Standards FAQ Details | Joint Commission
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Sunday 11:44 CST, March 18, 2018

Standards FAQ Details


Fire Extinguishment Systems - Testing and Cleaning
Modify | April 11, 2016
What is the requirement for testing kitchen automatic fire extinguishing systems and cleaning requirements?

The Joint Commission has no specific checklist for semi-annual inspection tasks for these systems. Criteria is found in NFPA 96-2011 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 fusible link replacement. The organization must also be able to demonstrate on-going compliance with required system design components described in LS.02.01.35, which includes proper portable fire extinguishers in the vicinity, proper grease removal devices, fire alarm system activation, deactivation of the cooking fuel source and proper operation of the exhaust system. Note that NFPA 101-2012 allows for no activation of the building fire alarm system by the commercial cooking equipment extinguishing system when the kitchen is fully sprinkler protected. Guidance for cleaning can be found in NFPA 96-2011, but The Joint Commission has no specific standard that requires exact compliance. The organization is required to have a strategy in place for cleaning based upon an assessment of manufacturer's requirements, risk levels and hospital experience as described in EC.02.05.01.

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