There’s nothing more frustrating to a Joint Commission Life Safety Code® Surveyor than a document review that exceeds 90 minutes for a single building. Conversely, one of the most constructive steps you can take is to have a handle on how long it takes you to present all the required facility maintenance related documents. Time yourself. If it takes you more than 90 minutes, expect eyes to roll. Kid you not, a well-organized document review sets the tone for your survey.  

The entire document review hinges upon four standards: EC 02.03.05; EC 02.05.07; EC 02.05.09 & LS.01.02.01. Therefore, your binder should be organized accordingly. Now, let’s talk content. I can’t emphasize enough the importance of having ALL your documentation available during the document review. Surveyors are trained not to accept documentation after the document session is completed. So, let’s go through each section of the binder, one at a time, so we can knock this review out in 90 minutes. Start your timer. 

The First 45 Minutes: EC 02.03.05  

Fire Protection & Suppression Testing and Inspection (EPs 1-28.) Tab your binder to reflect the element of performance. If the EP requires monthly testing, insert twelve sections which correspond to the past 12 months. The same applies to quarterly and semi-annual testing, respectively.  

Each element of performance must be device specific. In other words, you must have a complete inventory that references the test outcome for ALL devices.  

Tip:  The following EPs are scored more frequently than the others with this standard: 

  • EP 6: Record the run time, suction and discharge pressures, in addition to, diesel engines record battery status. 
  • EP 11: Record the run time, volts, and amps.* 
  • EP 18: Record 1-year inspection after installation for all newly installed dampers. 
  • EP 19: Record HVAC shutdown test results for air handlers. 

Note: If there’s a recorded device failure, close the loop. Record the status as open or closed. 

*Be sure to easily have available the last two years of test results for EP 9 and EP 11, respectively. 

The Next 15 Minutes: EC 02.05.09 Medical Gas System Inspections (EPs 1-14) 

  • EP 7: Develop a policy that identifies the testing frequency. 
  • EP 12: Develop a policy that identifies physically segregating full and empty cylinders from each other to assist staff in selecting the proper cylinder. 

Note: Again, if there’s a recorded device failure, please close the loop. Record the status as open or closed. 

20 Minutes in the Home Stretch: EC 02.05.07 Emergency Power Systems (EPs 1-10) 

Use the same approach as you did for EC 02.03.05. Tab your binder inserts to reflect the number of elements of performance (EPs). Each EP is device- or equipment-specific. If there’s a recorded device or equipment failure, please close the loop. Record the status as either open or closed.  

A Few More Tips:

The letter D that’s placed before each EP indicates that documentation is required. EP 1: Present a written inventory of all battery powered lights and EXIT LIGHTS with the test/inspection results. 

EP 4: Record the generator battery status in the form of voltage or electrolyte levels weekly. Check specific gravity monthly. 

EP 6: Validate the annual load bank documentation to ensure the load test is at least 1 hour and 30 minutes (50% load for 30 minutes, 75% load for 1 hour).  

EP 7: Ensure ALL automatic transfer switches (ATS) are inventoried, tested, and documented each month. 

EP 10: Record the test result of all retested equipment and devices.

Note: Record test results of all failed equipment that was retested and placed back into service. In our experience, this step is frequently overlooked. 

The following are acceptable Joint Commission testing intervals: 

  • Every 36 months/every 3 years = 36 months from the last event, plus or minus 45 days 
  • Annually/every 12 months/once a year/every year = 1 year from the last event, plus or minus 30 days 
  • Every 6 months = 6 months from the last event, plus or minus 20 days 
  • Quarterly/every quarter = every 3 months, plus or minus 10 days 
  • Monthly/30-day intervals/every month = 12 times a year, once per calendar month 
  • Every week = once per calendar week 

The Final 10 Minutes: LS 01.02.01 Interim Life Safety Measures (ILSM) (EPs 1-15) 

Organizations are required to have an ILSM policy and a risk assessment that identifies when and to what extent Interim Life Safety Measures are implemented. 

Interim Life Safety Measures are probably the most underutilized standard in the Life Safety Chapter. There is a purpose, however, for implementing ILSM as they relate to life safety. It’s simply to perform a risk assessment to evaluate an identified deficiency within the organization’s fire alarm system that could not be corrected in four hours or an identified deficiency within the sprinkler system that could not be corrected within 10 hours in a 24-hour period. Identified fire or smoke barrier penetrations are risk-assessed on a case-by-case basis to determine whether implementing ILSM are appropriate. So, you’ll want to have this in place and available.  

Here are a few last tips for getting these standards organized and through a timely review process. 

  • Have a copy of the Document Review Checklist, which is provided by the Joint Commission. 
  • Have all the documentation on hand and organized.  
  • Lastly, have the subject-matter experts present.  

If you’re prepared in this way, the time it takes to address questions and assess your compliance with the standards will be drastically reduced. If you nail your document review to 90 minutes, you will have delivered a knock-out punch in round 1. Now, your surveyor can glide into round 2, the building tour, whistling “Zip-A-Dee-Doo-Dah” for the rest of the day. 


About Ken Blackwell, LCSC, CHSP

Ken Blackwell, LCSC, CHSP, is a Senior Consultant with Compass Clinical Consulting. A former Joint Commission surveyor, Ken has surveyed nearly 600 healthcare organizations, including military hospitals and Veterans Health Administration facilities. He has nearly 20 years of experience in the healthcare industry, with expertise in the accreditation and regulatory standards and a commitment to continuous quality improvement in the areas of life safety, fire safety, equipment management, emergency management, utilities management, and safety management. Read more about Ken.


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