The joint commission update 2013
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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

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The Joint Commission Update 2013

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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

        • Sleeping Suite <5000 sq ft

        • Non-sleeping suite <10,000 sq ft

    • EP 22: Patient sleeping room is not locked

    • EP 27-28: Lighting

Doors: Locking EP 1

  • Doors within a required means of egress shall not be locked from the egress side

    • Exceptions

      • Clinical needs of the patient for security measures – staff must be able to unlock at all times

      • One (1) delayed-egress lock in any egress path

        • Access controlled in accordance with

    • 3 types of locking arrangements found:

      • Clinical Needs Locking

      • Delayed Egress Locking

      • Access Control Locking

Corridor Storage

  • “If the corridor looks cluttered…it probably is”

  • Carts Allowed:

    • Crash Carts

    • Isolation Carts

    • Chemo Carts

  • Anything in the egress corridor more than 30 minutes is storage

  • Dead end corridors may be used for storage

    • Less than or equal to 50sqft space


  • Not identified on drawings

    • Boundaries

    • Dimensions

    • Exits

Egress Illumination EP 27

  • Means of egress are illuminated

    • Corridors

    • Passageways

    • Stairways

    • Stairway Landings

    • Exit Doors

    • Exit Discharges

  • Angles and Intersections of the above

  • Must be illuminated within 10 seconds

Egress Illumination EP 28

  • Failure of one bulb or fixture shall not result in total darkness

    • Minimum illumination required is 0.2 foot-candle in any designated area

#3: LS.02.01.10 46%

  • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

    • EP 9 Fire Barrier Penetrations

    • EPs 5 – 7 Door issues

    • EPs 1 & 2 Building Type issues

    • EP 8 Duct issues

#5: EC.02.03.05 40%

  • The hospital maintains fire safety equipment and fire safety building features.

    • Features of fire protection

Need for Inventory

  • EC.02.03.05 EP 1 – 20:

    • Each device that is required to be tested must be documented in an inventory

      • If xdevices were tested last year, and x-1 were tested this year, which device was missed?

        • Each device must be on the inventory to identify which device was missed

        • Total number of devices (quantity) is not adequate

    • Lack of an inventory (written, electronic or other) results in a finding at each EP


EPs 1 -20:

  • Missing documentation: scored at each EP as non-compliant

    • Also write a finding at EP 25 for documentation not being readily available to the AHJ

  • LD.04.01.05 EP 4: Staff held accountable

    • If 3 or more findings at EC.02.03.05 EP 1 – 20

  • EC.02.03.05 EP 25

    • Name of the activity

    • Date of the activity

    • Required frequency of the activity

    • Name and contact information, including affiliation, of the person who performed the activity

    • NFPA standard(s) referenced for the activity

    • Results of the activity

    #6: LS.02.01.30 39%

    • The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

      • EPs 16 – 23 Smoke Barriers & Doors

      • EP2 Hazardous Areas

    LS.02.01.30 EP 1

    • Vertical Openings

      • The following vertical openings must be enclosed with at least 1-hour fire rated construction:

        • Exit stairs (unless >4 stories, then 2-hour FRR)

        • Ramps

        • Elevator Shafts

        • Ventilation Shafts

        • Light Shafts

        • Trash or linen chutes

        • Utility chases

    LS.02.01.30 EP 2

    • Hazardous areas defined, include, but not limited to:

      • Laboratories that use flammable or combustibles in quantities less than those considered severe hazard

      • Laboratories that are determined severe hazard

      • Areas used for general storage >50ft2

      • Central / bulk laundries >100ft2

      • Boiler or furnace room

      • Soiled Linen & Trash Collection Rooms

      • Fuel storage

      • Janitor closets and

      • Maintenance & Paint shops

    LS.02.01.30 EP 4 & 5

    • Interior Wall, Floor, and Ceiling Finishes

      • In existing buildings, interior finishes are required to be rated Class A or B

      • When newly installed, finishes must be Class A

    LS.02.01.30 EP 6 & 7

    • Corridor Partitions

      • Partitions that separate corridors in unsprinklered areas must be:

        • ½-hour Fire rating, continuous from floor slab to underside of the floor or roof above, through any concealed spaces, such as those above suspended ceilings and including interstitial spaces

        • Constructed to limit the transfer of smoke with all penetrations properly sealed

        • NOTE: If sprinklered, ceiling is allowed to be the smoke barrier

        • In new buildings, unrated walls are smoke tight

    LS.02.01.30 EP 9 – 11

    • Corridor Doors

      • Doors must be substantial, made of >1¾ inch solid bonded wood core or equivalent (without louvers unless wet locations)

      • Free of protective plates >48” above the bottom of the door

      • Doors must be fitted with positive latching hardware and able to restrict the movement of smoke

      • All corridor doors must swing. Pocket or sliding doors are not acceptable

    #7: EC.02.06.01 35%

    • EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided

      • The organization must provide a safe environment

        • Unsecured oxygen cylinders

        • Child safe plugs


    • EP 13 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided

      • Ventilation:

        • i.e. doors held open by air pressure; odors

      • Temperature:

        • Hot / Cold calls

      • Humidity

        • Primary concern is for areas >60%RH

          • Mold growth is possible

  • EP 20: Patient care areas are clean and free of offensive odors

  • #9: LS.02.01.35 34%

    EP 1: monitor authorized automatic sprinkler system

    EP 2: water flow alarm

    • There are 18” or more of open space maintained below the sprinkler deflector to the top of storage.

      NOTE: Perimeter wall and stack shelving may

      NFPA 13-1999, 5-6.6

    18” rule

    Perimeter Shelving

    Perimeter Shelving










    #10: EC.02.05.01 33%

    • EC.02.05.01 EP 1: Improper system design

      • Inability of the mechanical system to achieve required results

    • EC.02.05.01 EP 4: Lack of written inspection, testing & maintaining frequencies

      • Continuous monitoring by a building automation system (BAS) is acceptable


    • EC.02.05.01 EP 6: Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies

      • Specific areas lack

        • negative or positive pressures in relationship to adjacent areas

          • i.e. Endoscopy Processing Room should be negative to the egress corridor

        • the correct number of air changes per hour

        • Improper filtration

    EC.02.05.01 EP 6

    In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.

    Air Pressure Relationship Testing

    Electronic Monitoring

    Smoke Testing

    Flutter Strip Testing

    #11: EC.02.02.01 30%

    Hazardous Materials and Waste

    • EP 1: Inventory

    • EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures

    • EP’s 6 – 7: Hazardous energy sources

      • Escorts to Hot Lab based on organization policy

        • Perspectives, July 2012

    Personal Protective Equipment Testing


    Self -Contained




    • Accurate inventory

    • Testing frequencies (based on policy)

    • Training for PPE users

    Gases & Vapors

    • EP 10: Gases and vapors that are monitored include, but are not limited to

      • Formaldehyde

      • Ethylene Oxide (EtO)

      • Glutaraldehyde

      • Waste anesthetic gases

      • Acetic Acid

      • Methyl/Ethyl Alcohol

    #15: EC.02.05.09 23%

    • Medical Gas Systems

      • EP 1: Inspection Testing and Maintaining

      • EP 2: Test when modified, installed or repaired

      • EP 3: Obstructions

      • EP 3: Labeling

        • Contents of piping

        • Areas served

          • Accuracy

    #17: EC.02.05.07 22%

    EPs 4 – 7

    • Missed Generator & Automatic Transfer Switch (ATS) Tests

      • 12 times per year between 20 & 40 days

        • Each emergency generator must be tested with a load of at least 30% of nameplate

        • Each ATS must be tested

    • Missed triennial 4 hour test

    #21: EC.02.03.01 19%

    • Fire Safety (EP 1)

      • Open junction boxes

      • More than 300cuft of nonflammable medical gases (i.e. oxygen) per smoke compartment, open to the egress corridor

    • Fire Plan (EP 9 & 10)

      • Lack of fire safety training as per fire plan

        • Surgical site fires

    Categorical Waivers

    S&C 13-58

    Issued August 30th, 2013

    Covers several “categorical waivers”

    Medical Gas Master Alarms

    • Allows substitution of a centralized computer system for (one) Category 1 medical gas master alarm.

    Openings in Exit Enclosures

    • Permits existing openings in exit enclosures to mechanical equipment spaces if they are protected by fire-rated door assemblies.

    Emergency Generators and Standby Power Systems

    • Reduces the annual diesel-powered generator exercising requirement from two (2) continuous hours to one hour and 30 minutes.


    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.

    Extinguishing Requirements

    Allows for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type waterflow alarm devices to semiannual, and electric motor-driven pump assemblies to monthly.

    Clean Waste & Patient Record Recycling Containers

    Allows the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96-gallons

    S&C 12-21

    • Corridor Width

    • New “Effective” Corridor width

      • Fixed furniture allowed

      • Rolling carts, equipment and movement aids allowed






    • Increases the amount of wall space that may be covered by combustible decorations

      • 20% Not Sprinklered

      • 30% Sprinklered

      • 50% Sprinklered in patient room (less than 4)


    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

    S&C 13-25

    OR Relative Humidity

    lowering the humidity requirement for operating rooms and other anesthetizing locations from at least 35percent to at least 20 percent.

    How to request a categorical waiver

    Document your desire and that you comply with the waiver provisions in your policy and procedures manual.

    Verbally announce that you are requesting the waivers at each entrance interview of a survey

    Check with your State Agency and verify the waivers will be accepted for licensing

    Indicate Life Safety waiver requests in your BBI

    Indicate Environment of Care waiver requests in your management plan


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