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MHHS

MEMORIAL HERMANN (YOUR) HOSPITAL

POLICY AND PROCEDURE MANUAL

POLICY TITLE: Portable Fire Extinguishers
CATEGORY: Engineering Services
INDEX NUMBER: LS 307
ORIGINAL DATE:
LAST REVIEW DATE:
SUPERSEDES:

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1.PURPOSE

1.1To ensure that all portable fire extinguishers are available and ready for use at all times through a regular inspection, testing and maintenance program

2.APPLICABILITY OF STANDARDS

2.1This policy and procedure is based on, but not limited to the following codes and standards:

2.1.1National Fire Protection Association (NFPA)

2.1.2City of Houston or other Municipal Fire Code

2.1.3Joint Commission on the Accreditation of Healthcare Organization Environment of Care Standards

3.STATEMENT OF POLICY

3.1It shall be the policy of a Memorial Hermann Hospital System facility to conduct inspection, testing and maintenance of activities on portable fire extinguishers as outlined in this policy.

4.PROCEDURES

4.1General

4.1.1Portable fire extinguishers should be maintained in a fully charged and operable condition at all times.

4.1.2Fire extinguishers shall be conspicuously located where they will be readily accessible and available in the event of a fire.

4.1.3Fire extinguishers shall be mounted or kept in cabinets and furthermore shall not be obstructed or obscured from view.

4.2Selection of fire extinguishers

4.2.1All fire extinguishers shall be UL approved and tagged in accordance with applicable regulations.

4.3Inspection

4.3.1Portable fire extinguishers shall be visually inspected monthly by Facilities Engineering

4.3.2Visual inspection shall consist of, but not be limited to the following items:

4.3.2.1Location: in their designated place and visible;

4.3.2.2Operating instructions and nameplate facing outward;

4.3.2.3Seals or tamper indicators not broken or missing

4.3.2.4Any obvious physical damage, corrosion, leakage or clogged nozzle; and

4.3.2.5Pressure gauge reading or indicator in the operable range or position.

4.3.3When an inspection reveals any deficiency listed in Section 4.3.2, immediate corrective action shall be taken.

4.3.4All monthly inspections shall be marked on the tag provided on the extinguisher.

4.4Maintenance

4.4.1All fire extinguishers shall be subjected to prescribed maintenance annually by a state licensed service company.

4.4.2All extinguishers undergoing annual maintenance shall be tagged by the service representative and indicate the month, year, type of maintenance performed and the license number of the firm.

4.4.3All fire extinguishers shall be hydrostatically tested at intervals prescribed by NFPA and appropriate local regulations. This is performed by a licensed firm; see 4.4.2.

5.DEPARTMENT INTERFACE

5.1This policy and procedure applies to Facilities Engineering.

Revised: 06/07/04