By Brad Keyes / Special to Healthcare Facilities Today

Q: How long is a grace period for the annual fire pump test to be past due?

A: Well, technically, there is no grace period. Either you are compliant or you are not. But most AHJs usually have their way of determining time when it involves frequencies for testing and inspection.

One AHJ may be “by the NFPA book” and when the NFPA code or standard says annually, that means it needs to be done during the calendar year. So, an annual flow test could be done in May one year and it could be done in September of the next year.

But accreditation organizations (AO) seem to have a stricter interpretation of time. Where NFPA says annually, one AO could mean 12 months from the previous test, plus or minus 30 days. But CMS does not like the “plus” side of the equation, meaning they don’t mind if you do your flow-test before 12 months has pass from the last test, but they don’t care for one day beyond 12 months. So, state agencies surveying on behalf of CMS would likely cite an organization if the test is one or more days beyond 12 months from the last test.

This is one area where NFPA has not clearly defined how they interpret the different time periods for testing or inspection. They purposefully leave this open for the AHJ to decide, but the problem is, hospitals typically have 5 or 6 different AHJs who inspect them for compliance with the Life Safety Code. Chances are, you will never get all 5 or 6 AHJs to agree on what it means. It’s a crap-shoot sometimes. You don’t know how one particular AHJ will respond until they are onsite and write a citation. So, the hospital has to follow the most restrictive interpretation.

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.