I recently had a reader ask me about fire pump testing. He said that since Joint Commission does not ask to see that the hospital fire pump is tested under emergency power at peak capacity (150% of nameplate rating), then why should we perform that test?
The Joint Commission does not often (if ever) ask to see the fire pump tested under emergency power at peak capacity (150% of nameplate), even though it is a NFPA 25 requirement. However, other authorities having jurisdiction (AHJ) may very well expect that you comply with this requirement, such as CMS, the state department of public health, state and local fire marshals, and insurance companies.
Make no mistake about it, it is an NFPA 25 requirement, and it is referenced by the Life Safety Code®, so therefore, you are required to conduct this test under EM power.
Unfortunately, many hospitals only comply with the Life Safety Code® to the point where the AHJ with the loudest bark (or bite) enforces it. So, if a hospital is only preparing for a TJC tri-annual survey, then they typically only comply with what TJC requires. They are placing their hospitals in a position where they may be cited by one or more AHJs that will eventually come knocking on their doors.
Ironically, many hospitals plan their level of compliance based on what their contractors and vendors tell them. In the case of annual fire pump testing, the testing contractor often does not perform the EM power test due to a couple of reasons: 1) They may not know that the EM power test is required per NFPA 25; or 2) they may have suggested it to the hospital facility manager and he rejects the idea because The Joint Commission does not require it.
Therefore, the testing contractor stops suggesting it. This speaks to one of my tips about compliance: YOU HAVE TO BE SMARTER THAN THE CONTRACTORS: Do not take their word on any subject involving compliance. Always verify what they are telling you with what the codes and standards require.