Fire Alarm Testing

We are considering doing our annual fire alarm testing in 4 quarterly sections.  This has the advantage of having our contractor in the building, working with the system much more often; however, it presents the difficulty that parts of the building done in the 4th quarter will have gone past 12 months since their last test.  Given an intelligent F/A system, do you think this would be a problem with the Joint Commission? The alternative is to do an extra, very expensive, full system test before starting quarterly testing. 

You have a 30-day window of opportunity for annual testing. Any testing following outside of the following parameters will probably be subject to scoring during a TJC survey.

In TJC’s 2009 Hospital Accreditation Standards manual, at the beginning of the Environment of Care (EC) chapter under ”Other Issues for Consideration,” they state under item No. 2. “A number of elements of performance describe time frames for completing certain tasks or functions. TJC recognizes that it will not always be possible to meet the exact time frames cited in the requirements. For evaluation purposes, therefore, the following intervals are acceptable:

-          Annual/every 12 months/once a year/every year = 1 year from the date of the last event, plus or minus 30 days

-          Every 6 months = 6 months from the date of the last event, plus or minus 20 days

-          Quarterly = 4 times a year, once I each quarter”