Compliance News: TJC Provides More Corridor Clutter Guidance

Compliance News:  TJC Provides More Corridor Clutter Guidance 

by David Stymiest, PE, CHFM, CHSP, FASHE 

  

TJC continued providing corridor clutter clarifications and expectations in the September 2012 edition of The Joint Commission Perspectives®, which is TJC’s official newsletter. In this issue TJC Department of Engineering Director George Mills followed up on his August 2012 column by addressing several additional issues including latching patient room doors, corridor walls, corridors and air supply, corridor projections. He also provided additional guidance related to the CMS waiver policy regarding certain provisions of the 2012 Life Safety Code.

Mr. Mills discussed the differences between the required patient room door latches and the self-closing or automatic closing devices that are not required for patient room doors. He discussed TJC’s expectation that accredited organizations are required to have in their fire response plans a process to ensure that patient room doors close and latch in a fire emergency. Because this requirement must be in the facility fire response plan, staff are accountable for checking patient room doors and closing the open ones during both fire drills and non-drill fire events.

Compliance News: Corridor Clutter Remains an Issue in Many Hospitals

By David Stymiest, PE, CHFM, FASHE


An article by TJC Director of Engineering George Mills in the August 2012 edition of EC News discussed at length the continuing issue of corridor clutter. This article is in the EC News “Clarifications and Expectations” column that is intended to increase accredited organizations’ awareness of the NFPA 101 Life Safety Code®.1 We recommend that you obtain and review this article and its follow-up article in the next issue of EC News.

Corridors need to be kept clear of clutter because of NFPA 101 Life Safety Code® requirements and also for ease of rapid patient movement in response to emergency conditions.

Crash carts and isolation carts may be stored in corridors while they are “in use” according to TJC. Crash carts must always be available and ready for use, so they are always “in use.” Isolation carts are in use as long as they are outside a patient room to which the patient for that cart has been assigned. An isolation cart outside a patient room is not in use after that patient has been discharged. If a hospital chooses to use door-hanging isolation cabinets rather than isolation carts, it is important to ensure that all NFPA 101 Life Safety Code® clear width requirements are maintained when the door is open. With the door closed the maximum six inch obstruction rule (reducing corridor width by not more than six inches) still applies even to that cabinet.

Compliance News: CMS Eases Hospital Corridor Clutter Waiver Process

By David Stymiest, PE, CHFM, FASHE


CMS issued new Survey and Clarification Memo # S&C-12-21-LSC, which applies to both hospitals and nursing homes, on March 9, 2012. CMS is easing its process for obtaining waivers in order to take advantage of four provisions in the NFPA 101 Life Safety Code© 2012 edition. CMS will now “allow providers to implement these four changes by considering waivers of the current LSC requirements found in the 2000 edition of the LSC without showing ‘unreasonable hardship’.” The four 2012 Life Safety Code© portions referenced by CMS are 18/19.2.3.4 under Capacity of Means of Egress; 18/19.3.2.5.2, 18/19.3.2.5.3, 18/19.3.2.5.4 and sections 18/19.3.2.5.5 under Cooking Facilities; 18/19.5.2.3(2), (3) and (4) under Heating, Ventilating, and Air Conditioning; and 18/19.7.5.6 under Furnishings, Mattresses, and Decorations. CMS stated “Due to the complex nature of some of the requirements, each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.”

ASHE members should have already received both an ASHE Advocacy Alert and Issue Brief regarding this topic. Since CMS waivers are issued after adverse findings during validation surveys, our recommendation is that organizations stay tuned and follow the development of this issue. As of this writing The Joint Commission has not commented publically.

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?