Documentation over the past few years has become more of a focus during accreditation surveys. This is partially due to the many different versions of the NFPA that are being utilized today. For example, NFPA 101’s current edition is the 2018 edition, but CMS and hospitals are operating on the 2012 edition. Meanwhile, there is also a 2015 edition of the NFPA 101 as well.

Having different versions causes confusion with vendors. They are trying to stay up to date with the current version of the codes, or the inverse they are still working off an older code. Vendors unfortunately struggle with understanding the requirements for hospitals. They can become somewhat of an adversary to you and your organization because of not understanding the difference between healthcare and business/commercial occupancies.

Most vendors come into a healthcare environment expecting to have less work to do because of the business world’s testing standards being much more relaxed. When surveying, I would still see issues (as late as 2020) with inventory and NFPA required documentation of the items tested. This was due to vendors who did not understand or refused to provide a report that breaks out each unit as requested.

Once vendors realize that they must provide a detailed report to meet healthcare standards, they immediately panic and push back on requests. This can put the facility director in a tough position and in a major time crunch, since they usually are within their allotted testing window. If your vendor keeps giving you resistance, it forces the facility director to consistently keep working with the vendor/owner to meet the standards.

Communication and setting up a process with your vendor is key. Here are some compliance tips when working with a vendor:

1. Meet with each vendor individually while you are receiving bids for testing and explain to them specifically what is required for testing and documentation.

1. Provide them with the NFPA year utilized for testing.
2. Make sure they are current on the standards.
3. Provide them with a small example of a report that shows exactly what to provide.

1. Provide them the wording for EC 02.03.05 EP 28. They need to provide the following:

1. Name of the Activity
2. Date of the Activity
3. Inventory of Devices
4. Required Frequency of Testing
5. Name and Contact Information (including affiliation) of the person who completed the testing
6. NFPA Referenced
7. Results of the Testing.

1. Ensure that the vendor is able to meet your timelines referenced below:

1. 3 Years/36 Months – 36 months from the last event, plus or minus 45 days.
2. Annually/12 months  - 1 year from the last event, plus or minus 30 days.
3. Semi-annually/ 6 months – 6 months from the last event, plus or minus 20 days.
4. Quarterly / every three months – Every 3 months from last event, plus or minus 10 days.
5. Monthly / 30-day interval – 12 times a year, once per calendar month
6. Weekly – once per calendar week.

If you follow these guidelines, you will minimize mistakes with your documentation. Additionally, if you have three or more findings in EC 02.03.05, it immediately initiates a leadership finding (LD 04.01.05 EP 4). Be aware, leadership is usually not happy to get those findings, since they already feel like it is double jeopardy. It is identified twice within the final report.  

I hope this empowers you and your vendor to get the documentation your facility needs. This should start a dialogue and process you can both rely on going forward.

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