Directional Exit Signs

The Joint Commission Statement of Conditions™ requires exit signs to be readily visible from any direction of access and it refers the user to NFPA 101®, Life Safety Code® section 7.10.1.2.

Exits, other than the main exterior exit doors that obviously and clearly are identifiable as readily visible from any direction of exit access.

An exit sign with directional indicator should be installed to indicate the direction of travel to the exit. While there are many situations where the actual need for exit signs is debatable, it is desirable to be on the safe side by providing signs, because it is known that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving toward exits where signs are visible within a reasonable distance in the path of travel.

Damaged Sprinklers

NFPA 101®, Life Safety Code®, 2000 edition mandates in Section 9.7.5 that “All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested and maintained  in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems” [1998 edition]. Section 2-2.1.1 of NFPA 25 states, “Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation, e.g., upright, pendant, or sidewall. Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” A damaged sprinkler (pictured) can have a detrimental effect on the performance of sprinklers by affecting water distribution pattern, or rendering the sprinkler ineffectual. In its new Life Safety Chapter (which will take effect January 1, 2009), The Joint Commission has a relative requirement in standard LS.02.01.35, Element of Performance No. 5, which states, “Sprinkler heads are not damaged and are free of corrosion, foreign materials and paint.”

Transformers

What  installation requirements affect transformers in healthcare occupancies?

Privacy Curtain Requirements

What kind of requirements are there for privacy and cubicle curtains?

Eliminating Immediate Threat to Life Situation Time Limit

Is there a time limit to eliminate an “immediate threat to life” situation for all TJC accreditation programs?

ILSMs - Emergency Management

Should emergency management scenarios include ILSM plans?

Sleep Lab

What is the occupancy classification for a sleep lab?

Seismic Design Category C

Does the code say that if you are in a Seismic Design Category C, you have to have 96 hours of fuel supply on site?

Backup Fuel to Hospital Boilers

Does The Joint Commission have a requirement for providing backup fuel to hospital boilers?  (e.g. Natural gas boiler with fuel oil backup.)

USP-NF Chapter 797

We have a Pharmacy area that is not compliant with the Chapter 797 ruling in the mixing room that will be renovated in the next year but not before our survey, is this something that would fall under the EOC Guidelines?  

Post-op Infection Control

Are there any Joint Commission requirements or standards that restrict a surgical scrub technician or circulating nurse from helping with the turnover and cleaning of a surgical room between cases?

Generator testing - dynamic vs. static loads

TJC Standard EC.02.05.07, EP5 requires annual load testing under certain conditions.  Specifically the EP states "The emergency generator [20 to 40 day] tests are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers’ exhaust gas 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 they must test each 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."

Hospitals often want to know what the difference is between dynamic loads and static loads.  Simply put, dynamic loads are the hospital emergency power loads that are connected to the transfer devices - motors, lights, receptacle loads, and the like.  Static loads, on the other hand, are load banks.

NFPA 110 does not use this terminology.  The related paragraph from NFPA 110 only refers to "supplemental loads."

Readers may also want to refer to my separate blog entry discussing the "not less than" terminology found in the latest version of NFPA 110.

NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at http://www.nfpa.org/.

Compliance News: PFI Extension Requests

By Dean Samet, CHSP

The Joint Commission allows organizations to exceed their electronic Statement of Conditions™ (eSOC) Plan for Improvement (PFI) “projected completion date” by up to six months on previously accepted or original PFIs without any penalty. However, once that PFI has been accepted by TJC, the organization can further request a one-time extension when it appears that they are going to exceed their projected completion date(s).

The following information is required to be provided:

• Original and proposed projected completion date(s)
• Brief description of the deficiency or deficiencies
• Reason(s) for the extension request
• Confirmation that the extended PFI will be given a high priority for completion

Compliance News: Continuous TJC Compliance - An Uphill Battle

By Dean Samet, CHSP





Continuous compliance with The Joint Commission standards helps accredited organizations maintain safe and functional environments for patients, visitors and staff and maintain/improve safe, quality patient care.

What are the possible ramifications of not being continuously prepared and ready for survey, and what difficulties lay therein?

1. Loss of accreditation resulting in loss of deemed status
2. Loss of Medicare reimbursements due to loss of accreditation
3. Potential reduction in staff, services, quality of patient care, and a less safe environment due to loss of Medicare reimbursements
4. Cessation of services or possible closure of hospital due to loss of Medicare reimbursements

Compliance News: CMS Life Safety Code® Waivers

By Dean Samet, CHSP






There are times when certain provisions of the NFPA 101® Life Safety Code® might not be met. The Centers for Medicare & Medicaid Services has a “waiver” process per 42 CFR 483.70(a) (2) specifying that a waiver may be granted where it would not adversely affect resident health and safety (while a reasonable degree of fire safety is being provided) and it would impose an “unreasonable hardship” on the facility to meet specific LSC provisions. When it is not readily practical for a health care facility to comply fully with all of the specific requirements of the LSC, the fire authorities having jurisdiction (AHJs) may evaluate the degree of enforcement necessary to provide a reasonable measure of safety and an equivalent degree of protection.

The NFPA 101 is the code for safety to life from fire in buildings and structures. The basic requirement for facilities participating in the Medicare and Medicaid programs is compliance with the 2000 edition of the LSC. This edition is also referenced by the various hospital-accrediting bodies granted deeming authority and recognized by CMS such as The Joint Commission (TJC), American Osteopathic Association (AOA), and Det Norske Veritas Healthcare (DNVHC), as well as many local and state fire marshals across the country.

Generator Testing

If during the monthly emergency generator test a critical procedure interrupts the testing of the automatic transfer switches and some of them do not get tested at that time, must the untested switches be tested prior to the next scheduled monthly generator test?

Bomb Threat Exercises

How many times must a bomb threat exercise be held annually?

Doors in Residential Treatment Centers

Is my residential treatment center required to install a self-closing or automatic closing device on the doors in the sleeping rooms?

EOC Standards for Business Occupancy

Is there a single publication we could use that clearly outlines EOC standards  for Business Occupancy Medical Offices?

Electronic Cigarettes

We recently had a patient smoke an “electronic cigarette” in his isolation room.  I have researched the issue and, as you can imagine, FDA is against them and the manufacturers are pro.  FDA got a recent ruling that they can regulate the device as a drug administration item and not as a tobacco item.  What is the official stance on "electronic cigarettes"?

Infant/Child Abduction Security System

Which TJC standard mentions the testing of the security system for infant/child abduction?

Emergency Light Battery Testing

Does annually replacing the batteries in emergency lights (with a 1.5 hour test of 10%) eliminate the need for monthly 30 second testing?

Corridor Clutter

We have a Pediatric ward with some anorexic patients and the nurses have removed some of the furniture from the room and placed them in the corridor to help prevent the patients from hiding their food and misrepresenting their meal status.  Is there a discrepancy with the Life Safety Code by having the furniture in the corridor?

ILSMs in Business Occupancies

Do ILSMs apply to Business occupancies?  If so, where in NFPA-101 are they required?

Duct Detector Annual Testing

We are reviewing our practice of fire system testing and have a question. Can you clarify whether we are or are not required to set off individual air handler duct detectors and confirm air handler shut down for each annually or could we put the fire alarm system in bypass, smoke each detector, and confirm that it has been acknowledged at the fire panel?  (We currently do this once each year.)  If we had to have each air handler shut down, we would be shutting down 67 units 67 times, creating a nightmare and a life safety issue in its own right. Actually every air handler has two, a supply and a return, making the issue even more paramount. Can you shed some light on this vital issue?

Christmas Trees

Is a Christmas tree considered a flammable decoration?  Community relations wants to place a tree in our main lobby but I cannot find any that are flame retardant.

Fire Extinguisher Annual Inspection

We are due for a TJC visit anytime in the next 30 days. We just completed our Annual fire extinguisher inspections and service. We now have the 2011 tags that were punched for this month. The next time our staff will do the monthly inspection will be December and will date and initial. Should we be concerned that the TJC surveyor will want to see the 2010 tags where they were checked each month? 

Risk Assessment for Approved Appliances

I would like to put together a policy for “approved” appliances to allow in employee lounges / break rooms that is reasonable. We prohibit any open element device.  What is allowable?

E-Sized Cylinders of Oxygen

We have a new building that is an annex to the hospital building where the 4th floor only is an overnight patient care floor and just now going through licensing.  We want to keep 12 e cylinders of oxygen on the floor.  Can you tell me what I have to do to be in compliance?

Notify TJC of New Hospital Opening

We are opening a new hospital that will be affiliated with our current TJC accredited hospital.  Should we notify TJC of the opening of the new hospital?  Will it be included in our current accreditation?

Perimeter Wall Shelving

Please clarify the 18-inch rule and how it pertains to storage on shelving lined up along the perimeter of a store room or office bookshelves along the walls.

How often should we test line isolation monitors (LIMs)?  Is monthly often enough for maintenance testing?

Treatment Open to the Corridor

We have two treatment areas open to the corridor, neither space is within a suite, in a new healthcare occupancy.  Is this a Life Safety Code violation?

1/8-Inch Gaps

Are 1/8-inch gaps at penetrations in corridor walls still allowed?

Testing Tamper Switches

I read that tamper switches were still due semi-annually, but in EC.02.03.05 EP2 it states that every quarter  tampers will be tested along with water flows.  Which is correct?

Under-Sink Cabinet Storage

Do Joint Commission standards prohibit use of under-sink cabinets for storage?

Flammable Liquid Storage

When should flammable liquids storage cabinets be used?

Storage in Sprinklered Areas

What type of storage is allowable in a sprinklered area? Is storage up to the ceiling permissible, as long as it is not obstructing a sprinkler?

Business Occupancies

How do we deem our outlying clinics as business so that they are not inspected by TJC?

Shipping Containers

When supplies arrive at our facility in cardboard boxes or other shipping containers, can we bring those boxes and containers into patient care areas and store them?

Egress Doors & Releasing Devices

What are the specific requirements for egress doors and their releasing devices?

Transfer Grilles

Are transfer grilles allowed in a hospital?

Non-Rated Protective Plates

Where can protective plates be used in the hospital?

Extension for SOC-PFI

What are the conditions allowing an extension of an SOC-PFI?  Does it apply to all PFIs?

Preventing Accidents and Injuries in the MRI Suite

What are the potential safety hazards associated with the magnetic resonance imaging (MRI) scanning
process?

Concealed Sprinklers

What are concealed sprinklers and are they allowed?

Eliminating Immediate Threat to Life Situation Time Limit

How much time does an organization have to eliminate an "immediate threat to life" situation discovered by a surveyor?

Disputed Survey Findings

Whenever you feel The Joint Commission (TJC) surveyors have mistakenly cited you for a Life Safety Code® violation or Environment of Care (EC) standards issue, what steps should you take before this issue becomes a part of the official accreditation report as a Requirement for Improvement (RFI)? 

Preventing Coil Freeze Up

There are some proactive steps you can take this fall to ensure your chilled water coils do not freeze up this winter. The first step is to make sure that the freeze stat on each of your air handlers has been tested in the last 60 days. If testing has not been done, you might want to check the freeze stats for proper operation. Typically, they should be set on 35 degrees F with the tubing on the leaving side of the chilled water coil. If you are not sure how to check your freeze stat, check with your controls contractor for assistance.

Difference between Smoke Barriers/Partitions/Walls/Compartments

What is the difference between Smoke Barriers/Partitions/Compartments?

Compliance News: Arrangement of Means of Egress

By Robert Trotter, CBO, CFM

The 2000 edition of NFPA 101®, Life Safety Code® requires all occupied rooms in a health care facility to have direct access to a corridor leading to an exit, or must be arranged to comply with one of the exemptions. The term “habitable room” does not include bathrooms, closets, and similar spaces as well as briefly occupied work spaces. Section 19.2.5.1 states “Every habitable room shall have an exit access door leading directly to an exit access corridor.” There are four exceptions to the prescriptive requirement:

Exception No. 1: If there is an exit door opening directly to the outside from the room at ground level.

Exception No. 2: Exit access from a patient sleeping room with not more than eight patient beds shall be permitted to pass through one intervening room to reach the exit access corridor.

Exception No. 3: Exit access from a special nursing suite shall be permitted to pass through one intervening room to reach the exit access corridor where the arrangement allows for direct and constant visual supervision by nursing personnel.

Exception No. 4: Exit access from a suite of rooms, other than patient sleeping rooms, shall be permitted to pass through not more than two adjacent rooms to reach the exit access corridor where the travel distance within the suite is in accordance with 19.2.5.8. [One intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet (example pictured above) and two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.]

Compliance News: Plenum Requirements for Egress Corridors in Health Care Facilities

By Robert Trotter, CBO, CFM


In the built environment a plenum is a separate space for air circulation for HVAC systems, typically provided in the space between the structural floor/ceiling and suspended-grid acoustical tile ceiling. Incorporating a plenum can have its design advantages but corridors serving adjoining areas of health care occupancies are prohibited from being used for a portion of an air supply, air return, or exhaust air plenum.

Using building cavities as return air plenums can draw them below atmospheric pressure if not properly designed, causing outdoor air to be drawn into the building fabric. In humid climates, this can result in condensation of moisture from outdoor air within architectural cavities, consequently resulting in mold and mildew growth. Also, under certain circumstances, plenum configurations can have an adverse effect on life/fire safety. Clearly, plenum returns should not be used where codes prohibit them, such as health care occupancies, where individual space pressures must be controlled. These provisions are prescribed in the NFPA 101®, Life Safety Code® and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

Compliance News: Preparing an Emergency Water Supply Plan

By Dean Samet, CHSP

The Centers for Disease Control and Prevention (CDC) and American Water Works Association (AWWA) recently released a guide entitled Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities¹. Guidance is provided to assist health care facilities in developing an Emergency Water Supply Plan (EWSP) that prepares for, responds to, and recovers from a partial or total interruption of the normal water supply. Obviously a water supply loss would have a significant adverse effect on the daily operations of any health care facility, potentially affecting both patient safety and the quality of patient care. While there is little that can be done to prevent losing an offsite supply, developing and exercising an EWSP can help lessen the impact should such an incident occur.

The CDC EWSP Guide provides a four-step process for developing an emergency water supply plan:

1. Assemble the appropriate EWSP team and the necessary background documents for your facility;

2. Understand your water usage by performing a water use audit;

3. Analyze your emergency water supply alternatives; and,

4. Develop and exercise your EWSP.

Above Ceiling Wiring & Cable

Is above ceiling wiring and cable in a hospital required to be plenum rated, and if so, where is the code reference?

Fuel Hours for Emergency Generators

For how many hours of run time is an emergency generator required to be fueled? EC.1.7.1 only states that a generator is required to have “adequate fuel supplies for emergency use and sustained operation.”

Sprinklers in Walk-in Boxes and Freezers

Does a hospital need to have sprinklers in walk-in boxes and/or freezers in order to be considered fully sprinklered?

Piped Medical Gas System in ASC

Can you tell me what types of ambulatory surgery centers (ASC's) require a piped medical gas system? 

Temperature/Humidity in Central Supply

Are the temperatures and humidity levels for Central Supply supposed to be monitored?  Based on the AAMI National Standards, 4 areas should be monitored and data recorded daily for temperature and humidity.

Fire Extinguisher Signage

Does The Joint Commission require signage above recessed fire extinguisher cabinets?

Routine Electrical Receptacle Testing

What are the requirements for routine electrical receptacle testing?

Clean Utility Rooms

Does a clean utility room require local exhaust fans?  I thought soiled utility rooms were the only rooms requiring exhaust fans to make the room negative.

Fire Alarm Testing

We are considering doing our annual fire alarm testing in 4 quarterly sections.  This has the advantage of having our contractor in the building, working with the system much more often; however, it presents the difficulty that parts of the building done in the 4th quarter will have gone past 12 months since their last test.  Given an intelligent F/A system, do you think this would be a problem with the Joint Commission? The alternative is to do an extra, very expensive, full system test before starting quarterly testing. 

Business Occupancies

Does the Joint Commission include business occupancies in determining how many days a Life Safety Specialist Surveyor will be at a facility?

Decorations in Corridors

Is there a specific reference to the amount of papers/posters that can be affixed to a corridor wall in hospital? 

UPS Testing

Is EC.02.05.07 EP3- SEPSS (UPS) testing required if they are connected to emergency power (generator)?

PM Documentation

For PM documentation within our Documentation for Administrative Surveyor, how much do you suggest we show a surveyor in these books for daily, weekly, monthly, etc?

Fire Drill Response

When a code Red is called in a hospital, is there a general expectation or standard that states the floor above, below and lateral shall respond by closing doors, etc?  Do other locations have the same response?

Door Swing Requirements

What are the requirements for a door's swing?

Smoke Detectors in Doctors Sleep Rooms

What code requires smoke detection in doctors sleep rooms?

Waste Gas Testing

What is the recommended regularity of testing for waste gas in Operating Rooms?

ILSM Assessments

Does TJC require documented ILSM assessments for all life safety code deficiencies, or is documenting ILSM assessments only required for the more significant life safety code deficiencies (>45 day items) ok?

Fire Extinguisher Inspection

For monthly fire extinguisher inspections, is TJC expecting the documentation (tag) to include: MM\DD\YY + initials, or is MM\YY + initials ok?

Sleep Centers

What life safety issues would apply to Sleep Centers?

Drinking Water for Disasters

Is there a standard in Emergency Management for how much drinking water a healthcare facility (Hospital, Rehab., Nursing Home) needs on hand during a disaster event?  If so, what is the potable water requirements for the different areas in a healthcare facility?

Emergency Water Supply

CDC introduces Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities 

In order to maintain daily operations and patient care services, health care facilities need to develop an Emergency Water Supply Plan (EWSP) to prepare for, respond to, and recover from a total or partial interruption of the facilities’ normal water supply. Water supply interruption can be caused by several types of events such as natural disaster, a failure of the community water system, construction damage or even an act of terrorism. Because water supplies can and do fail, it is imperative to understand and address how patient safety, quality of care, and the operations of your facility will be impacted.

A health care facility must be able to respond to and recover from a water supply interruption. A robust EWSP can provide a road map for response and recovery by providing the guidance to assess water usage, response capabilities, and water alternatives.

Read it here

Decommissioning Dampers

We are considering decommissioning multiple dampers that are not required. Is there a requirement that the organization notify in writing to The Joint Commission that a number of specified dampers are being decommissioned?

Sprinklers in Elevator Equipment Rooms

We removed all sprinkler heads in the elevator equipment rooms in lieu of installing shunt trips.  Does this mean our facility is no longer fully sprinklered?

Smoke Evac Systems in ORs

Is there a code requirement that ORs without outside windows must have engineered a smoke evacuation system?

Sensor Lighting in Stairwells

In order to reduce energy costs, we are looking at installing lighting fixtures that have motion/proximity sensors for when there is no activity (they will drop to a night light mode until someone enters the stairwell again).  Are these allowed by code?

Space Heaters

Are space heaters allowed in offices within a healthcare occupancy?

Notices Taped to Cabinets

Can notices, flyers, and so on be taped to cabinets and walls?

Shelving and Sprinkler Heads

I know JCAHO requires that shelving not be closer than 18 inches to sprinkler heads. What about shelving on the walls on the perimeter of the room? Some of ours go almost to the ceiling. Are wall units exempt from the 18-inches rule?

Plenum Requirements For Egress Corridors In Health Care Environments

By Robert Trotter, CBO, CFM (in Engineered Systems July 1, 2011)


Incorporating a plenum can have its design advantages, but corridors serving adjoining areas of health care occupancies are prohibited from being used for a portion of an air supply, air return, or exhaust air plenum. This article and its illustrations can strengthen your grasp of the related NFPA code details and exceptions so you can design and ventilate properly for this special population.
 
In the built environment, a plenum is a separate space specifically for air circulation for HVAC, typically provided in the space between the structural floor/ceiling and a suspended-grid acoustical tile ceiling. When making design decisions, you should consider the advantages and disadvantages of  plenum configurations. 

Read entire article here: Plenum Requirements for Egress Corridors in Health Care Environments

Argon Use

We have a number of electrosurgical units that use a high purity laboratory-grade argon gas. Is it permissible to store extra cylinders of argon in the same storage room in which medical gas cylinders are stored?

Infection Control Risk Assessment

How many signatures are required on an Infection Control Risk Assessment (ICRA) document? And when do we need to perform an ICRA?

Compliance News: Guards in the Means of Egress

By Robert Trotter, CBO, CFM, MCP

While the guard pictured in the example is aesthetically pleasing it may not provide for the greatest level of protection for life safety.  In fact, NFPA 101®, Life Safety Code® specifically addresses guards in the means of egress.  Means of egress components that might require protection with guards include stairs, landings, balconies, corridors, passageways, floor or roof openings, ramps, aisles, porches, and mezzanines.  To understand the Life Safety Code® provisions for guards, consult the adopted edition for your jurisdiction. 

The fundamental requirements for guards in the means of egress that are more than 30 inches above the floor or grade below include the following:

• Guards are to be provided with guards to prevent falls over the open side. 
• The height of guards is measured vertically to the top of the guard from the surface adjacent thereto. 
• Guards should not be less than 42 inches high. 
• Open guards, other than approved, existing open guards, must have intermediate rails or an ornamental pattern such that a sphere four inches in diameter cannot not pass through any opening up to a height of 34 inches. Relative to the example pictured, vertical intermediate rails are preferred to reduce climbability.  

Handrails are often incorporated into guards as part of a protection package for the means of egress components described above.

Compliance News: Risk Assessments: Proactive Process for Managing EOC Safety Risks

By Dean Samet, CHSP

Performing a risk assessment is an accepted approach to identifying and minimizing safety hazards associated with the health care physical environment and services. 

Per The Joint Commission’s 2011 Hospital Accreditation Standards manual, standard EC.01.01.01: The hospital plans activities to minimize risks in the environment of care.                                                                                                                            

The Rationale for EC.01.01.01 provides the background and further explanatory information: “Risks are inherent in the environment because of the types of care provided and the equipment and materials that are necessary to provide that care. The best way to manage these risks is through a systematic approach that involves the proactive evaluation of the harm that could occur. By identifying one or more individuals to coordinate and manage risk assessment and reduction activities—and to intervene when conditions immediately threaten life and health—organizations can be more confident that they have minimized the potential for harm.

Compliance News: Carts in Corridor: 30 Minute "In Use" Rule

By Dean Samet, CHSP

In a Q & A segment of The Joint Commission’s Environment of Care® News, June 2009, Volume 12, Issue 6, TJC’s Standards Interpretation Group (SIG) answers questions on how long computer on wheels and other wheeled carts may be in corridors, provided that they are “in use.” This issue continues to be a common finding during The Joint Commission surveys and Centers for Medicare & Medicaid Services inspections.  

Compliance News: Unsealed Spaces 1/8 Inch or Less in Corridor Partitions to be Sealed

By Dean Samet, CHSP



Effective February 1, 2011, unsealed penetrations above the ceiling in existing corridor partitions of 1/8-inch wide or less around pipes, conduits, ducts, and wires will no longer be permitted by The Joint Commission according to the April 2011 edition of The Joint Commission’s Environment of Care News. Note #1 of Standard LS.02.01.30, Element of Performance No. 6, has been deleted.

Compliance News: Notifying TJC about Organization Changes

By Dean Samet, CHSP

If and when significant changes occur within a hospital, the hospital staff must notify The Joint Commission in writing or through its Joint Commission Connect site not more than 30 calendar days after such a change is made. The staff must also notify TJC in writing or in its electronic application (e-APP) if it opens or closes any units or services.

There are three change categories addressed in the 2011 Hospital Accreditation Standards manual’s The Accreditation Process (ACC) chapter:

• Changes affecting e-APP Information

• Changes to the Site of Care, Treatment, or Services

• Mergers, Consolidations, and Acquisitions

 

Smoke Damper Testing

Does TJC allow for “remote testing of dampers” via fire alarm and building controls system, rather than a physical test?  For example: if they remotely command the smoke dampers to close via the fire alarm system relay, and then they wait to see that the building control system (which monitors them) shows them changing from “open” to “close”.

Hazardous Materials and Waste

Health care organizations are responsible for adhering to local, state, and federal regulations for proper handling and disposal of hazardous materials and wastes. How is it possible for Joint Commission surveyors to determine whether an organization is complying with all these codes, standards, and regulations when they often differ from one location or state to another?

Requirements for Infant/ Child Abduction Drills

Does the Joint Commission require infant/child abduction drills?

ID Badges

What are the requirements for ID badges?

Security Sensitive Areas

Does the Joint Commission recommend what areas are to be classified as security sensitive?

Call Buttons

What are the requirements for an emergency call button in a public accessible restroom? Is the requirement different if the restroom is used by patients only? Is the requirement different in a health care occupancy compared to a business occupancy?

PFI Change Request

When is a Plan for Improvement (PFI) change request necessary?

Computers on Wheels

How long can computers on wheels be in corridors? Are they allowed to charge in the corridors?

Locking of Electrical Panels

Are electrical panels that are located in patient care corridors required to be locked?

EM Drills

When are tabletop drills acceptable as emergency management drills?

Fire Drill Announcements

If we make an announcement prior to activating the fire alarm system for a fire drill, is that considered an announced or unannounced fire drill?

Data Room Suppression System

A hospital has a data room suppression system that is not sprinklered, but the rest of the facility is sprinklered.  Would TJC still consider the hospital to be fully sprinklered?

Refrigerator Temperature

What are some general concerns regarding refrigerator temperature and monitoring?

Fire Drills

We have several buildings where outpatient behavioral health care, administrative, and business activities are conducted.  We rarely achieve the one-minute standard we have set for total egress of the buildings to the designated assembly areas.  What is the NFPA code requirement for the drill execution, or are we to use the drill execution time set by the local municipality?

Suicide Prevention Structural Precautions for Behavioral Health

We have an inpatient behavioral medicine unit that is made up of two separate areas. One side is a locked high-risk unit, and the other side is a voluntary unit.  Is the voluntary unit required to have the same suicide prevention structural precautions that we have in the locked unit?

Utility Room Doors

A nearby hospital recently told us that they were advised to lock their clean and dirty utility rooms. We hadn’t heard this expectation before and can’t find it in the standards. Is it indeed a requirement to lock clean and dirty utility rooms?

Evacuation Maps

Are evacuation maps required to be posted in health care organizations? If so, where? And how many are needed?

Fire Extinguisher Inspection

Do all portable Fire Extinguishers require monthly inspections or only those that are classified as a healthcare occupancy?  

Isolation Rooms

What is the required testing frequency for TB Isolation Rooms?

Medical Gas System Inspection

What is the definition of a med gas flexible hose and flexible connection related to routine system inspections?   

Electrical Outlet Marking

Is circuit labeling required on all electrical outlets, or just emergency power?  And is this required in the entire facility or just patient care areas?  Where is the code reference?

Emergency Plans

Does DNV differ from TJC with regard to having a 96 hour Emergency Operation Plan in place?

Life Safety Essentials: Reasons Why Sprinklers Fail to Operate

Learning Objective: To identify possible causes of non-functioning sprinklers.
 

By Robert Trotter, CBO, CFM, MCP - Manager, Sr. Life Safety Specialist

Automatic fire sprinkler systems are the most widely recognized fire protection feature for building protection and life safety. Sprinklers have been in existence since 1874 and today all new health care occupancies are required to be sprinklered. The reasons sprinklers fail to operate can easily be controlled procedurally, which will also ensure proper inspection, testing and maintenance. 

According to a 2009 report Experience with Sprinklers and other Automatic Fire Extinguishing Equipment, John R. Hall, Jr. of the National Fire Protection Association categorized five reasons why sprinklers fail to operate. The chart seen here identifies those reasons and compares health care occupancies to all structures. While it is recognized that there are times when sprinklers are shut down (such as during construction), limiting the affected area and firewatch may be helpful to reduce the statistic for when the system is shut off before the fire.  Lack of maintenance is one of the easiest categories to get under control. To reduce risks, liability, and responsibility for contributing to property damage and the cause of death and injury proper maintenance is essential. 

Inappropriate systems for a fire generally come into consideration when something changes, like using a room designed for light hazard operations for large storage of combustibles. In health care, manual intervention defeating the system is the leading cause of sprinkler failures. Health care managers must keep an accurate and continuous account of the status of systems and be on alert for inoperable systems. Damaged components may include valves, piping and sprinkler heads - all of which may affect water reaching the hazard or affect the distribution pattern.

Hazard Vulnerability Analysis

Does the Joint Commission have a prescribed template for performing a hazard vulnerability analysis (HVA)? 

Tamper-Resistant Electrical Receptacles

What are the requirements for tamper-resistant electrical receptacles? I was told to install these in all waiting areas or anywhere there may be children.  This is not a pediatric hospital, and we do not have a pediatric unit. If I do need to install them, can I use a cover that has a slide system and is called a child-resistant cover? 

Major Vs. Minor Renovations

What qualifies a renovation as major, and therefore necessary to classify it as New Healthcare?

Testing Frequency Flexibility

If the required time frames can't be met to complete a task or function as specified in TJC's 2010 Hospital Accreditation Standards, what kind of leeway is there in completing them?

Immediate Threat to Health or Safety

What triggers an “Immediate Threat to Health or Safety” condition in the environment of care?

Chute Discharge Doors

Is it the intent that the chute discharge door that opens into the chute discharge room be a listed self-closing fire door assembly with a minimum 1-hour rating?

Compliance News: Fire Protection Systems Testing Revisions by TJC

By Dean Samet, CHSP

In the May 2011 edition of The Joint Commission Perspectives, TJC an­nounced a change effec­tive July 1, 2011 for Envi­ronment of Care Standard EC.02.03.05, EP 2 and introduced a new EP 25. The standard, “the hos­pital maintains fire safety equipment and fire safety building features” remains unchanged.

EP 2 has been changed and will require quarterly testing of water-flow devices. TJC stan­dards previously required testing every six months or semi-annu­ally in accordance with NFPA 72, 1999 edition. EP 2 will read as follows: “For hospitals that use Joint Commission accreditation for deemed status purposes: At least quarterly, the hospital tests wa­ter-flow devices. Every six months, the hospital tests valve tamper switches. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 25, 1998 edition (Sections 2-3.3 and 3-3.3) and NFPA 25, 1999 edition (Ta­ble 7-3.2). For hospitals that do not use accreditation for deemed status purposes: Every six months, the hospital tests valve tamper switches and water-flow devices. The completion date of these tests is documented.”

Compliance News: Disinfection Note Revision for TJC Infection Prevention and Control Standard

By Dean Samet, CHSP

Effective April 1, 2011, The Joint Commission made a slight revi­sion to the Note for Standard IC.02.02.01, EP 2. The following lan­guage has been deleted: “Intermediate level disinfection is used for items such as specula.”

The standard and note now read as follows: “The [organization] implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.* (See also EC.02.04.03, EP 4.)

Note: Sterilization is used for items such as implants and surgi­cal instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes.

* For further information regarding performing immediate and high-level disinfection of medical equipment, devices, and sup­plies, refer to the web site of the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/hicpac/Disinfection_Ster­ilization/acknowledg.html (Guide for Disinfection and Sterilization in Healthcare Facilities, 2008).

Compliance News: Emergency Management - Exercises

By Susan McLaughlin, MBA, FASHE, CHSP

The Joint Commission requirements for emergency exercises have been relatively static over the past several years. But there have been several minor changes, primarily in the notes to ele­ments of performance in EC.03.01.03, that merit taking a closer look at what is needed.

First the schedule, which hasn’t changed in and of itself. Hospi­tals must do two “live” exercises per year (as opposed to tabletops) to include the following three scenarios: Influx of patients (EP 2), Sustainability (EP 3), and Community integration (EP 4).

The twice a year requirement comes out of EM.03.01.03, EP 1, which contains Note 2, “Staff in freestanding buildings classified as a business occupancy (as defined by the Life Safety Code®) that do not offer emergency services nor are community designated as disaster receiving stations need to conduct only one emergency exercise annually.” Conversely, if there are business occupancies that DO offer emergency services and/or ARE disaster receiving stations, the implication is that these facilities are under the same exercise requirements as a hospital.

Compliance News: ECRI's Top 10 Health Technology Hazards for 2011

By David Stymiest, PE, FASHE, CHFM


Emergency Care Research Institute (ECRI) recently published a Health Devices guidance article entitled “Top 10 Technology Hazards For 2011” listing ten sources of potential danger that ECRI believes warrant the greatest attention in 2011 for protecting patients and staff. The article, available on www.ecri.org, provides detailed guidance for each of the following issues.

1.  Radiation Overdose and Other Dose Errors during Radia­tion Therapy* - Stating that this can take the form of deliver­ing the wrong dose, treating the wrong site on the patient, or treating the wrong patient, ECRI included specific recom­mendations for support, training, installation, commissioning, maintenance, procedures, oversight, and implementation of corrective actions. 

2.  Alarm Hazards* - Discussing alarm-related adverse incidents typically involving staff being overwhelmed by the number of alarms, alarm settings not being restored, and alarms not being properly relayed to ancillary notification systems, ECRI made specific recommendations for examining the entire alarm environment, establishing protocols for settings and response, implementing and monitoring policies to control alarm silencing, modification, and disabling. 

Notifying TJC about Significant Changes

What is the maximum amount of time after an addition is made to a hospital does the hospital have to notify TJC of the change?

Managing the Impact and Costs of Emergency Power Testing on Hospital Operations: A Case Study

By David L. Stymiest, PE CHFM FASHE; Jack W Dean, PE; and Anand K. Seth, PE CEM 
(This white paper was first presented at ASHE's 35th Annual Conference, July 1998.  It has not been updated for 2011 and is provided here as an historical reference only.)

Introduction

Hospitals are required to have an emergency power testing program in place to meet the requirements of NFPA 70, NFPA 99 and NFPA 110, as well as standards established by accreditation organizations such as JCAHO. The goal of the emergency power testing program should be to comply with regulatory requirements without adversely affecting the operation of the hospital or the well-being of the patients. The specific requirements to be met are referenced by the forerunner to this paper. That technical document addresses the importance of simulating actual loading conditions during the testing period and the necessity of following up on the test results to identify problems and take corrective action. This paper builds upon that publication by detailing a case study of emergency power testing occurring over a significant period of time at the Massachusetts General Hospital (MGH), issues uncovered (which might be described as second order consequences of the emergency power testing effort) and the steps taken to eliminate problematic issues.

Emergency power testing programs involve transferring the power sources of operating systems from utility power to the emergency generators and back. This action can cause disruption to increasingly more complex clinical and building equipment, building automation systems, and hospital operations. When managed properly and proactively followed through, these disruptions are valuable learning experiences and provide opportunities to improve the hospital infrastructure, improve hospital operations and reduce the hidden costs of testing. This case study presents a number of lessons learned and offers proactive strategies for managing the process. The lessons learned also illustrate areas where future system designs should be improved.

Read entire article here: Managing the Impact and Costs of Emergency Power Testing 

Medical Records Protection

One of the bullet points in IM.2.20,EP 6, mentions protecting records in a manner that minimizes the possibility of damage from fire or water. How can we protect our records from both fire and water when we are mandated to have sprinklers in the chart room in case of fire? We will have a problem with water if the sprinklers go off.

Using Load Profiles to Determine EPSS Peak Demand Load

David Stymiest, PE CHFM FASHE, DStymiest@ssr-inc.com

The author has used load profiling to determine EPSS peak demand load for more than 20 years.  The discussion below is intended to highlight some of the lessons learned.  For a full discussion, refer to the author’s 2009 ASHE Management Monograph, “Managing Hospital Emergency Power Systems – Testing, Operation, Maintenance and Power Failure Planning” available at http://www.ashe.org/.

NFPA Disclaimer: Although the author is Chair of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents.  NFPA members can obtain NFPA staff interpretations at www.nfpa.org.

Hospitals should document their actual EPSS peak demand load.  It is not enough to assume that the highest emergency generator kilowatt (kW) demand during an early-morning monthly test represents the true peak EPSS demand load.  This is a poor assumption due to the variability of mechanical, building, and clinical process loads during a typical hospital workday.  If an EPSS test time is chosen due to low clinical activity, then that avoided clinical load will not be reflected in the EPSS test loading.  Additionally, some equipment, such as smoke control systems and fire pumps, will not operate except during atypical situations.