Our facility (Existing Hospital) was sited on our last Annual Inspection by the State Fire Inspector. We have asked the State Bureau of Fire Services, but they have not yet provided any clarification. Specifically, the citation said, "there were no records available to indicate that the 'Operating Room 4-hour power outage' test had been performed in the last 36 months. I've looked up Testing for a Type 1 EES (NFPA 99 (2012), 6.4.4; Operational Inspection and Testing for a Level 1 EPSS (NFPA 110 (2010); 8.4.9, Table 4.1(a) - Classification of EPSSs as well as the appendix A.8.4.9. The best thing I can find is that the Suggested Maintenance Schedule for Emergency Power Supply (Figure A.8.3.1(a)) in NFPA110 (2010) has a footnote for "EPS at minimum of 30% nameplate rating" is to be "Every 3 years for 4 hours". However, nothing that I could find in code specifically calls out Operating Room 4-hour Power Outage Test.
The Joint Commission (JC) has an Environment of Care Standard EC .02.05.07 EPs 9 & 10 for a 36-month test of 30% load for 4-hours, however, the inspector was conducting the annual safe safety inspection for the state, not a JC survey. But even the EC standard doesn't call out Operating Room testing.
Just want to know if anyone else has been called out for this documentation.