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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 …
Q: Now that we have some clarification from CMS on annual door inspection [See CMS S&C memo 17-38, dated July 28, 2017], I wanted to see if there was any …
Q: I'd like some clarification concerning the new requirement for annual fire door inspections: NFPA 101 2012, Chapter 7.2.1.15 States "Where required by Chapters 11 through 43, the following door …
Q: Do doors in smoke barriers in healthcare occupancies have to be tested and inspected? Section 7.2.1.15.2 of the 2012 Life Safety Code says smoke door assemblies have to be …
Q: In regards to fire door inspections, what are the qualifications of the person to perform the inspection? A: NFPA 80-2010, section 5.2.3.1 says fire doors must be tested by …
Q: Our organization is accredited by Joint Commission. I know for inspection purposes we need to have the current year plus that past three years of documentation for LS and …
Q: In regards to the new annual fire rated door assembly inspection, are we to inspect every door that has a fire rating or the doors that are located in …
Q: For off-site satellite facilities, where the building is not owned by the hospital but where the space inside the building is licensed by the hospital, are monthly fire extinguisher …
Q: What are the testing requirements for a two story medical office building with a fire alarm system and sprinkler system? I believe we are required to have an annual …
My recent series of articles on Documentation created quite a bit of response. One individual had this question: "What is your opinion of documentation being kept electronically rather than in …
What do we do with smoke dampers now that the hospital is fully protected with sprinklers? That question is asked many times by facility managers who are looking to cut …
Many of you may be familiar with the Joint Commission's standard practice for inaccessible fire dampers: If the fire damper is inaccessible during the required testing period, the hospital can choose …
Fire alarm test reports are the number one item that surveyors look at during the document review session. It is also the number one document that draws the most findings …
Q: What are the testing frequencies for fire alarm panel batteries and where do you find this requirement? A: The testing frequencies for batteries for fire alarm control panels (including …
As mentioned in last week's posting, The Joint Commission announced changes to their standards that takes affect January 1, 2014. We discussed already the change they are making with time …
Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define …
Q: What is the required inspection frequency on sprinkler systems for a building classified as business occupancy? Is it less than what would be required for the main hospital? A: …
One of the requirements that CMS and Joint Commission surveyors is requesting from hospitals and nursing homes is documentation that the elevators have been tested for 'Recall'. Elevator recall is a test …
Q: During a recent survey, the inspector cited us for not exercising our circuit breakers downstream of our generator. Does the LSC require annual exercising of all circuit breakers between …
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