Q&A: New Testing and Inspection Requirements for Healthcare Facilities

  September 23, 2016

By Cathryn Jakicic

Brad Keyes, CHSP, owner of KEYES Life Safety Compliance, writes a weekly column for the Healthcare Facilities Today website. His expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.

Q: I met with our facility engineer and CEO on the required inspections to be compliant with the new 2012 Life Safety Code prior to November of this year. I stated that all testing would need to be completed prior to November, which included the smoke and fire damper tests which are due every 6 years, along with the standpipe flow tests which are due every 5 years.  Ours are not due until 2019. The CEO is wanting to see the requirement that these must be performed “early” by November of 2016 in writing. I may have stated this requirement to them incorrectly.  If so, please let me know.  Could you please direct me to where I can find documentation to back up the requirements?

A: The new requirements called for in the 2012 Life Safety Code need to be completed by November 1, 2016… not the existing requirements. If you last performed fire damper tests in 2013, then you do not have to do them again until 2019. There is no requirement to perform existing tests by November 1, 2016.

New requirements (testing and inspection) that are called for in the 2012 LSC that were never required before, and which you need to have completed by November 1, 2016 are:

Fire door testing (all side-hinged fire door assemblies need to be tested annually)

• Fire hose valve inspections (quarterly)

• Fire hose valve tests (2.5 inch annually; 1.5 inch every 3 years)

• Sprinkler pipe inspections (every 5 years)

• One main drain test if sprinkler water is through a backflow preventer (quarterly)

• Fire drills in OR (annually)


The point is… these items above are new requirements, something that was never required before. Some are quarterly… some are annually… and some are required less frequent than annually. But the first test/inspection must be completed by November 1, 2016. CMS says in their S&C memo 16-29 that hospitals have to be fully compliant with the 2012 LSC by then.

This Quick Read was submitted by Cathryn Jakicic, Healthcare Industries Editor, Facilities.net




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