The Joint Commission Update 2013. Dave Dagenais. Ranking Results: 11 out of 21 in 2012. #2: LS.02.01.20 51%. The hospital maintains the integrity of the means of egress. EP 1 Door locking EP 13 Corridor Clutter EPs 16 – 21 Suites issues Boundaries & Size defined
EPs 1 -20:
EP 1: monitor authorized automatic sprinkler system
EP 2: water flow alarm
NOTE: Perimeter wall and stack shelving may
NFPA 13-1999, 5-6.6
In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.
Flutter Strip Testing
Hazardous Materials and Waste
EPs 4 – 7
Issued August 30th, 2013
Covers several “categorical waivers”
Allows more than one delayed-egress lock in the egress path where the clinical needs require specialized security measures or when a patient requires specialized protective measures for safety.
Accommodates the use of suites by allowing: (1) one of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior; and (3) an increase in sleeping room suite size up to 10,000 ft2.
Allows for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type waterflow alarm devices to semiannual, and electric motor-driven pump assemblies to monthly.
Allows the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96-gallons
Allows certain types of alternative type kitchen cooking arrangements including kitchens, serving less than 30 residents, to be open to corridors as long as they are contained within smoke compartments
Allows the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of
solid fuel burning fireplaces in areas other than patient sleeping areas
OR Relative Humidity
lowering the humidity requirement for operating rooms and other anesthetizing locations from at least 35percent to at least 20 percent.
Document your desire and that you comply with the waiver provisions in your policy and procedures manual.
Verbally announce that you are requesting the waivers at each entrance interview of a survey
Check with your State Agency and verify the waivers will be accepted for licensing
Indicate Life Safety waiver requests in your BBI
Indicate Environment of Care waiver requests in your management plan