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      Documentation - Part 4: The Rest of the Story

      by Brad Keyes, CHSP, on May 1, 2014 12:00:00 AM

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      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

      Topics: Article Documentation (Life Safety Code)

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