By David Stymiest, PE, CHFM, CHSP, FASHE
Take a close look at your 2014 schedules for quarterly requirements such as fire safety system testing found in several elements of performance (EPs) under Standard EC.02.03.05. The brand new 2014 TJC definition of QUARTERLY can be found on page EC-3 at the beginning of the EC Chapter in the 2014 Hospital Accreditation Standards. The previous definition allowed quarterly activities to be accomplished anytime during a calendar quarter. The 2014 definition, however, is “every three months, plus or minus 10 days.” We recommend that you interpret this new requirement conservatively as three months from the date of the previous activity, plus or minus 10 days.
By David Stymiest, PE CHFM CHSP FASHE
The Joint Commission (TJC) Engineering Director George Mills addressed the issue of fire safety equipment inventories at his 2013 ASHE Annual Conference plenary in July.
Mr. Mills stated that with respect to Standard EC.02.03.05, Elements of Performance (EPs) # 1 through # 20 inclusive, every device required to be tested must be documented in an inventory. He further stated that TJC surveyors will expect the facility to be able to identify specific variances in devices tested from year to year, and that simply having the total quantity of devices without more specific definition will not be adequate. Finally, Mr. Mills stated that lack of a written, electronic, or other form of inventory addressing the devices covered by any of the 20 EPs could result in a finding against that EP. Needless to say, Organizations who have yet not finalized their EC.02.03.05 inventories can be subject to numerous RFIs during survey.
