Testing & Inspection Frequencies
Q: I can't find it, but I feel fairly certain that I read that the plus/minus for time intervals has been changed by CMS to be only minus. For example: Quarterly is every 3 months, plus or minus 10 days. As such, it would be every 3 months, minus 10 days. In essence, you would have to repeat the inspection at 3 months later, but it could be done up to 10 days earlier. However, at any point past 3 months of the last inspection, it would be considered late. Do you know if this is true?
A: Yes, it is true for CMS. In an unofficial communication between the Baltimore CMS home office and certain accreditors, CMS has stated they do not want inspections, testing, and maintenance (ITM) activities to go beyond what is required, or what NFPA allows. As you say, quarterly ITM activities is 3 months from the previous activity. Not 3 months plus or minus 10-days, as Joint Commission allows. However, they did say in this communication that they will allow the ITM activity to be anytime during the 3rd month, so technically that could mean minus 30-days.
But NFPA does allow plus or minus in certain ITM activities. For example, in NFPA 72-2010, section 3.3.106.5 allows for annual frequency on ITM activities for fire alarm systems to be once per year with a minimum of 9-months and a maximum of 15-months. And CMS Baltimore has said they will abide what NFPA says, so for fire alarm systems you do have a plus or minus window of 3-months for annual frequency.
Other areas where NFPA allows for a plus or minus window on ITM activities is in section 7.9.3.1.1(1) of the 2012 Life Safety Code for battery-powered emergency lighting. Monthly testing is required to be a minimum of 3 weeks and a maximum of 5 weeks.
I don’t know why CMS Baltimore does not make these decisions/interpretations public and/or official in the form of a memo… It is frustrating that they tell one accreditor that this is the rule and then they do not share that with the rest of the accreditors. But be aware, this is what CMS is enforcing.
