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.