Simplify Compliance Complexities

Life Safety Documentation Requirements with TJC Standards

Are you feeling confused about what Life Safety assets to inspect, test, or maintain per NFPA 101?

How about the frequencies? Or what information you need to capture to comply with code requirements? 

How many of you can relate to this? 

You are responsible for the Life Safety documentation for your healthcare facility. The back wall of your office looks like an Office Depot as you have 20 or so binders stacked nicely on a series of shelving units you have acquired over the years. You have about 10+ different vendors that help you maintain the Life Safety systems within your healthcare facility, along with a whole bunch of internal staff that contribute to this effort. Each report looks slightly different as to how the information is laid out, just enough that it’s a challenge to track down the information you need. 

Your accreditation agency shows up for their tri-annual survey, and the first place they start is a deep dive into your beautiful binder set up that houses all of the Life Safety documentation. The first few questions go well, and then pow! They ask you for something that you are struggling to find a record of. You find it after some digging, but it took a little bit. Pow! It happens again, and then again. Frustrations start to grow on your end, as well as the surveyors. Feel free to fill in the blank as to how the rest of the survey goes. 

Well, here is a document that can help prevent that feeling of frustration.

Our Life Safety expert, Brad Keyes, has put together a helpful document that will allow you to keep track of your Life Safety documentation. 

It includes:

  • Required assets per NFPA 101
  • Frequencies of testing
  • Standard reference
  • Documentation requirements
  • Space for tracking progress