Dissecting the definition of ‘monthly’ compliance
As in every form of communication, details are important. This month, we are taking what should seemingly be a simple term, “monthly,” and elaborating on the definition as it applies to regulatory compliance.
When it comes to life safety frequencies, each inspection, testing and maintenance (ITM) preventive maintenance (PM) task is well defined. Carrying out these PM tasks per defined methods and at defined intervals is crucial to establishing and maintaining compliance.
A number of these tasks must be carried out monthly. Monthly inspections include portable fire extinguishers, kitchen hood systems, carbon dioxide systems, control valves and exit signs. Monthly testing includes automatic transfer switches, elevator recall, ground fault circuit interrupters and battery emergency lights.
Each PM task has differing definitions of monthly for their respective task. For instance, the monthly load test required in NFPA 110, Standard for Emergency and Standby Power Systems, is defined as 20-40 days, while other tests are defined simply as “monthly.” To compound this further, accreditation organizations (AOs) and the National Fire Protection Association (NFPA) have their own definitions.
The Centers for Medicare & Medicaid Services, The Joint Commission, DNV GL and HFAP define “monthly” as every 30 days; the completion of the activity is performed anytime during the calendar month. NFPA has two definitions: “occurring once per calendar month and 12 times per year” and “once per calendar month.”
So, how do we clarify this? One solution is to adopt the AO’s definition. This can be measured in your maintenance software or other methods used to track frequencies, due dates and dates completed. (Pay close attention to the PM task and know the difference between inspection, test, maintenance or other.) This needs to be communicated in a contractual agreement with vendors as a condition of deliverable, with other definitions of frequency, test, inspection and maintenance. Lastly, we should advocate for consensus on common definitions.
ASHE members can access a table of monthly tasks at ashe.org/monthlytasks.
Related Articles
DNV changes its accreditation process
The accrediting organization updated its surveying requirements for documentation access and review.
The Joint Commission announces changes to its survey process
The accrediting organization has modified its processes for verifying credentials and documentation review.
CMS provides shared space guidance for critical access hospitals
The guidance details Conditions of Participation expectations for critical access hospitals engaged in shared space agreements.