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Sample checklist, EC 5.40, part 2

Emergency Management Alert, October 23, 2007

Staying up to date with The Joint Commission's standard EC.5.40, which requires hospitals to maintain "fire-safety equipment and building features," is really about paying attention to every facet of the standard, says Jodi Eisenberg, CPMSM, CPHQ, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago. She and Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant in Trabuco Canyon, CA, spoke to HCPro, Inc., editors this month about how to handle EC.5.40 and other problematic Joint Commission standards. One tool they recommended is this checklist:

EC.5.40-EP 4
EP 4: Test fire pumps weekly under no-flow conditions
Survey highlights
-  Did you verify whether there is a program (process) in place that provides evidence of weekly (not seven-day) no-flow tests?
-  Is this test done manually or on a pressure drop?
-  Can you ensure compliant running time?
-  Can you check power supply for phase-reversal and single-phase conditions?
-  Is there a timer on the fire pump control panel?
-  Have you inspected the fire pump area or room?
-  Is the pump seal wet or dry?
-  Is the person responsible for the pump competent and knowledgeable with the workings of the pump, its process, and NFPA 20?
-  Have you checked NFPA 25?

Source: The Joint Commission's Life Safety Survey: Demonstrated Techniques to Avoid Pitfalls, by Thomas Salamone, director of safety, security fire prevention, Norwalk Hospital, Norwalk, CT, and Thomas Huser, MS, CHSP, Indianapolis, IN.

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