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The Joint Commission requires facilities to perform and document proper NFPA code inspections. This page provides the explanations, frequency and a direct link to all the Joint Commission inspection forms (in electronic format) required to be completed in order to be a Joint Commission approved facility. (Standard: Environment of Care, EC.02.03.05)

List of the Joint Commission Inspection Forms, Frequencies & NFPA Code References
NFPA 72 Requirements

1. At least quarterly, the organization tests supervisory signal devices on the inventory (except valve tamper switches). The results and completion dates are documented.
Note 1: For additional guidance performing tests, see NFPA 72-2010: Table 14.4 .5.
Note 2: Supervisory signals include the following: control valves; pressure supervisory; pressure tank, pressure supervisory for a dry pipe (both high and low conditions), steam pressure; water level supervisory signal initiating device; water temperature supervisory; and room temperature supervisory.

2. Every 6 months, the organization tests vane-type and pressure-type water flow devices and valve tamper switches on the inventory. The results and completion dates are documented.
Note 1: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5.
Note 2: Mechanical water-flow devices (including, but not limited to, water motor gongs ) are tested quarterly. The results and completion dates are documented. (For full text, refer to NFPA 25-2011: Table 5.1.1.2)

3. Every 12 months, the organization tests duct detectors, heat detectors, manual fire alarm boxes, and smoke detectors on the inventory. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5; 17.14.

4. Every 12 months, the organization tests visual and audible fire alarm s, including speakers and door-releasing devices on the inventory. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 72- 2010: Table 14.4 .5.

5. Every 12 months, the organization tests fire alarm equipment on the inventory for notifying off-site fire responders. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 72-2010: Table 14.4.5.

28. Documentation of maintenance, testing, and inspection activities for EC.02.03.05, EPs 1-20, 25 (including fire alarm and fire protection features) includes the following:
– Name of the activity
– Date of the activity
– Inventory of devices, equipment, or other items
– Required frequency of the activity
– Name and contact information, including affiliation, of the person who performed the activity
– NFPA standard(s) referenced for the activity
– Results of the activity
Note: For additional guidance on documenting activities, see NFPA 25-2011: 4.3; 4.4; NFPA 72-2010: 14.2.1; 14.2.2; 14.2.3; 14.2.4; NFPA 101-2012: 18/19.7.2.1.5.10.1; 7.2.1.5.11.

NFPA 25 Requirements

6. For automatic sprinkler systems: The organization tests electric motor-driven fire pumps monthly and diesel engine – driven fire pumps every week under no-flow conditions. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 25-2011: 8.3.1; 8.3.2.

7. For automatic sprinkler systems: Every six months, the organization tests water-storage tank high- and low-water level alarms. The results and completion dates are documented.
Note: For a additional guidance on performing tests, see NFPA 25-2011: 9.3; Table 9.1.1.2.

8. For automatic sprinkler systems: Every month during cold weather, the organization tests water-storage tank temperature alarms. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 25- 2011: 9.2.4; Table 9.1.1.2.

9. For automatic sprinkler systems: Every 12 months, the organization tests main drains at system low point or at all system risers. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 25-2011: 13.2.5; 13.3.3.4; Table 13.1.1.2; Table 13.8.1.

10. For automatic sprinkler systems: Every quarter, the organization inspects all fire department water supply connections. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 25-2011: 13.7; Table 13.1.1.2.

11. For automatic sprinkler systems: Every 12 months, the organization tests fire pumps underflow. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 25-2011: 8.3.3.

12. Every 5 years, the organization conducts hydrostatic and water-flow tests for standpipe systems. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 25-2011: 6.3.1; 6.3.2; Table 6.1.1.2.

17. The organization conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and every 3 years thereafter er. The results and completion dates are documented.
Note: For additional guidance on hydrostatic testing, see NFPA 1962-2008: Chapter 7 and NFPA 25-2011: Chapter 6.

NFPA 96 Requirements

13. Every 6 months, the organization inspects any automatic fire -extinguish ing system in a kitchen. The results and completion dates are documented.
Note 1: Discharge of the fire-extinguishing systems is not required.
Note 2: For additional guidance on performing ing inspections, see NFPA 96-2011: 11.2.

NFPA 13/12A Requirements

14. Every 12 months, the organization tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The results and completion dates are documented.
Note 1: Discharge of the fire-ext inguishing systems is not required.
Note 2: For full text, refer to NFPA 13-2011: 4.8.3 and NFPA 12A-2009: Chapter 6.

NFPA 10 Requirements

15. At least monthly, the organization inspects portable fire extinguishers. The results and completion dates are documented.
Note 1: There are many ways to document the inspections, such as using bar-coding equipment, using check marks on a tag, or using an inventory.
Note 2: Inspections involve a visual check to determine the correct type of and clear and unobstructed access to a fire extinguisher, in addition to a check for broken parts and full charge.
Note 3: For additional guidance on inspection of fire extinguishers, see NFPA 10-2010: 7.2.2; 7.2.4.

16. Every 12 months, the organization performs maintenance on portable fire extinguishers, including recharging. Individuals performing annual maintenance on extinguishers are certified. The results and completion dates are documented.
Note 1: There are many ways to document the maintenance, such as using bar-coding equipment, using check marks on a tag, or using an inventory.
Note 2: For additional guidance on maintaining fire extinguishers, see NFPA 10-2010: 7.1.2; 7.2.2; 7.2.4; 7.3.1.

NFPA 80/90A/105 Requirements

18. The organization operates fire and smoke dampers one year after installation and then at least every six years to verify that they fully close. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 90A-2012: 5.4.8; NFPA 80-2010: 19.4; NFPA 105-2010: 6.5.

19. Every 12 months, the organization tests automatic smoke-detection shutdown devices for air-handling equipment. The results and completion dates are documented.
Note: For additional guidance on performing tests, see NFPA 90A-2012: 6.4.1.

20. Every 12 months, the organization tests sliding and rolling fire doors, smoke barrier sliding or rolling doors, and sliding and rolling fire doors in corridor walls and partitions for proper operation and full closure. The results and completion dates are documented.
Note: For full text, refer to NFPA 80 -2010: 5.2.14.3; NFPA 105-2010: 5.2.1; 5.2.2.

25. The organization has annual inspection and testing of fire door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Test ing begins with a pre-test visual inspection; testing includes both sides of the opening.
Note 1: Nonrated doors, including corridor doors to patient care rooms and smoke barrier doors, are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.
Note 2: For additional guidance on testing of door assemblies, see NFPA 101-2012: 7.2.1.5.10.1; 7.2.1.5.11; 7.2.1.15; NFPA 80-2010: 4.8.4; 5.2.1; 5.2.3; 5.2.4; 5.2.6; 5.2.7; 6.3.1.7; NFPA 105-2010: 5.2.1.

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