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:

Device/Test/Inspection		Frequency	NFPA   Standard
Portable   fire extinguishers	Inspection	Monthly	10-1998; 4-3.1
	Maintenance	Annually	10-1998; 4-4.1
Alternative   suppression systems	Kitchen hood system – inspection	Monthly	17A-1998; 5-2.1
	Kitchen hood system – test	Semi-annually	17A-1998; 5-3.1.1
	Halon system – inspection & test	Semi-annually	12A-1997; 4-1.1
	CO2 system – inspection	Monthly	12-1998; 1-10.1
	CO2 system – tank weigh	Semi-annually	12-1998; 1-10.3.5
	CO2 system – test	Annually	12-1998; 1-10.3.2
	Clean agent system – inspection	Semi-annually	2001-2000; 4-1.3
	Clean agent system – test	Annually	2001-2000; 4-1.1
Emergency   power generators	Inspection	Weekly	110-1999; 6-4.1
	Battery electrolyte levels	Weekly	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; 3-4.4.1.1
	Annual load test (if required)	Annually	110-1999; 6-4.2.2
	3-Year 4-Hour load test	3-Years	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; 3-4.4.1.1
Medical   gas and Vacuum sys	Maintenance & testing	As per policy, but not more than 12   months without risk assessment	99-1999; 4-3.4.1.1
	Cross-contamination test	After breaching of system	99-1999; 4-3.4.1.1
	Purity and pressure test	After breaching of system	99-1999; 4-3.4.1.1
Alternative   Life Safety Measures	Policy	Review policy	101-2000; 4.6.10.1
	Implementation	Review implementation documents	101-2000; 4.6.10.1
	Fire Watch	Review fire watch documents	101-2000; 9.6.1.8 &   101-2000; 9.7.6.1
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	Annually	80-1999; 15-2.4.3
‘Exit’   signs	Illumination inspection	Monthly	101-2000; 7.10.9.1
Elevator   recall	Test of all elevators equipped with   Fire Fighter Service	Monthly	101-2000; 9.4.6
Fire   Drills	Healthcare occupancy	Quarterly on each shift	101-2000; 19.7.1.2