1. 2009 The Physical Environment Overview Environment of Care Life Safety Chapter Emergency Management Q & A
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission

2. Standards Improvement Initiative (SII)
Overview
Standards Improvement Initiative (SII)

3. Re-structuring Highlights
SII did not create any new requirements
Deeming language added for clarity
Replaced bulleted lists with expanded Elements of Performance
Enhance clarity and objectivity of standards and EPs
Removed words like “appropriate”
New numbering conventions
EC EP 2 The organization inspects, tests & maintains all life support equipment. These activities are documented. (See also EC EPs 3 &4; PC.02.01,11 EP 2)

4. Re-structuring Environment of Care (EC) Life Safety Chapter (LS)
Merging Safety & Security
Training moved from HR to EC
Life Safety Chapter (LS)
Compliance with the Life Safety Code
Moved ILSM from EC
Emergency Management (EM)
Major changes in 2008
Hazard Vulnerability Analysis (HVA)
Emergency Operations Plan (EOP)

5. CMS Deeming Issue
Joint Commission is required to reconcile our Elements of Performance (EP) with CMS Conditions of Participation (COP)
COPs are the expectations of compliance CMS has related to Medicare/Medicaid reimbursements
COPs are federal laws
To reconcile the Joint Commission has added 1 additional EP in the Physical Environment
LS EP 4
Maintain documentation of any inspections or approvals by AHJs related to fire safety

6. Scoring

7. Scoring & Decision Process
Scoring Scale
0 = Insufficient Compliance
1 = Partial Compliance
2 = Full Compliance
Requirement for Improvement (RFI)
All findings of less than full compliance will be cited as a RFI
All RFIs require resolution through an Evidence of Standards Compliance (ESC)
This includes findings scored partial
“Supplemental Findings” (2008 term) are eliminated

8. EP Scoring Categories A: Structural requirements
EP’s scored yes (2) or no (0)
May address issues requiring full compliance
C: Based on number of times an EP is not met
Score 2: 0-1 instances of non-compliance
Score 1: 2 instances of non-compliance
Score 0: > 3 instances of non-compliance
Above is based on a sample of 10
NOTE: The ‘B’ Category has been eliminated

9. Example: Category A EC.02.04.02 EP 2:
The hospital inspects, tests & maintains all life support equipment. These activities are documented.
Did you do it? Yes or No [100%]
Is there documentation?

10. Example: Category C EC.02.04.02 EP 3:
The hospital inspects, tests & maintains all non-life support equipment identified on the medical inventory. These activities are documented.
How many times did you not do it?
Is there documentation?

11. Criticality of Findings & Immediacy of Risk
The amount of time for submitting the ESC is based on the criticality of the finding and the immediacy of risk as follows:
Direct Impact 45 Within Days
Indirect Impact 60 Within Days

12. Criticality
Criticality defined as “the immediacy of risk to patient safety or quality of care as a result of noncompliance with a Joint Commission requirement.”
4 Levels of Criticality
1. Immediate Threat to Life (ITL)
PDA until resolved
2. Situational Decision Rules
Based on specific situations at time of survey
3. Direct Impact Requirements
Noncompliance may create an immediate risk to patient safety or quality of care
4. Indirect Impact Requirements
Based on planning and evaluation or care processes

13. 2009 Scoring Decision Model

14. 2009 Scoring Decision Model
Immediate Threat to Life
Situations, identified during survey, which have or may potentially have a serious adverse effect on patient health and safety.
The Joint Commission President can issue an expedited Preliminary Denial of Accreditation (PDA) decision.
PDA remains until corrective action is demonstrated, via an on-site validation review.
PDA changes to Conditional Accreditation which includes a follow-up review to assess sustained implementation of corrective action.
Examples:
Inoperable fire alarm system
Lack of Master Alarms for Medical Gas System

15. 2009 Scoring Decision Model
Situational Decision Rules
Situations in which a decision of PDA or CON is recommended to the Accreditation Committee
Demonstration of resolution through submission of Evidence of Standards Compliance (ESC).
Onsite review to validate implementation of corrective action.
Examples:
Failure to implement corrective action in response to accepted PFI
unlicensed facility

16. 2009 Scoring Decision Model
Direct Impact Requirements
Non-compliance results in direct impact on quality of care and patient safety
“Implementation” based requirements
Non-compliant requirements must be addressed via ESC submission process
Short time-frame (45 days)
Decision is pending submission of ESC within established timeframe
Failure to resolve results in progressively more adverse decision (e.g., Provisional, Conditional, PDC)
Example:
Inspects, tests & maintains Life Support Systems

17. 2009 Scoring Decision Model
Indirect Impact Requirements
Initially less immediacy of risk; failure to resolve non-compliance increases risk
“Planning” and “Evaluation” based requirements
Non-compliant requirements must be addressed via ESC submission process
Longer time-frame (60 days)
Decision is pending submission of ESC within established timeframe
Failure to resolve = progressively more adverse certification decision (e.g., Provisional, Conditional, PDC)
Examples:
Piping used for AASS is not used to support any other item
Hospital provides storage space to meet patient needs

18. Direct Impact Count Environment of Care 38 Direct Impact
Life Safety Chapter
7 Administrative (LS.01)
20 Healthcare (LS.02)
56 Total (62 ‘z’ items in 2008)
Emergency Management
3 Direct Impact

19. Internal Intensive Review
Quantitative measure for identifying organization whose survey findings should be subject to a more intensive review by Central Office
Bands of screening points have been established to adjust for differences in size and complexity
HAP Screening Points: # Non-compliant
Surveyor Days Direct Impact Stds
1 –
5 –
7 –
10 –
>

20. Survey Process

21. Life Safety Code Specialist
LSCS Background
Facilities or Environment of Care based
Prefer CHFM certification
LSCS Agenda
On-Site one day (typically on day 1 or day 2)
Interfaces with survey team member(s)
LSCS Focus
EC Fire Protection Systems
EC Emergency Power
EC Medical Gas and Vacuum
LS Life Safety Code
LS Interim Life Safety Measures (ILSM)

22. Life Safety Code Specialist Update
Other EC “Observations”
May also survey
LD EP 4
LD EP 4
LD EP 2
Greater than 750,000 sq ft second survey day for the LSCS
Greater than 1.5 million sq ft third survey day for the LSCS [PROPOSED for 2009]
Critical Access Hospitals ONLY:
Survey EC, LS and EM

23. Observed but Corrected on Site
First and foremost, Surveyors, Reviewers, and LSCS must use their professional judgment. Draw upon your critical thinking skills that have been honed throughout your careers. Findings that are appropriately documented as "Observed but Corrected On-Site" have the following characteristics:
The deficiencies are easily corrected and do not pose a significant threat to patient safety.
The correction should not require any organizational planning or forethought
The practice is correct but the policy needed amending to coincide with the practice, so the policy was amended
Corrections to a form that was missing an element or piece of information and the change would not impact the process

24. Correct Use of “Observed but Corrected on Site”
Gap in ceiling tile that is repositioned
Stretcher or gurney blocking medical gas shut-off valves that could easily be moved
Food cart parked in front of a fire extinguisher but can be easily moved
Partially burned out exit light that is corrected on discovery
A few cigarette butts on the roof near a piece of equipment

25. When NOT to allow “Corrected on Site”
Penetrations in a rated barrier
A policy is written or amended during survey that requires change in practice, education of staff and/or implementation
Adding a suicide risk assessment to an assessment form (would require careful consideration of the population served, education of the staff in terms of conducting the assessment, etc)
Multiple fire doors fail to latch

26. Time Defined
For the Physical Environment the Joint Commission has defined time in the Introduction of the EC chapter:
Daily, weekly, monthly and quarterly are calendar references
Semi-annual is 6 months from last occurrence +/- 20 days
Annual is 12 months from last occurrence +/- 30 days

27. Does Every mean Every ? EC
EP 2 Every 6 months the hospital tests valve tamper switches and water-flow devices. The completion date of the test is documented.
Every 6 months +/- 20 days
EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented.
Every 12 months +/- 30 days
At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented.
Tested within the calendar month

28. Environment of Care

29. Environment of Care: Structure
Plan (EC )
Implement
Safety and Security (EC , )
Hazardous Materials and Wastes (EC )
Fire Safety (EC , , )
Medical Equipment (EC , )
Utilities (EC , , , , )
Other Physical Environment Requirements (EC , )
Staff Demonstrate Competence (EC )
Monitor and Improve (EC , , )

30. EC EPs 1 & 3
1 The hospital identifies safety & security risks associated with the environment of care. Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high risk processes, and from credible external sources such as Sentinel Event Alerts.
3 The hospital takes actions to minimize or eliminate identified safety and security risks in the physical environment.

31. Medical Equipment
EC The hospital manages medical equipment risks.
EP 1 The hospital solicits input from individuals who operate and service equipment when it selects and acquires equipment.
EP 2 The hospital maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory. (see also EC EP 7)

32. Utilities Management EC.02.05.01 EP 3
The hospital identifies in writing inspection and maintenance activities for all operating components of utility systems on the inventory. (See also EC EPs 3 – 5 and EC EP 1)
NOTE: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability-centered maintenance, interval based inspections, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.

33. Utilities Management EC.02.05.07 EP 4
Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each generator for at least 30 continuous minutes. The completion date of the tests is documented.

34. Utilities Management EC.02.05.01, EP 4
The [organization] defines in writing intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory based upon criteria such as manufacturers’ recommendations, risk levels, and current hospital experience.

35. Built Environment
Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided
Lighting is suitable for care, treatment and services
Hospital maintains ventilation, temperature and humidity levels suitable to the care, treatment and services provided
Interior spaces accommodate the use of equipment, such as wheelchairs, necessary to the activities of daily living

36. Design Criteria
When planning for new, altered, or renovated space the hospital uses one of the following design criteria:
State rules & regulations
AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities (2001 edition)
Other reputable standards and guidelines that provide equivalent design criteria

37. PRA EC.02.06.03 Preconstruction Risk Assessment (PRA)
Construction or renovation in occupied healthcare facilities can result in environmental problems such as:
Noise
Vibration
Creation or spread of contaminants
Disruption of essential services
Emergency Procedures
Air quality
One type of risk assessment that most of us are familiar with is the infection control risk assessment (ICRA).
An ICRA needs to be conducted when construction or renovation in occupied healthcare facilities can result in environmental problems, examples of this include (go over list) 37

38. Life Safety Chapter

39. Life Safety Chapter Based on the Life Safety Code® NFPA 101-2000
Format to be consistent with NFPA
CMS K-Tags reconciled
Three occupancies
Healthcare
Ambulatory
Residential
Exception language accepted
Annual Life Safety Assessment will occur as part of Periodic Performance Review

40. Life Safety Chapter
Removed optional Building Maintenance Program (BMP)
Standards & Elements of Performance
LS Administrative
LS Interim Life Safety Measures LS
LS.02 Healthcare
LS.03 Ambulatory
LS.04 Residential
LS < 16 Rooming & Lodging
LS > 17 Hotel & Dormitory

41. LS .02 .01 .34 EPs are sequentially listed Exception language accepted
Life Healthcare Building Protection Fire
Safety Type Alarm
EPs are sequentially listed
Exception language accepted
Interim Life Safety Measures (ILSM) applies to LSC deficiencies
Construction and non-construction

42. Life Safety Process
Overview: When an [organization] finds that it is out of compliance with Standards LS through LS , the hospital either resolves the deficiencies immediately or manages it through one of the following options:
a maintenance management process that documents the deficiency and corrective resolution within 45 days; or
a Plan For Improvement derived from the Statement of Conditions™; or
a Life Safety Code Equivalency approved by The Joint Commission.

43. Life Safety Chapter LS
The organization maintains the integrity of the means of egress
EP 13 Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice. (For full text and any exceptions, refer to: NFPA , 18/ )

44. Emergency Management

45. Overview Is now an accreditation manual chapter
All Standards and Elements of Performance from 2008 are incorporated into the 2009 Emergency Management Chapter
No new Standards or Elements of Performance in 2009
This new chapter contains some standards that were in HR, EC and MS
Survey Process is similar to 2008

46. History of Disasters Hospital/Community Debriefings:
Tropical Storm Allison-June 2001
Terrorist Attacks-September 2001
Power Outage- Summer 2003
S. California Wild Fires-Summer 2003
SARS (Asia/Toronto)-Spring 2003
Florida Hurricanes (Frances, Charley, Jeanne) - Aug/Sept 2004
Hurricane Katrina, Rita, Wilma- Aug, Sept & Oct 2005 G

47. Assessment Conclusions
Major Issues Began to Surface:
Scalable approach emergency management
Problems with Communication
Inadequate emergency generator backup
Faulty Incident Command Systems
Lack of Involvement with Emergency Operations Center (EOC)
The extend of an organization’s planning is dictated by the impact of their worst recent disaster

48. Conduct a Hazard Vulnerability Analysis
Documented
Annual Review
Site specific: one or many
Organization and community partners prioritize HVA
Includes disclosing to community needs and vulnerabilities
HVA to plan mitigation
HVA to plan preparedness
EP 8 Documented inventory of resources & assets
Fuel
Personal Protective Equipment (PPE)
Water
Medical/surgical supplies
Other

49. Emergency Operations Plan
Emergency Operations Plan (EOP) describes response procedures
Written plan
Capabilities to self-sustain for up to 96 hours
EOP describes
Recovery strategies
Initiation and termination of response and recovery phases
Defines authorities
Alternative care sites
Actual implementation is documented

50. Six Critical Components
Communication [EM ]
Resources & Assets [EM ]
Safety & Security [EM ]
Staff responsibilities [EM ]
Utilities Management [EM ]
Patient, clinical & support activities [EM ]

51. Emergency Management Development
EM Communication
EP 14 establishes backup communication systems and technologies for communication activities identified in EPs
EM Resources & Assets
EP 3 replenish non-medical supplies
EP 6 process to monitor quantities of its resources and assets during an emergency
EM Safety & Security
EPs 4 & 5 manage hazardous materials
EPs 6 & 7 controls access and movement

52. Emergency Management Development
EM Staff Roles & Responsibilities
EP 3 Define staff assignments
EP 7 Provide training for staff assignments
EM Utilities
Contingencies
EM Patient Care Issues
EP 3 Evacuation strategies
EP 11 Evaluate advance preparedness based on HVA
EM Annual Evaluation
EM Exercise Emergency Management Plan
EP 3 Escalating component

53. Surveying Emergency Management
Review of the organizations Emergency Operations Plan
Two themes:
Discussion
Prefer to conduct in ICS
This EM tracer will be based on a review of the Hazard Vulnerability Analysis
Top 3 issues
Observations
Integrated with other survey tracers

54. 2009 The Physical Environment Questions & Answers
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission

55. Questions & Answers Q. Can you please address decorations on walls.
A. See NPFA
18/
10.2.5

56. Questions & Answers
Q. On a mock survey a surveyor quoted "Most of the elevators lobbies do not have the required one hour rated barrier isolating the elevators from occupied areas” and cited LSC My question : Why a barrier is needed in an elevator lobby, when their are two fire doors in the beginning of the two wings next to the lobby and building is 100 % sprinklered?
A. This LSC reference is about using the elevators for fire service evacuation

57. Questions & Answers
Q. In an ongoing effort to become fully sprinkled here we added sprinkler heads in a space where we were storing records.
One of my fellow workers was told by CMS in a recent seminar that we could not have sprinkler heads over the records.
I was trying to meet NFPA guidelines for a hazardous space. But I was told CMS said that we either had to install a 200 gaseous system or have fully enclosed metal cabinets to store the records in.
This is so that if there were an accidental discharge from a sprinkler head that the records would not sustain any water damage.
A. The Joint Commission would allow you to add the sprinkler protection in these areas without other restrictions.
You will need to address CMS directly or through ASHE’s Advocacy

58. Questions & Answers LS.02 = Healthcare LS.03 = Ambulatory Healthcare
Q. There are many redundant LS elements of performance (EP's) whose only difference is the  NFPA code they reference . For example:
LS , EP 1 and LS , EP 4. Both EP's have exactly the same verbiage but reference different NFPA standards, and all references direct you to NFPA , 9.4.
LS.02 = Healthcare
LS.03 = Ambulatory Healthcare

59. Questions & Answers
Q. Where does the information go in the electronic SOC that used to be called Plan for Improvement Long Form?
A. It is still there: see PFI, PFI MENU, Create New, Resolution, then click on Additional Information

60. Questions & Answers

61. Questions & Answers
Q. A personal concern and experience is that the EC EP 6 only requires that auto transfer switches be tested and date recorded. I got cited and it has been an issue with a couple of others (one being a local acute hospital got the same hit) that the surveyors want transfer times documented. My form had the date and that the load was carried but he cited me anyway. Why are they allowing the surveyors to be more restrictive than the code states?
A. I will address this internally with the surveyors.

62. LS
The hospital prohibits portable space heaters within smoke compartments containing patient sleeping areas and treatment areas. (For full text and any exceptions, refer to NFPA /19.7.8)

63. LS
NFPA Portable space- heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements if such devices do not exceed 212°F.

64. Fire Extinguisher: Dating
Month, day year and initials of inspector as per NFPA EC EP 15
4-3.4 Inspection Recordkeeping.
Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.
At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

65. PFI modifications
Q. Can users of the PFI make changes to their PFIs created since the previous survey, including planned completion dates up to the point that the eSOC is locked for the survey. Is this still true for 2009?
A. Provided the PFI item has not been accepted by a Joint Commission surveyor, the user may make modifications as needed to manage the process.
The View All screen of the PFI indicates modifications have been made, and Joint Commission surveyors may inquire regarding the modification.

66. Testing Requirements
The Joint Commission Standards and Elements of Performance identify for accredited organizations compliance requirements. 
In the Environment of Care there are requirements for compliance with specific codes found in the National Fire Protection Association (NFPA) body of codes. 
The NFPA, which is consensus-based code development body, has a convention of codes and annex material. 
The codes are enforceable if adopted by an authority having jurisdiction (AHJ)
Annex material is not enforceable, as it is informational or explanatory material only.  

67. EC Tank Farm
EC , EP 1 states the hospital tests, inspects and maintains critical components of the piped medical gas systems. 
The bulk storage tank(s) and associated systems are critical components of the piped medical gas system.  

68. Sleeping Accommodations
Q. A sleep center with 8 beds within an otherwise Business occupancy. Is a sleep study considered "treatment", and therefore should this be classified as a Lodging and Rooming House occupancy in the eBBI under the Residential Treatment Center heading in the eBBI? A. No, this is a business occupancy, because the occupants are not rendered incapable of self preservation.

69. MASTER ALARM PANEL: LS.02.01.34 EP 2
The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and ¾ hour fire rated doors) that is continuously occupied
OR in an area with a smoke detector.
NFPA &

70. General Life Safety Interpretations
Rated doors must have legible labels on the door and jambs
Jambs prior to 1966 may not have a rating label
Missing labels may be equivalized if evidence of compliance is provided to central office
Alternative is to have third party testing agency re-label doors
Are ILSM in place where non-compliant door assemblies are found?

71. General Life Safety Interpretations
Fire stop: existing application is acceptable if:
It was installed in a manner consistent with original design specifications
It is in acceptable condition currently
If the firestop is cracking, etc, then it is to be removed and repaired using current technologies
JC does not accept the expanding foam used for insulation in any fire or smoke barrier
This product does have a UL label, for insulation properties
Easily ignited
Toxic gases when burned

72. Non Flammable Medical Gas Storage: General Issues
<300 ft³: 12 ‘e’ cylinders per smoke compartment, in rack or appropriate holders
Each ‘e’ cylinder is ft³
Smoke Compartment is limited to 22,500 ft²
Between 300 and 3000 ft³ must be stored in a room that is limited construction with doors that can be locked
“In use” verses “in storage”
On gurney is considered “in use”
In rack is “in storage”
limited to 12 racked, per smoke compartment
“Empty” are NOT considered part of the 12 “in storage”

73. Non-Flammable Gas Storage: NFPA 99-2005
NFPA edition has additional language regarding O2 storage requirements, specifically:
Storage of nonflammable gases:
9.4.1 > 3000 cubic feet
– 3000 cubic feet
cubic feet
Other:
design and construction
ventilation of locations for manifolds
ventilation for motor driven equipment
ventilation for outdoors
NOTE: CMS also recognizes the above references

74. General Life Safety Issues
Fully sprinklered buildings
Not required in elevator mechanical rooms if state codes do not allow (i.e. Ohio, Massachusetts)
Ensure sprinkler piping is not used to support wiring or other material
Score as life safety code deficiency (LS EP 4)
Piping supports are not damaged or loose (LS EP 3)

75. Changes to Scoring Standard / EP D / I Category Text LS.01.01.01 EP 2
Maintains current SOC
LS EP 3 C
Horizontal exits
LS EP 8
Exit discharge
LS EP 15
Two required exits
LS EP 29
Stair signage
LS EP 3
Remote panel
LS EP 6
18“ issue
LS EP 7
Domestic sprinklers
LS EP 9
K Class Extinguisher
LS EP 13
Controls exhaust fans
LS EP 4
Elevators

76. Changes to Scoring Ambulatory Healthcare Standard / EP
Direct or Indirect
Category
Text
LS EP 3 D I A C
Exit discharge
LS EP 18
Signs: No Exit
LS EP 3
Remote panel
LS EP 6
18“ issue
LS EP 1
Elevators

77. Contingency Planning
Utilities exist to provide a safe and comfortable environment of care
Failure of utilities could directly impact patient care delivery
Activities associated with managing utilities are designed to ensure the reliability of the systems day to day
Contingency plans are developed to ensure reliability of utilities systems
Contingency plans address at least two issues:
Equipment failure or disruption
Emergency related failures or disruption

78. Contingency Planning: Survey
Organizations ensure their contingency plans are current and accurate
Discuss the organization Memorandum of Understanding and its impact in the community
Evaluate against Standards & Elements of Performance
Suggest the organization include exercising these contingency plans with their Emergency Exercise

79. EC Utilities Mgmt.
EP 7 The hospital maps the distribution of utility systems
EP 8 The hospital labels controls for a partial or complete emergency shutdown
EP 9 The hospitals has procedures for responding to utility system disruptions
EP 10 The hospitals' procedures address shutting off the malfunctioning system and notifying staff in affected areas
EP 11 The hospitals procedures address performing emergency clinical interventions during utility systems disruptions
EP 12 The hospitals procedures addresses the following: How to obtain emergency repair services
EP 13 The hospital responds to utility system disruptions as described in its procedures

80. EM
Emergency Operations Plan identifies alternative means of providing:
EP 2 electricity
EP 3 water needed for consumption and essential care activities
EP 4 water needed for equipment and sanitary purposes
EP 5 fuel required for building operations or essential transport activities
EP 6 medical gas/vacuum systems
EP 7 Utility systems defined as essential, such as
Vertical & horizontal transport
Heating & cooling systems
Steam for sterilization
EP 8 Utility needs identified in the HVA

81. Survey Expectations Current Documentation EC/Safety Committee Minutes
EC Management Plans
Annual Evaluations of EC Plans
EC EP 15
Statement of Conditions
LS EP 2
Inspect, Test & Maintain EC EC

82. Damper Inspection: Actual EP Language: EC.02.05.05 EP 18
The hospital operates fire and smoke dampers one year after installation and then at least every six years to verify that they fully close. The completion date is documented.1
Note: The initial test that must occur one year after installation applies only to dampers installed on and after January 1, 2008.
1For additional guidance, see NFPA ( ) and NFPA (6.5.2).

83. NFPA Standards
NFPA Chapter 19, Installation, Testing and Maintenance of fire dampers
The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.
NFPA Chapter 6, Installation, Testing and Maintenance of smoke dampers
6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

84. LD.04.01.05 EP 4: What to do when the documentation isn’t there…
During survey documentation is reviewed
If the information is not readily available, but will be available later in the survey this may result in a finding at LD EP 4
The requested information should be utilized by the organization, so not having the information may indicate a lack of responsibility by the organization
If the documentation arrives late, non-compliance has already been established
Scored at LD EP4
Leaders hold staff accountable for their responsibilities

85. Corridor Clutter If the corridor looks cluttered, it probably is
Carts with wheels that are not parked and forgotten (not longer than 30 minutes), but are actively used are allowed provided they are "in use"
Crash Carts are always considered "in use" and allowed with staff understanding that in an emergency situation the cart is moved out of the corridor
Isolation carts, located outside a occupied patient room & required would be “in use”

86. Computers on Wheels
Computers on Wheels and other wheeled carts may be stored in a corridor for not more than 30 minutes
Computers on Wheels may be stored in alcoves
The corridor width must not be compromised
Computers on Wheels may be charging in the corridor while being used

87. Computers on Wheels What about the Batteries?
Battery and charging systems must meet the following design requirements to ensure safe operation:
Sealed Lead-Acid Batteries:
Absorbed Glass Mat design and
Sealed Case (Sealed Lead-Acid)
All Battery Systems (SLA, NiMH, Li+ Ion, Li+ Ion Polymer):
Smart Charging system with overcharge protection and
Shorted cell protection that shuts down upon detecting a shorted cell

88. Electronic Statement of Conditions (eSOC)

89. Government Suspension

90. Government Suspension

91. After Gov’t Suspension

92. Sites & Building Page

93. Fire Watch
An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable.
In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled.
A scheduled activity would be an event known to and under the knowledge of and control of organization staff
a construction project
servicing or upgrading the fire alarm system or sprinkler system.

94. Fire Watch
Other situations would typically be considered unscheduled activities
The fire alarm system or the sprinkler system was disrupted for 2 hours in the morning, restored, and then failed again for at least another 2 hours.
The fire watch should be implemented until the fire alarm system or sprinkler system is once again stable and fully functioning.

95. Who conducts the fire watch?
In 1998, the Healthcare Interpretations Task Force (HITF) agreed that
Clinical staff in an area affected by a fire alarm impairment or a sprinkler system impairment can be used to satisfy the requirements for a fire watch, provided
there is adequate staffing to continuously patrol the affected area
staff have the means to make proper notification to other occupants in the event of a fire.

96. ILSM Evaluation Required?
Service Situation
Fire Watch Required?
ILSM Evaluation Required?
Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours No
Recommended
Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area.
Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational
Yes
Rationale: During a controlled event the organization is managing the deficien­cy. The area would be continually monitored, and ILSM should be implemented as per policy.
Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours
● Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system)
Not in all cases
Yes (emphasis on occupant notification)
Rationale: During a controlled event, the organization is managing the defi­ciency. The area would be continually monitored, and ILSM would be implemented as per policy.
● Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure)

97. The Joint Commission Disclaimer
These slides are current as of 06/18/ The Joint Commission reserves the right to change the content of the information, as appropriate.
These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.
These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

98. SIG Support: 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer SIG
Jerry Gervais, CHFM Engineer SIG
John Maurer CHSP, CHFM Engineer SIG
Open Position
Engineer SIG