Testing Requirements

Q: On annual testing requirements, how many days do you have on either side of the test date?

A: If the NFPA standard simply says the test is required ‘annually’, then that can be interpreted differently depending on the many different authorities having jurisdiction. I do know that CMS is okay with an ‘annual’ test requirement to happen once per calendar year, as long as you do not exceed 12 months. This means if you tested something on July 1, the next test may occur anytime between January 1 and June 30 the following year. You just cannot exceed 12 months between tests. But not all accreditation organizations (AOs) agree with that. They typically have a more restrictive requirement, such as ‘annual’ means 12 months from the previous test, and must be conducted during the 12th month. So, if you did the test on July 1, then you must do the next test between June 1 and June 30. Some AOs even have said 12 months from the previous test, plus or minus 30 days. But CMS has told them that they do not like the “plus 30 days” because that exceeds 12 months between tests. So that pretty much limits the test to 12 months from the previous test, minus 30 days.

But CMS has said in informal communications with the AOs that they will honor the NFPA 72-2010 3.3.106 definition of annual testing for fire alarm system components, which is no sooner than 9 months and no later than 15 months from the previous annual inspection/test. But there is no guarantee that the AOs will honor this. And, this only applies to fire alarm system testing… not any other feature of life safety.

AHJ on Fire Door Inspections

Q:  Does the authority having jurisdiction have the final say whether or not an individual has the ‘knowledge and understanding’ required to perform fire door inspections?

A: Yes they do. Take a look at 4.6.1.1 of the 2012 LSC “The authority having jurisdiction shall determine whether the provisions of this Code are met.” That means the AHJ decides if the organization is compliant with the applicable NFPA codes and standards. But, keep in mind the typical hospital has 5 or 6 different AHJs that inspect their facility for compliance with the LSC:

  • CMS
  • Accreditation organization
  • State health department
  • State agency with over-sight on hospital construction
  • State fire marshal
  • Local fire inspector
  • Liability insurance company

Not one AHJ can over-ride another AHJ’s decision. All AHJs are equal… but different. If 5 AHJs say the qualifications of the person performing the fire door inspections are fine, but 1 AHJ says no, then the hospital must comply with the most restrictive requirements and comply with the latter AHJ’s desires. An AHJ may have rules and requirements that exceed NFPA standards, as well they should. NFPA standards are minimal standards, and most hospitals exceed the NFPA standards in some capacity, often due to local ordinances or state regulations (and sometimes at the whim of the design professional). But, if the AHJ decides to have standards that exceed the minimal NFPA requirements, they need to be able to justify that decision.

It is not at all uncommon for a healthcare organization to seek permission from a state or local AHJ (i.e. state fire marshal) to install a particular device or have a particular feature, only to find out later that their accreditation organization does not agree, and cites the issue. Both the state or local AHJ and the accreditation organization are correct; they are interpreting the Life Safety Code as they see fit. Whatever was approved by the state or local AHJ is just an approval for the state or local regulations. What was cited by the accreditation organization was cited based on the accreditation organization’s regulations and understanding of the Life Safety Code.

This is why healthcare organizations need to obtain permission and interpretations from all of their AHJs… not just one or two.

Follow-Up From an Earlier Post….

I recently posted on documentation retention, and how long you should keep test/inspection records. A reader contacted me and said they attended a recent ASHE regional event where the speaker said the CMS K-Tags require some records to be kept for the life of the building, and the reader wanted to know if I was familiar with this requirement.

I said no, I was not, but I decided to get an answer direct from CMS themselves. I did receive a reply from CMS which is considered an informal non-public response, and here is a summary of what they said:

  • CMS has not issued any formal policy on retention of records for LS test/inspections.
  • Surveyors typically look back one (1) year to establish compliance.
  • However, the extent of the record review would consider the frequency of a particular test/inspection requirement.
  • If the test/inspection requirement was a monthly requirement, the surveyor may review 12-months’ worth of documentation to confirm compliance.
  • If the test/inspection requirement was an annual requirement, then the surveyor may review 3-years’ worth of documentation to confirm compliance.
  • In addition, retention of records would consider any NFPA, State, or manufacturer requirements.

It’s important to point out that there is a special requirement in NFPA 99-2012, section 5.1.14.4.1 that does require ‘permanent’ records of certain medical gas tests. Permanent would mean retention for the life of the building (or system), but section 5.1.14.4.1 only refers to initial system verification test records… not routine annual inspections. And it only applies to medical gas and vacuum systems, not other mechanical or electrical systems identified in NFPA 99.

CMS K-Tags 907 and 908 refer to a routine maintenance program and a test/inspection program for medical gas systems. These K-Tags says records are to be maintained as required. Since the K-Tags are a CMS product, they are obviously saying maintenance records and routine test/inspection records are to be kept long enough to establish a pattern of compliance. For annual test/inspection records, that would mean you must retain the records for 3-years, not necessarily for the life of the building.

Similarly, K-Tag 921 discusses a testing and maintenance program for electrical equipment, and it says records are maintained for a period of time to demonstrate compliance. This is consistent with the CMS informal comment that a ‘period of time’ would be 1-year for monthly requirements and 3-years for annual requirements.

Since accreditation organizations operate with the authority granted to them by CMS, it would be expected that the accreditation organizations would comply with the same requirements and informal policies as CMS.

But, I will fallback on what I believe: You should never throw away any records that demonstrate compliance with a regulatory requirement. That’s Brads opinion.

Joint Commission Quarterly Testing Requirements

Q: Do you find that TJC only enforces the quarterly plus or minus 10 days from the MONTH of last test on quarterly inspections (instead of the day)? This is what others are learning at the JCR base camps evidently, and they showed me a page from their training book, which appears to show that TJC is using the ‘month of testing’ as the basis unlike we thought when first discussed.

A: You have touched on an issue that is very interesting. The Joint Commission standards say one thing, but the Joint Commission Engineering Department says something different.

To be sure, Joint Commission has always said that their official position is only found in their standards, in their Frequently Asked Questions and in their Perspectives magazine. No other Joint Commission or Joint Commission Resources publication is official. Therefore, when referencing their ‘official’ position on quarterly testing, we must look at their Hospital Accreditation Standards.

On page EC-3 of the Joint Commission 2015 Hospital Accreditation Standards (HAS) manual, it states: “Quarterly/every quarter = every three months, plus or minus 10 days”. This implies that if the last activity was March 15, then the next activity is due June 15, plus or minus 10 days. So the window for the next activity is June 5 to June 25, or 20 days.

There is no reference in the HAS manual that the “every three months” is from the month of the last activity, just the date of the last activity. Now, representatives from the Joint Commission Engineering department have stated at various times that they are interpreting the above requirement for quarterly testing to be 3 months from the month of the last activity (not the date of the last activity), plus or minus 10 days. This means if the last activity was March 15, then 3 months from March is June, so plus ten days is July 10 and minus ten days is May 21. So, based on this interpretation, you have an open window of 50 days instead of the tighter window of 20 days.

I believe the Joint Commission Engineering Department is honestly trying to help hospitals by making an interpretation that is easier for their clients to have larger window of opportunity for quarterly testing. And who can say that is wrong? But the basic premise is the HAS standards do not clearly state that this is the official interpretation. Since the Engineering Department’s interpretation is not cited in Perspectives, the Frequently Asked Questions, or in the Standards, then it is not official.

As long as the surveyors stick with the Engineering Department’s interpretation you should not have any problems. But what happens when a surveyor holds you accountable to what their HAS standards say? Then you have no recourse since the other interpretations are not official.

Quarterly Testing and Inspection Challenges

Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not always able to schedule us within the tight 20-day window each quarter that Joint Commission will now require. So by definition our schedule will now be in flux, depending on the completion date of the last inspection, rather than set on the same month each quarter. I realize they do not want people to schedule inspections in back to back months, which we do not do, but this seems like it will cause more instability than anything. 

A: I see your dilemma and understand the difficulty in the logistics of your situation. Scheduling a contractor to be onsite within the new 20-day window each quarter will be a challenge to large organizations like yours.

For the record, the Engineering department at the Joint Commission was not in favor of the requirement that quarterly testing and inspections to be performed 3 months from the previous test/inspection, plus or minus 10 days. But the power-that-be above them made that decision.

To answer your question: I do not know what other organizations are doing in regard to challenges with the new quarterly testing requirements. However, I think there is a way you can deal with this issue.

I suggest you contact the Standards Interpretation Group at the Joint Commission and discuss your options concerning the challenges in meeting the quarterly test/inspection window. Ask them if you can have some leeway that would allow you a wider window each quarter for the testing/inspection frequency other than the plus or minus 10 day window. My guess is they will allow it as long as you can demonstrate the hardship in meeting this requirement.