2012
THE HEALTHCARE ENVIRONMENT
George Mills, Director
Engineering Department
The Joint Commission
© Copyright, The Joint Commission
UPDATE
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
Department of Engineering 2012 - 2
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
LS.02.01.20 (56%)
of the means of egress.
EP 13 Corridor Clutter
 Also scored
EPs 16 – 22 Suites issues
 Equivalize > 5000 sq ft
EP 1 Doors locked in means of
egress
Department of Engineering 2012 - 3
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 The hospital maintains the integrity
CORRIDOR STORAGE
 “If the corridor looks cluttered…it probably is”
 Corridor clutter is not a PFI issue
 Carts Allowed:
Carts
 Isolation Carts
 Chemo Carts
 Based on a HITF the following carts are not
allowed:
 Linen Hampers
 Latex Carts
 Anything in the egress corridor more than 30
minutes is storage
Department of Engineering 2012 - 4
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 Crash
CORRIDOR STORAGE
storage
Less than or equal to 50sqft space
 Surge issue: based on policy patients
may be treated in the egress corridor
during surge conditions
 Goal is continuous compliance for
patient safety
 NOT
oscillating compliance
Department of Engineering 2012 - 5
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 Dead end corridors may be used for
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
Department of Engineering 2012 - 6
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
LS.02.01.10 (52%)
 Building and fire protection features
are designed and maintained to
minimize the effects of fire, smoke,
and heat.
9 Penetrations
 EPs 5 – 7 Door issues
 EPs 1 & 2 Building Type issues
 EP 8 Duct issues
Department of Engineering 2012 - 7
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 EP
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
Department of Engineering 2012 - 8
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
LS.02.01.30 (45%)
 The hospital provides and maintains
building features to protect
individuals from the hazards of fire
and smoke.
16 – 23 Smoke Barriers & Doors
 EP 2 Hazardous Areas
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 EPs
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
Department of Engineering 2012 - 10
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 40% EC.02.03.05
EC.02.03.05 (40%)
 The hospital maintains fire safety
equipment and fire safety building
features.
of fire protection
NOTE: #1 for Critical Access Hospitals
Department of Engineering 2012 - 11
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 Features
LD.04.01.05 EP 4: WHAT TO DO WHEN THE
DOCUMENTATION ISN’T THERE…
as non-compliant
 Also score LD.04.01.05 EP 4
 If the documentation becomes available later in the survey
to the survey team, the team can:
 Consider removing the previous finding if documentation
confirms the activity was completed as per the EP
 LD.04.01.05 EP 4 may also be removed during survey
 If the survey team would prefer not to evaluate the
documentation the organization can submit clarification
 If the organization clarifies after survey:
 SIG Engineers will review and evaluate compliance
 LD.04.01.05 EP 4 remains
Department of Engineering 2012 - 12
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 During survey specific documentation is reviewed
 If the documentation is not available write the observation
LS & EC RANKING IN TOP 10 IN 2011
EP 13 Corridor Clutter
EP 9 & 5
& Rated Doors
EP 2 Hazardous Areas
All EP’s Fire Safety
Testing
10. 31% LS.02.01.35 Sprinkler System
Department of Engineering 2012 - 13
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2. 56% LS.02.01.20
3. 52% LS.02.01.10
Penetrations
4. 45% LS.02.01.30
5. 42% EC.02.03.05
LS.02.01.35 EP 6
 There are 18” or more of open
NOTE: Perimeter wall and stack
shelving may NFPA 25-1998, 2-2.1.1
Department of Engineering 2012 - 14
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space maintained below the
sprinkler deflector to the top of
storage.
Perimeter
Shelving
18” RULE
Perimeter
Shelving
Ceiling
18”
18”
Wall
OK
Wrong
OK
OK
Department of Engineering 2012 - 15
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Wall
LIFE SAFETY CODE SURVEYOR
 LSCS Background
or Environment of Care based
 Prefer CHFM certification
All HAP and CAH will be surveyed for a minimum of
2 days by a LSCS
 Greater than 1.5 million sq ft will be surveyed
for a third day by the LSCS
 An additional day is added for every three
buildings that are classified as healthcare
Example: for a HAP organization with 2 million
square feet of healthcare occupancy and 5
buildings classified as healthcare occupancy:
the number of LSCS days would be 4
Department of Engineering 2012 - 16
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 Facilities
LIFE SAFETY CODE SURVEYOR
 Interfaces with survey team member(s)
 LSCS Survey Focus
Safety Chapter
 EC.02.05.03
 EC.02.05.07
 EC.02.05.09
 May conduct the EC Session
 May conduct the EM Session
 Other “Observations”
 May also survey
 LD.04.01.05 EP 4 Accountability
 LD.04.04.01 EP 2 Hi-Priority
 LD.01.03.01 EP 5 Resources
Department of Engineering 2012 - 17
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 Life
WHAT TRIGGERS ITL
(IMMEDIATE THREAT TO LIFE)
system
 Significantly compromised sprinkler system
 Significantly compromised emergency
power supply system
 Significantly compromised medical gas
master panel
 Significantly compromised exits
 Other situations that place patients, staff
or visitors at extreme danger
Department of Engineering 2012 - 18
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 Significantly compromised fire alarm
WHAT TRIGGERS ITL
(IMMEDIATE THREAT TO LIFE)
 CONT01
The Immediate Treat to Health or
Safety has been successfully abated
and verified through the direct
observation or other determining
method.
Department of Engineering 2012 - 19
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 PDA01
An Immediate Threat to Health or
Safety exists for patients or the public
within the hospital.
AFS 10 IS RELATED TO THE
SOC AND PFIS
previously accepted PFIs (LS.01.01.01 EP 2)
 Failure to develop ILSM policy and
implement appropriate ILSMs (LS.01.02.01
EP 3)
 Failure to manage previously accepted PFIs
affects the Joint Commission
 Both organizations are aware of
deficiencies that have been managed
using the PFI process
Department of Engineering 2012 - 20
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 Failure to make sufficient progress on

Resolution to a deficiency:
 Resolve it immediately
 Correct it within 45 days:
 Management process that
documents the deficiency and
actions to resolve
 ILSM must be considered
 Plan For Improvement located in the
Statement of Conditions™
 Corrected within 6 months of the
Projected Completion Date
 ILSM must be considered
Department of Engineering 2012 - 21
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DEFICIENCY RESOLUTION
45 DAY CORRECTIVE ACTION
 Documented
 Origination date
 Completion date
 Kept available for rolling 3 years
 Life Safety deficiencies
 Must not exceed 45 days
Improvement (PFI)
 If originally a work order, close out as complete
and generate the PFI
 Must be made available to the Joint Commission
 During survey to confirm management of the
deficiency
 During CMS/Joint Commission validation process
upon request
Department of Engineering 2012 - 22
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 If greater than 45 days create a Plan For
HOW MANY OPEN PFIS
ARE TOO MANY?
organizations to self assess and create a
Plan for Improvement
 The self disclosure has never defined how
many is too many
 The ILSM process was created to allow both
the organization and The Joint Commission
to be aware of Life Safety Code deficiencies
 Failure to make progress on previously
accepted PFIs, including failure to
implement ILSMs results in Conditional
Accreditation
Department of Engineering 2012 - 23
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 The PFI process was created to allow
HOW MANY OPEN PFIS
ARE TOO MANY?
 Survey Process:
is no limit to the number of PFIs
 Evaluate both closed and currently open PFIs
in the View All screen
 Spot check during building tour both some
closed and open PFIs to evaluate how well the
organization is managing the PFI process
 Evaluate the scope of PFI entries
 Are there life safety deficiencies
 Are they greater than maintenance items
(i.e. screws missing from a door hinge)
Department of Engineering 2012 - 24
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 There
STATEMENT OF CONDITIONS: PFI
 PFIs should be related to the LS Chapter
clutter is not a legitimate PFI
 PFIs should provide specific information
 No blanket statements
 “…penetrations on 3rd floor”
 Specific references to Life Safety Drawings is
acceptable
 32 penetrations as identified on LS
Drawing 3rd Floor, Center Tower dated
3/3/2010
 Projected Completion Date is for all listed
items (i.e. “32 penetrations”)
Department of Engineering 2012 - 25
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 Corridor
TWO FORMS OF EQUIVALENCIES
 Fire Safety Evaluation System (FSES)
process of calculating the features of life
safety and deducting any deficiencies, with the
outcome determining if the building is
equivalized based on the FSES
 Traditional Equivalency
 A process of field verification identifying
alternative methods of fire safety that off-set
the identified deficiency
 Field verification from one of the following:
 Registered architect
 Fire Protection Engineer
 Local AHJ responsible for fire safety
Department of Engineering 2012 - 26
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A
HISTORY AUDIT TRAIL
Engineers when considering extensions or
other activities related to an organization
 Prior to surveying, the surveyor must
preview the History Audit Trail to discover
if equivalencies or other actions have
occurred by SIG Engineers
 When surveying, brief but accurate
information entered in the File Room is
important
Department of Engineering 2012 - 27
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 The History Audit Trail is used by SIG
George Mills, Director
Department of Engineering
The Joint Commission
© Copyright, The Joint Commission
2012 LIFE SAFETY CODE
NFPA 101-2012
1. Means of Egress Enhanced
Patient lift & transport equipment may be
stored in the Means of Egress, provided
 5ft clear corridor width is maintained
 Fire plan addresses management of
storage
 Accommodates current “equipment in use”
Department of Engineering 2012 - 29
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
NFPA 101-2012
Fixed seating permitted
 provided 6ft clear width
 < 50sqft with 10’ between
groupings
 Groupings must be on same
side of the egress corridor
Department of Engineering 2012 - 30
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2.
4. Cooking Facilities
 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)
Department of Engineering 2012 - 31
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NFPA 101-2012 CORRIDOR COOKING
NFPA 101-2012 FIREPLACES
patient sleeping rooms
 Section 18/19.5.2(2), (3) and (4)
 Allow the installation of direct vent
gas fireplaces
 In smoke compartments containing
patient sleeping rooms
 Installation of solid fuel burning
fireplaces in areas other than patient
sleeping areas
Department of Engineering 2012 - 32
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5. Fireplaces in smoke compartments with
NFPA 101-2012 DECORATIONS
Allow the use of Furnishings, Mattresses,
and Decorations including Section 18/19.7.5
 Allows the installation of combustible
decorations on
 Walls
 Doors
 Ceilings
 LSC Section 18/19.7.5.6
Department of Engineering 2012 - 33
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6.
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GENERAL
INTERPRETATIONS
BUILDING MAINTENANCE PROGRAM
(BMP)
All EPs related to the original
ten BMP items are ‘C’ categories
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The BMP is no longer available to offset
findings during survey, but is
considered “best practice”
GENERAL LIFE SAFETY INTERPRETATIONS
placement:
 LS.02.01.29 EP 12 and NFPA 101
19.3.2.6 (6) states, The dispensers
shall not be installed over or directly
adjacent to an ignition source.
 The Joint Commission published
information in 2006 defining
“adjacent to” as no closer than
6inches, center of the dispenser to
center of the ignition source
Department of Engineering 2012 - 36
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 Alcohol Based Hand Rub (ABHR)
NFPA 101, 2012: 18/19.3.2.6. (8) Dispensers
shall not be installed in the following
locations:
 Above an ignition source for a horizontal
distance of 1 in (25 mm) to each side of
the ignition source.
 To the side of an ignition source within a
1 in. (25 mm) horizontal distance from
the ignition source.
 Beneath an ignition source within a 1 in.
(25 mm) vertical distance from the
ignition source.
Department of Engineering 2012 - 37
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GENERAL LIFE SAFETY INTERPRETATIONS
FIRE & SMOKE DAMPER INSPECTIONS
are by random sampling
 Confirm ILSM policy is implemented
for any horizontal exits or egress
enclosures that are compromised
by inaccessible dampers
 Evaluate adequacy of damper
accessibility plan
Department of Engineering 2012 - 38
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 Ensure inaccessible dampers truly
EC.02.06.05 EP 1
recognize the Facilities Guidelines Institute (FGI)
Guidelines for Design & Construction of Health Care
Facilities
 ASHRAE 170 has been attached to the Guidelines
 Ventilation Table
 20 – 60 % RH requirement of relative humidity in
seven affected areas of the Surgical
Environment, and one in Diagnostic & Treatment.
 NOTE CMS has not adopted this, but remains
at 35 – 60%RH
 The established 60% upper range however
should be maintained for issues such as mold
growth.
Department of Engineering 2012 - 39
© Copyright, The Joint Commission
 Effective 1/1/2011 the Joint Commission will
RH% TREATMENT AREAS
 Class A Operating/Procedure room
 Class B and C operating rooms
 Operating/surgical cystoscopic rooms
 Delivery room (Caesarean)
 Treatment rooms
 Laser eye room
 Diagnostic & Treatment: Gastrointestinal
Endoscopy Procedure Room
Department of Engineering 2012 - 40
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 Trauma room (crisis or shock)
CENTRAL STERILE LAYOUT
 Physically separated soiled and clean work rooms
Soiled Work Room:
 Work surface, sink, washer/sterilizer decontaminators
 Soiled room is not to have direct contact with the OR
 Clean assembly /work room
 Hand washing station
 Sufficient workspace and equipment
 Self-closing door or pass through is acceptable between
soiled and clean work rooms
 Storage
 provisions for humidity, temperature, and ventilation
 Location of storage may be within the clean assembly/
workroom in a permanently designated space
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.7-5.1.2 - 3.7-5.1.2.3
Department of Engineering 2012 - 41
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
ENDOSCOPY PROCESSING ROOM
 May be one room, dedicated to endoscopy equipment processing
Sized as per amount of equipment processed
 Work flow from soiled to clean
 Clean should not be exposed to soiled
• 3ft min clearance clean from soiled at all times
• Droplet contamination is concern
 Work surface and sink
 Hand washing station
 Sufficient workspace, utilities and equipment
 Ventilation
 Negative air pressure to surrounding areas
 Minimum 10 ach (2 fresh, outside); direct exhaust
 NO requirements for temperature or humidity
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.9-5.1.1 - 3.9-5.1.1.2
Department of Engineering 2012 - 42
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
ENDOSCOPY PROCESSING ROOM
 Storage
May be a cabinet in the endoscopy processing room
 Cabinet must have doors
 Cabinet must be at least 3ft from potential
droplet contamination
• Consider route from processor to the cabinet
• Route should not cross through soiled
processing area
 Storage may be in a separate room
 Inventory of Scopes
 Recommended practice is to include scopes in the
Medical Equipment Inventory
Guidelines for Design & Construction of Health Care Facilities
FGI 2010 edition 3.9-5.1.1 - 3.9-5.1.1.2
Department of Engineering 2012 - 43
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
SCORING
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
Department of Engineering 2012 - 44
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 EC.02.05.01 EP 1: Improper system
SCORING
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
• MERV = minimum efficiency reporting
value
Department of Engineering 2012 - 45
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 EC.02.05.01 EP 6: Ventilation system is unable
SCORING
evaluate if further investigation needs to occur
 To perform the flutter test take a tissue and let it hang
just off the floor near the bottom edge of a door
 If the tissue indicates incorrect air flow, stabilize the
area by closing doors and windows, wait a few minutes
and re-screen
 If the organization presents a Testing & Balancing
report the following questions should be asked
• when was the balancing done (seasonal issues)
• are any specific requirements (such as keeping a
door closed) needed to achieve satisfactory
results
 If non-compliance is determined write a clear and
specific finding
Department of Engineering 2012 - 46
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 Tissue test: only to be used as a pre-screening tool to
SCORING

Maintains ventilation, temperature and humidity
levels suitable for 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
Department of Engineering 2012 - 47
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 EC.02.06.01 EP 13
SCORING
 EC.02.05.05 EP’s 4 & 5
4: Infection Control systems are not
maintained
 i.e. an isolation room that should be
negative is positive
 EP 5: non-life support utility system
components are not inspected, tested or
maintained
 Improper number of air changes results in
offensive odors in geriatric unit
Department of Engineering 2012 - 48
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 EP
GENERAL LIFE SAFETY INTERPRETATIONS
labels on the door and jambs
Jambs prior to 1966 may not
have a rating label
Are ILSM in place where noncompliant door assemblies
are found?
Department of Engineering 2012 - 49
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Rated doors must have legible
NON FLAMMABLE MEDICAL GAS
VOLUME & STORAGE: SCORING
Score EC.02.03.01 EP 1 …fire risk
‘E’ cylinders (<300ft³) per smoke compartment
(22,500ft²) may be open to the egress corridor in a rack
or appropriate holders
Between 300 and 3000ft³ must be stored in a room that
is limited construction with doors that can be locked
 “In use” verses “in storage”
 Properly secured to a gurney is considered “in use”
 Properly racked is “in storage”
 Empty are NOT considered part of the 12 in storage
 Empty and full must be stored (racked) separately
Department of Engineering 2012 - 50
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12
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 9.4.3 reference
Department of Engineering 2012 - 51
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NON-FLAMMABLE GAS STORAGE:
NFPA 99-2005
NON-FLAMMABLE MEDICAL GAS
UNSAFE CONDITIONS: SCORING
Score EC.02.06.01 …unsafe condition
cylinders
 Laying on top a gurney mattress; leaning against the wall
 Free standing
 Comingling of full and empty cylinders
 Transfilling liquid oxygen
 Transfer of any gases from one cylinder to another in
patient care areas of health care facilities is prohibited.
 Transfilling of liquid oxygen only in an area that is:
• mechanically ventilated
• sprinklered
• ceramic or concrete flooring
• separated with at least 1 hour construction from any
patient care areas

Department of Engineering 2012 - 52
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 Unsecured
TANK FARM
maintains critical components of the piped medical gas
systems.
 Tank Farm is included in this EP
 The bulk storage tank(s) and associated systems are
critical components of the piped medical gas system
 Tanks above ground, not on roofs
 No electrical service above tanks
 10’ Clear from vehicles & sidewalks
 50’ from wood frame buildings
• At least 1’-0” from other buildings
• At least 10’ form any opening in wall of adjacent
structures
• Concrete pads at all spill points (3’ min)
 Permanent signage:
OXYGEN – NO SMOKING – NO OPEN FLAMES
 Access controlled (i.e. locked)
Department of Engineering 2012 - 53
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 EC.02.05.09 EP 1 states the hospital tests, inspects and
NFPA 110: EMERGENCY &
STANDBY POWER SYSTEMS
devices that have normal electrical power entering
and leaving the ATS
 The power continues on to distribution panels
 When a ATS senses a disruption in power it sends a
signal to the alternative power source seeking power
 This start circuit initiates the emergency generator
starter
 The ATS is also equipped with a test switch to
simulate the power disruption
 Recommended practice is to rotate which ATS
initiates the start circuit to the emergency
generator
Department of Engineering 2012 - 54
© Copyright, The Joint Commission
 Automatic Transfer Switches (ATS) are self-acting
Month, day year and initials of inspector as per NFPA 10-1998
EC.02.03.05 EP 15
4-3.4 Inspection Recordkeeping.
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.
DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION
Department of Engineering 2012 - 55
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FIRE EXTINGUISHER: DATING
GENERAL LIFE SAFETY INTERPRETATIONS
 Perimeter shelving and sprinkler provision:
 Are
perimeter wall shelving that
extends to the ceiling required to be
fastened to the wall?
 NO
Shelving is not required for storage
 There is no correlation between
• Shelving
• Clearance
• The need to secure any shelving
Department of Engineering 2012 - 56
© Copyright, The Joint Commission

Firestop:
Existing application is acceptable when
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
Department of Engineering 2012 - 57
© Copyright, The Joint Commission
GENERAL LIFE SAFETY INTERPRETATIONS
GENERAL LIFE SAFETY INTERPRETATIONS
purposes is NOT an acceptable
firestop in any fire or smoke barrier
 This product does have a UL label:
for insulation properties
 Easily ignited
 Toxic gases may occur when
burned
NOTE: There are several acceptable
fire stop products that expand when
installed
Department of Engineering 2012 - 58
© Copyright, The Joint Commission
 Expanding foam used for insulation
 Electrical
 Unlocked distribution panels in patient
care areas
 Based on policy
 Consider risk assessment
 Score EC.02.01.06 EP 1
 Open junction boxes
 Score at EC.02.03.01 EP 1
• Risk: arcing resulting in fire or loss
of service
Department of Engineering 2012 - 59
© Copyright, The Joint Commission
GENERAL LIFE SAFETY INTERPRETATIONS
 Staff Safety
 EC.02.02.01
 EP 3: Precautions & PPE
 EP 4: Spill procedures
 EPs 5 – 10: minimizes risk
 EC.04.01.01
 EP 1: Monitoring & Reporting
 EPs 2 – 11: Specifics
 Manifests: EP 11
 DOT training for those signing
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GENERAL LIFE SAFETY INTERPRETATIONS
OUTDOOR SAFETY
 EC.02.01.01 EP 5
hospital maintains all grounds and
equipment
 Grounds includes
 Sidewalks
 Parking lots
 Park ways
 Picnic and patio areas
 Play structures
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 The
OUTDOOR SAFETY
 EC.02.01.01 EP 5
hospital maintains all grounds and
equipment
 Equipment includes
 Lawn maintenance equipment
 Snow removal equipment
 Maintenance equipment
 Paving
 Road repair
 Lighting
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 The
GENERAL LIFE SAFETY INTERPRETATIONS
 A stairwell may be allowed to be
substituted as an “exit access
corridor”
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 Suite Exiting
 LS.02.01.20 EP 21 (18/19.2.5.1)
 Suites have access to an “exit
access corridor”
 LS.02.01.20 EP 17(18/19.2.5.3)
 Suites must have at least two exits
remote from one another
SURGICAL SITE FIRES
 >50 million hospital & ASC surgeries
100 surgery fires per year
 20 Serious
 1 – 2 deaths
 Fire sites:
 34% airway
 28% head/face
 38% other
 74% occurred in oxygen enriched
environment
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 Estimated
SURGICAL SITE FIRES
 Source:
electrosurgical equipment
 13% lasers
 Recommendations:
 Fire drills & Staff Education
 Review alarm procedures
 Review rescue techniques
 Review shut off locations
 Joint Commission response:
 Life Safety Code Surveyors gown and survey
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 68%
CMS CONDITIONS OF PARTICIPATION
 42 CFR 482.41
must maintain adequate facilities for its
services
 42 CFR 482.41(c)(2)
 Facilities, supplies and equipment must be
maintained to ensure an acceptable level of
safety and quality.
 The CMS Interpretive Guideline states “the
hospital must monitor, test, calibrate and maintain
equipment periodically in accordance with the
manufacturer’s recommendation and Fed and
State law.”
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 Hospital
BACKGROUND
on 42 CFR 482.41(c)(2)
 2009 hospital system implemented EQ56
 CMS Regional Office stated that any risk or
evidence based program conflicted with 42
CFR 482.41(c)(2)
 Other CMS Regional Offices accepted the
Joint Commission processes
 The hospital system asked CMS why they
were inconsistent with 42 CFR 482.41(c)(2)
 1/2010 CMS instructed Joint Commission to
comply with 42 CFR 482.41(c)(2)
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 2007 two hospitals cited by state agents based
CMS RESPONSE
CMS Deputy Director
July 26, 2010
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I am happy to inform you that the
Joint Commission’s approach of
utilizing a preventive maintenance
schedule has been approved.
Thank you for your cooperation
and collaboration.
S&C: 12-07-HOSPITAL PUBLISHED 12/11
 Allows non-life support to adjust frequencies
 Restricts non-life support from adjusting


FTE & other re-occurring costs ($4 – 10 Billion):
 Clinical Equipment: $2 – 5 Billion
 Facilities Equipment: $2 – 5 Billion
New capital investment ($2 – 6 Billion):
 Clinical Equipment: $1 – 3 Billion
 Facilities Equipment: $1 – 3 Billion
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maintenance activities
 Restricts life support from frequencies and
maintenance activity adjustments
 Restricts equipment maintenance methods
 Estimated financial impact to comply:
4/9/2012 DISCUSSION WITH CMS
 Ad Hoc team began to meet every Monday to
create united response to CMS
 Provided council and resources
 Joint Commission leadership is supportive of
discussing the issues with CMS

Joint Commission met with CMS to discuss the
S&C: 12-07 April 9, 2012
 Restriction related to test equipment lifted
Saving estimated as $2 – 6 Billion to healthcare
 Collaborative discussion with the conclusion
research would be of benefit
 Research should be specific to reliability of
the Joint Commission process in EC.02.04.01
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
 Research Issues:
 How many organizations use the Joint
Commission process?
 What guidance is used to modify
frequency and maintenance activities?
 Have there been any adverse outcomes
based on solely on this process
 If so, what?
 Self diagnostic equipment:
 How many devices with this feature?
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DISCUSSION, CONTINUED
ACTION ITEMS
 AAMI & ASHE hosted Survey Monkeys
webinars to review Joint Commission
standards and make the field aware of the
importance of the survey
 AAMI had 526 sites
 ASHE had 216 sites
 JCR had 794 sites
 Survey responses:
 AAMI had 1526
 ASHE had 790
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 5/18 AAMI, ASHE & JCR hosted free
QUESTION 1
Range
Percentages
Responses
<100
27.1
221
100 – 200
15.7
123
201 – 350
23.5
183
351 – 500
12.8
100
>500
20.9
162
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How many acute care beds is your
organization licensed or authorized for?
QUESTION 2
Range
Percentages
Responses
<500
20.1
158
500 – 1,000
19.1
150
1,000 – 2,500
22.8
180
2,500 – 5,000
17.4
135
>5,000
20.6
162
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How many pieces of equipment are in
your inventory?
QUESTION 3
Percentages
Responses
Yes
90.9
714
No
9.1
70
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Do you use the Joint Commission
process identified in EC.02.05.01
EPs 2 – 4 (i.e. have an inventory
based on risk and other criteria)?
QUESTION 4
Percentage
Responses
Yes
92.7
728
No
7.3
57
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Do you use the Joint Commission
process identified in EC.02.05.01 EP 3
to establish maintenance activities (i.e.
preventive maintenance procedure)?
QUESTION 5
Percentage
Responses
Yes
90.9
711
No
9.1
71
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Do you use the Joint Commission
process identified in EC.02.05.01 EP 4
to establish maintenance frequencies?
QUESTION 6
Percentage
Responses
Yes
1.0
8
No
99.0
782
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Have you had any adverse outcomes
(i.e. patient injuries or deaths)
because you have modified the PM
procedures or frequencies from the
manufacturer’s recommendations,
using the Joint Commission process
identified in EC.02.05.01 EPs 2 – 4?
None of the 12 that answered YES to
question 6 had an adverse event
 4 are not accredited by the Joint
Commission
 3 had comments that did not pertain to
the topic
 4 were pro-Joint Commission process
comments
 1 reported a bed brake failed to engage
and a patient fell when leaning on the
bed
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COMMENTS TO QUESTION 6
NEXT STEPS
continued to actively help navigate
this process
 AAMI, ASHE and Joint Commission
will be meeting with CMS to review
the research results
 Goal is to resolve the conflict with
sound evidence provided by the
research
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 The Ad Hoc committee has
© Copyright, The Joint Commission
QUESTIONS?
DEPARTMENT OF ENGINEERING
630 792 5900
George Mills, MBA, FASHE, CEM, CHFM, CHSP
Director
Michael Chisholm, CPE, CHFM
Engineer
John Maurer, CHFM, CHSP
Engineer
Bruce Boggan, MBA, CHFM
Engineer
Department of Engineering 2012 - 82
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Anne Guglielmo, CFPS, LEED, A.P., CHSP
Engineer
THE JOINT COMMISSION DISCLAIMER
 These slides are current as of 6/21/2012. 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
 These slides are copyrighted and may not be further
used, shared or distributed without permission of the
original presenter or The Joint Commission.
Department of Engineering 2012 - 83
© Copyright, The Joint Commission
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.
EYE WASH STATION
FEDERAL REQUIREMENTS: OSHA
recommendation to
 reduce the risk of injury from contact with caustic and
corrosive materials in areas such as
 Power Plant
 Lab
 Placed so that the eyewash is within 10 seconds or 55
feet from where the corrosive chemicals is used
 Weekly flush until clear is required
 Annual inspection to ensure the system is fully functional
 Mixing valve recommended to achieve tepid
 Risk assess potential exposure to determine if cold
water only would be acceptable
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 Score Eye Wash issues at EC.02.02.01 EP 5
 Risk assess location / application based on OSHA
Medical services and first aid 1910.151(c)
The eyes or body of any person may be exposed to injurious
corrosive materials, suitable facilities for quick drenching
or flushing of the eyes and body shall be provided within
the work area for immediate emergency use.
Formaldehyde 1910.1048(i)(3)
 If there is any possibility that an employee's eyes may be
splashed with solutions containing 0.1 percent or greater
formaldehyde, the employer shall provide acceptable
eyewash facilities within the immediate work area for
emergency use.
Battery charging and changing 1917.157(i)
 Facilities for flushing the eyes, body and work area with
water shall be provided wherever electrolyte is handled,
except that this requirement does not apply when
employees are only checking battery electrolyte levels or
adding water.
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EYE WASH STATION:
RECOMMENDED LOCATIONS (I.E. OSHA)
© Copyright, The Joint Commission
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