Compliance News: Environment of Care Time Notations

By Dean Samet, CHSP



The Joint Commission has a number of time notations designated in the Environment of Care standards’ elements of performance for its expectations when certain inspections, tests, tasks, functions, events, or drills are to occur. TJC recognizes that it will not always be possible to meet the exact time frames cited in their EPs. Therefore, as delineated in the November 2010 Environment of Care News article Time Defined, TJC has provided the following definitions which include some leeway and allowable deviation.


The Joint Commission provided some stipulations to the below definitions. “The definitions do not pertain to or affect specific time frames defined in the elements of performance” such as EC.02.05.07 EP4, “Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes. The completion dates are documented.” You must comply with these specific time frames.


TJC also stated that they will allow an organization “to establish written policies that vary from the definitions given here, within reason. For example, if the organization’s written policy states that "semiannual’ is ‘plus or minus (+/-) 45 days,’ The Joint Commission would expect compliance with that timeframe in lieu of The Joint Commission’s stated policy.” One final note is that the 2000 NFPA 101® Life Safety Code®, referenced by TJC, does not define “time” as delineated in the referenced EC News article above.


Calendar References:


•   Daily: Performing something once per day [and anytime the next day]
•   Weekly: Performing something once per week (Sunday-Saturday) [and anytime the next week]
•   Monthly: Performing something within the calendar month [and anytime the next calendar month]
•   Quarterly: Performing something within the calendar quarter [and anytime the next calendar quarter]
•   Semiannual: 6 months from actual month in which the scheduled work was completed, plus or minus 20 days.
•   Annual: 12 months from the actual month in which the scheduled work was completed, plus or minus 30 days.
•   Triennial: 36 months from the actual month in which the scheduled work was completed, plus or minus 45 days.


Note: TJC considers the entire scheduled month as the due date.  For any of the above timeframes, you may not leave the calendar boundaries.