Proper inspection, testing and maintenance of hospital fire alarm and suppression systems keeps patients, visitors, staff and providers safe from harm.

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It’s the first day of the triennial Joint Commission survey, and the life safety engineer sits down to look at the documentation. They say, “Let’s start with [The Joint Commission] EC.02.03.05. Let’s grab the great big notebook full of paper, take a deep breath and dive in head first.”

Fire alarm and fire suppression documentation for any regulatory agency is one of the most important responsibilities of a facility manager. Proper inspection, testing and maintenance (ITM) of hospital fire alarm and suppression systems keeps patients, visitors, staff and providers safe from harm of fire and products of combustion, such as smoke. It allows them to go about their work without worry that the building will not protect them from adverse events. Documentation of this ITM is vital to ensuring this safety, as well as ensuring ongoing accreditation by the deemed authority.

The requirements of fire alarm and suppression testing and documentation are reviewed here. Tips on keeping this documentation clear and surveyor friendly is provided, as well as tools to select the right testing company, if the facility chooses to use one. In this way, a deep breath won’t be needed at survey time.

Documentation requirements

All facilities managers have read the EC.02.03.05 standard and the associated 23 elements of performance (EPs) or the associated Centers for Medicare & Medicaid Services (CMS) K-tags (K345, K352, K353, K355 and K531). Most are very good at assuring completion of the appropriate weekly, monthly, quarterly, semiannual and annual testing. But many fail in assuring the documentation is complete and accurate.

EC.02.03.05 EP 28 is very clear in describing what must be documented:

  • Name of activity (e.g., testing of supervisory signals).
  • Date of testing.
  • Inventory.
  • Required frequency (e.g., quarterly testing of supervisory signals).
  • Name, contact and affiliation of person performing activity. The facility manager must assure that the ITM vendor (if the hospital uses one) provides the full name, contact number and any credentials of the individuals performing the activity on all documentation.
  • National Fire Protection Association (NFPA) standards for the activity. The facility manager must assure that the documentation has the correct standards on the report. They should match the standards on the report to those listed in The Joint Commission standards or CMS Conditions of Participation.
  • Results of the activity. Did the device pass or fail? If it failed, was it repaired and re-tested? When it was re-tested, did it pass?

Accurate inventory

Health facility managers should start with an accurate inventory of all fire alarm and suppression devices to assure that the requirements are met. Each of the elements of performance listed in EC.02.03.05 specifically states that testing must be completed on those items listed on the inventory.

A sample template to track the inventory and compare it against testing completed throughout the year.

Graphic by Carol J. McCormick, SASHE, CHFM

Managers should remember that the inventory is different than the ITM report. The table on above, which can be accessed as a spreadsheet by American Society for Health Care Engineering (ASHE) members, is a sample template to track the inventory and compare it against testing completed throughout the year. It is also important for facility managers to remember to track any changes made during construction projects and maintenance work so the inventory remains current.

A good practice is to require all general contractors or fire detection and suppression subcontractors to provide a list of all added devices as well as any changes made to the current system during a project. Payment for the project can be held until this information is provided.

Facility managers should ensure the inventory includes supervisory signals, water flows, tampers, duct detectors, heat detectors, pull stations, smoke detectors, audio and visual devices, door releasing devices, fire extinguishers, fire/smoke dampers, and any sliding/rolling fire doors and fire door assemblies (including frame, door and walls.). 

Any additions can quickly be added to the spreadsheet with a note describing why the inventory changed.

Presentation for review

Facility managers generally agree that if the document review goes well, the rest of the survey is likely to go well. The documentation review sets the tone. The presentation of documents is very important because it is the first impression the life safety surveyor has of the hospital.

The following information outlines how to organize and present documents to a surveyor, administrator or anyone else who may need to see them. A successful practice is to provide the surveyor with one notebook for EC.02.03.05 (if possible). Facility managers should present the documents by EP with a tab separating each EP. If there is an EP that is not applicable to the facility, they should place a note under this tab that states “This EP is not applicable.”

The best practice includes the following in the notebook:

  • A summary spreadsheet that includes inventory of all devices.
  • Twelve months of data. (Remember that surveyors can ask for three years of data.)
  • A copy of a closed work order from the computerized maintenance management system (CMMS), signed and dated by the facility engineer in charge of the item and the vendor that did the testing (if applicable).
  • A report from the vendor, if applicable, with the specific EP completion documented and highlighted. Some vendors will document numerous EPs on one report. Facility managers should make copies and highlight the specific item for that EP and place it in the appropriate tab, if necessary.
  • The deficiency summary that shows date of deficiency, date of correction, and date of retest and pass.
  • A copy of all closed work orders from the CMMS system for all deficiencies, signed and dated by the facility engineer assigned to the work order, and the vendor that completed the repair (if applicable)
  • A copy of all interim life safety measure (ILSM) assessments and any implemented ILSMs due to deficiencies.

To vendor or not?

One of the biggest questions faced by a facility manager is whether or not to keep fire detection and suppression testing in-house or outsource it to a third party. Numerous things should be considered to truly answer this question.

It is recommended to complete a risk assessment that answers the following questions:

  • Does the facility have the staff to appropriately complete all required testing (yes or no)?
  • Is only testing going to be in-house, or will repairs and maintenance also be done in-house?
  • Does the facility have staff that is qualified (licensed or certified) to complete required testing (yes or no)?
  • What is the cost associated with the staff to complete the testing and certification? What is the cost of staff to repair and maintain the system? Do they have the knowledge and training to repair and reprogram the system, if necessary? What is the cost of software to properly document ITM?
  • Are there any city, state, regional or national codes that prohibit in-house testing of this manner? For example, Omaha, Neb., strongly discourages back-flow testing to be completed in-house.
  • Other questions that may be specific to a particular facility, city or region.

If the decision is made to go with a third-party vendor, the facility manager must determine the vendor’s qualifications. Facility managers should interview two to three vendors and determine the following:

  • Does the company have the required certifications for the city, state and region?
  • Does the company have a clear and deep knowledge of the requirements of applicable codes and standards, and knowledge of health care requirements?
  • Does the company have experience in ITM in a health care setting? If a vendor doesn’t, who will spend the time training the vendor to work in a health care environment?
  • Does the company have the bandwidth to take on the facility or facilities? Does the company understand the importance of timely testing and inspection? The last thing a facility manager wants is to get a call from the facilities ITM vendor delaying testing and inspection that has a defined completion time.
  • Require no less than three references from other clients. Call each of the references and ask: Does the company keep appropriate certifications up to date? Does the company provide daily updates of any deficiencies during a testing cycle? Are the inspectors courteous, polite and dressed appropriately? Do the inspectors follow appropriate policy and procedure, as provided by the facility during training?
  • Does the company use a specific software program? There are a number of commercial software programs for ITM of fire alarm systems. Software is not necessary, but it is normally easier for tracking purposes, especially for device failures. How the company documents should be a significant consideration, but not a specific point of elimination. A high-quality vendor will know the code and documentation requirements.
  • Can the company provide a sample report? Facility managers should check the report to assure that all CMS conditions of participation and Joint Commission requirements are included.
  • Does the format of the report align with the hospital’s expectations? Is the report simple to follow? Does it include all the necessary information to ensure the testing is completed correctly? Can the report be accessed online? The ability to review reports in real time instead of waiting for paper provides up-to-date information. This allows deficiencies to be corrected quickly and ILSMs to be implemented in a timely manner.
  • Is the vendor able and willing to customize the reports to a specific facility, state and region? If the vendor says no, they should be challenged. Many programs can be customized with a little extra time and effort.
  • What does the service cost? Is a contract necessary? How many years of service does the vendor require on the contract? Facility managers should get a very specific listing of the items provided under the contract. They should double check to ensure that all required testing is listed in the contract. Is there an additional cost to set up in the software system, or is it included in the contract price?
  • Does the vendor provide testing for both fire alarm/detection and fire suppression? Does the company excel at both? Facility managers should evaluate what is best for the facility. There are pros and cons to both, depending on specifics for various vendors. Using multiple vendors means more to track and additional coordination.
  • Does the vendor provide service as well as testing and inspection? Will the company fix a deficiency immediately when it is found during inspection or will it need to come back on a time and material basis?
  • Provide the vendor with the timelines and deadlines necessary to keep the ITM program up to date. If they hesitate when asked if they can meet them, they are not the best fit for the hospital.

The interview process for finding the correct vendor for fire alarm/detection and fire suppression testing is vital to the success of a program. Managers should make sure that all questions are answered thoroughly and completely. They should re-ask questions if a complete and thorough answer is not given. Facility managers should make sure the vendor understands the importance of this program and is willing to meet the hospital’s requirements. Above all else, they should not compromise.

Tips and tricks

The documentation process for proper fire alarm/detection and fire suppression testing can be daunting. A few more tips and tricks include:

  • Use the resources that are available through ASHE, the local ASHE Chapter, NFPA, The Joint Commission and Joint Commission Resources.
  • Network and ask colleagues. Many facility managers have developed best practices over the years and continue to refine them as codes change. They can be found at the local ASHE chapter meeting.
  • Become a member of ASHE, the National Fire Protection Association (NFPA) and any other professional organization that provides resources for maintaining a quality compliance program.
  • Join ASHE and use the MyASHE online member community. This is a great place to network with other people in the field and get questions answered. Members are more than willing to share documents they have developed over the years.
  • Create a robust library of necessary NFPA code books, Facility Guidelines Institute (FGI) Guidelines and other resources to help answer any questions that may arise. Suggestions include NFPA 10, 25, 72, 80, 99, 101 and 105 regulations, plus the appropriate FGI Guidelines for the hospital’s state. All NFPA codes can be accessed online through a subscription. Several codes also can be purchased as apps and stored on personal devices.

Breathe easy

Facility managers must have a variety of items ready during the EC.02.03.05 portion of the accreditation document review.

Documents in good order with an up-to-date inventory of all devices, an easy-to-follow method of presentation and documentation that includes all necessary requirements will enable any facility manager to be successful.

Whether the hospital chooses to perform ITM in-house or utilize a vendor, these tips will make breathing easier. 

Carol J. McCormick, SASHE, CHFM, is the facilities director at CHI Health in Nebraska. She can be reached at She was assisted by Paul Cantrell, CE, CPE, CHFM, of Lahey Health, Burlington, Mass.