ISHE Update

The Joint Commission announced the following revisions to life safety testing requirements for Critical Access Hospitals. These revisions are effective January, 2012.

"Standard EC.02.03.05
The critical access hospital maintains fire safety equipment and fire safety building features.

Note: This standard does not require critical access hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.

Elements of Performance for EC.02.03.05

(A)2. At least quarterly, the critical access hospital tests water-flow devices. Every 6 months, the critical access 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 72, 1999 edition (Table 7-3.2).

(C) 25. Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems include the following:
· Name of the 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)."

Please share this information with the appropriate leadership and staff responsible for life safety system(s) testing and maintenance. All maintenance and testing schedules should be reviewed and revised to meet these new requirements. All testing records including those done by outside vendors, should be modified to assure that all requirements noted under EP 25 is documented for each test completed.