1. Understanding TJC 2009 Life Safety Code Chapter
Presentation prepared for the Healthcare Facilities Managers of Delaware Valley
Leon Dender and
Dan Campbell

2. Life Safety Code Chapter Breakdown
Based on the NFPA 2000 edition Life Safety Code 101
Hospitals have 192 elements of performance.
Scoring is effective as January 01, 2009

3. Life Safety Code Chapter Breakdown
New Chapter has three main components.
Physical statement of conditions (SOC) deficiency survey for LSC compliance
Building maintenance program (BMP)
Has no scoring advantage
Maintaining the practice of inspections greatly helps with SOC.
ILSM’s
Huge emphasis on documentation requirements.

4. Life Safety Code Chapter Breakdown
Scoring
Supplemental findings eliminated
There are only “A” and “C” requirements
“A” requirements are yes or no
“C” requirements are three or more findings in the same category.
Requirement for Improvement (RFI)
Evidence of Compliance. (ESC)
Required to be submitted for all standards that are found to be out of compliance regardless of criticality.

5. Life Safety Code Chapter Breakdown
Scoring is broken down into four levels
Immediate threat to life
Situational decision rules
Direct impact requirements
Indirect impact requirements

6. Life Safety Code Chapter Breakdown
Level one Immediate threat to life
CON-04 or PDA possible
Three examples cited in physical environment
Inoperable fire alarm
Failure to provide appropriate exits during construction.
The absence of master alarms for medical gas systems
Other Immediate threats to life are mentioned in the Utility and Fire Safety Chapter

7. Life Safety Code Chapter Breakdown
Level 2 Situational Decision Rules
Conditional Accreditation (CON-O4) or Preliminary Denial of Accreditation
Symbol 2 with a Triangle

8. Life Safety Code Chapter Breakdown (slide one of two)
Deficiencies that can lead to a
Conditional Accreditation
• CON 04
Failure to make sufficient progress toward the corrective actions described in a statement of conditions Part 4, Plan for Improvement which was previously accepted by the Joint Commission
LS EP 3
“When the hospital plans to resolve a deficiency through a
Plan for Improvement (PFI), the hospital meets the time
frames identified in the PFI accepted by The Joint
Commission. “

9. Life Safety Code Chapter Breakdown (Slide Two of Two)or
Has failed to implement or enforce applicable Interim Life Safety measures
LS EP 3
“The hospital has a written interim life safety measure
(ILSM) policy that covers situations when Life Safety
Code deficiencies cannot be immediately corrected or
during periods of construction. The policy includes
criteria for evaluating when and to what extent the
hospital follows special measures to compensate for
increased life safety risk.”

10. Life Safety Code Chapter Breakdown
Level 3 Direct Impact Requirements
Findings of non-compliance accumulate”
toward CON
• 45 days to correct with evidence of standard compliance (ESC)
Indicated by Triangle with a number 3

11. Life Safety Code Chapter Breakdown
Protecting occupants during periods when the Life Safety Code is not met or during periods of construction.
ILSM procedures.
Perform a risk assessment (see handout)
Conduct daily surveys and issue hot work permits as needed.
Educate the workers and in-house staff in the area for exiting pattern changes.
Educate staff in surrounding areas of code deficiencies and protective measures implemented.

12. Managing Risk, Evaluating Construction, Non-Construction, and Potential ILSM Locations
Are there risks with flammable gas cylinders on the construction site?
Yes No Comment: ____________________________________________
Are there any risks involving temporary partitions and fire suppression and detection systems? Yes No Comment: ____________________________________________
Are there any doors in smoke or fire partitions compromised by blocking or other means? Yes No Comment: ____________________________________________
4. Are there any risks with hole penetration in and around the construction site? Yes No Comment: ____________________________________________
5. Are there any unusual circumstances effecting fire, or life safety?
Yes No Comment: _____________________________________________
If Yes, Explain: _________________________________________________________
_________________________________________________________

13. Managing Risk, Evaluating Construction, Non-Construction, and Potential ILSM Locations
1. General Statement: All SOC items identified as 45-day work order deficiencies following an in-house SOC survey shall not require ILSM’s. ILSM’s shall be required when a specific deficiency or deficiencies have been deemed required by the Facilities Management or the Fire Marshal. Such deficiencies shall be identified on the 45-day work issued.
2. Deficiency: ___________________________ Location: ________________________
Comment: ______________________________________________________________
3. Deficiency: ___________________________ Location: ________________________
4. Deficiency: ___________________________ Location: ________________________
1. Potential ILSM Location: Items identified during Building Maintenance Program (BMP) inspections shall be evaluated for completion within 45 days. Life Safety compliance items shall be identified on an ILSM grid for BMP deficiencies that will possibly require modified ILSM’s, as determined by the Fire Marshall.
2. BMP deficiency items expected to take more than 45 days to complete shall be placed on the eSOC.

14. ILSM Risk Assessment Requirements (page one of two)
Asterisk = Direct Impact Requirements for ILSM
*LS EP-1 Notify Fire Depart. And initiate fire watch when the fire alarm or sprinkler system is out of service more than 4 hours in a 24 hr. period in an occupied building.
*LS EP-2 Post signage identifying the location of alternate exits to everyone affected.
LS EP-3 Written ILSM policy that covers situations when LSC deficiencies cannot be immediately corrected or during construction. Policy includes criteria to what extent special measures to follow to compensate for increased LS risk.
*LS EP-4 Inspects exits on daily basis.
*LS EP-5 Provides temporary but equivalent fire alarm and detection system, when system is impaired.
*LS EP-6 Provides additional fire fighting equipment.
LS EP-7 Temporary partitions are smoke tight, or made of non-combustible material or made of limited combustible material and do not add to development or spread of fire.

15. ILSM Risk Assessment Requirements (page two of two)
LS EP-8 Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.
LS EP-9 Enforces storage, housekeeping, and debris removal to fire load to the lowest feasible level.
LS EP-10 Provides additional training to those who work in the hospital on use of fire-fighting equipment.
LS EP-11 Conducts one additional fire drill per shift per quarter.
LS EP-12 Inspects and tests temporary systems monthly. The completion date of tests is documented.
*LS EP-13 Hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.
*LS EP-14 Hospital trains those who work in the hospital to compensate for the impaired structural or compartmental fire safety features.

16. Level 3 Direct Impact Requirements
Review the daily ILSM inspection form topics that were provided in the handouts.
Construction Site and Renovated Areas
Exit Inspection
Alarm Systems
Fire Drills
Training
Comments

17. Level 3 Direct Impact Requirements
Review the Direct Impact Requirements in handout sections.
LS Building fire protection features designed and maintained to minimize the effects of fire, smoke, and heat.
LS Maintain the integrity of the means of egress.
LS Hospital provides and maintains fire alarm system.
LS Hospital provides and maintains systems for extinguishing fires.
LS Hospital provides and maintains special features to protect individuals from fire and smoke.

18. Level Four Indirect Impact Requirements
Largest group of Requirements
Indirect Impact Requirements Findings do not “accumulate” toward CON normally deficiencies
can take up to 60 days to correct and submit ESC.
However If a Direct Impact Requirement EP is out of compliance, then any Indirect impact requirement EPs under that standard that are out of compliance must be corrected within 45 days and submit ESC.
Most Indirect Impact Requirements are “C” items (total of 87) and there are ten “A” items to look out for.
Three of the “C” items have measures for success, all are related to ILSM’s.

19. Level Four Indirect Impact Requirements
Ten “A” Items of Indirect Impact Requirements are:
LS EP-1 Competent individual is assigned to assess LSC compliance.
LS EP-2 Maintains current accurate eSOC.
LS EP-7 Temporary partitions are smoke tight, or made of non-combustible material or made of limited combustible material and do not add to development or spread of fire.
LS EP-10 Provide additional training to those who work in the hospital on use of fire-fighting equipment.
LS EP-11 Conducts one additional drill per shift per quarter.
LS EP-3 Two hr. walls extend from floor below to roof slab above.
LS EP-4 Openings in two hr. walls are rated for 11/2 hr.
LS EP-14 At least two smoke compartments for every story that has more than 30 patient beds.
LS EP-15 At least two smoke compartments for every story with inpatient sleeping or treatment and non-sleeping stories with 50 or more people.

20. Recommendations • Review eSOC PFI’s
Review and or revise your ILSM plan and its implementation
• Be aware of EP’s that can adversely
impact your accreditation. Use handouts as checklist.
• Do not ignore indirect impact EPs. Especially the ten “A” items.

21. Questions ??????

22. Additional
Scoring
Information

23. 2009 Scoring/Accreditation Decision Model
Immediate Threat to Life
Situations, identified at the time of survey, which have or may potentially have a serious adverse effect on patient health and safety (i.e., inoperable fire alarm, high rate of infections).
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 survey.
PDA changes to Conditional Accreditation which includes a follow-up survey to assess sustained implementation of corrective action.

24. Immediate Threat to Life (Tier 1)
Expedited decision of Preliminary Denial of Accreditation (PDA) issued by The Joint Commission president
PDA remains in effect until corrective action is validated during on-site follow-up survey
After corrective action is validated, organization’s accreditation status will change to Conditional Accreditation pending follow-up survey in four to six months to assess ongoing implementation of corrective action

25. 2009 Scoring/Accreditation Decision Model
Situational Decision Rules
Situations in which an accreditation decision of Preliminary Denial of Accreditation or Conditional Accreditation is recommended to the Accreditation Committee (i.e., unlicensed facility, unlicensed individual who requires a license, failure to implement corrective action in response to identified Life Safety Code deficiencies).
Demonstration of resolution through submission of Evidence of Standards Compliance (ESC).
Onsite survey to validate implementation of corrective action.

26. Situational Decision Rules (Tier 2)
Recommendation of Preliminary Denial of Accreditation or Conditional Accreditation based on specific situations at the time of survey
Organizations must demonstrate resolution of identified issues through Evidence of Standards Compliance (ESC) submission within 45 days, and have a follow-up, on-site survey to validate implementation of corrective action
Examples of Situational Decision Rule findings are:
Evidence of an unlicensed facility
Unlicensed individual who requires a license
Failure to implement corrective action in response to identified Life Safety deficiencies

27. 2009 Scoring/Accreditation Decision Model
Direct Impact Requirements
Non-compliance = more direct impact on quality of care and patient safety.
“Implementation” based requirements.
Evaluation via the tracer methodology.
All less than fully compliant requirements must be addressed, via the ESC submission process, in a short time-frame (45 days).
Accreditation decision is pending submission of ESC within established timeframe.
Failure to resolve = progressively more adverse accreditation decision (e.g., Provisional, Conditional, PDA).

28. 2009 Scoring/Accreditation Decision Model
Indirect Impact Requirements
Initially less immediacy of risk, but failure to resolve non-compliance increases risk.
“Planning” and “Evaluation” based requirements.
Evaluation via the tracer methodology.
All less than fully compliant requirements must be addressed, via the ESC submission process, in a longer time-frame (60 days).
Accreditation decision is pending submission of ESC within established timeframe.
Failure to resolve = progressively more adverse accreditation decision (e.g., Provisional, Conditional, PDA).

29. 2009 Thresholds
2009 thresholds, which serve as triggers for recommendations for adverse accreditation decisions for all programs, will be reviewed by the Accreditation Committee in August 2008
Fixed thresholds may be established based on the number of less than fully compliant Direct Impact requirements which, if met, results in a recommendation for Conditional Accreditation or Preliminary Denial of Accreditation
Fixed thresholds may be established based on the total number of less than fully compliant standards at the time of survey which, if met, results in:
An onsite survey to validate implementation of the ESC, or
A recommendation for Conditional Accreditation or Preliminary Denial of Accreditation due to “egregious” noncompliance
Upon approval, the 2009 thresholds will be published in Perspectives

30. Post Survey Process (cont’d.)
Summary of Survey Findings Report will not include the potential accreditation decision
Official survey report posted on organization’s extranet site post-survey will include the potential accreditation decision
Typically, survey reports will be posted within 24 to 48 hours after the survey (weekends excluded) unless the report requires central office review
The final accreditation decision will be made after The Joint Commission receives and approves the Evidence of Standards Compliance (ESC)

31. Latest Scoring News
Thresholds will not trigger automatic PDA’s in 2009
Thresholds that trigger CON or PDA decisions may be established for 2010.
The central office will review survey findings (screening process) in identification of RFI’s via submission of ESC, or recommendations for CON or PDA.
The TJC will track the results of 2009 surveys.