Posted on 05/08/2015

By Lynn O’Donnell, Director of Marketing, Healthcare

The Joint Commission has added three categorical waivers within its 2015 updates. These waivers are important for healthcare organizations to understand, as they may affect your accreditation.

1.     Testing of Sprinkler Alarms

The new testing of sprinkler alarm devices waiver permits a reduction of testing frequencies for certain sprinkler system alarm devices and pump assemblies. There are two elements of performance (EPs) that must be met before using this waiver:

EC.02.03.05, EP 2
At least quarterly, the hospital tests water-flow devices. Every 6 months, the hospital tests valve tamper switches. The completion date of the tests is documented. (NFPA 25, 1998 - Sections 2-3.3 & 3-3.3) (NFPA 72, 1999 - table 7-3.2)

EC.02.03.05, EP 6
Automatic Sprinkler Systems: Every week, the hospital tests fire pumps under no-flow conditions. The completion date of the tests is documented. (NFPA 25, 1998)

2.     Medical Gas Alarms

The Medical Gas Alarms waiver allows the substitution of a centralized computer system for one category 1 medical gas master alarm. This waiver requires one EP:

EC.02.05.01, EP 1
The hospital designs and installs utility systems that meet patient care and operational needs.

3.     Emergency Generators

The annual testing of emergency generators waiver permits a reduction in the annual diesel-powered generator exercising requirements. This waiver requires two EPs:

EC.02.05.07, EP 4
Twelve times a year, at intervals not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes. The completion dates of the test must be documented.

EC.02.05.07, EP 5
The monthly tests for diesel powered emergency generators are conducted with a dramatic load that is at least 30% of the nameplate rating of the generator or meets the manufacture recommended prime movers exhaust temperature if the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07, EP 4, then it must test the emergency generator once every 12 months using supplemental, dynamic or static, loads of 25% of nameplate rating for 30 minutes followed by 50% of nameplate rating for 30 minutes followed by 75% of nameplate rating for 60 minutes for a total of 2 continuous hours.

Using a Waiver

If a hospital decides to make use of any of the new or existing waivers for its facilities, it is required to do the following:

  • In the "Additional Comments" field of the Basic Building Information (BBI) in the electronic Statement of Conditions" (SOC), document the waiver(s) being used and the location(s) where each waiver is being applied.
  • At the beginning of a survey, present this documentation to a Joint Commission surveyor. This is critical! It is not acceptable for an organization to wait until after a surveyor discovers a compliance issue to notify the surveyor that it wishes to use a categorical waiver.

For more information on the content and use of these waivers, visit The Joint Commission’s website.

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