The Joint Commission Update 2013
Dave Dagenais
Ranking Results: 11 out of 21 in 2012
Top 20
Rank
2012 RFIs
2011
RFIs
Standard
2
LS.02.01.20
51%
56%
Means of Egress
3
LS.02.01.10
46%
52%
General LSC Requirements
5
EC.02.03.05
40%
40%
Features of Fire Safety
6
LS.02.01.30
39%
45%
Life Safety Protection
7
EC.02.06.01
35%
31%
Built Environment
9
LS.02.01.35
34%
29%
Fire Suppression Systems
10
EC.02.05.01
33%
23%
Utility Systems (Ventilation)
11
EC.02.02.01
30%
25%
Hazardous Materials & Waste
15
EC.02.05.09
23%
22%
Medical Gases
17
EC.02.05.07
22%
26%
Emergency Power
21
EC.02.03.01
19%
21%
Fire Safety
Subject
#2: LS.02.01.20 51%
• The hospital maintains the integrity of the means of
egress.
• EP 1 Door locking
• EP 13 Corridor Clutter
• EPs 16 – 21 Suites issues
• Boundaries & Size defined
• Sleeping Suite <5000 sq ft
• Non-sleeping suite <10,000 sq ft
• EP 22: Patient sleeping room is not locked
• EP 27-28: Lighting
Doors: Locking
EP 1
• Doors within a required means of egress shall not be locked
from the egress side
• Exceptions
• Clinical needs of the patient for security measures – staff
must be able to unlock at all times
• One (1) delayed-egress lock in any egress path
• Access controlled in accordance with 7.2.1.6.2
• 3 types of locking arrangements found:
• Clinical Needs Locking
• Delayed Egress Locking
• Access Control Locking
Corridor Storage
• “If the corridor looks cluttered…it probably is”
• Carts Allowed:
• Crash Carts
• Isolation Carts
• Chemo Carts
• Anything in the egress corridor more than 30
minutes is storage
• Dead end corridors may be used for storage
• Less than or equal to 50sqft space
Suites
• Not identified on drawings
• Boundaries
• Dimensions
• Exits
Egress Illumination
EP 27
• Means of egress are illuminated
• Corridors
• Passageways
• Stairways
• Stairway Landings
• Exit Doors
• Exit Discharges
• Angles and Intersections of the above
• Must be illuminated within 10 seconds
Egress Illumination
EP 28
• Failure of one bulb or fixture shall not result in total darkness
• Minimum illumination required is 0.2 foot-candle in any
designated area
8
#3: LS.02.01.10 46%
• Building and fire protection features are designed and
maintained to minimize the effects of fire, smoke, and heat.
• EP 9 Fire Barrier Penetrations
• EPs 5 – 7 Door issues
• EPs 1 & 2 Building Type issues
• EP 8 Duct issues
#5: EC.02.03.05 40%
• The hospital maintains fire safety equipment and fire safety
building features.
• Features of fire protection
Need for Inventory
• EC.02.03.05 EP 1 – 20:
• Each device that is required to be tested must be
documented in an inventory
• If x devices were tested last year, and x-1 were tested this
year, which device was missed?
• Each device must be on the inventory to identify which
device was missed
• Total number of devices (quantity) is not adequate
• Lack of an inventory (written, electronic or other) results in
a finding at each EP
EC.02.03.05
EPs 1 -20:
• Missing documentation: scored at each EP as noncompliant
• Also write a finding at EP 25 for documentation not being
readily available to the AHJ
• LD.04.01.05 EP 4: Staff held accountable
• If 3 or more findings at EC.02.03.05 EP 1 – 20
EC.02.03.05 EP 25
 Name of the activity
 Date of the activity
 Required frequency of the activity
 Name and contact information, including
affiliation, of the person who performed the
activity
 NFPA standard(s) referenced for the activity
 Results of the activity
#6: LS.02.01.30 39%
• The hospital provides and maintains
building features to protect individuals
from the hazards of fire and smoke.
• EPs 16 – 23 Smoke Barriers & Doors
• EP2 Hazardous Areas
LS.02.01.30
EP 1
• Vertical Openings
• The following vertical openings must be enclosed with at
least 1-hour fire rated construction:
• Exit stairs (unless >4 stories, then 2-hour FRR)
• Ramps
• Elevator Shafts
• Ventilation Shafts
• Light Shafts
• Trash or linen chutes
• Utility chases
LS.02.01.30
EP 2
• Hazardous areas defined, include, but not limited to:
• Laboratories that use flammable or combustibles in
quantities less than those considered severe hazard
• Laboratories that are determined severe hazard
• Areas used for general storage >50ft2
• Central / bulk laundries >100ft2
• Boiler or furnace room
• Soiled Linen & Trash Collection Rooms
• Fuel storage
• Janitor closets and
• Maintenance & Paint shops
LS.02.01.30
EP 4 & 5
• Interior Wall, Floor, and Ceiling Finishes
• In existing buildings, interior finishes are required to be
rated Class A or B
• When newly installed, finishes must be Class A
LS.02.01.30
EP 6 & 7
• Corridor Partitions
• Partitions that separate corridors in unsprinklered areas
must be:
• ½-hour Fire rating, continuous from floor slab to
underside of the floor or roof above, through any
concealed spaces, such as those above suspended
ceilings and including interstitial spaces
• Constructed to limit the transfer of smoke with all
penetrations properly sealed
• NOTE: If sprinklered, ceiling is allowed to be the smoke
barrier
• In new buildings, unrated walls are smoke tight
LS.02.01.30
EP 9 – 11
• Corridor Doors
• Doors must be substantial, made of >1¾ inch solid bonded
wood core or equivalent (without louvers unless wet
locations)
• Free of protective plates >48” above the bottom of the
door
• Doors must be fitted with positive latching hardware and
able to restrict the movement of smoke
• All corridor doors must swing. Pocket or sliding doors are
not acceptable
#7: EC.02.06.01 35%
• EP 1 Interior spaces meet the needs of the patient population
and are safe and suitable to the care, treatment and services
provided
• The organization must provide a safe
environment
• Unsecured oxygen cylinders
• Child safe plugs
EC.02.06.01
• EP 13 The organization maintains ventilation, temperature
and humidity levels suitable for the care, treatment and
services provided
• Ventilation:
• i.e. doors held open by air pressure; odors
• Temperature:
• Hot / Cold calls
• Humidity
• Primary concern is for areas >60%RH
• Mold growth is possible
• EP 20: Patient care areas are clean and free of offensive
odors
#9: LS.02.01.35 34%
EP 1: monitor authorized automatic sprinkler system
EP 2: water flow alarm
• There are 18” or more of open space maintained below the
sprinkler deflector to the top of storage.
NOTE: Perimeter wall and stack shelving may
NFPA 13-1999, 5-6.6
Perimeter
Shelving
18” rule
Perimeter
Shelving
Ceiling
18”
18”
Wall
Wall
OK
Wrong
OK
OK
#10: EC.02.05.01 33%
• EC.02.05.01 EP 1: Improper system design
• Inability of the mechanical system to
achieve required results
• EC.02.05.01 EP 4: Lack of written inspection, testing &
maintaining frequencies
• Continuous monitoring by a building
automation system (BAS) is acceptable
EC.02.05.01
• EC.02.05.01 EP 6: Ventilation system is unable to provide
appropriate pressure relationships, air-exchange rates and
filtration efficiencies
• Specific areas lack
• negative or positive pressures in relationship to adjacent
areas
• i.e. Endoscopy Processing Room should be negative to
the egress corridor
• the correct number of air changes per hour
• Improper filtration
EC.02.05.01 EP 6
In areas designed to control airborne
contaminants (such as biological agents,
gases, fumes, dust), the ventilation system
provides appropriate pressure relationships,
air-exchange rates, and filtration
efficiencies.
Air Pressure Relationship Testing
Electronic Monitoring
Smoke Testing
Flutter Strip Testing
#11: EC.02.02.01 30%
Hazardous Materials and Waste
• EP 1: Inventory
• EP’s 3 – 5: Personal Protective Equipment and the process to
manage hazardous materials and waste handling and
exposures
• EP’s 6 – 7: Hazardous energy sources
• Escorts to Hot Lab based on organization policy
• Perspectives, July 2012
Personal Protective Equipment Testing
DOSIMETRY
BADGES
LEAD APRONS
Self Contained
Breathing
Apparatus
•Accurate inventory
•Testing frequencies (based on policy)
•Training for PPE users
Gases & Vapors
• EP 10: Gases and vapors that are monitored include, but are
not limited to
• Formaldehyde
• Ethylene Oxide (EtO)
• Glutaraldehyde
• Waste anesthetic gases
• Acetic Acid
• Methyl/Ethyl Alcohol
#15: EC.02.05.09 23%
• Medical Gas Systems
• EP 1: Inspection Testing and Maintaining
• EP 2: Test when modified, installed or repaired
• EP 3: Obstructions
• EP 3: Labeling
• Contents of piping
• Areas served
• Accuracy
#17: EC.02.05.07 22%
EPs 4 – 7
• Missed Generator & Automatic Transfer Switch (ATS) Tests
• 12 times per year between 20 & 40 days
• Each emergency generator must be tested
with a load of at least 30% of nameplate
• Each ATS must be tested
• Missed triennial 4 hour test
#21: EC.02.03.01 19%
• Fire Safety (EP 1)
• Open junction boxes
• More than 300cuft of nonflammable medical gases (i.e.
oxygen) per smoke compartment, open to the egress
corridor
• Fire Plan (EP 9 & 10)
• Lack of fire safety training as per fire plan
• Surgical site fires
Categorical Waivers
S&C 13-58
• Issued August 30th, 2013
• Covers several “categorical waivers”
Medical Gas Master Alarms
• Allows substitution of a
centralized computer system for
(one) Category 1 medical gas
master alarm.
Openings in Exit Enclosures
• Permits existing openings in exit
enclosures to mechanical
equipment spaces if they are
protected by fire-rated door
assemblies.
Emergency Generators and Standby Power
Systems
• Reduces the annual dieselpowered generator exercising
requirement from two (2)
continuous hours to one hour
and 30 minutes.
Doors
Allows more than one delayedegress lock in the egress path
where the clinical needs require
specialized security measures or
when a patient requires
specialized protective measures
for safety.
Suites
Accommodates the use of suites by
allowing: (1) one of the required
means of egress from sleeping
and non-sleeping suites to be
through another suite, provided
adequate separation exists
between suites; (2) one of the
two required exit access doors
from sleeping and non-sleeping
suites to be into an exit stair, exit
passageway, or exit door to the
exterior; and (3) an increase in
sleeping room suite size up to
10,000 ft2.
Extinguishing Requirements
Allows for the reduction in
the testing frequencies for
sprinkler system vane-type
and pressure switch type
waterflow alarm devices to
semiannual, and electric
motor-driven pump
assemblies to monthly.
Clean Waste & Patient Record Recycling
Containers
Allows the increase in size of
containers used solely for
recycling clean waste or for
patient records awaiting
destruction outside of a
hazardous storage area to be a
maximum of 96-gallons
S&C 12-21
• Corridor Width
• New “Effective” Corridor width
• Fixed furniture allowed
• Rolling carts, equipment and
movement aids allowed
5’-0”
8’-0”
Bench
c.c
.
Decorations
• Increases the amount of wall space that may be covered by
combustible decorations
• 20% Not Sprinklered
• 30% Sprinklered
• 50% Sprinklered in patient room (less than 4)
Kitchens
• Allows certain types of alternative type kitchen cooking
arrangements including kitchens, serving less than 30
residents, to be open to corridors as long as they are
contained within smoke compartments
Fireplaces
• Allows 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
S&C 13-25
• OR Relative Humidity
• lowering the humidity requirement for operating rooms and
other anesthetizing locations from at least 35percent to at
least 20 percent.
How to request a categorical waiver
• Document your desire and that you comply with the waiver
provisions in your policy and procedures manual.
• Verbally announce that you are requesting the waivers at
each entrance interview of a survey
• Check with your State Agency and verify the waivers will be
accepted for licensing
• Indicate Life Safety waiver requests in your BBI
• Indicate Environment of Care waiver requests in your
management plan
Questions