alarm and Signaling Code, outlines the installation and ITM requirements for these systems. A facility manager should understand the basic operation of fire alarms and what the various signals may mean. Quarterly, semi-annual, and annual system inspection, testing, and maintenance are required, and diligent records must be maintained of all ITM work and results.

Generator and alternate power sources

A facility, like a hospital, with alternate sources of power, connected to distribution systems and ancillary equipment require specific fire safety protocols. Depending on your risk category your EES (Essential Electrical System) may change. Category 1 Requires Type 1 EES, Category 2 can use either Type 1 or Type 2 EES, Category 3 and 4 do not require and EES.

Emergency evacuation plans

In a healthcare facility, your emergency planning must be communicated often and well-thought-out. Quarterly evacuation drills are required for each shift, and records must be diligently kept. General housekeeping of keeping egress paths clear, “no smoking” policies, decorated hallways and patient rooms should be fire-resistant, and soiled lines and trash should be regularly emptied is essential to communicate to your team. 

With all these requirements, it’s important to understand exactly what you need to do in order to keep your building safe from harm. Here are a few items on your checklist you need to go over.

Fire protection operations:

  • First and foremost, make sure your hazard emergency plans are in place and are well-thought-out for your specific building. Healthcare facilities must maintain emergency and evacuation plans, and employees must be regularly trained on these plans and their roles within them. Emergency plans should include instructions for fire emergencies and general building evacuations.
  • Once you have found your plan, make sure all employees are trained regularly, and that training is documented. Quarterly evacuation drills are required for each shift, and records of these drills must be maintained. Additionally, hospital staff should be aware of and sustain general housekeeping standards. These activities include maintaining clear access to exits, enforcing “no smoking” policies, making sure decorations in halls and patient rooms are fire resistant and do not exceed allowed limits, and ensuring soiled linens and trash are regularly emptied and not permitted to accumulate beyond allowed maximums (0.5 gallons per room, 32 gallons total in a protected area).
  • Make sure you conduct fire drills quarterly, and these drills are documented.
  • Are your “non-smoking” areas in place and enforced?

Fire Sprinkler Systems:

  • Fire sprinklers must be installed throughout healthcare occupancies. These systems are installed following NFPA 13: Standard for the Installation of Sprinkler Systems, and they are maintained according to NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
  • NFPA 25 outlines the required inspection, testing, and maintenance (ITM) frequency and procedures. Major system components are required to be inspected quarterly, semi-annually, and annually. At each of these intervals, specific items must be maintained and tested. There are also weekly and monthly inspection requirements for items that must only be visually inspected—these components include gauges, valves, private hydrants, and fire pumps.
  • Monthly inspections of your fire sprinkler systems must be conducted and documented.
  • Quarterly, semi-annual, and annual inspection, testing, and maintenance should be conducted and documented. 
  • Five-year inspection, testing, and maintenance should be conducted and documented (if applicable)
  • Your fire hose should be tested and the testing should be documented.

Fire Pumps:

  • Pump runs should be conducted and documented on a weekly or monthly basis depending on type.
  • Annual pump testing should be conducted and documented.

Fire Alarm Systems

  • Quarterly, semi-annual, and annual inspection, testing, and maintenance should be conducted and documented.

Fire Suppression Systems:

  • The kitchen hood and ductwork should be cleaned regularly depending on your building (quarterly, semi-annually, or annually) and documented.
  • Your kitchen suppression system should be inspected, tested, and maintained semi-annually and the services should be documented. 

Fire Extinguishers 

  • Monthly inspections of your fire extinguishers must be conducted and documented. 
  • Annual inspections by a licensed fire protection professional must be conducted and documented. Any deficiencies found from that inspection must be corrected and fire extinguishers must be certified. Inspection reports and repairs must be documented.
How to Keep your Commercial Kitchen Safe Even During COVID

By Jackie Berens

How to Keep your Commercial Kitchen Safe Even During COVID

UberEats is still a thing… how to keep your commercial kitchen safe even during COVID 

Though COVID may have your indoor dining capabilities on hold, the risk of kitchen fires remains. With DoorDash, Postmates, UberEats, and other take-out and delivery services, your kitchen can still be up and running! With cooking equipment being the leading cause of fires, with 61% of incidents, it’s important your kitchen remains safe with the proper equipment in place.

While fire may be essential to your kitchen’s functionality, it’s important that you don’t let that fire let loose on your personnel. Here are a few ways you can protect your kitchen today:

Ensure your cooking equipment is maintained. 

The majority of restaurant fires are due to cooking equipment. Ensure your equipment is in proper working condition and is fitted with suppression systems. Suppression systems can be extremely beneficial, as they shut down gas and electrical when a fire occurs. 

The suppression system’s ability to shut down gas and electricity can be the difference between a flare-up and a devastating fire. It’s important as a business owner to have their fire suppression systems inspected by professionals. 

Provide training for your employees.

Be sure your kitchen staff is informed on the proper fire safety and protocols in place to protect their wellbeing. In a kitchen, there are various types of fires that can occur, be sure your employees know how to handle each fire with care. 

In kitchens, grease fires are common, meaning your employees need to know what to do and what not to do during a grease fire. The nature of grease fires causes a reaction with fire, therefore the flames spread higher and can cause more injury. The best way to handle a grease fire is to smother it, if it can be done safely. 

Another aspect of training that is essential is how to prevent fires before they occur. In order for the kitchen staff to perform their duties in a safe way, they must maintain good practices within the kitchen. 

Ensure you have a proper escape plan in place

Illustrating an escape plan that puts your people out of harm’s way should be a top priority. When a fire grows uncontrollably, your employees need to get out. It should be designed to avoid a crowd of people, and ensure no injury is caused to all those leaving the restaurant. 

Clean up grease

Cleaning your kitchen is an essential part of fire safety for your business. Grease is extremely flammable and extremely dangerous as we mentioned above. When fires get out of control, it looks for a source of combustible energy… aka grease. It literally acts as fuel to the fire. Make sure your team has a thorough and regular cleaning schedule that includes cleaning off all built-up grease from surfaces.

One important place your team needs to clean grease is the ventilation system. This system is one of the most volatile and can multiply the effect of the fire. The ventilation serves as a trap for grease, smoke, and particles that are extremely combustible. Per the NFPA fire code, the hood, fan, and ductwork should be inspected and cleaned regularly. 

Be sure your sprinkler system works effectively.

Your kitchen’s sprinkler system will kick in when a fire gets large enough to activate sprinkler systems. These systems are triggered by smoke from the fire, so it is essential they are working properly. 

While fire sprinkler systems are the last defense against an out of control kitchen fire, they can be extremely effective in saving your building. All employees should be out of the kitchen at the point the sprinklers can be the difference between a burned kitchen and a burned down restaurant. 

Have extinguishers… and then have backup extinguishers

Fast-acting crew members are sometimes needed to help douse the flames and extinguish the fire. Ensure your fire extinguishers are clearly marked and in an accessible area for your team members. These extinguishers need to be inspected regularly by both your building manager as well as an expert inspector. 

Be sure all flammable material is away from flames

As we stated above, fire needs fuel. Once it begins to grow, it will continue if given the proper fuel. Within a kitchen, a fire can get out of control by being close to flammable materials that shouldn’t be close to the flames.

Flammable materials that may cause harm are items like food, clothing, paper, or towels. If your kitchen remains organized, you should be in good shape to prevent potential fires. 

Lastly, watch electrical cords within the kitchen area

Electrical equipment causes a large amount of fires, both within the kitchen and outside the kitchen. Within the kitchen, there are a lot of electrical appliances. When simultaneously running appliances, your restaurant’s electrical system can be burdened, leading to a fire.

Over time, electrical cables can fray and melt. Poorly designed outlets can become damaged. These damages can cause the equipment to malfunction. Inform your employees to look out for obvious damage and report it to management right away. 

At VFS, we understand how important your fire safety systems are to the wellbeing of your employees and the survival of your building. Because of this, we implement the specific fire and security systems needed for your unique building. 

We also provide inspections, testing, and maintenance of fire sprinkler and fire alarm systems, All inspections are conducted by VFS trained personnel as outlined by the requirements of the NFPA and local codes. 

Following every inspection, our staff will submit a report listing any changes or corrections that need to be made in order to ensure continued compliance. Your success is our success. We want to make sure your people and buildings remain safe. Contact us today to learn more! 

Your 2021 Fire protection checklist

By Jackie Berens

Your 2021 Fire Protection Checklist

It’s a new year… you’ve already skipped the gym don’t skip on your fire protection. Here’s a checklist to help

We’re four days into the new year, if you haven’t already ditched your resolutions, you’re amazing. We’re not going to lie… we snuck a piece of chocolate cake after dinner last night. While a piece of chocolate cake, or a day off of the gym won’t seriously harm your wellbeing, there is one resolution you can’t forget about- fire protection for your building.

This year, it’s time to make fire protection a top priority. That being said, we’ve come up with a few items that should be on the top of your mind if you’re committed to fire safety. 

First, ensure your building has a clear path of egress/ exit. 

Identifying the ‘means of egress’ from your building is essential to keeping your employees safe from harm. Properly designed exits provide a safe path of escape from a fire or other emergency environments. The design of the exit should permit all occupants to reach a safe place before they are endangered by fire, smoke, or heat. The goal of an effective means of egress is to get everyone out of hazardous areas in the shortest amount of time possible.

A few components make up the means of egress, including exit access, exit, and exit discharge.

  • Exit access is the travel path or area between where a person is located and an exit.
  • Exit is the portion of the means of egress that is separated by construction or equipment from other areas of the building. Components of an exit include walls, floors, doors, etc. An exit may include vertical or horizontal means of travel, like stairways, ramps, and passageways. It is important to note that elevators are not accepted as exits!
  • Exit discharge is the portion of a means of egress between the end of the exit and a public way or other safe places.

As a building manager or owner, it is important that you self-inspect these means of egress. In doing this, you need to make sure each component is easily identifiable, visible, accessible, and unobstructed. The door must operate in the direction of the exit so people won’t be trapped inside. 

Next, check your electrical wiring and power cords.

NFPA 70: National Electrical Code (NEC) ensures all wiring and electrical installations comply with regulations. Building owners and managers do not need to be an expert in electrical code, however there are a few things you should be on the lookout for to be cautious!

The first thing you should do to ensure your electrical wiring is safe is to ensure all electrical boxes, switches, and outlets have their covers in place. Also, be sure to check that extension cords are in good condition and free of any cuts or splices. Extension cords should never be a substitute for permanent wiring, they are only permitted to be used with temporary equipment. 

Surge protectors must be connected directly to an outlet and, like extension cords, cannot be attached to the structure, extend through walls or the ceilings, be run under doors, or be covered by floor coverings.

The last item to check in the electrical wiring category is electrical panel boxes. Electrical panel boxes and main building disconnect must be identified and accessible for fire department personnel. All panels and breakers must be labeled and open spaces should have proper covers in place. 

Good housekeeping is essential– no we’re not talking about dusting and mopping. 

In the ‘fire safety’ sense, housekeeping refers to the general condition of the building and the items stored within it. Be sure you properly dispose of flammables, combustibles, trash, and debris, and ensure these items do not accumulate. Flammables and combustible liquids must be stored in approved containers and cabinets and should be clearly labeled to avoid accidental ignition. 

Electrical, boiler and HVAC rooms cannot be used for storage and must remain clear of items that are not essential to the operation of the equipment within them. 

Ensure fire sprinkler systems run effectively in between inspections

Fire sprinkler systems must meet NFPA 25: Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems requirements. These standards require that different parts of the sprinkler systems receive inspections in quarterly, semi-annual, annual, and five-year intervals. 

The inspections are performed by the fire protection contractors and other qualified personnel. As a building owner or manager, you do not have to directly handle any of the actual inspections. However, as a building owner, there are a few things you can do to ensure these inspections run efficiently and effectively, starting with scheduling the inspection appointments when due!

Once you receive an inspection, you must maintain the report and other documentation, as well as ensure all problems found are repaired as soon as possible. 

A building owner or manager can utilize a simple visual inspection to ensure these systems run effectively between inspections. First, ensure that no items are stored within 18” of any sprinkler head. Next, ensure all sprinkler heads are free of paint and corrosion and nothing is attached to them. If you come across violations of these requirements during your visual inspections, the issues should be reported and remedied immediately. 

Fire alarm maintenance and inspections

Under NFPA 72: National Fire Alarm and Signaling Code all fire alarm systems must be inspected, tested, and maintained at semi-annual, annual, and even quarterly intervals. Like sprinkler systems, these inspections are done by trained and certified inspection personnel. Fire alarm system experts are trained in the inspection, maintenance, and testing of a particular brand of fire alarm systems. 

As a building owner, your responsibility is to maintain all reports and correct any deficiencies noted. Building owners and managers can also make sure the fire alarm panel is accessible, the location is labeled, and all documentation is maintained and available. Manual pull stations should be visible and accessible. All alerts should be reported to the alarm company so that any issues can be addressed quickly. 

Lastly, look at your fire extinguisher. 

NFPA 10: Standard for Portable Fire Extinguishers illustrates the requirements to select, place, test, and maintain fire extinguishers. A trained and certified expert must perform annual inspection and maintenance. Additionally, building owners are responsible for inspecting all extinguishers once a month.

The inspection requires that extinguishers are visible and accessible. They must also be free of rust, damage, and the gauge read in the “green” operation level. Additionally, all extinguishers must mount on the wall. The weight of the extinguisher determines the appropriate height of placement: 40 lbs or less may be installed at 5 feet above the floor. Any heavier should sit at a maximum height of 3 ½ feet. The base must be at least 4 inches above the floor. 

As you look to ensure your fire safety in your building for the new year, start by utilizing this checklist! Ensuring you remain prepared for the unexpected is the first step to ensuring the safety of your people and your building’s safety.

How Fire Protection Systems Can Help Your Business During the Holidays

By Jackie Berens

How Fire Protection Systems Can Help Your Business During the Holidays

It’s the week before Christmas, and all through the office, not a fire was burning… because of VFS

The last thing you want to deal with during the holiday season is an office fire or a security breach. Being around extended family is enough stress for all of us! With that being said, it’s important to have all the systems in place to keep your business safe while you’re not there. 

At VFS, we believe in protecting your business like it’s our own. We implement specific systems catered to your business’ needs. A few of the systems and processes we put in place include:

Fire Sprinklers

Our full-service in-house Design/Build departments and our in-house manufacturing shop work together to ensure the highest quality and most accurate results. We use state of the art hydraulic modeling software for our Fire Sprinkler Services. Some of our Fire Sprinkler Services include:

  • Commercial/Industrial and Retail New Construction sprinkler installation
  • Retrofit or Tenant Improvement 
  • Wet or Dry Pipe Systems
  • Special Hazards
  • In-Rack Sprinklers
  • Fire Pumps
  • Microbiologically Influenced Corrosion Testing and Remediation
  • Underground pipe repair
  • NFPA-25 Inspection, Testing and Maintenance
  • 24-hour Emergency Service
  •  Fire Alarm Design, Detection, and Monitoring


VFS offers our clients in-house design experts to develop solutions and meet your site-specific needs. Whether that means protecting your healthcare institution, your education facility, a distribution center, or a refinery, our experts are ready to help. With our alarm systems, we offer a few unique services:

  • Installation by trained and certified technicians
  • In-house design
  • Testing and mass-notification
  • Safety monitoring
  • 24-hour emergency service
  • Preventative maintenance

Security Systems

Taking proper security measures for your business, especially during the holidays, is essential to its safety. At VFS, we implement the proper security measures that address your specific business needs. These measures include:

  • Access control systems
  • Mass notification systems
  • Video surveillance
  • Intrusion alarm systems. 

We utilize the best combination of hardware and software to provide reliable, cost-effective, integrated solutions for your business’ needs. 

Special Hazard Protection 

We pride ourselves on our expertise in special hazard protection. As renowned leaders in Fire and Life Safety Systems for Special Hazard Facilities, we have a reputation to uphold! 

VFS is one of the few companies able to perform the highly technical and sophisticated projects surrounding special hazards. We provide design-build solutions from the concept and budgeting phase to the final construction and occupancy phase for facilities across all 50 states!

Our company pillars are built on safety and security in everything we do, so you have peace of mind that you’re entrusting your business in good hands. Our CEO, Randy Nelson sits on the technical committees for NFPA 16 (code standard for the installation of foam-water sprinkler). Needless to say, we’re prepared to provide your business with the best possible solutions.

Ongoing Inspections

We utilize state-of-the-art technology to keep inspections simple for our clients. We give you a one-stop-shop to manage all your inspection requirements, whether that be for your single facility or your nationwide portfolio of properties. 

Emergency Response Communication Systems (ERRCS)

VFS Fire & Security Systems is an FCC licensed hold contractor, which is required for the installation of ERRCS. Our experts are prepared to design, furnish, and install the systems that your specific building requires. The ERRCS signal enhancement systems include indoor antennas, coaxial cables, DAS headend (booster amplifier), outside coax cable, outside directional antenna, and vertical 2-hour rated enclosures. 

The holiday season brings about a lot of stress for most people. At VFS, we want to eliminate the stress surrounding your building’s safety and security. Contact us today to implement proper systems and processes today.

Healthcare Facility Fire Protection Requirements
Healthcare Facility Fire Protection Requirements
How to Keep your Commercial Kitchen Safe Even During COVID
How to Keep your Commercial Kitchen Safe Even During COVID
Your 2021 Fire protection checklist
Your 2021 Fire Protection Checklist
How Fire Protection Systems Can Help Your Business During the Holidays
How Fire Protection Systems Can Help Your Business During the Holidays