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?