Our Document Review Service provides healthcare organizations with expert evaluation of their Inspection, Testing, and Maintenance (ITM) records for compliance with NFPA standards and The Joint Commission’s Environment of Care (EC) and Life Safety (LS) requirements.
A compliant ITM program is essential to both patient safety and accreditation readiness.
Our team reviews documentation to ensure all life safety, fire protection, medical gas, utility, and critical equipment systems are inspected, tested, and maintained in accordance with required frequencies, documentation standards, and performance expectations defined by:
NFPA 10, 25, 72, 80, 90A, 99, and 101
The Joint Commission EC.02.03.03, EC.02.03.05, and related standards
Our review process verifies that all ITM documentation meets The Joint Commission’s Elements of Performance (EPs) and includes:
The activity name, test date, inventory of devices, and required frequency
The NFPA standard reference and qualified person performing the task
Clear results (Pass/Fail) with documented follow-up for deficiencies
Evidence of timely repairs, re-tests, and compliance with required intervals
We also review:
Fire alarm and suppression testing (supervisory signals, waterflow, tamper switches, detectors, extinguishers, pumps, dampers, doors)
Fire drill documentation and Interim Life Safety Measures (ILSM) procedures
A strong documentation program not only proves compliance—it ensures the safety systems protecting your patients and staff are ready when needed. During surveys, the ITM documentation review sets the tone for your entire Life Safety and Environment of Care evaluation.
FP&CC applies a structured, cross-referenced checklist aligned with NFPA and Joint Commission expectations. We provide:
Gap identification and corrective action guidance
Crosswalks to the applicable NFPA references
Recommendations to improve accuracy, frequency tracking, and record retention
Our detailed review helps facilities:
Maintain continuous compliance
Prepare confidently for accreditation surveys
Ensure every protective system operates as designed in the moments that matter most
FP&CC’s ITM Record Review service evaluates inspection, testing, and maintenance documentation to confirm compliance with NFPA and Joint Commission standards.
Accurate ITM records prove compliance and ensure critical life safety systems are properly maintained and ready for accreditation surveys.