November 05, 2013 | | Comments 1
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In-house fire alarm testing documentation must include the required elements

When it comes to the Life Safety document review, there is still a fair amount of survey risk exposure and (no surprise) a fair amount of survey findings. EC.02.03.05 is the 6th most frequently cited standard; 44% of the hospitals surveyed in the first six months of 2013 were cited under this standard!

Some of the findings have related to irregularities in the testing process. You have to make sure that your device inventory numbers match up; if you had 50 pull stations last year and 55 pull stations this year in the testing documentation, you had better know why and it better be because you added some pull stations, otherwise it could get ugly. But one thing I’ve seen in a couple of recent surveys (both TJC and in my own practice) is the documentation of fire alarm and sprinkler system testing and maintenance that is performed by in-house staff. A typical one is the weekly fire pump test—pretty much everyone does that one in house. Now, there’s nothing wrong with that, but you have to make sure that the documentation of in-house activities is in compliance with EP 25, which requires the inclusion of the following information:

 

  • Name of the activity
  • Date of the activity
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

In my experience, most folks have the first three pretty well in hand, but sometimes those last three get lost a bit in the shuffle. It might be worth a review of your in-house documentation to make sure you have all the required elements in place.

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Filed Under: Environment of careThe Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Current fire pump performance vs. the previous quarter’s performance is a critical aspect of fire suppression. NFPA Code requires investigation if change is more than + or (-) 5%. We use the net churn test pressure from the previous quarter compared to the current quarter as an EOC Indicator for Utilites in our EOC Task Force.

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