Memorial Hermann Hospital System

Memorial Hermann Hospital System Facilities Engineering/Environment of Care Committee Tasks Environment of Care Compliance Matrices

Life Safety Management (minimum requirements) Weekly Monthly Quarterly Biannually Annually Life Safety Management X Fire Drills (Healthcare) (each shift) Fire Drills (Business Occupancy) X X Fire Drills (ILSM) (additional) Fire Response Team Training X Smoke Evacuation System Testing X Stair Pressurization System Testing X Smoke/Fire Barriers and Doors X Critique Effectiveness of Fire Plan/Fire Drills X

Fire Alarm and Detection Equipment All supervisory signal devices (except valve tamper switches) X Valve tamper switches and water flow devices X Smoke Detectors (including duct detectors) X Electromechanical door releasing devices X Heat Detectors X Manual Fire Alarm Boxes X Occupant Alarm Notification Devices (all audible devices, speakers, and visual devices) X Transmission Equipment for Fire Department Notification (i.e., your Central Station) X

Automatic Extinguishing Equipment Fire Pumps – Churn (no flow) X Fire Pumps – full flow X Water Tank High and Low Level Alarms X X In cold Water Tank Low Temperature Alarms weather Main Drains (at all system risers) X X Siamese Connections – Fire Department Inspect Package Suppression Systems over Cooking X Equipment Inspect X

CO2 and Other Gas Package Suppression Systems maintain

Memorial Hermann Hospital System 1 Revised 06/24/04 Facilities Engineering/Environment of Care Committee Tasks Environment of Care Compliance Matrices

Life Safety Management (continued) Weekly Monthly Quarterly Biannually Annually Portable Fire Extinguishers and Standpipe Systems X X Portable Fire Extinguishers Inspect Maintain Test 5 years after installation then every 3 X Occupant Hoses (1-1½ inches) years Inspect Test X Standpipe Systems Every 5 years Inspect Test Stand Pipe Flow Tests Every 5 years

Building Fire Protection Equipment Test and maintain every 5 years (operate X Fire Dampers damper) 25% Test and maintain every 5 years (operate X Smoke Dampers damper 25% HVAC Shutdown Devices X Sliding and Rolling Fire Doors X

Management Plan Review Plan Annually X Review Objectives, Scope, Performance and Effectiveness Annually X Report to Governing Body/Quality X

2 Revised 06/24/04