Compliance News: Fire Protection Systems Testing Revisions by TJC

By Dean Samet, CHSP

In the May 2011 edition of The Joint Commission Perspectives, TJC an­nounced a change effec­tive July 1, 2011 for Envi­ronment of Care Standard EC.02.03.05, EP 2 and introduced a new EP 25. The standard, “the hos­pital maintains fire safety equipment and fire safety building features” remains unchanged.

EP 2 has been changed and will require quarterly testing of water-flow devices. TJC stan­dards previously required testing every six months or semi-annu­ally in accordance with NFPA 72, 1999 edition. EP 2 will read as follows: “For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly, the hospital tests wa­ter-flow devices. Every six months, the hospital tests valve tamper switches. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 25, 1998 edition (Sections 2-3.3 and 3-3.3) and NFPA 25, 1999 edition (Ta­ble 7-3.2). For hospitals that do not use accreditation for deemed status purposes: Every six months, the hospital tests valve tamper switches and water-flow devices. The completion date of these tests is documented.”

New EP 25 will read as follows: “For hospitals that use ac­creditation for deemed status purposes: Documentation of main­tenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:

• Name of activity
• Date of the activity
• Required frequency of the activity
• Name and contact information, including affiliation of the per­son who performed the activity
• NFPA standard(s) referenced for the activity
• Results of the activity

 Note: For additional guidance on documenting activities, see NFPA 25, 1998 edition (Section 2-1.3) and NFPA 72, 1999 edition (Section 7-5.2).