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RTN1403_B5_EC.02.03.05 (EP5-6) – Notification Devices/No-flow Pumps


*EC: Effective Maintenance and Testing Protects Life Safety: Progressing further into EC.02.03.05: EPs 5 and 6, testing notification devices and no-flow fire pumps[®] [REF: EOC] EC News, March 2014, Vol 17, #3, Pg 5  JCe1403_B5

What is a ‘Churn Test’? How often should it be done and is it OK to start one manually? Not knowing the answer to such questions is one of the reasons EC.02.03.05 is one of the most frequently cited standards for TJC hospitals (EP6) in general, and our SPHCC member psychiatric hospitals (EP5) in particular. This article continues a series begun in December 2013 that has focused in detail on the requirements for compliance with each of this standard’s Eps.  Although the most frequently cited EP for our Psychiatric Hospitals is EP3, this article is an excellent review for this challenging standard.  EP5 focuses on the quarterly testing of notification devices. Did you know that documents related to fire alarm certification and fire alarm service providers should be located within 36 inches of the fire control panel? EP6 addresses the weekly Churn Test (for water-based fire protection systems) referenced at the beginning of this review.  If you didn’t know the answers, you should definitely read this article.  You should also know that the new CMS categorical waivers include one which allows the required weekly churn testing to be performed monthly for fire pumps that are electric motor-driven.   

Tip: Use the Checklist for Weekly No-Flow Fire Pump Testing provided in this article to guide your testing process. If your testing is performed by an outside contractor, include it as part of the contract to help ensure their compliant performance. 

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2 responses to “RTN1403_B5_EC.02.03.05 (EP5-6) – Notification Devices/No-flow Pumps”

  1. Below is our Review for Part 1 of the article:
    * EC: Maintaining Fire Equipment and Building Features: A deep dive into EC.02.03.05[®] [REF: EOC, SFT] EC News October 2013, Vol 16, #10, Pg 5 JCe1312_B5

    EC.02.03.05 has been among the top 10 most frequently cited during hospital surveys for the last 4 years. It has gradually fallen from #4 in 2010 to #6 in 2013. Still, TJC is sufficiently concerned enough that it is dedicating its Clarifications & Expectations series to the 21 EPs of this standard over the next several months. This article briefly overviews the intent of EPs 1-4, relating to Signal devices (EP1), Water-flow devices and valve tamper switches (EP2), Notification devices (EP3), Visual and Audible Fire Alarms (EP4). The survey activity related to each is briefly described and suggestions for assessing compliance is provided.

    Tip: This is a good review tool. Also, use the EC.02.03.05 Compliance Checklist (sidebar on page 7) as a guide for your FSA and mock survey/tracer activity for EOC.

    – See more at:


    Re: Categorical Waivers
    • EC: – Clarifications and Expectations: What the CMS Life Safety Code Waivers Mean for You: Getting your questions answered[®] [REF: CMS, EOC, SFT] EC News November 2013, Vol 16, #11, Pg 1 JCe1311_B8

    Two months ago in the 9/11/13 issue of Joint Commission Online, TJC reported on the seven topical areas (i.e., • Openings in exit enclosures • Emergency generators and standby power systems • Doors • Suites • Extinguishing requirements • Clean waste and patient record recycling containers • Medical gas alarms) in which CMS had granted Categorical Waivers. The waivers themselves were announced in CMS Survey and Certification Letter 13-58-LSC on 8/30/13. This article accomplishes two things:

    1 – It reports that four more topics (i.e., • Wheeled equipment in the egress corridor • One alternative kitchen cooking arrangement open to the egress corridor per smoke compartment • Direct vent gas fireplaces and solid fuel-burning fireplaces • Combustible decorations) have been added to the original seven and

    2 – Through a Q&A format, it provides a more in-depth explanation of categorical waivers, the 11 categories and more specifics about the actual waivers available in each.

    Tip: EOC and Safety leaders should review this article for a quick overview of what is addressed in each category of waiver and determine if any seem appropriate for your facility. If so, consult S&C 13-58-LSC for more details. Pay particular attention to the waiver available in the Doors category for psychiatric patients.
    See also: See this article’s “Comments” for additional background information and RTN1309_B5_CMS Waivers @ LSC/NFPA

    – See more at:

    • JCo: – CMS grants waivers to several areas of the Life Safety Code®[®] [REF: CMS, E&M, JCSC, SFT, LDR] Joint Commission Online, September 11, 2013, Pg 1 #JCo1309_B5

    Concern about potentially unreasonable hardship on organizations attempting to comply with selected Life Safety Code requirements has resulted in CMS granting waivers in the following areas:

    •Medical gas master alarms
    •Openings in exit enclosures
    •Emergency generators and standby power systems
    •Extinguishing requirements
    •Clean waste and patient record recycling containers

    TJC says, “Health care organizations can immediately take advantage of the waivers without seeking formal approval from CMS. However, organizations are expected to have written documentation that they have elected to use a waiver. This can be done by noting it in the “Additional Comments” field of the statement of conditions (SOC) in the basic building information (BBI) for those categorical waivers associated with the Life Safety Code. For the requirements in the Environment of Care (EC) chapter, organizations should document the decision in the EC committee minutes (or an equivalent place).” CMS S&C 13-58-LSC) explains the waiver process details including the conditions for alternative approaches.
    Tip: As per TJC, “Organizations should also notify the surveyor at the beginning of a survey that they have chosen the waiver. It is not acceptable for an organization to first notify surveyors of waiver election after an LSC citation has been issued”.

    – See more at:

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