Question: We had a mock survey at our hospital from an accrediting body. One of the surveyors on the Life Safety team told us that if we removed the batteries from our exit signs that we would no longer have to do the monthly tests on the signs since they are connected to the emergency generator. Everything that I can find insists otherwise but another member of staff insists on having them removed. Is this a valid claim?
Answer from Brad Keyes: No, I do not believe it is. That seems to be a surveyor’s preference, and would violate the manufacturer’s recommendations. You are required to comply with the manufacturer’s recommendations for preventive maintenance frequencies and methods, unless you qualify for a CMS approved Alternative Equipment Management (AEM) program.
Regardless if the “EXIT” sign has a battery-backup for emergency power or relies on the facility’s generator, you still need to do monthly inspections to ensure the signs are still illuminated.
Unless you get it in writing from that particular accreditation organization, removing the batteries from a battery-powered “EXIT” would violate the manufacturer’s recommendations and is likely to be cited by some other knowledgeable surveyor. And it would likely not be approved by the CMS surveyors if they conducted a validation survey.
Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.