1. © Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT Anne M. Guglielmo, Engineer Department of Engineering The Joint Commission

2. Department of Engineering 2014 - 2 © Copyright, The Joint Commission Standard/NPSG 2012 Non Compliance 2013 Non Compliance RC.01.01.0161%55% LS.02.01.2051%54% IC.02.02.0142%47% EC.02.05.0134%46% LS.02.01.1046% EC.02.03.0540%44% LS.02.01.3039%43% LS.02.01.3534%38% EC.02.06.0135%36% MM.03.01.0135%33%

3. Department of Engineering 2014 - 3 © Copyright, The Joint Commission Standard/NPSG 2012 Non Compliance 2013 Non Compliance EC.02.02.0130%33% PC.01.03.0125%26% MM.04.01.0126%24% EC.02.05.0722%23% EC.02.05.0923%22% HR.01.02.0516%22% PC.01.02.0325%21% EC.02.03.0119% MS.01.01.0121%18% PC.03.01.0319%18%

4. Department of Engineering 2014 - 4 © Copyright, The Joint Commission NOTE: T HIS JUST IN ASHRAE voted in July 2013 to move endoscopy procedure rooms from positive to N/A. FGI is planning on releasing this in the November publication of the 2014 FGI Guidelines. Therefore, if an organization had made a documented decision based on risk assessment to no longer monitor endoscopy procedure rooms as per the 2013 ASHRAE action, we would accept this. If the organization has not made a documented decision, the room should be evaluated as per the below table and construction date. No change to bronchoscopy procedure rooms.

5. Department of Engineering 2014 - 5 © Copyright, The Joint Commission G UIDELINES V ENTILATION T ABLE : E NDOSCOPY & B RONCHOSCOPY E NDOSCOPY B RONCHOSCOPY Edition P ROCEDURE P ROCESSING (C LEANING )P ROCEDURE P RESSURE D IRECT E XHAUST P RESSURE D IRECT E XHAUST P RESSURE D IRECT E XHAUST 2014 (pending) N/A Negative (-) YES Negative (-) YES 2010 Positive (+) N/A Negative (-) YES Negative (-) YES 2006 Neutral N/A Negative (-) YES Negative (-) YES 2001 Negative (-) N/A Negative (-) YES 1996/1997 N/A Negative (-) YES 1992/1993 N/A 1987 N/A 1979 N/A

6. Department of Engineering 2014 - 6 © Copyright, The Joint Commission B ARRIER M ANAGEMENT S YMPOSIUM...at no cost to the attendee...

7. Department of Engineering 2014 - 7 © Copyright, The Joint Commission B ARRIER M ANAGEMENT S YMPOSIUM Program Developers: Joint Commission Firestop Contractors International Association Underwriters Laboratories Participating Organizations: American Society for Healthcare Engineering AWCI & Gypsum Institute Fire Damper Industry Fire Rated Glazing Industry National Concrete Masonry Association

8. © Copyright, The Joint Commission 2012 L IFE S AFETY C ODE U PDATE T HE FOLLOWING ARE AVAILABLE WITH CERTAIN PROVISIONS. T HESE ARE BASED ON CMS S&C 13-58-LSC

9. Department of Engineering 2014 - 9 © Copyright, The Joint Commission B ACKGROUND The Joint Commission provided CMS with a list of items, based on later editions of the Life Safety Code, that would immediately have a positive impact on all healthcare CMS acted on the Joint Commission recommendation in the form of a State & Certification letter (S&C 13-58-LSC) The action is a series of Categorical Waivers

10. Department of Engineering 2014 - 10 © Copyright, The Joint Commission P ROCESS If the organization decides to adopt these categorical waivers they must 1.Ensure full compliance with the appropriate code reference 2.Document the decision to adopt the categorical waiver For Life Safety Code items annotate the Additional Comments Section in the Statement of Conditions Basic Building Information (BBI) For Environment of Care items document by Minutes in discussion at the Environment of Care Committee (or equivalent) 3.Declare the decision at the beginning of any survey

11. Department of Engineering 2014 - 11 © Copyright, The Joint Commission M EANS OF E GRESS 18/19.2.1 18/19.2.1 which allow, under certain circumstances, existing openings to exit enclosures to mechanical room spaces as provided at section 7.1.3.2 Exits and more specifically the requirements at 7.1.3.2(9)(c)

12. Department of Engineering 2014 - 12 © Copyright, The Joint Commission E XISTING O PENINGS TO M ECHANICAL S PACES 18/19.2.1 requires compliance with Chapter 7, including Section 7.1.3.2.1(9)(c): (c) Existing openings to mechanical equipment spaces protected by approved existing fire protection–rated door assemblies shall be permitted, provided that the following criteria are met: The space is used solely for non-fuel-fired mechanical equipment. The space contains no storage of combustible materials. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

13. Department of Engineering 2014 - 13 © Copyright, The Joint Commission 18/19.2.5.7 S UITES 18/19.2.5.7.2.1(B) which allow, under certain circumstances, one of the exit access doors in a sleeping suite be permitted to be directly to an exit stair, exit passageway or exit to the exterior; 18/19.2.5.7.3.1(B) which allow, under certain circumstances, one of the exit access doors in a non-sleeping suite be permitted to be directly to an exit stair, exit passageway or exit to the exterior; 18/19.2.5.7.1.2 which allow, under certain circumstances, suites to be separated by corridor wall requirements;

14. Department of Engineering 2014 - 14 © Copyright, The Joint Commission M EANS OF E GRESS 18/19.2.2.2 18/19.2.2.2.4 which allow, under certain circumstances, more than one delayed egress in the egress path 18/19.2.2.2.6 which allow, under certain circumstances, remote control of locks for the rapid removal of occupants

15. Department of Engineering 2014 - 15 © Copyright, The Joint Commission M EANS OF E GRESS 18/19.2.2.2 18/19.2.2.2.5.1 which allow, under certain circumstances, door locking arrangements where clinical needs of patients require specialized security measures or where patients pose a security threat 18/19.2.2.2.5.2 which allow, under certain circumstances, door locking arrangements based on the patient special needs requiring specialized security measures for their safety

16. Department of Engineering 2014 - 16 © Copyright, The Joint Commission S UITES 18/19.2.5.7.2.3(B) and 18/19.2.5.7.2.3(C) which allow, under certain circumstances, patient sleeping suites up to 10,000square feet 18/19.2.5.7.2.2(C) which allow, under certain circumstances, one of the two required exits in a sleeping suite to exit into another suite 18/19.2.5.7.3.2(C) which allow, under certain circumstances, one of the two required exits in a non-sleeping suite to exit into another suite;

17. Department of Engineering 2014 - 17 © Copyright, The Joint Commission 96 G ALLON C ONTAINERS 18/19.7.5.1 which allow, under certain circumstances container used solely for recycling clean waste or patient records awaiting destruction up to 96 gallons not be stored in a room identified as hazardous storage. Soiled linen or trash receptacles shall not exceed 32 gallons and comply with 18/19.7.5.7.1

18. Department of Engineering 2014 - 18 © Copyright, The Joint Commission M ODIFIED S&C 12-21-LSC C ATEGORICAL W AIVER N OW A PPLIES : W HEELED E QUIPMENT E XPANDED 18/19.2.3 Capacity of Means of Egress and more specifically the requirements at 18/19.2.3.4 which allow, under certain circumstances, projections into the means of egress corridor width for wheeled equipment including lifts and transport equipment Provided 5ft clear corridor width is maintained Fire plan addresses management of storage Accommodates current equipment in use criteria

19. Department of Engineering 2014 - 19 © Copyright, The Joint Commission M ODIFIED S&C 12-21-LSC C ATEGORICAL W AIVER N OW A PPLIES : F IXED S EATING A LLOWED 18/19.2.3 Capacity of Means of Egress and more specifically the requirements at 18/19.2.3.4 which allow, under certain circumstances, projections into the means of egress corridor width for fixed furniture Provided provided 6ft clear width < 50sqft with 10 between groupings Groupings must be on same side of the egress corridor

20. Department of Engineering 2014 - 20 © Copyright, The Joint Commission M ODIFIED S&C 12-21-LSC C ATEGORICAL W AIVER N OW A PPLIES : C ORRIDOR C OOKING A LLOWED 18/19.3.2.5 Cooking Facilities, more specifically the requirements at 18/19.3.2.5.2 - 18/19.3.2.5.5 which allow certain types of alternative kitchen cooking arrangements One cooking area may be open to the egress corridor per smoke compartment Any additional cooking areas must be in protected room similar to hazardous areas Provisions: No deep fat fryers Safety equipment to de-activate fuel supply Grease baffles installed No solid fuel (i.e. charcoal)

21. Department of Engineering 2014 - 21 © Copyright, The Joint Commission M ODIFIED S&C 12-21-LSC C ATEGORICAL W AIVER N OW A PPLIES : F IREPLACES PLACEMENT MODIFIED 18/19.5.2 Heating, Ventilating, and Air Conditioning more specifically the requirements at 18/19.5.2.3(2), (3) and (4) which allow the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of solid fuel burning fireplaces in areas other than patient sleeping areas

22. Department of Engineering 2014 - 22 © Copyright, The Joint Commission M ODIFIED S&C 12-21-LSC C ATEGORICAL W AIVER N OW A PPLIES : C OMBUSTIBLE D ECORATIONS A DJUSTED 18/19.7.5 Furnishings, Mattresses, and Decorations including sections 18/19.7.5.6 which allow the installation of combustible decorations on walls, doors and ceilings. 1.On non-fire rated doors and do not interfere with latching or area limits at 18/19.7.5.6(b), (c), (d) 2.< 20% of wall, ceiling and door, inside a room or space of a smoke compartment that is not protected throughout with approved automatic sprinkler system

23. Department of Engineering 2014 - 23 © Copyright, The Joint Commission M ODIFIED S&C 12-21-LSC C ATEGORICAL W AIVER N OW A PPLIES : C OMBUSTIBLE D ECORATIONS A DJUSTED Continued: 3.< 30% of wall, ceiling and door inside a room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system 4.< 50% of wall, ceiling and door, inside a patient sleeping room with capacity of < 4 persons in a smoke compartment that is protected throughout with approved, supervised automatic sprinkler system

24. Department of Engineering 2014 - 24 © Copyright, The Joint Commission C ENTRALIZED C OMPUTER S YSTEM FOR M EDICAL G AS M ASTER A LARM 101-2012 Section 2.2 refers to the 2012 edition of the Health Care Facilities Code, and more specifically 5.1.9.2.2 which allows a centralized computer system to be permitted to be substituted for one of the medical gas master alarms required at 5.1.9.2.1 if the computer system complies with 5.1.9.4.

25. Department of Engineering 2014 - 25 © Copyright, The Joint Commission A NNUAL L OAD B ANK T EST R EDUCED 25% SAVINGS 18/19.2.9 Emergency Lighting, more specifically the requirements at 8/19.2.9.1 which refers to 7.9, which refers to NFPA 110-2010 which includes requirements for annual load bank tests as follows: 30 minutes at 50% of nameplate, and 60 minutes at 75% of nameplate see NFPA 110-2010 8.4.2.3 Cost savings of 25% based on reduction of two hour test by 25%

26. Department of Engineering 2014 - 26 © Copyright, The Joint Commission W EEKLY C HURN N OW M ONTHLY : E LECTRIC M OTOR D RIVEN F IRE P UMP LSC sections 18/19.3.5 Extinguishment Requirements, and more specifically the requirements at 9.7.5 Maintenance and Testing which refers to NFPA 25-2011. This edition of NFPA 25, the Standard for the Inspection, Testing & Maintaining of Water-Based Fire Protection Systems section 8.3.1.2.which requires the electric motor driven fire pump exercise to be monthly; Cost savings of reducing a weekly test to monthly is a 77% cost savings

27. Department of Engineering 2014 - 27 © Copyright, The Joint Commission W ATER F LOW A LARM T EST S EMI -A NNUALLY 18/19.3.5 Extinguishment Requirements, and more specifically the requirements at 9.7.5 Maintenance and Testing which refers to NFPA 25-2011. This edition of NFPA 25, the Standard for the Inspection, Testing & Maintaining of Water-Based Fire Protection Systems section 5.3.3.2 which requires the vane type pressure switch water flow alarm to be tested every six months; Cost savings of 50% when reducing a quarterly test to semiannual

28. Department of Engineering 2014 - 28 © Copyright, The Joint Commission PRA EC.02.06.05 EP S 2 & 3 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

29. Department of Engineering 2014 - 29 © Copyright, The Joint Commission I NTERIM L IFE S AFETY M EASURES Order of Standards (LS.01.02.01) EP 1 & 2 regardless of ILSM policy EP 3 must clearly define the ILSM policy including AFS 10 Process When to implement What to do to protect occupants Both construction related and non- compliance with the LSC EPs 4 – 14 align with policy and implementation strategies

30. Department of Engineering 2014 - 30 © Copyright, The Joint Commission RH 20 – 60% R ANGE CMS first issued a Categorical Waiver in S&C 13-25-LSC & ASC to align with the 2010 FGI Guidelines for Design & Construction of Health Care Facilities use of ASHRAE 170- 2008 Reduced the relative humidity (RH) in certain areas to a range of 20 – 60% This 2013 CMS action matched the Joint Commissions 1/2011 adoption of the 2010 Guidelines and the 20 – 60% RH range provided The S&C had two criteria 1.Document the decision 2.Declare at the beginning of a survey the decision

31. © Copyright, The Joint Commission 2014 T HE H EALTHCARE E NVIRONMENT S TATEMENT OF C ONDITIONS U PDATE Anne M. Guglielmo Department of Engineering The Joint Commission

32. Department of Engineering 2014 - 32 © Copyright, The Joint Commission S TATEMENT OF C ONDITIONS The Statement of Conditions has received an update. Most of the update was to the operating system and updating the appearance of the site There are no significant functional changes to the program that affect how the organization uses the SOC Management of the Statement of Conditions is required for Hospitals, Critical Access Hospitals, Behavioral Health Care, and Ambulatory Health Care (not business) (LS.01.01.01)

33. Department of Engineering 2014 - 33 © Copyright, The Joint Commission ILSM A SSESSMENT : Y/N For NEW PFIS: ILSM Assessment Y/N This must be answered as either Yes or No Yes indicates that the organization assessed based on the ILSM policy No indicates that the organization has not assessed based on the organization ILSM policy The View All screen has a column that identifies this decision.

34. Department of Engineering 2014 - 34 © Copyright, The Joint Commission A DDITIONAL F EATURES OF THE SOC Another feature is a management tool which displays PFI status in a pie chart Filter by One Building All Buildings Open Closed All PFIs

35. Department of Engineering 2014 - 35 © Copyright, The Joint Commission A DDITIONAL F EATURES OF THE SOC Enhanced access to BBI or PFI Selecting PFI bypasses the BBI The BBI may be modified if changes occur in the building The BBI includes the Construction Type table from NFPA 101-2000 18/19/1.6.2 as a pop up table Select Cancel to return to the BBI

36. Department of Engineering 2014 - 36 © Copyright, The Joint Commission E NTERING THE S TATEMENT OF C ONDITIONS

37. Department of Engineering 2014 - 37 © Copyright, The Joint Commission B ASIC B UILDING I NFORMATION (BBI)

38. Department of Engineering 2014 - 38 © Copyright, The Joint Commission Construction Types

39. Department of Engineering 2014 - 39 © Copyright, The Joint Commission Entering the PFI Section

40. Department of Engineering 2014 - 40 © Copyright, The Joint Commission Create New PFI : Deficiency

41. Department of Engineering 2014 - 41 © Copyright, The Joint Commission ILSM Assessment?

42. Department of Engineering 2014 - 42 © Copyright, The Joint Commission Create New PFI : Resolution

43. Department of Engineering 2014 - 43 © Copyright, The Joint Commission PFI View All Screen

44. Department of Engineering 2014 - 44 © Copyright, The Joint Commission H ISTORY A UDIT T RAIL

45. © Copyright, The Joint Commission T HE H EALTHCARE E NVIRONMENT C HANGES TO S TANDARDS L ANGUAGE 2014 Anne M. Guglielmo Department of Engineering The Joint Commission

46. Department of Engineering 2014 - 46 © Copyright, The Joint Commission C HANGES TO E LEMENTS OF P ERFORMANCE Standard EC.02.02.01 EP11: For managing hazardous materials and waste, the hospital has the permits, licenses, manifests, and material safety data sheets required by law and regulation EC.02.05.07, EP 4 Twelve times a year, at intervals of not less than 20 days and not more than 40 days, At least monthly, the hospital tests each emergency generator under load for at least 30 continuous minutes. The completion dates of the tests are documented. EC.02.05.07, EP 6 Twelve times a year, at intervals of not less than 20 days and not more than 40 days, At least monthly, the hospital tests all automatic transfer switches. The completion date of the tests is documented.

47. Department of Engineering 2014 - 47 © Copyright, The Joint Commission C HANGES TO E LEMENTS OF P ERFORMANCE EC.02.05.07, EP 5 The emergency generator monthly tests for diesel-powered emergency generators are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator or meets the manufacturers recommended prime movers exhaust gas temperature. If the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07, EP 4, then it must test each the emergency generator once every 12 months using supplemental (dynamic or static) loads of 25% of nameplate rating for 30 minutes, followed by 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 2 continuous hours. Note: For non diesel-powered generators tests need only to be conducted with available load.

48. Department of Engineering 2014 - 48 © Copyright, The Joint Commission C HANGES TO E LEMENTS OF P ERFORMANCE EC.02.05.07, EP 7 At least once every 36 months, hospitals with a diesel-powered generator providing emergency power for the services listed in EC.02.05.03, EPs 5 and 6, test each the emergency generator for a minimum of 4 continuous hours. The completion date of the tests is documented. Note: For additional guidance, see NFPA 110, 2005 edition, Standard for Emergency & Standby Power Systems. EC.02.05.07, EP 8 The 36-month diesel-powered emergency generator test uses a dynamic or static load that is at least 30% of the nameplate rating of the generator or meets the manufacturers recommended prime movers' exhaust gas temperature. Note: For non diesel-powered generators tests need only to be conducted with available load.

49. Department of Engineering 2014 - 49 © Copyright, The Joint Commission T IME RE-D EFINED The Joint Commission EC chapter defines time as: Daily, weekly, monthly are calendar references Quarterly will be once every three months +/- 10 days January 1, 2014 Semi-annual is 6 months from the last scheduled event month +/- 20 days Annual is 12 months from the last scheduled event month +/- 30 days 3 years is 36 months from the last scheduled event month +/- 45 days NOTE 1: The above does not apply to required frequencies NOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable

50. Department of Engineering 2014 - 50 © Copyright, The Joint Commission Q UARTERLY : +/- 10 DAYS S EMIANNUAL : +/- 20 DAYS A NNUAL : +/- 30 DAYS Due Date Scheduled Month 20 30 JulySeptOctAugNov June Dec Jan F M A J JON Semiannual Annual + + Jan M AS D Frequencies required by Code may not be modified (e.g. EC.02.05.07 EP 4 & 7) 10 JanFebruary March Apr Quarterly

51. Department of Engineering 2014 - 51 © Copyright, The Joint Commission C HANGES TO E LEMENTS OF P ERFORMANCE E FFECTIVE 7/1/2014 EC.02.05.07, EP 1 At least monthly, the hospital performs a functional test of battery-powered lights required for egress for a minimum duration of 30 seconds. The completion date of the tests is documented. Replaced At 30 day intervals…

52. Department of Engineering 2014 - 52 © Copyright, The Joint Commission C HANGES TO E LEMENTS OF P ERFORMANCE E FFECTIVE 7/1/2014 EC.02.03.03, EP 4 Staff who work in buildings where patients are housed or treated participate in drills according to the hospitals fire response plan. Note: When drills are conducted between 9:00 p.m. and 6:00 a.m., the hospital may use alternative methods to notify staff instead of activating audible alarms. Replaced: …the buildings fire alarm system.

53. Department of Engineering 2014 - 53 © Copyright, The Joint Commission C HANGES TO E LEMENTS OF P ERFORMANCE E FFECTIVE 7/1/2014 EC.02.03.03, EP 3 When quarterly fire drills are required, at least 50% are unannounced. Fire drills are held at unexpected times and under varying conditions. Added: Fire drills are held at unexpected times and under varying conditions.

54. Department of Engineering 2014 - 54 © Copyright, The Joint Commission D EPARTMENT OF E NGINEERING 630 792 5900 George Mills, MBA, FASHE, CEM, CHFM, CHSP, Green Belt Director Anne Guglielmo, CFPS, LEED, A.P., CHSP Engineer John Maurer, CHFM, CHSP, SASHE Engineer Kathy Tolomeo, CHEM Engineer James Woodson, P.E., CHFM Engineer

55. Department of Engineering 2014 - 55 © Copyright, The Joint Commission These slides are current as of 2/28/2014. 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. T HE J OINT C OMMISSION D ISCLAIMER