Incorrect Duration

Joint Commission standard EC.02.03.05 specifically addresses the requirements for maintenance, testing, and inspection of fire safety equipment and building features, including fire alarm systems, automatic sprinkler systems, portable fire extinguishers, sliding and rolling fire doors, fire and smoke dampers, shutdown for air handling equipment, and automatic fire extinguishing systems. Within the various Elements of Performance, this standard outlines the testing frequencies for these devices based on the various NFPA standards. Elements of Performance within this standard were frequently cited by The Joint Commission during hospitals surveys conducted in 2014. The most often cited device that did not correctly identify the appropriate testing duration was offsite notification devices.

Incorrect duration graph

The Joint Commission recognizes that it will not always be possible to meet the exact time frames cited in the requirements. For evaluation purposes, therefore, the following intervals are acceptable:

  • Every 36 months/every 3 years = 36 months from the date of the last event, plus or minus 45 days
  • Annually/every 12 months/once a year/every year = 1 year from the date of the last event, plus or minus 30 days 
  • Every 6 months = 6 months from the date of the last event, plus or minus 20 days
  • Quarterly/every quarter = every three months, plus or minus 10 days
  • Monthly/30-day intervals/every month = 12 times a year, once per month
  • Every week = once per week

In regards to those requirements that are every 5 or 6 years which are not defined above it is recommended that these time frames be defined in a facility policy.  (These Intervals are reprinted here with permission from the Joint Commission)

ASHE strongly recommends that the same time range, plus or minus 45 days, as used in the 3 year definition be considered.

The mitigation tools provided below provide the device type, required testing frequency and the appropriate reference standard based on EC.02.03.05.

Mitiagtion Tools

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