Environment of Care (EC) (Critical Access Hospitals / Critical Access Hospitals)
Inspection Reports - Fire Safety Format
Publish | January 01, 0001
What is the required format for fire safety system inspection reports?
The Joint Commission does not require a specific format for fire safety system inspection reports since there is wide variation in the installed systems for the heath care organizations that TJC accredits. Standard EC.02.03.05 EP 25 requires the name of the activity, the date of the activity, the required frequency of the activity, the name and contact information (including affiliation) for the person who performed the activity, and the NFPA testing standard used (including the edition and section). It is also important to note that with regard to test results, because fire alarm and fire extinguishing systems are considered critical to a fire-safe environment, there is to be a documented pass/fail indication (result of the activity) for functional tests associated with each uniquely identified device or piece of equipment tested when identified in an EC.02.03.05 element of performance, if that component is installed in the facility. This includes each audible and visual device, each releasing device, each fire department connection, etc. Test results for input devices (detectors, pull stations, etc.) are to be distinguishable from test results for output devices (annunciating devices, releases, AHU shut-down, etc.) . There is to be documented evidence that each deficiency identified was corrected in a timely manner. The report should be formatted so that the person presenting the report during a TJC survey is familiar with the content. A common issue during the survey process is that the organization is not adequately familiar with the content of the report and the configuration of their fire safety systems. An effective way to accomplish this is for the testing entity to closely review the report with the organization's representative. [EC.02.03.05]
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