Joint Commission revises requirements for fire alarm and protection systems

Hospital Safety Insider, April 28, 2011

Want to receive articles like this one in your inbox? Subscribe to Hospital Safety Insider!

The following is an excerpt from the April issue of Briefings on Hospital Safety.

Starting July 1, hospitals will need to meet some new Joint Commission requirements for their fire alarm and protection systems.

In January, The Joint Commission announced revisions to standard EC.02.03.05 from the Environment of Care chapter of the Comprehensive Accreditation Manual for Hospitals. The reason for the changes to two of the standard's elements of performance (EP) is to comply with the Centers for Medicare & Medicaid Services' (CMS) Conditions of Participation (CoP).

The changes may actually make life simpler for hospitals by aligning Joint Commission and CMS requirements, says Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in ¬Danvers, MA.

The Joint Commission revised EP 2 and created a new EP 25.

The accreditor made the changes in order to maintain CMS deeming authority, according to the January 12 Joint Commission Online. The Joint Commission must ensure that its standards and EPs are equivalent to the requirements in the CoP.

EC.02.03.05 requires hospitals to maintain fire safety equipment and fire safety building features.

Here's what's changing:

EP 2 will require quarterly testing of a hospital's valve tamper switches and water flow devices, instead of the current testing every six months.

The new EP 25 requires documentation of the maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems. Documentation must include the following:

  • Name of the activity
  • Date of the activity
  • Required frequency
  • Name and contact information, including affiliation, of the person who performed the activity
  • National Fire Protection Association (NFPA) standards referenced for the activity
  • Results of the activity


Want to receive articles like this one in your inbox? Subscribe to Hospital Safety Insider!

Most Popular