One of our clients that operates a residential treatment program recently underwent their initial TJC survey. They were surveyed under the Life Safety Code Residential Occupancy requirements for Lodging and Rooming Houses that have from 4 to 16 occupants. The organization had a finding that we had never seen before in the Life Safety chapter and thus wanted to share with our readers. The finding related to the battery operated smoke detectors in clients’ bedrooms. The surveyor cited the organization for not having a written policy describing how the smoke detectors are tested and maintained and the procedure for replacing batteries. Here’s the details:

Standard: LS.04.01.30: The organization maintains and protects vertical openings, fire alarm systems, and separation of sleeping rooms.

Element of Performance #5: Sleeping rooms have approved, single station smoke alarms powered by the building’s electrical service.

Note: Existing buildings may have battery powered smoke detectors as long as a written policy exists with procedures defining testing, maintenance, and battery replacement. These activities are documented.

Surveyor Finding: “There was no written policy at time of survey which outlined the testing, maintenance, and battery replacement of battery operated smoke detectors. The organization documents weekly testing of the devices but has not developed a plan for maintenance and battery replacement.”

We were well aware that any program using battery operated smoke detectors needs to maintain and test them and replace the batteries on a regular schedule. However, we had not taken note that a written policy is required for this process. In addition, we have never in 15 years of consulting seen a surveyor cite an organization for lack of such a written policy.

So, heads up if you have battery operated smoke detectors. Take the time to develop a simple written policy that describes the procedures for testing, maintenance and battery replacement and save yourself an RFI on your next survey!