There have been some significant changes to The Joint Commission’s (TJC) standards and scoring for 2009. The Emergency Management (EM) requirements have been removed from the Environment of Care chapter and incorporated into their own EM chapter. The Life Safety Code® requirements, Statement of onditions™ (SOC™), and Interim Life Safety Measures (ILSM) have all been relocated to a new Life Safety (LS) chapter. While there are purportedly no new requirements as a result of all these changes, there are some subtle nuances that may be viewed as new requirements along with items that might have been implied in the past which are now specified. However, the most significant changes can be found in the scoring.
Thursday, January 29, 2009
Compliance News: TJC Thresholds to Serve as Screens for PDA & CA Decisions
By Dean Samet, CHSP
In their December 2008 The Joint Commission Perspectives, Volume 28, Number 12, The Joint Commission (TJC) reported that at its October 2008 meeting, TJC’s Accreditation Committee (AC) approved the remaining component for the 2009 accreditation decision methodology which included elimination of the use of thresholds” as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA). Thresholds have been used by TJC for years to determine whether to invoke or recommend CA or PDA if and when an organization had exceeded a preset number of Requirements for Improvement (RFIs).
In their December 2008 The Joint Commission Perspectives, Volume 28, Number 12, The Joint Commission (TJC) reported that at its October 2008 meeting, TJC’s Accreditation Committee (AC) approved the remaining component for the 2009 accreditation decision methodology which included elimination of the use of thresholds” as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA). Thresholds have been used by TJC for years to determine whether to invoke or recommend CA or PDA if and when an organization had exceeded a preset number of Requirements for Improvement (RFIs).
Compliance News: Sprinkler Obstructions
By Robert Trotter, CBO, CFM
The Joint Commission’s Life Safety Standard LS.02.01.10 states, “…buildings contain approved automatic sprinkler systems as required…” In order to determine where sprinklers are required facility managers should consult NFPA 13, Standard for the Installation of Sprinkler Systems. Recently, TJC surveyors have recognized deficiencies related to sprinkler obstructions and noted such observations. NFPA 13 states, “Sprinklers shall be installed under fixed obstructions over 4 foot wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. Sprinklers are not required under obstructions that are not fixed in place such as conference tables.” The example shows sprinkler protection under an HVAC duct which was an obstruction that prevents sprinkler discharge from reaching the hazard. Consult your licensed fire sprinkler contractor for assistance.
The Joint Commission’s Life Safety Standard LS.02.01.10 states, “…buildings contain approved automatic sprinkler systems as required…” In order to determine where sprinklers are required facility managers should consult NFPA 13, Standard for the Installation of Sprinkler Systems. Recently, TJC surveyors have recognized deficiencies related to sprinkler obstructions and noted such observations. NFPA 13 states, “Sprinklers shall be installed under fixed obstructions over 4 foot wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. Sprinklers are not required under obstructions that are not fixed in place such as conference tables.” The example shows sprinkler protection under an HVAC duct which was an obstruction that prevents sprinkler discharge from reaching the hazard. Consult your licensed fire sprinkler contractor for assistance.
Compliance News: Beyond Level of Exit Discharge
By Robert Trotter, CBO, CFM
NFPA 101®, Life Safety Code® states in section 7.7.3 “Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.” The example shown is a barrier that restricts downward travel. Upward travel to the rooftop may also require a barrier. The LSC also prescribes provisions for signs. Section 7.10.8.3.1 states, “Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.” The NO EXIT sign shall have the word NO in letters two inches high, with a stroke width of ⅜ inch, and the word EXIT in letters one inch high, with the word EXIT below the word NO, unless such sign is an approved existing sign. The sign in the example may be an approved existing sign as it appears to be meeting the intent of the code.
NFPA 101®, Life Safety Code® states in section 7.7.3 “Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.” The example shown is a barrier that restricts downward travel. Upward travel to the rooftop may also require a barrier. The LSC also prescribes provisions for signs. Section 7.10.8.3.1 states, “Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.” The NO EXIT sign shall have the word NO in letters two inches high, with a stroke width of ⅜ inch, and the word EXIT in letters one inch high, with the word EXIT below the word NO, unless such sign is an approved existing sign. The sign in the example may be an approved existing sign as it appears to be meeting the intent of the code.
Compliance News: Storage in Exit Enclosures
By Robert Trotter, CBO, CFM
Maintaining the means of egress is a critical role for any facility manager. It is important to note that NFPA 101®, Life Safety Code® section 7.2.2.5.3.1 addresses storage in exit enclosures,“Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.” Clearly by
the examples shown, this storage arrangement has the potential to interfere with egress by leaving this stairway completely inaccessible should these stored materials catch on fire. Moreover, it also presents an opportunity for an incendiary fire.
Maintaining the means of egress is a critical role for any facility manager. It is important to note that NFPA 101®, Life Safety Code® section 7.2.2.5.3.1 addresses storage in exit enclosures,“Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.” Clearly by
the examples shown, this storage arrangement has the potential to interfere with egress by leaving this stairway completely inaccessible should these stored materials catch on fire. Moreover, it also presents an opportunity for an incendiary fire.
Compliance News: Combustible Decorations
By Robert Trotter, CBO, CFM
Evaluation of combustible decorations is always difficult because interpretation of the requirement is subjective. One person may believe the decorations are acceptable and do not constitute a hazard, while another may feel that the decorations are too much. Regardless, combustible decorations must meet the requirements of the Life Safety Code®. For those organizations accredited by The Joint Commission, requirements for combustible decorations are found in the Life Safety Chapter. For example, the hospital accreditation program Standard LS.02.01.70 Element of Performance (1) states, “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)” Both the new and existing health care occupancy chapters state, “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”
Evaluation of combustible decorations is always difficult because interpretation of the requirement is subjective. One person may believe the decorations are acceptable and do not constitute a hazard, while another may feel that the decorations are too much. Regardless, combustible decorations must meet the requirements of the Life Safety Code®. For those organizations accredited by The Joint Commission, requirements for combustible decorations are found in the Life Safety Chapter. For example, the hospital accreditation program Standard LS.02.01.70 Element of Performance (1) states, “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)” Both the new and existing health care occupancy chapters state, “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”
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