Documentation – Part 4: The Rest of the Story


This is the last 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.

When you’re finished with this update and improvement to your documentation for life safety equipment, you should have a very nice row of binders, not unlike the picture to the left. Many hospitals maintain these binders on a cart so they can be wheeled anywhere they are needed in a moment’s notice.

When I was the Safety Officer at the hospital where I worked, I kept these documents in my office where I could keep an eye on them. When the time came for the document review session, I just wheeled the cart into the respective conference room and let the show begin.

One last comment I want to bring to your attention… I was at the Joint Commission home office in Oakbrook Terrace, IL, earlier this spring and George Mills (director of engineering for Joint Commission) was speaking to a group of hospital engineers from Northern Illinois, and he mentioned that Joint Commission is taking a much tougher stand on the documentation of the life safety features in the hospital. He explained that there will be new consequences to multiple findings under standard EC.02.03.05, and made this announcement:

“If we write findings in three (3) or more EPs in EC.02.03.05, we are also writing a finding under the leadership standard, LD.04.01.05, EP 4 which says leadership must hold staff accountable for their responsibilities” said Mills. “If this is the way that the fire safety features are managed, shouldn’t there be some repercussions? Then the facility manager can explain to the CEO why it is okay to not know the level of reliability of the fire alarm system. It’s all about managing the process.”

So… You have it straight from George’s mouth: The Joint Commission in cracking down on multiple (3 or more) findings under the standard that governs testing and inspection of the life safety features in the hospital. And remember: If you performed the test or inspection but do not have the documentation to prove it… it is still a finding and the AHJ will cite you for non-compliance.

As a reminder… If you want to download the entire document review sheet that this article is based on, go to “Tools” page, and look under “Life Safety Document Review Session” heading, and click on “Acute Care Hospital Documentation Requirements”.

Now, as promised, the rest of the documents that need to be included for the document review session:



NFPA   Standard

Portable   fire extinguishers



10-1998; 4-3.1



10-1998; 4-4.1

Alternative   suppression systems

Kitchen hood system – inspection


17A-1998; 5-2.1

Kitchen hood system – test


17A-1998; 5-3.1.1

Halon system – inspection & test


12A-1997; 4-1.1

CO2 system – inspection


12-1998; 1-10.1

CO2 system – tank weigh


12-1998; 1-10.3.5

CO2 system – test


12-1998; 1-10.3.2

Clean agent system – inspection


2001-2000; 4-1.3

Clean agent system – test


2001-2000; 4-1.1

Emergency   power generators



110-1999; 6-4.1

Battery electrolyte levels


110-1999; 6-3.6

Monthly load test

No less than 20 days; no more than 40   days

110-1999; 6-4.2 and 99-1999; 3-

Annual load test (if required)


110-1999; 6-4.2.2

3-Year 4-Hour load test


110-2005; 8.4.9

Automatic   Transfer Switches

Monthly test with generator

No less than 20 days; no more than 40   days

110-1999; 6-4.5 and 99-1999; 3-

Medical   gas and Vacuum sys

Maintenance & testing

As per policy, but not more than 12   months without risk assessment

99-1999; 4-

Cross-contamination test

After breaching of system

99-1999; 4-

Purity and pressure test

After breaching of system

99-1999; 4-

Alternative   Life Safety Measures


Review policy



Review implementation documents


Fire Watch

Review fire watch documents

101-2000; &   101-2000;

Fire/Smoke   damper test

Inside hospital facility

1-Year after installation; Every 6   years thereafter

80-2007; 19.4 and 105-2007; 6.5.2

Outside hospital facility

1-Year after installation; Every 4 years   thereafter

80-2007; 19.4 and 105-2007; 6.5.2

Horizontal   sliding/Vertical rolling fire doors

Drop test


80-1999; 15-2.4.3

‘Exit’   signs

Illumination inspection



Elevator   recall

Test of all elevators equipped with   Fire Fighter Service


101-2000; 9.4.6

Fire   Drills

Healthcare occupancy

Quarterly on each shift