Hospital survey rules have been updated by The Joint Commission (TJC) – each physical address = minimum 2 Life Safety Code Surveyor days.
Life Safety Code Surveyor Days changed in July 2020 – LSCS added one day for each free‐standing emergency department and ambulatory surgery center.
Surveying what space? … The Joint Commission requires the LSC survey to extend to all inpatient locations and to locations where patients customarily go to receive patient care; see the new Life Safety Code Business Occupancy Standard (LS.05.01.10, LS.05.01.20, LS.05.01.30, LS.05.01.34, and LS.05.01.35) which will be effective July 1, 2021.
COVID 19 Pandemic 1135 Waiver Reminder
Suspended onsite surveys on March 15, 2020
Resumed onsite surveys on June 1, 2020
Pandemic Health Emergency began March 1, 2020. TJC authored in collaboration with ASHE an 11‐page ITM waiver request document, which was submitted to CMS on April 2, 2020. CMS responded on April 30, 2020 and CMS added ABHR, Fire Drills, and later Temporary Construction on May 11, 2020.
Most important, to take advantage of the 1135, did the organization activate emergency operations plan (EOP)? And the implementation of the 1135 waiver should be documented in the organizations eSOC and document in the safety meeting minutes.
The Joint Commission COVID-19 position on conducting fire drills is often quarterly fire drills can move mass number of staff together, because of this engaging activity, TJC will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area.
1135 waivers have been provided for many elements of performances within the standards for inspection, testing, and maintenance requirements. The Joint Commission is honoring these waivers for both deemed and non‐deemed organizations. The Joint Commission is not focusing on these tasks during the period covering the beginning of the public health emergency until the time the organization has established survey ready date.
Hospital Accreditation standards / elements of performance that can be waived as published in The Joint Commission Environment of Care News, August 2020 edition are as follows:
When survey ready date is reached, surveyors will ensure that any/all spaces surveyed are compliant with regulatory design requirements. Inherent in that state of readiness is that the organization is no longer operating under its emergency operations plan, which is the impetus for creating alternate care sites that in turn, may impact the operating parameters for an HVAC system(s).
For example, in terms of fans in patient care rooms, what would be the reason for maintaining these fans? If the organization is considering permanently repurposing the space(s) in question, then the organization should follow NFPA and FGI guidance for the new use of the space.
TJC continues to expect all spaces to comply with regulatory requirements. The need for creating negative pressure areas is to deal with the circumstances brought about by the public health emergency. If these environments no longer exist, what would be the justification for keeping the fans in place?
Lastly, check with your local State Agencies for use of the 1135 Waiver.
Water Management Standard updated for now as follows:
EC.02.05.01 The hospital manages risk associated with its utility systems.
EP14 The hospital minimizes pathogenic biological agents in cooling towers, domestic hot‐ and cold‐water systems, and other aerosolizing water systems.
However, Coming Soon a New Water Management Standard: The new Water Management Standard EC.02.05.02 to go into practice July 2021; The organization has a water management program. Note: The water management program is in accordance with law and regulation.
Other Pointers:
A reminder to check your hospital’s inventory of different types of sprinkler heads, and then ensure you have at least six spare sprinkler heads for each type and temperature rating of those installed in your facility. Spare sprinkler heads and appropriate wrench or tool will need to be readily available and stored in a cabinet. The location of the storage cabinet must be in an area that does not exceed 100°F. See the revised language in Standard LS.02.01.35, EP 7 (effective January 1, 2021).
LSCS will also be focusing on pre‐construction risk assessment to ensure infection prevention and general safety strategies are in place.
Basic Building Information is scheduled for an update regarding additional building data, sometime in January 2021. Reminder, as of January 2020, a new EP 7 was added to LS.01.01.01 for organizations to update their eBBI.
Blow out or scab patches on protective barriers can be an area of concern during the above ceiling survey for further information see the September 2020 - EC News and additional information for repair of fire rated gypsum panel product systems review # GA‐225‐2019 provided by the American Gypsum Association.
Future Changes in the Works:
The Joint Commission is considering a Workplace Violence Future Standard with EPs
The proposed Elements of Performance requirements are to mandate that hospitals:
The Joint Commission modified its Environment of Care (EC) survey process for ambulatory surgery centers, critical access hospitals, and hospitals to provide a more meaningful assessment. The modification eliminates the one-hour Environment of Care discussion with members of the hospital Safety / EC committee. The information gathered from this former practice will be integrated into the document review and building tours conducted by the Life Safety Code Surveyor. To prepare your organization, facility managers should be aware that The Joint Commission has updated its Life Safety & Environment of Care Document List and Review Tool, the Kitchen Tracer checklist and developed a new Imaging Document Review Guide for Healthcare Organization; all of these documents can be found in the 2021 Annual Survey Activity Guide for Health Care Organizations (Effective: 1/1/2021). I have reviewed the annual survey guide and it is rich with information.
New Emergency Management (2022 update to EM standards) session – proposed July 2021
Edmund Lydon, MS, CHFM, FASHE
Advocacy Liaison