Fold-down Charting Stations in Corridors

What is The Joint Commission’s position on the use of springloaded, fold-down charting stations installed in corridors outside patient rooms? Are these a violation of the NFPA Life Safety Code, Section 7.1.10?

Preconstruction Risk Assessment

Is a preconstruction risk assessment required for every planned project? If not, how extensive must the construction project be before this is required? Does this apply to hospitals only, to ambulatory health care, or to other categories?

Life Safety Drawings

During a recent survey, a surveyor asked for our current LS drawings. We were unable to provide them, and the surveyor gave us a Requirement for Improvement (RFI), stating that we did not have a current Statement of Conditions (SOC). What is the link between current LS drawings and the SOC? What is required in a current set of LS drawings?

Emergency Lighting in Anesthetizing Locations

Does my organization need emergency lighting in anesthetizing locations? If so, where is this discussed?

Alcohol-based Hand Rub Volume

When calculating the volume of alcohol-based hand rub (ABHR) permitted in a single smoke compartment, do I need to include the amount in patient room dispensers?

CMS Recognizes Joint Commission Critical Access Hospital Accreditation

The Centers for Medicare & Medicaid Services (CMS) has again granted The Joint Commission deeming authority for the accreditation of critical access hospitals. The designation is effective November 21, 2011, through November 21, 2017, and means that critical access hospitals accredited by The Joint Commission may request to be “deemed” as meeting Medicare and Medicaid certification requirements.


From February 2012 EC News

New Joint Commission Partner Offers ISO Certification Option

The Joint Commission announced a new partnership with SGS Group that offers hospitals and critical access hospitals in the United States the option of pursuing both accreditation and certification with various International Organization for Standardization (ISO) and industry best-practice standards. Hospitals can select from a menu of certifications and tests, including ISO 9001 (quality management system), ISO 14001 (environmental management), ISO 27001 (information security), OHSAS 18001 (occupational health and safety), ISO 17025 (testing and calibration laboratories), and food safety testing and certification.


From February 2012 EC News

Joint Commission Issues Sentinel Event Alert on Health Care Worker Fatigue

The Joint Commission has issued a new Sentinel Event Alert: “Health care worker fatigue and patient safety.” The Alert urges greater attention to preventing fatigue among health care workers and suggests specific actions health care organizations can take to mitigate the risks. The Joint Commission Journal on Quality and Patient Safety reported that health care professionals who work long hours are at increased risk of injuring themselves on the job. The Alert is available on The Joint Commission website, at http://www.jointcommission.org/sea_issue_48.


From February 2012 EC News

Mesh Cubicle Curtains

What is the mesh requirement for cubicle curtains in hospitals?

Sprinkler Distance from Wall

What is the allowable distance a sprinkler head can be installed to a wall?

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: