The 2014 TJC Hospital Accreditation Standards include wording changes in Standard EC.02.05.07, EP-4 (generator test intervals) and EP-6 (transfer switch test intervals) that tweak the required test intervals a little.

The new 2014 test interval language in both EPs states “At least monthly, the hospital tests ….” This is a change from the 2013 TJC wording in both EPs that stated “Twelve times a year, at intervals of not less than 20 days and not more than 40 days ….”

The use of the term “monthly” has also been in NFPA 110 since at least 1999. That 1999 edition is referenced by the 2000 edition of NFPA 101, which is still enforced by CMS. The NFPA 110-1999 language states:

6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

However we suggest that TJC-accredited organizations be careful before relaxing their existing test interval schedules. We understand that CMS is still enforcing the NFPA 99-1999 language, which states:

5.4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days…

We suggest that organizations consider maintaining a testing schedule that meets both the “monthly” criteria and the “20-40 day” criteria until both CMS and TJC agree with each other.

What about the 2012 editions of NFPA 101 and NFPA 99 that the healthcare facilities industry is eagerly anticipating for CMS adoption?

NFPA 110-2010 (which is referenced by both NFPA 101-2012 and NFPA 99-2012) states:

“8.4.2* Diesel generator sets in service shall be exercised at least once monthly….”

NFPA 99-2012, on the other hand, states:

“6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).
(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.”

Our recommendation above – continue to meet both sets of criteria – stands.

NFPA Disclaimer: Although the author is Chairman of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. NFPA members can obtain NFPA staff interpretations at www.nfpa.org.