2009
Overview
Environment of Care
Life Safety Chapter
Emergency Management
Q&A
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission
© Copyright, The Joint Commission
The Physical Environment
Overview
© Copyright, The Joint Commission
Standards Improvement Initiative (SII)
Re-structuring Highlights
SII did not create any new requirements
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.02.04.03 EP 2 The organization inspects,
tests & maintains all life support equipment.
These activities are documented. (See also
EC.02.04.01 EPs 3 &4; PC.02.01,11 EP 2)
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Deeming
 Environment of Care (EC)
 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)
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Re-structuring
CMS Deeming Issue
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.01.01.01 EP 4
 Maintain documentation of any
inspections or approvals by AHJs related
to fire safety
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 Joint Commission is required to reconcile our
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Scoring
 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
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Scoring & Decision Process
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
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EP Scoring Categories
Example: Category A
Did
you do it? Yes or No
Is there documentation?
[100%]
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EC.02.04.02 EP 2:
The hospital inspects, tests &
maintains all life support equipment.
These activities are documented.
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?
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Example: Category C
Criticality of Findings &
Immediacy of Risk
Direct
Impact
Indirect Impact
45 Within Days
60 Within Days
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The amount of time for submitting
the ESC is based on the
criticality of the finding and the
immediacy of risk as follows:
Criticality
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
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 Criticality defined as “the immediacy of risk to patient
2009 Scoring Decision Model
Immediacy of risk to patient care
and the organization’s
certification status
Higher
Timeline for resolution of
non-compliant findings
ITL
PDA until
resolved
Shorter
Direct Impact Requirements
“Implementation” Based Requirements
(Short Resolution Timeframe)
Lower
Indirect Impact Requirements
“Planning” and “Evaluation” Based Requirements
(Longer Resolution Timeframe)
Longer
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“Situational”
Decision Rules
CON & PDA
2009 Scoring Decision Model
Immediate Threat to Life
ITL
“Situational”
Decision Rules
Direct Impact Requirements
Indirect Impact Requirements
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 onsite 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
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Situations, identified during
2009 Scoring Decision Model
Situational Decision Rules
ITL
“Situational”
Decision Rules
Direct Impact Requirements
Indirect Impact Requirements
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
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Situations in which a decision
2009 Scoring Decision Model
Direct Impact Requirements
ITL
“Situational”
Decision Rules
Direct Impact Requirements
Indirect Impact Requirements
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
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Non-compliance results in direct
2009 Scoring Decision Model
Indirect Impact Requirements
Initially less immediacy of risk; failure
“Situational”
Decision Rules
Direct Impact Requirements
Piping used for AASS is not used to
support any other item
 Hospital provides storage space to
meet patient needs

Indirect Impact Requirements
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ITL
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:
Direct Impact Count
 Environment of Care
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
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 38
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
 HAP Screening Points:
Surveyor Days
1–4
5–6
7–9
10 – 13
> 14
# Non-compliant
Direct Impact Stds
7
8
9
11
13
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established to adjust for differences in size and
complexity
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Survey Process
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.02.03.05 Fire Protection Systems
 EC.02.05.07 Emergency Power
 EC.02.05.09 Medical Gas and Vacuum
 LS.01.01.01 Life Safety Code
 LS.01.02.01 Interim Life Safety Measures (ILSM)
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
Life Safety Code Specialist Update
 Other EC “Observations”
 May also survey
EP 4
 LD.03.03.01 EP 4
 LD.04.04.01 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
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 LD.04.01.05
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
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Observed but Corrected on Site
Correct Use of “Observed but
Corrected on Site”
 Gap in ceiling tile that is repositioned
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
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 Stretcher or gurney blocking medical
When NOT to allow “Corrected on Site”
 Penetrations in a rated barrier
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
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 A policy is written or amended during
Time Defined
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
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 For the Physical Environment the Joint
EC.02.03.05
 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
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Does Every mean Every ?
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Environment of Care
Environment of Care: Structure
Plan (EC.01.01.01)
Implement
and Security (EC.02.01.01, 02.01.03)
Hazardous Materials and Wastes (EC.02.02.01)
Fire Safety (EC.02.03.01, 02.03.03, 02.03.05)
Medical Equipment (EC.02.04.01, 02.04.03)
Utilities (EC.02.05.01, 02.05.03, 02.05.05,
02.05.07, 02.05.09)
Other Physical Environment Requirements
(EC.02.06.01, 02.06.05)
Staff Demonstrate Competence (EC.03.01.01)
Monitor and Improve (EC.04.01.01, 04.01.03,
04.01.05)
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Safety
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.
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EC.02.01.01 EPs 1 & 3
EC.04.01.01 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.01.01.01 EP 7)
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Medical Equipment
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.02.05.05 EPs 3 – 5
and EC.02.05.09 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.
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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.
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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.
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Utilities Management
Built Environment
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
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 Interior spaces meet the needs of the
Design Criteria
 When planning for new, altered, or
renovated space the hospital uses
one of the following design criteria:
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
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 State
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
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PRA
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Life Safety Chapter
Life Safety Chapter
 Based on the Life Safety Code®





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
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 NFPA
Life Safety Chapter
Maintenance Program (BMP)
 Standards & Elements of Performance
 LS.01.01.01 Administrative
 LS.01.02.01 Interim Life Safety
Measures
 LS.02 - .04
 LS.02
Healthcare
 LS.03 Ambulatory
 LS.04 Residential
 LS.04.01 < 16 Rooming & Lodging
 LS.04.02 > 17 Hotel & Dormitory
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 Removed optional Building
LS .02 .01 .34
LS
.02
Life Healthcare
Safety
.01
Building
Type
.3
Protection
4
Fire
Alarm
 Exception language accepted
 Interim Life Safety Measures (ILSM)
applies to LSC deficiencies

Construction and non-construction
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 EPs are sequentially listed
Overview: When an [organization] finds that
it is out of compliance with Standards
LS.02.01.10 through LS.04.02.05, 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.
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Life Safety Process
Life Safety Chapter
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 101-2000,
18/19.2.3.3.)
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 LS.02.01.20
© Copyright, The Joint Commission
Emergency Management
Overview
 Is now an accreditation manual chapter
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
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 All Standards and Elements of
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, WilmaAug, Sept & Oct 2005
G
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History of Disasters
Assessment Conclusions
Major Issues Began to Surface:
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
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 Scalable
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
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
Emergency Operations Plan
 Emergency Operations Plan (EOP)
describes response procedures
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
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 Written
Six Critical Components
2.
3.
4.
5.
6.
[EM.02.02.01]
Resources & Assets
[EM.02.02.03]
Safety & Security
[EM.02.02.05]
Staff responsibilities
[EM.02.02.07]
Utilities Management
[EM.02.02.09]
Patient, clinical & support activities
[EM.02.02.11]
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1. Communication
Emergency Management Development
 EM.02.02.03 Resources & Assets
 EP 3 replenish non-medical supplies
 EP 6 process to monitor quantities of its
resources and assets during an emergency
 EM.02.02.05 Safety & Security
 EPs 4 & 5 manage hazardous materials
 EPs 6 & 7 controls access and movement
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 EM.02.02.01 Communication
 EP 14 establishes backup communication
systems and technologies for communication
activities identified in EPs 1 - 13
Emergency Management Development
 EM.02.02.07 Staff Roles & Responsibilities




3 Define staff assignments
 EP 7 Provide training for staff assignments
EM.02.02.09 Utilities
 Contingencies
EM.02.02.11 Patient Care Issues
 EP 3 Evacuation strategies
 EP 11 Evaluate advance preparedness based
on HVA
EM.03.01.01 Annual Evaluation
EM.03.03.03 Exercise Emergency Management
Plan
 EP 3 Escalating component
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 EP
Surveying Emergency Management
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
•
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 Review
2009
The Physical Environment
George Mills, Sr. Engineer
Standard Interpretation Group
The Joint Commission
© Copyright, The Joint Commission
Questions
&
Answers
Questions & Answers
Q. Can you please address decorations
on walls.
A. See NPFA 101-2000
 18/19.7.5.4
© Copyright, The Joint Commission
 10.2.5
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 7.2.13.3. 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
© Copyright, The Joint Commission
Questions & Answers
Questions & Answers
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
© Copyright, The Joint Commission
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.
Questions & Answers
Q. There are many redundant LS elements
of performance (EP's) whose only
difference is the NFPA code they
reference . For example:
LS.03.01.50, EP 1 and LS.02.01.50, EP 4.
Both EP's have exactly the same verbiage
but reference different NFPA 101-2000
standards, and all references direct you to
NFPA 101-2000, 9.4.
LS.02 = Healthcare
LS.03 = Ambulatory Healthcare
© Copyright, The Joint Commission

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
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Questions & Answers
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Questions & Answers
Q. A personal concern and experience is
that the EC .02.05.05 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.
© Copyright, The Joint Commission
Questions & Answers
LS.02.01.70
space heaters within smoke
compartments containing patient
sleeping areas and treatment
areas. (For full text and any
exceptions, refer to NFPA 1012000 18/19.7.8)
© Copyright, The Joint Commission
 The hospital prohibits portable
LS.02.01.70
 NFPA 19.7.8 Portable space-
heating Devices. Portable spaceheating devices shall be prohibited
in all health care occupancies.
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.
© Copyright, The Joint Commission
 Exception:
Fire Extinguisher: Dating
Month, day year and initials of inspector as per NFPA 101998 EC.02.03.05 EP 15
4-3.4.1 Personnel making inspections shall keep records
of all fire extinguishers inspected, including those found
to require corrective action.
4-3.4.2 At least monthly, the date the inspection was
performed and the initials of the person performing the
inspection shall be recorded.
4-3.4.3 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.
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4-3.4 Inspection Recordkeeping.
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.
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PFI modifications
Testing Requirements
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.
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 The Joint Commission Standards and Elements of
EC.02.05.09, 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.
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EC.02.05.09 Tank Farm
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.
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Sleeping Accommodations
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
72-1999 1-5.6 & 3-8.4.1.3.3.2
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MASTER ALARM PANEL:
LS.02.01.34 EP 2
General Life Safety Interpretations
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 noncompliant door assemblies are found?
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 Rated doors must have legible labels on
General Life Safety Interpretations
 Fire stop: existing application is acceptable if:
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
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 It
Non Flammable Medical Gas
Storage: General Issues
rack or appropriate holders
• Each ‘e’ cylinder is 24.96 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”
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 <300 ft³: 12 ‘e’ cylinders per smoke compartment, in
NFPA 99-2005 edition has additional language
regarding O2 storage requirements, specifically:
Storage of nonflammable gases:
9.4.1
> 3000 cubic feet
9.4.2
300 – 3000 cubic feet
9.4.3
0 - 300 cubic feet
Other:
5.1.3.3.2
design and construction
5.1.3.3.3
ventilation of locations for manifolds
5.1.3.3.3.2 ventilation for motor driven equipment
5.1.3.3.3.3 ventilation for outdoors
NOTE: CMS also recognizes the above references
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Non-Flammable Gas Storage:
NFPA 99-2005
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.02.01.35 EP 4)
 Piping supports are not damaged
or loose (LS.02.01.35 EP 3)
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General Life Safety Issues
Changes to Scoring
LS.01.01.01 EP 2
D/ I
D
Category
Text
Maintains current SOC
I
A
I
A
C
Horizontal exits
I
A
C
Exit discharge
LS.02.01.20 EP 15
I
A
C
Two required exits
LS.02.01.20 EP 29
I
A
C
Stair signage
LS.02.01.34 EP 3
I
A
C
Remote panel
C
18“ issue
LS.02.01.20 EP 3
LS.02.01.20 EP 8
D
LS.02.01.35 EP 6
D
I
LS.02.01.35 EP 7
D
I
A
LS.02.01.35 EP 9
I
A
C
K Class Extinguisher
LS.02.01.35 EP 13
I
A
C
Controls exhaust fans
I
A
C
Elevators
LS.02.01.50 EP 4
D
Domestic sprinklers
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Standard / EP
Changes to Scoring
Ambulatory Healthcare
LS.03.01.20 EP 3
Category
Text
I
A
C
Exit discharge
LS.03.01.20 EP 18
I
A
C
Signs: No Exit
LS.03.01.34 EP 3
I
A
C
Remote panel
C
18“ issue
C
Elevators
D
LS.03.01.35 EP 6
D
I
LS.032.01.50 EP 1
D
I
A
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Standard / EP
Direct
or
Indirect
Contingency Planning




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
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 Utilities exist to provide a safe and comfortable
Contingency Planning: Survey
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
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 Organizations ensure their contingency
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
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EC.02.05.01 Utilities Mgmt.
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
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EM.02.02.09
Survey Expectations
 Documentation
Current
EC/Safety Committee Minutes
EC Management Plans
Annual Evaluations of EC Plans
• EC.04.01.01 EP 15
 Statement of Conditions
• LS.01.01.01 EP 2
 Inspect, Test & Maintain
• EC.02.05.05
• EC.02.05.07
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


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 80-2007
(19.4.1.1) and NFPA 105-2007 (6.5.2).
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Damper Inspection: Actual EP Language:
EC.02.05.05 EP 18
NFPA Standards
 NFPA 80-2007 Chapter 19, Installation,
Testing and Maintenance of fire dampers
 19.4.1.1 The test and inspection frequency
shall then be every 4 years, except in
hospitals, where the frequency shall be
every 6 years.
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.
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 NFPA 105-2007 Chapter 6, Installation,
LD.04.01.05 EP 4: What to do when
the documentation isn’t there…
will be available later in the survey this may
result in a finding at LD.04.01.05 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, noncompliance has already been established
 Scored at LD.04.01.05 EP4
 Leaders hold staff accountable for their
responsibilities
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 During survey documentation is reviewed
 If the information is not readily available, but
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”
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Corridor Clutter
Computers on Wheels
 Computers on Wheels and other
 The
corridor width must not be
compromised
 Computers on Wheels may be
charging in the corridor while being
used
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wheeled carts may be stored in a
corridor for not more than 30
minutes
 Computers on Wheels may be
stored in alcoves
Computers on Wheels
What about the Batteries?
 Battery and charging systems must
meet the following design requirements
to ensure safe operation:
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
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 Sealed
© Copyright, The Joint Commission
Electronic Statement of
Conditions (eSOC)
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Government Suspension
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Government Suspension
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After Gov’t Suspension
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Sites & Building Page
Fire Watch
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.
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An organization experiencing a compromising
Fire Watch
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.
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 Other situations would typically be
Who conducts the fire watch?
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.
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 In 1998, the Healthcare Interpretations
Service Situation
Putting a shield over one smoke detector to prevent dust/false
alarms for more than 4 hours
Fire Watch ILSM Evaluation
Required?
Required?
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
No
Yes
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)
Yes
Yes
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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.
The Joint Commission Disclaimer
 These slides are current as of 06/18/2009. The Joint
Commission reserves the right to change the content of
the information, as appropriate.
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.
SIG Engineering 2009 - 97
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 These slides are only meant to be cue points, which
SIG Support: 630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Senior Engineer
SIG
John Maurer CHSP, CHFM
Engineer
SIG
Open Position
Engineer
SIG
SIG Engineering 2009 - 98
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Jerry Gervais, CHFM
Engineer
SIG