Documentation- Part 2: Fire Alarm System

imagesT4IH0BMLThis is the second in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Last week I presented some general suggestions on how to improve your documentation for easier retrieval during a survey. I suggested placing the test and inspection reports in 3-ring binders and separating them by categories. Use tabs to separate the categories so you can access the reports easier and faster.

The different categories that I present below are based on the Joint Commission Environment of Care standard EC.02.03.05; HFAP chapter 13 on Life Safety;  DNV PE.1, SR.2; and CMS Conditions of Participation. Here are the categories of the different test/inspection reports that you will likely need:

  • Fire alarm test reports
  • Sprinkler system inspection/test reports
  • Fire pump test reports
  • Alternative fire suppression test reports
  • Generator test reports
  • ATS test reports
  • Medical gas & vacuum system test reports
  • Interim Life Safety Measures assessments
  • Fire & smoke damper test reports
  • Fire door test reports
  • Exit sign inspection reports
  • Elevator recall test reports
  • Fire drills

Today I will identify what you need to have for a valid fire alarm test report.

Fire Alarm System

With the exception of the sprinkler water-flow switches, all of the other devices connected to the fire alarm system must be tested according to the frequency specified in NFPA 72 (1999 edition), section 7-3.2.  Water-flow switches must be tested according to the frequency specified in NFAP 25 (1998 edition), section 2-3.3. This list does not take into consideration any changes to testing frequency based on acceptance of the CMS Categorical waivers.




Initiating devices

Water-flow switches


Smoke detectors


Heat detectors


Duct detectors


Manual pull stations


Supervisory signal devices

Low air pressure   switches


Low water level   switches


Tamper switches


Notification devices









Interface relays and   modules

Magnetic hold-open


Air handler shutdown


Kitchen hood   suppression


Elevator recall


Magnetic locks


Fire pump


Smoke dampers


Clean agent suppression


Sprinkler dry pipe


Sprinkler pre-action


Overhead rolling fire doors


Control panel batteries

Charger test


Discharge test


Load voltage test


Smoke detector sensitivity test


Off-premises monitoring transmission equipment


 If you have these devices connected to your fire alarm system, then you need to have evidenced that each individual device was tested. That means you also need an accurate inventory of every device, complete with a description as to where it is located. The test report needs to list each and every individual device, a description of where it is located, and whether it passed or failed its test. This means there may be over 50 pages to an average test report since a typical 200 bed hospital may have over 2,000 devices connected to its fire alarm system.

Next week we will look at the sprinkler system.

Documentation – Part 1: General Suggestions


This is the first in a series of articles on improving the way the testing & inspection documents are maintained, in order to facilitate an easier document review session during a survey.

Surveyors and inspectors, whether they are from Joint Commission, HFAP, DNV, CIHQ, or your state agency surveying on behalf of CMS, all find it a bit frustrating when they have to wait and wait for hospital facility managers to dig through their piles of paperwork, looking for a specific test or inspection report. And making a surveyor frustrated is not a good thing during a survey.

I receive comments from surveyors all the time that they are astounded on how poorly organized some hospitals are when it comes to retrieving a specific report. Surveyors will cite an organization for non-compliance with a standard if the hospital cannot present the evidence to document that the test or inspection was completed. It doesn’t matter if the hospital actually performed the test or inspection if they cannot present the documents proving that it was completed.

A couple of hours of preparation prior to the survey can help make the whole documentation review process go a lot easier. This article (and subsequent articles on this same subject) will identify how you can organize your documentation so you can easily retrieve any test or inspection report that the surveyor wants to review.

I will post a new document review sheet titled “Acute Care Hospital Documentation Requirements” under my “Tools” page for you to down-load if you wish. That document is based on NFPA requirements for testing  and inspection, not necessarily what the accreditation organizations (AO) are enforcing. This is mainly due to the fact that the AO’s typically do not enforce everything that the NFPA codes and standards require.

General Suggestions

Suggestions on preparing your documentation:

  1. Put all inspection and testing work orders or contractor reports in a 3-ring binder, and categorize them by topic. Maintain the binders in an area where they are easily retrievable by anyone in event you are not onsite when the survey begins.
  2. You can have binders with multiple categories, or multiple binders with one category, whatever works for you. Since fire alarm test reports can be rather lengthy, they may deserve their own binder. Similarly, some contracted testing/inspection reports may be presented to you in their own binders.
  3. Each binder should reflect 1-years worth of documentation for that category, or one inspection/test if intervals are more than 1-year. For example, it doesn’t make sense to have a binder each year for fire & smoke damper testing when the test intervals is every 6 years for hospitals.
  4. Only include documents that actually demonstrate a test or an inspection. Do not include copies of invoices, purchase orders, or any other document that is not relevant for testing and inspection. All too often a hospital will present a purchase order or a contractor’s invoice as evidence that a life safety device was tested. That doesn’t prove the device was tested; only that you contracted to have it tested or you paid someone to have it tested. Do not add unnecessary information, such as a re-print of the standard that specifies the testing/inspection activities. The surveyors are not interested in that; they only want to see the evidence that the devices were tested or inspected.
  5. If a device was found to be defective or impaired during the testing/inspection activity, and it was not repaired/replaced the same day it was discovered, then make sure you have a copy of the Interim Life Safety Measures (ILSM) assessment document in the binder. All LSC deficiencies need to be assessed for ILSM when they cannot be immediately resolved. Having proof that you assessed the deficiency for ILSM in the binder next to the report, is a turn-key approach to managing the problem.
  6. If repairs or follow-up activities are required, then include copies of work orders, contractor test reports, or work tickets that demonstrate the device was repaired/replaced, and re-tested. You must be able to prove to the surveyor that the device was repaired or replaced, and that the repaired or replaced device was actually tested and it passed its test. Have a copy of this document stapled to the test report so you don’t have to spend time looking for it.
  7. Make sure the documents are legible… You may need to requests originals where carbonless copies are not readable.

Next week we will discuss what is actually required for an acceptable fire alarm test report, according to NFPA standards.

How Long Do I Need To Keep Documentation?

I get asked this question from time to time…”How long must I keep test and inspections reports?” My answer has always been… Forever. Don’t throw anything out. You never know when you will need to prove something to your boss, a surveyor, or heaven-forbid, a lawyer.

At the hospital where I worked, early in my career I was either told by someone with more authority than me, or I just decided to do it, but I never threw anything out. I did clean out my files from time to time, but I would pack up the paper documents in boxes and hide them away in a crawl space in the hospital. It really wasn’t a secrete space, because every plant operator in the facilities department at one time or another crawled back into this area to service some air handlers. But it was pretty secure for my purposes, and the boxes were never removed, as long as I worked there. And there was more than one instance where I returned to the boxes to retrieve a document that proved to be rather valuable.

Now, I know Joint Commission says they want to see 12 months track record for testing and inspection on all fire safety systems, or back to the last cycle of testing, whichever is longest, but they have the right to look back even farther if they want. There have been multiple cases where surveyors found something that was suspect or wrong, such as a lack of proper main drain tests being conducted, and they traced back 3 years to see if the test was ever done successfully. This is ultimately helpful to the hospital as in many cases the organization can prove to the surveyor that the test was originally conducted but for whatever reason it wasn’t conducted at the time of the survey. This is helpful to prove to the surveyor that the test was inadvertently not conducted. If a surveyor found a history trail of a particular test not being conducted for many years, then they may cite the organization for non-compliance with the Centers for Medicare & Medicaid Services (CMS) Condition of Participation (CoP) 482.41, which requires the hospital to be maintained to ensure the safety of the patient. That is something you don’t want to happen.

I have been told by state agencies who perform validation surveys on behalf of the CMS that they want to see 3 years worth of testing and inspection documentation for all fire safety systems. It is apparent that depending on the state agency, they can and will hold you accountable for 3 years worth of tests and inspections.

So, the prudent thing to do is never throw anything out… just put it in a box and store it in a dry place. Being facilities people, we should know where all the ‘secrete’ storage spaces are located, and it doesn’t even have to be inside the hospital. Put it in the basement of the medical building down the street.