TJC announced a change earlier in the year calling for quarterly testing of water-flow devices and valve tamper switches and then flip-flopped & revised their stance with the valve tamper switches going back to the original NFPA requirement for semi-annual testing.
Effective July 1, 2011
EC.02.03.05, EP 2:
For hospitals that use TJC accreditation for deemed status purposes (Hospital receives Medicare reimbursements) : At least quarterly, the hospital tests water-flow devices. Every 6 months, the hospital tests valve tamper switches. The completion date of the tests is documented.
For hospitals that do not use accreditation for deemed status purposes (Hospital does not receive Medicare reimbursements): Every 6 months, the hospital tests valve tamper switches and water-flow devices. The completion date of these tests is documented.
Effective July 1, 2011
EC.02.03.05, New EP 25:
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 & date of activity
- Required frequency of 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: The above changes have been made by TJC to demonstrate to the Centers for Medicare & Medicaid Services that its standards and elements of performance (EPs) are in line with and equivalent to CMS’s Conditions of Participation (COPs) in order to maintain CMS deeming authority.
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