The deficiencies are in the details

In reviewing the April 2024 edition of Joint Commission Perspectives, specifically the Consistent Interpretations column, I noticed that almost a third of the hospitals surveyed in 2023 were cited for issues relating to the weekly inspection of Emergency Power Supply System (EPSS) equipment, with the tipping point being (or so it would seem) the amount of detail included in the documentation of the weekly activities. This, I suspect, has a lot to do with what one can expect from the survey process going forward—it is not enough to document that the process was completed in a timely fashion. You also have to make sure that the process clearly indicates that each required element (more on how that sorts itself in a moment) is completed. But what does each required element even mean?

From a practical standpoint, there are those activities required by code, in this case, primarily NFPA 110 Standard for Emergency & Stand-By Power Systems (if you don’t have a copy, you should definitely be budgeting for that sooner rather than later), but then you have to take into account the manufacturer Instructions for Use (IFU) for whatever piece of equipment is in the mix. If you have more than one manufacturer of emergency generator equipment, can you “get away” with a single process for all of your generators (and equipment) or do you have to come up with a process for each type? This is where things can get murky, and it probably makes sense to work with whoever you have in line to perform the significant maintenance activities (most folks in my experience have to use external vendors for the “big jobs”) to ensure that you have all your “I’s” dotted and your “T’s” crossed.

As another example of what might be coming down the pipeline, there is some indication that some of the accrediting organizations are going to be looking for documentation of the monthly owner’s inspection of the fire suppression systems in kitchens. As a general rule, if you have a fire suppression system in the kitchen (and, if you have a kitchen, this is likely the case), then you have to comply with NFPA 96. Where things get a little tricky is that NFPA 96 requires you to comply with NFPA 17/17A (depending on whether you have a wet or dry system), both of which require a monthly owner’s inspection. The inspection elements are pretty straightforward, and probably could be managed through your work order system/process. For example:

  • The extinguishing system is in its proper location
  • The manual actuators are unobstructed
  • The tamper indicators and seals are intact
  • The maintenance tag or certificate is in place
  • No obvious physical damage or condition exists that might prevent operation
  • The pressure gauge(s), if provided, is in operable range
  • The nozzle blow-off caps are intact and undamaged
  • The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated

I suppose there have always been processes within processes—you need to ensure that not only is the activity completed in a timely fashion, but also ensuring that the process/activity is correctly administered, so make sure your documentation reflects not just the frequency, but the content as well.


About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at