Regulatory Compliance EC/LS Audit

• Regulatory Compliance EC /LS Audit

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Follow Up to be performed before:

  Date

• Name of person conducting survey:

  Sign

• Contact Information:

  Sign

• Is the occupancy healthcare, ambulatory healthcare or business?

  Healthcare

  Ambulatory

  Business

The hospital designs and manages the physical environment to comply with the Life Safety Code.

• LS.01.01.01 EP 1. The hospital assigns an individual(s) to assess compliance with the Life Safety Code, complete the eSOC and manage the resolution of deficiencies.

  Compliant

  Non-Compliant

  PFI

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP2 The hospital maintains a current electronic Statement of Conditions. <br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Problem identified -isolated /facility wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP3 When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by The Joint Commission. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction. (ILSM)

• LS. 01.02.01 EP 1 The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented (NFPA 101-2000: 9.6.1.8 and 9.7.6.1)<br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 2 The hospital posts signage identifying the location of alternative exits to everyone affected.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 3 The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP4 Inspects exits in affected areas on a daily basis. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP5 Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP6 Provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital's interim life safety measure (ILSM) policy.<br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP7 Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP8 Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.0 EP9 Enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP10 Provides additional training to those who work in the hospital on the use of firefighting equipment. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP11 Conducts one additional fire drill per shift per quarter. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP12 Inspects and tests temporary systems monthly. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP13 The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP14 The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital manages risks associated with its utility systems.

• EC.02.05.01 EP 6 (CLD) In areas designed to control airborne contaminants, the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.01 EP7 The hospital maps the distribution of its utility systems. <br>

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.01 EP 8 The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital inspects, tests, and maintains emergency power systems

• EC.02.05.07 EP 1 Battery powered egress lights are tested monthly for 30 seconds.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 2 Battery powered egress lights are tested annually for 90 seconds

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 3 quarterly function of SEPSS for 5 min./class / 60% full duration of class Annually.<br>SEPSS for critical areas inspected monthly

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 4. Twelve times a year, once a month or at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 5. monthly load test 30% of exhaust gas temp or annual load bank 20/50/75%

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 6. All transfer switches 12 times per year.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 7. Generator load test once every 36 months for 4 hours. (30%of nameplate)

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital establishes and maintains a safe, functional environment.

• EC.02.06.01 EP 13 (CLD) The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided.

  Yes

  No

  N/A

• Problem identified - Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

Building tour deficiencies (as applicable)

• Other:

  Work order

• Follow up needed:

  Healthcare

  Ambulatory

  Business

Asset History: At a minimum, check at least 3 assets and validate history.

• Asset # 1

  Yes

  No

  N/A

• Asset # 2

  Yes

  No

  N/A

• Asset # 3

  Yes

  No

  N/A

The Organization provides and maintains fire alarm systems.

• LS.02.01.34 EP 1 The fire alarm signal automatically transmits to a Central Monitoring station as described in NFPA 72 1999; 5-2

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34 EP 2 The master fire alarm control panel is located in a protected environment (an area enclosed with a 1-hour fire-rated walls and 3/4-hour fire-rated doors) that is continuously occupied or in an area with a smoke detector.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34 EP 3 The remote ancillary annunciator panel is in a location approved by the local fire department or its equivalent.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34 EP 4 Pull stations are unobstructed.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The Clinic provides and maintains systems for extinguishing fires.

• LS.02.01.35 EP 5 Sprinkler heads are not damaged and are free from corrosion, foreign materials and pain.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 6 There are 18" or more of open space maintained below the sprinkler deflector to the top of storage.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 8 The travel distance from any point to the nearest fire extinguisher is 75 ft. or less.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization prohibits smoking.

• EC.02.01.03 EP 1 Smoking is not permitted in the organization.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization conducts fire drills.

• EC.02.03.03 EP 2 The organization conducts fire drills every 12 months from the date of the last drill in each area that is defined as a business occupancy per year in each building defined as business occupancy by the Life Safety code and in which care, treatment or services are provided. Note 1: IN leased or rented spaces, drills need to be conducted only in areas of the building organization occupies.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization maintains fire safety equipment and fire safety building features.

• EC.02.03.05 EP 1 At least quarterly, the organization tests supervisory signals devices (except valve tamper switches).

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 2 Water flow devices are checked quarterly, while tamper switches are checked semi-annual.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 3 Every 12 months, the organization tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 4 Every 12 months, the organization tests visual ad audible fire alarms, including speakers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 5 Every quarter, the organization tests fire alarm equipment for notifying off-site fire responders.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 6 For automatic sprinkler systems: Every week, the organization tests fire pumps under no-flow conditions.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 7 For automatic sprinkler systems: Every 6 months the organization tests water-storage tank high-and low-water level alarms. The completion date is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 8 For automatic sprinkler systems: Every month during cold weather, the organization test water - storage tank temperature alarms. The completion date of the test is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 9 For automatic sprinkler systems: Every 12 months, the organization tests main drains at system low point or at all system risers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 10 For automatic sprinkler systems: Every quarter, the organization inspects all fire department water supply connections.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 11 For automatic sprinkler systems: Every 12 months, the organization tests fire pumps under flow.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 12 Every 5 years, the organization conducts water-flow tests for standpipe systems.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 13 Every 6 months, the organization inspects any automatic fire-extinguishing systems in a kitchen.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 14 Every 12 months, the organization tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The completion date of the test is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 15 At least monthly, the organization inspects portable fire extinguishers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 16 Every 12 months, the organization performs maintenance on portable fire extinguishers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 19 Every 12 months, the organization tests automatic smoke-detection shutdown devices for air-handling equipment.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 20 Every 12 months, the organization tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization inspects, tests and maintains emergency power system.

• EC.02.05.07 EP 1 At least monthly the organization performs a functional test of all battery-powered lights required for egress for a minimum of 30 seconds. The completion date is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 2 Every 12 months, the organization performs a functional test of battery-powered lights required for egress for a duration of 1 1/2 hours. The completion date is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 4 At least monthly the organization tests each emergency generator ay least 30 continuous minutes.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP EP 5 Diesel generators need to be tested annually. Non-diesel generators do not require an annual test.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 7 Every 36 months organizations with a generator providing emergency power shall test each generator for a minimum of 4 continuous hours.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital designs and manages the physical environment to comply with the Life Safety Code.

• LS.01.01.01 EP 1 The hospital assigns an individual(s) to assess compliance with the Life Safety Code, complete the eSOC and manage the resolution of deficiencies.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP 2 The hospital maintains a current electronic Statement of Conditions.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP 3 When the hospital plans to resolve a deficiency though a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by the Joint Commission.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP 4 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspection and approvals made by state or local fire control agencies.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital protects occupants during periods when the Life Safety Code in not met or during periods of construction. (ILSM)

• LS.01.02.01 EP 1 The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24 hour period in an occupied building. Notification and fire watch times are documented (NFPA 101-2000: 9.6.1.8 and 9.7.6.1)

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 2 The hospital posts signage identifying location of alternative exits to everyone affected.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 3 The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 4 Inspects exits in affected areas on a daily basis.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 5 Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 6 Provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital's interim life safety measure (ILSM) policy.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 7 Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 8 Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 9 Enforces storage, housekeeping, and debris removal practices that reduce the building's flammable and combustible fire load to the lowest feasible level.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 10 Provides additional training to those who work in the hospital on the use of firefighting equipment.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 11 Conducts one additional fire drill per shift per quarter.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 12 Inspects and tests temporary systems monthly.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 13 The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 14 The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

• LS.02.01.10 EP 5 Doors are equipped with self closing and self latching devices. Gaps between meeting edges of door pairs are no more than 1/8" wide and undercuts are no larger than 3/4".

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.10 EP 7 Doors requiring fire rating of 3/4 hour or linger are free of coverings, decorations, or other objects applied to the door face, with the exception of information signs.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.10 EP 8 Ducts that penetrate a 2-hour fire-rated separation are protected by dampers that are fire-rated for 1 1/2 hours.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital provides and maintains fire alarm systems.

• LS.02.01.34. EP 2 The master fire alarm control panel is located in a protected environment (an area enclosed with a 1-hour fire rated walls and 3/4-hour fire rated doors) that is continuously occupied or in an area with a smoke detector.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34. EP 3 The remote ancillary annunciator panel is in a location approved by the local fire department or its equivalent.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34. EP 4 Pull stations are unobstructed.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital provides and maintains systems for extinguishing fires.

• LS.02.01.35 EP 5 Sprinkler heads are not damaged and are free from corrosion, foreign materials and paint.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 6 There are 18" or mor of open space maintained below the sprinkler deflector to the top of storage.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 8 The travel distance from any point to the nearest fire extinguisher is 75 ft. or less.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 9 Class K - type portable fire extinguishers are located within 30 feet of grease-producing cooking devices.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 11, 12, and 13 The automatic fire extinguishing system for grease producing devices:<br>EP 11 Activates the building fire alarm system.<br>EP 12 Deactivates the fuel source.<br>EP 13 Controls the exhaust fans as designed.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital maintains fire safety equipment and fire safety building features.

• EC.02.03.05 EP 1 At least quarterly, the hospital tests supervisory signal devices ( except valve tamper switches).

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 2 Every 3 months, the hospital tests valve tamper switches and water-flow devices.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 3 Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 4 Every 12 months, the hospital tests visual and audible fire alarms, including speakers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 5 Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 6 For automatic sprinkler systems: Every week, the hospital tests fire pumps under no-flow conditions.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 7 For automatic sprinkler systems: Every 6 months the hospital tests water-storage tank high and low water level alarms. The completion date is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 8 For automatic sprinkler systems: Every month during cold weather, the hospital tests water storage tank temperature alarms. The completion date of the test is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 9 For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 10 For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 11 For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 12 Every 5 years, the hospital conducts water flow tests for standpipe systems.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 13 Every 6 months, the hospital inspects any automatic fire extinguishing systems in a kitchen.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 14 Every 12 months, the hospital tests carbon dioxide and other gaseous automatic fire extinguishing systems. The completion date of the test is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 15 At least monthly, the hospital inspects portable fire extinguishers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 16 Every 12 months, the hospital performs maintenance on portable fire extinguishers.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 17 The hospital conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and 3 years thereafter. Completion date is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 18 The hospital operates fire and smoke dampers 1 year after installation (commencing Jan 2010) and then at least every 6 years to verify that they fully close.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 19 Every 12 months, the hospital tests automatic smoke detection shutdown devices for air handling equipment.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 20 Every 12 months, the hospital tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 25 Documentation of maintenance, testing, and inspection activities for fire alarm and water based fire protection systems includes the following:<br>*Name of the activity<br>*Date of the activity<br>*Required frequency of activity<br>*Name and contact information, including affiliation of the person who performed the activity.<br>*NFPA Standard referenced for the activity (This information must be on ALL reports reflected in the Elements of Performance for EC.02.03.05.<br>*Results of the activity.<br><br>NOTE: Additional guidance on documenting activities, see NFPA 25, 1998 edition (Section 2.13) and NFPA 72, 1999 edition (Section 7-5.2)

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital inspects, tests, and maintains emergency power systems.

• EC.02.05.07 EP 1 Battery powered lights are tested monthly for 30 seconds.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 2 Battery powered lights are tested annually for 90 minutes.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 3 Quarterly functional test of SEPSS for 5 min/class. 60% full duration of class/annual.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 4 Twelve times a year, the hospital tests each emergency generator for at least 30 continuous minutes.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 5 Monthly load test 30% or exhaust gas temp or annual load bank 25/50/75%.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 6 All transfer switches 12 times per year.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 7 Generator load test every 3 years for 4 hours.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 8 Generator 4 hours test at least 30% of nameplate.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

Medical Gas and Vacuum Systems are Inspected.

• EC.02.05.09 EP 1 Review maintenance program and testing documentation.<br>*Test, inspect & maintain master panels, area alarms, automatic pressure switches, shut off valves, flexible connectors, and outlets.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization establishes and maintains a safe, functional environment.

• EC.02.06.01 EP 13 (CLD) The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided.

  Yes

  No

  N/A

• Problem Identified - Isolated/Facility Wide

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion: