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Fire Extinguishment Systems - Testing and Cleaning

What is the requirement for testing kitchen automatic fire extinguishing systems and cleaning requirements?

Any examples are for illustrative purposes only.

The Joint Commission references the 2011 edition of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, where all actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. This includes annual replacement of the fusible link.

The Joint Commission is not prescriptive for the procedures to be used to clean and maintain kitchen extinguishing systems. The organization is expected to have a plan in place for cleaning based upon the manufacturer's instructions for use.

The organization must also be able to demonstrate on-going compliance with required system design components described in LS.02.01.35 that include:
  • portable fire extinguishers in the vicinity
  • grease removal devices
  • fire alarm system activation
  • deactivation of the cooking fuel source
  • proper operation of the exhaust system
Manual: Hospital and Hospital Clinics
Chapter: Environment of Care EC
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on May 09, 2023 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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