Transcript Direct Impact Requirements

2009
Overview
Environment of Care
Emergency Management
Life Safety Chapter
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
 Joint Commission is required to reconcile
our Elements of Performance (EP) with
CMS Conditions of Participation (COP)
 COPs are the expectations of compliance
CMS has related to Medicare/Medicaid
reimbursements
are federal laws
 To reconcile the Joint Commission has
added 5 additional EPs
 None of these are beyond the current
expectations of the Joint Commission
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 COPs
CMS Deeming Issue: Specifics
 EC.02.02.01 EP 14
Testing badges for exposure from radiology
EC.02.02.01 EP 15
 Free from ionizing hazards for patients & staff
EC.02.04.03 EP 14
 Staff maintain nuclear medicine equipment
annually
EC.02.06.01 EP 20
 Environment is clean, sanitary and free of
odors
LS.01.01.01 EP 4
 Maintain documentation of any inspections or
approvals by AHJs related to fire safety




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
© Copyright, The Joint Commission
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




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
Refrigerator logs missing a few dates, but
temperatures before and after missing dates
are within range—no evidence of any trends
(could be applied to other types of logs)
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 Stretcher or gurney blocking medical gas shut-
When NOT to allow “Corrected on Site”
 Penetrations in a rated barrier
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
 Refrigerator logs with temperatures out of range
and no apparent action to correct or
determination if medications or food are
appropriate for use
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 A policy is written or amended during survey that
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
Environment of Care: Issues
EC.01.01.01: The hospital plans activities to
minimize risks in the environment of care.
One or more persons can be assigned to
manage risks associated with the
management plans described in this standard.
EP 3 The hospital has a written plan for
managing: environmental safety of
everyone who enters the hospitals
facilities
EP 4 The hospital has a written plan for
managing: security of everyone who
enters the hospitals facilities
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 Note:
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
LS.01.01.01 (Administrative)
EP 3
When the hospital plans to resolve a
deficiency through a Plan for
Improvement (PFI), the hospital
meets the time frame identified in
the PFI accepted by The Joint
Commission.
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Life Safety Chapter
Life Safety Chapter
The hospital has a written Interim Life
Safety Measures (ILSM) policy that covers
periods of construction or situations when
the Life Safety Code deficiencies cannot
be immediately corrected or when The
Joint Commission has not granted an
equivalency. The policy includes criteria
for evaluating when and to what extent
the hospital follows special measures to
compensate for increased risk.
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 LS.01.02.01 (ILSM) EP 3
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
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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
Q We have rental beds coming in the
facility at all hours for Bariatric
patients. The beds are being
ordered by the Doctors. The
standard says that all medical
equipment owned or otherwise
shall be inspected before use. What
can we do about this equipment?
A Manage the equipment
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Questions & Answers
Questions & Answers
Q. Can you please address decorations
on walls.
A. See NPFA 101-2000
 18/19.7.5.4
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 10.2.5
Q. Is it acceptable to identify smoke
and fire wall penetrations on a life
safety drawing for a single floor or
area and then enter the deficiencies
as a single PFI that references the
life safety drawing for location and
identification of the deficiency?
A. Possibly
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Questions & Answers
Q. During a recent mock survey, the Engineer surveyor
advised that we should complete a SOC, Part 2 for every
building within our system.
We have off campus facilities that are wood structures,
do not have sprinklers, and do not have fire alarms. This
would require us to complete a Part 2 for these
buildings.
We consider these free standing business occupancies
and have never completed a Part 2.
 In addition, this seems to contradict the Frequently
Ask Questions related to the eBBI where it is stated
that “Freestanding business occupancies are not
required to have en eBBI. Should we now complete a
Part 2 for this type building?
A. You are correct
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Questions & Answers
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". 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
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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
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
Questions & Answers
EP 4 addresses the fire alarm system
EP 5 addresses notification of the fire
responders (i.e. remote fire dept.)
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Q. Environment of Care also has a few
issues. Example: EC.02.03.05, EP's 4
and 5. If you are compliant with
quarterly testing then it would stand to
reason you are compliant with annual
testing. Unless I am missing
something, isn't EP 4 unnecessary?
Questions & Answers
A. No, but some numerical value
needs to be here

The $1000.50 is in the default
message
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Q. I was reporting an interim life
safety issue in the electronic
SOC. The cost was under
$1000.50. Is this figure a set
limit?
Q. JCAHO in EM 03.01.03 ep1, has changed to 2
drills a year with no guide lines to timing (no 4
month 8 month rules). With TJC going to
deemed status they are going by CMMS
guidelines and regulations. CMMS Physical
Environment A-0703 still requires the 4 and 8
month rule. This is a concern. We have to stay
with this guide line because we have 20 beds
licensed long term. If other of our facilities
have SNF beds they can potentially get into a
problem on drills.
A. The Joint Commission has removed this criteria,
but I have passed it on to DSSM for further
review. Thanks.
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Questions & Answers
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
© Copyright, The Joint Commission
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
sleeting 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.
If an organization realizes that they are running way
behind and are going to have trouble completing the
PFI, they need to communicate with The Joint
Commission before their planned completion date to
make arrangements. But if they are on track to finish
as they approach the planned completion date, and
know they will run a little over and are sure they will
be able to finish within 6 months, they can use that
grace period.
Q. Does the Joint Commission still allow a 6 month grace
period for completion of a PFI after the planned
completion date posted in the eSOC?
A. Yes. See “Managing Compliance with the NFPA Life
Safety Code in the introduction to the Life Safety
Chapter: “All corrections must be completed within 6
months of the Projected Completion Date.”
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PFI: 6 Month Grace Period
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
Q. 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 but are not referenced in the
scope of the EP.
A. This would be a new requirement
according to SII guidelines. We would
also like to address cylinder handling
and storage issues in the future.
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EC.02.05.09 Tank Farm
Revise existing Section 4.4.4.1.1.1 to read:
Maintenance of Alternate Power Source. The generator
set or other alternate power source and associated
equipment, including all appurtenant parts, shall be so
maintained as to be capable of supplying service
within the shortest time practicable and within the 10second interval specified in 4.4.1.1.10 and 4.4.3.1.
The 10-second criteria shall not apply during the
monthly testing of an essential electrical system. If
the 10-second criteria is not met during the monthly
test, a process shall be provided to annually confirm
the emergency systems capability to comply with
4.4.3.1.
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10 Second Transfer: NFPA 99-2009
Resolution
Maintenance shall be performed in accordance
with NFPA 110, Standard for Emergency and
Standby Power Systems, Chapter 8.
Substantiation: When testing is performed using
a test switch on an ATS, normal power is still
available to the system. This presents a
significant problem for systems with utility
paralleling, closed transition, or in phase
transfer to meet the 10-second criteria for
picking up the essential load. The standard
established the 10-second criteria for when
the normal power is lost, and not as a testing
criterion for the monthly load test.
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ATS Testing
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
MASTER ALARM PANEL:
LS.02.01.34 EP 2
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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 The master fire alarm control
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
 Testing has confirmed foam alcohol based
hand rub (ABHR) is equivalent to gel
 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
SIG Engineering 2009 - 84
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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
SIG Engineering 2009 - 86
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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)
SIG Engineering 2009 - 87
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General Life Safety Issues
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 - 88
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Jerry Gervais, CHSP, CHFM
Engineer
SIG