HOSPITAL {HOSPITAL NAME} HOSPITAL

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Controlled Document, Not to be Reproduced
Policy No: 0-0-0000-00-000
Departmental Policy Dept: Engineering Services
Version No: 00
Title: BUILDING MAINTENANCE PROGRAM (BMP) JCI Code: FMS
Supersedes: New Copy No: Page 1 of 2

1. PURPOSE:

1.1. Building maintenance program (BMP) is to provide for the ongoing maintenance of all
utility systems and equipment throughout the institution through repair, maintenance and
safety inspections of all equipment and utility systems.

2. POLICY:

2.1. An ongoing building maintenance program (BMP) has been developed to establish
frequencies of inspection, testing and adjustment of the components of life safety.

3. RESPONSIBILITY:

3.1. The Engineering Service Department Director is responsible for coordinating activities
and ensuring procedures are developed that specify the action to be taken during the
ongoing maintenance and they applying BMP in a ideal condition.

4. PROCEDURES:

4.1. The building maintenance program shall collect historical data and based on the data
changes will be made to the program.
4.2. The building maintenance program includes:

4.2.1. Strategies to manage the items in the program

4.2.2. Inspection schedules
4.2.3. Processes to evaluate the building maintenance program

4.3. An annual review of the program will be performed to ensure compliance with the NFPA's
Life Safety Code 101-2000.
4.4. The following components of the life safety program will be included in the building
maintenance program. All items will be properly functioning and properly sealed as
appropriate.

4.4.1. One-half (1/2) hour Fire Resistance Rated Assembly (FRRA) doors and one (1)
hour FRRA doors that include occupancy separation doors, stair doors, horizontal
exit doors and hazardous are room doors
4.4.2. Linen/trash chute inlet and outlet doors
4.4.3. Smoke barrier doors
4.4.4. Corridor doors
4.4.5. Smoke barrier wall penetrations
4.4.6. Corridor wall penetrations
4.4.7. Means of egress illumination devices
4.4.8. Exit signs
4.4.9. Means of egress maintained free of ice and snow
 HOSPITAL {HOSPITAL NAME} HOSPITAL
LOGO LOGO
Controlled Document, Not to be Reproduced
Policy No: 0-0-0000-00-000
Departmental Policy Dept: Engineering Services
Version No: 00
Title: BUILDING MAINTENANCE PROGRAM (BMP) JCI Code: FMS
Supersedes: New Copy No: Page 2 of 2

4.4.10. Exhaust hoods, exhaust duct systems and grease removal devices cleaned and
maintained

5. ORIGINATING DEPARTMENT/S

5.1. (HOSPITAL NAME) Engineering Services Department

5.2. (HOSPITAL NAME) Engineering Services Department

Compiled by: Signature: Date:

 Engineering Services Department

 Facility Management and Safety Signature Date:

Team
Reviewed by: Signature: Date:
Continuous Quality Improvement &
Patient Safety (CQI&PS)
Authorized & Approved by: Signature: Date:

(HOSPITAL NAME) Director

Date Reviewed Date of Next Review