Negative/Positive Air Pressure Testing

What are the requirements for testing for negative and or positive pressure in rooms, like isolation and OR's, and how often should it be tested?

Compliance News: Floor Level at Exit Doors

By Robert Trotter, CBO, CFM

According to the Life Safety Code® the elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 inch. The elevation must be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways may not exceed 1/2 inch in height. Raised thresholds and floor level changes in excess of 1/4 inch at doorways are to be bevelled with a slope not steeper than 1 in 2. However, in existing buildings where the door discharges to the outside or to an exterior balcony or exterior exit access, the floor level outside the door is permitted to be one step lower than the inside, but may not be in excess of 8 inches lower.

Compliance News: Loaded or Corroded Sprinklers

By Robert Trotter, CBO, CFM




The Life Safety Code® mandates that all automatic sprinkler and standpipe systems required by this Code must be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Section 2-2.1.1 of the 1998 edition states “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 must be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” The Appendix says that the conditions described above can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual.

Compliance News: CMS Hospital Equipment Maintenance Requirements Clarified

By Dean Samet, CHSP



Hospitals are expected to maintain equipment inventories and documentation of their maintenance activities. Federal or state laws and regulations may require that equipment maintenance activities be performed in accordance with the manufacturer’s recommendations, or may establish other maintenance requirements. In such instances, hospitals must be in compliance with the most stringent maintenance requirements mandated. Absent such mandated requirements, the Centers for Medicare & Medicaid Services (CMS) is allowing hospitals to follow one of the following: The manufacturer’s recommended maintenance schedule; to schedule more frequent maintenance than the manufacturer recommends; or, in some cases of non-critical equipment, to schedule less frequent equipment maintenance than the manufacturer calls for.

Compliance News: Influenza Vaccination Standard Revised by TJC

By Dean Samet, CHSP




In their December 2011 edition of The Joint Commission Perspectives, TJC announced their Infection Prevention and Control (IC) Standard IC.02.04.01 would be revised, strengthened, and extended to all TJC accreditation programs in which the standard is not currently applicable. The revised IC changes for hospital, critical access hospital, and long term care accreditation programs will be effective July 1, 2012. The revised IC changes for ambulatory care, behavioral health care, home care, laboratory, office-based surgery, and Medicare/Medicaid certification-based long term care accreditation programs will be implemented in a phased approach commencing July 1, 2012.


Revised Standard IC.02.04.01 elements of performance (EPs) will require accredited organizations to:

Compliance News: Alcohol-Based Hand-Rub Dispenser Placement

By Robert Trotter, CBO, CFM




Health care organizations should already be familiar with the current code-based requirements of NFPA 101®, Life Safety Code® and The Joint Commission (TJC) regarding the placement of Alcohol-Based Hand-Rub (ABHR) Dispensers. TJC is now allowing ABHR dispensers to be placed according to the requirements of the 2009 and 2012 editions of NFPA 101®,Life Safety Code®. The primary change from previous TJC requirements is the reduction of the minimum measurements from the ignition source to the dispenser. LSC Sections 18/19.3.2.6 (7) state: Dispensers shall not be installed in the following locations: 

• Above an ignition source within 1 inch (25 mm) horizontal distance from each side of the ignition source.
• To the side of an ignition source within a 1 inch (25 mm) horizontal distance from the ignition source.
• Beneath an ignition source within a 1 inch (25 mm) vertical distance from the ignition source.

For ignition sources such as duplex receptacles and light switches the measurements are taken from the side edges of the ignition source coverplate as depicted in the diagram.

Oxygen Storage

If storage under 300 cubic feet can be “open to the corridor” is there still a requirement to install a sign if the oxygen is stored in an enclosure versus being stored open to the corridor?  Would this be considered a Life Safety or an Environment of Care issue?

Blocked Exit Passageway

Our nursing department is conducting training and we need to have various types of equipment lined up along the corridor during that time for training.  Is there a way this setup could be legally permitted for a week or two?

Surgery Fire Plans

Our director of surgery is wanting to create their own plan.  Is it common for a facility to have a fire plan specific for surgery? 

Limiting Access to Clinical Lab

What standard requires organizations to limit access to the clinical lab area to authorized personnel only?

Recyclable Paper Containers

We keep large receptacles for recyclable paper in our nursing stations. The dimensions of the receptacles are approximately 18'' x 18'' x 36''. Is recycled paper considered to be “waste” by the Joint Commission? Is it okay to keep these receptacles in the hallway of a nursing unit?

Corridors in Suites

Are there any TJC requirements for the width of corridors within a suite?

Ceilings and Grab Bars

Our hospital received a supplemental recommendation for EC.1.10 in our psychiatric unit. The reference was to the potential for hanging oneself from grab bars and ceilings. The bathrooms have hard ceilings, but the patient rooms do not. I see that there is a requirement in the 2001 AIA Guidelines for Design and Construction for tamper resistant ceilings. Would clips of the tiles suffice? Also, no mention is made of grab bars.

Equipment Scheduled Maintenance

What is equipment scheduled maintenance based on?

AIA Guidelines for TJC

What year of AIA Guidelines does The Joint Commission follow?  If we are renovating a critical access hospital that will follow state rules and regulations, do we have to follow TJC?

Testing Hospital-Owned Fire Hydrants

We have on-campus exterior fire hydrants owned by the hospital.  Do they need to be tested?  

Written Management Plans

How many written management plans does The Joint Commission require?

Mixed Occupancies

Can a hospital have several classifications of types of care in the same building?

ABHR Placement

Has TJC adopted the NFPA 101, 2009 requirements for placing ABHR dispensers with the 1-inch in lieu of 6-inch spacing from ignition sources? 

CMS Corridor Door Gap Requirements

What does CMS say about the gap between the door and the door frame for a corridor door?