Oops! Brad Made a Mistake…

I need to apologize to you, as I made an error in an earlier post where I stated the expected dates for the new testing/inspection requirements of the new 2012 Life Safety Code.

Previously, I said healthcare organizations needed to get their first quarterly, annual, 3-year, and 5-year test/inspection completed by November 1, 2016, which is the date CMS said the requirements of the new 2012 LSC will be enforced.

That wasn’t quite true… I received an email from a friend who also is a reader of my blog and said that is not what Joint Commission said at the annual ASHE conference. So, I contacted CMS directly in Baltimore, and communicated with the people who make these interpretations, and they told me this:

Although CMS will begin surveying to the new 2012 LSC on November 1, 2016, the regulation still requires the facility to be in compliance with the 2012 LSC and the 2012 NFPA 99 as of July 5, 2016.

Therefore, when CMS begins to survey on November 1, 2016, the healthcare facility should be able to verify compliance with any new daily, weekly, or quarterly requirements as it has been over 3 months since July 5th. But a facility would not yet be required to meet the new annual, 3-year, or 5-year requirements.

The email from CMS went on to explain that the first annual test/inspection activity that is a new requirement of the 2012 LSC is due July 5, 2017. Similarly, the first 3-year activity is due July 5, 2019, and the first 5-year is due July 5, 2021.

Just as a refresher, here is a list of the new testing/inspecting requirements of the 2012 LSC and the 2012 NFPA 99:

  • Quarterly main drain test on one system riser downstream of the backflow preventer where the sole water supply to the sprinkler system is through a backflow preventer;
  • Quarterly inspection of fire hose valves;
  • Annual test/inspection of all fire-rated door assemblies;
  • Annual test of the 2.5 inch fire hose valves;
  • 18-month test of non-stationary medical gas booms and articulating assemblies using flexible connectors for medical gas outlets;
  • 3-year test of the 1.5 inch fire hose valves;
  • 5-year internal inspection of sprinkler pipe.

So… according to the information provided by CMS, when they begin surveying to the 2012 LSC on November 1, 2016, you need to have your first quarterly main drain test conducted and your first quarterly inspection of fire hose valves. However, the annual, 18-month, 3-year, and 5-year new requirements are not due until their respective anniversary from the July 5, 2016 effective date.

I apologize for this miscommunication…. And I’m glad my friend took the time to point that out to me.