Definition of Time
by Bob Armbrister, on Apr 15, 2020 12:00:00 AM
Q: Has there been an update to the definition of time by TJC/CMS? I'm looking at quarterly fire drills right now, but any changes/clarification on the definition for all intervals would be helpful. I don't know if you were aware, but there was a TJC FAQ response which stated that they interpret as 30 days from the 'month' +/- 10 days. It may be old/superseded now, but it was under maintenance - schedules and asked about grace periods. We always try to stay within the month (every 3 months, within the month), but I just want to assure that we're not vulnerable if/when CMS or another AHJ stops by and that I'm reporting compliance and vulnerabilities accurately to leadership, as possible.
A: I have not seen any updates regarding TJC’s interpretation. I do know that NFPA, in general, has not done anything to consolidate the definition for testing and inspection activities. Since NFPA hasn’t done so, The Joint Commission took this responsibility on many years ago. It proved to be very helpful when TJC did this and caught on with other accreditors (i.e. HFAP, DNV, and AAAHC). But all of these definitions of times were just interpretations and not based on anything more than common sense and practicalities.
Then a couple of years ago, CMS put their foot down and said they do not approve of any definition of time that allows testing or inspection activities beyond their NFPA prescribed length. So, what that means is a quarterly inspection can be conducted anytime during the quarter, but not more than 3 months beyond the last activity. So, this pretty much killed the concept of “3 months plus or minus 30 days”. CMS doesn’t mind the ‘minus 30 days’ but they don’t like the ‘plus 30 days’. This was communicated to the accreditation organizations informally (through private mails) and was not released to the public in a general S&C memo. So, TJC should modify their definition of time to not exceed the prescribed amount of time that NFPA designates for each testing and/or inspection activity.
For what it is worth, NFPA 72-2010, section 3.2.106 defines time for fire alarm system testing and inspection as follows:
- Weekly: 52 times per year, once per calendar week
- Monthly: 12 times per year, once per calendar month
- Quarterly: 4 times per year, with a minimum of 2 months and a maximum of 4 months
- Semiannual: Twice per year, with a minimum of 4 months, and a maximum of 8 months
- Annual: Once per year, with a minimum of 9 months and a maximum of 15 months
The above is only for fire alarm testing and CMS has said they will comply with these frequencies since it is written into the NFPA 72 standard. However, I am not sure the accreditation organizations have accepted it as well.
I suggest you contact your state and local authorities to determine how they define time when it is applied to testing/inspection frequencies.