Maintaining Compliance with NFPA 101-1997 and the Joint Commission's Statement of Conditions & Trade: A Building Maintenance Program Approach

Date: Winter 1998
Prepared by:
George Mills, SASHE, Director, Engineering & Compliance, ASHE
Douglas Erickson, FASHE, Codes & Standards, Consultant, ASHE
John Fishbeck, RA, Associate Director, JCAHO

Summary
Maintaining high-quality healthcare facilities is an ongoing endeavor that needs to be addressed in a management process, including the area of fire safety in the physical environment. The Joint Commission’s Environment of Care Standards™ (EC.1.7) already requires a life safety management plan. This technical document presents an approach for implementing a maintenance program for Life Safety Code® (LSC) compliance as a natural extension of this existing standard. Organizations may develop a building maintenance program for the physical environment similar to those programs for major components needing review; establishing frequencies of inspection, testing and adjustment; collecting historical data; and evaluating the data and making any changes to the program based on the data collection. Next, adjustments to the Building Maintenance Program and annual review for effectiveness would occur, ensuring compliance with the NFPA’s 101- 1997, Life Safety Code®.

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