September 11, 2014 | | Comments 0
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Make sure you go on (okay, over) the papers!

Another frequent survey finding of late (and I have to admit that, on many levels, this one really befuddles me) is a cornucopia of issues relating to fire alarm and sprinkler testing documentation. Basically, everything under EC.02.03.05 (and I do mean everything—it’s the soup, it’s the nuts, it’s the documentation—oy!). I had managed to convince myself that there was no way that EC.02.03.05 would continue to be among the most frequently cited standards, and sure enough, it’s #4 on The Joint Commission’s list of top-cited standards for the first half of 2014. For some reason (and we will discuss what contributing factors I’ve seen in the field in a moment), this one doesn’t seem to go away.

What I’ve seen pretty much breaks down into two fairly broad (but curiously specific on some levels) categories: the quality of the service (and by extension, the documentation) of fire alarm and sprinkler system testing vendors; and, a failure to “embrace” the elements of documentation that are prescribed by TJC.

The documentation requirements are, for all intents and purposes, very straightforward—come survey time, you either have all the elements—name of the activity, date of the activity, required frequency of the activity, name and contact information, including affiliation, of the person(s) who performed the activity, the NFPA standard(s) referenced for the activity; and the results of the activity. All your fire alarm, fire suppression, etc. documentation absolutely, positively has to have all of those elements. Doesn’t matter if the testing, etc. is performed by vendors or by in-house staff—every activity has to have this documentation every time. If you don’t have this in place for every activity, every time it happens, then you will be cited during survey. If the paperwork doesn’t indicate the testing results for each of your notification appliances (horns, strobes, etc.), then no soup for you! Someone in your organization had best be verifying that each of the required document elements is in place for all your testing activities – all of ‘em, all of ‘em, all of ‘em.

And speaking of looking over your documentation, please make sure that there are no ugly little deficiencies buried in the report that might push questions about how long it took to fix something—or indeed whether that ugly little deficiency has been corrected at all! Remember, the clock starts ticking when the deficiency is identified, and you know how much time you have (and believe you me, it ain’t much time) to get things taken care of. Also, make sure that those device counts are consistent from quarter to quarter/year to year and if they’re not consistent, that you have an explanation as to why the numbers don’t match up. If you had 60 pull stations tested last year and didn’t add or take any away, then there darn well better be 60 pull stations tested 12 months later. And if you have testing activities chunked into quarters, make sure the same chunks are tested in the same quarters year to year. I know this sounds simple (I also know I probably sound like a lunatic, but if you had seen what I’ve seen this year…), but way too many folks are getting jammed on this for me to stay quiet for long.

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Filed Under: Environment of careThe Joint Commission


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

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