Joint Commission: Tip for Documenting Fire Response Testing

Forty percent of all Joint Commission hospital surveys in 2011 and in the first half of 2012 included findings for standard EC.02.03.05, which requires documentation of the maintenance, inspection and testing of fire safety features.

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Under the standard, healthcare organizations must demonstrate that all fire safety devices have been tested by listing the devices on an inventory. Sometimes, items may be missed in an inventory or the healthcare organization may not know results of required systems testing. Failure to document all devices or testing results could lead to a citation.

In order to prevent this, The Joint Commission advises healthcare organizations to ask outside contractors to include inventory or a daily work summary of all failed devices in their request for bids. Contractors’ provision of these key data could help healthcare organizations better identify missing devices or failed tests and implement a corrective action plan.

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