Compliance News: Unsealed Spaces 1/8 Inch or Less in Corridor Partitions to be Sealed

By Dean Samet, CHSP



Effective February 1, 2011, unsealed penetrations above the ceiling in existing corridor partitions of 1/8-inch wide or less around pipes, conduits, ducts, and wires will no longer be permitted by The Joint Commission according to the April 2011 edition of The Joint Commission’s Environment of Care News. Note #1 of Standard LS.02.01.30, Element of Performance No. 6, has been deleted.


Standard LS.02.01.30 states, “The [hospital/critical access hospital] provides and maintains building features to protect individuals from the hazards of fire and smoke.” EP 6 states, “Existing corridor partitions are fire rated for 1/2-hour, are continuous from the floor slab to the floor or roof slab above, extended through any concealed spaces (such as those above suspended ceilings and interstitial spaces), are properly sealed, and are constructed to limit 
the transfer of smoke.” Note 1 had stated, “Unsealed spaces 1/8-inch wide or less around pipes, conduits, ducts, and wires above the ceiling are permitted.” Again, unsealed penetrations 
with a 1/8-inch gap or less above the ceiling will no longer be permitted.

This appears to be another move by The Joint Commission to demonstrate that its standards and elements of performance (EPs) are equivalent to the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COPs). This action allows TJC to maintain CMS-deeming authority and to better reflect the intent of CMS’s COPs.