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Revisions to Joint Commission's EC and LS chapters coming in early 2018

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May 18, 2017

Even as the accrediting organization awaits final CMS approval, here are several proposals to keep on your radar

As we barrel toward the second half of 2017, savvy healthcare facilities managers should be taking note of not only the standards currently in place, but also those on the horizon. Thanks to an involved CMS review, those standards keep changing bit by bit.

Surveyors for The Joint Commission began checking last November for compliance with the 2012 Life Safety Code® (LSC) and Health Care Facilities Code, as applied in the accrediting organization’s Environment of Care (EC) and Life Safety (LS) chapters. A set of chapter revisions took effect in January, another round is set to take effect in July, and yet another is planned for early 2018.

Although it might be tempting to procrastinate until CMS officials specify precisely what they expect, shrewd facilities managers will recognize the National Fire Protection Association’s (NFPA) two codebooks as containing keys to their own success, said George Mills, director of engineering for The Joint Commission.

“You need to have both of these documents on your desk, I believe, to be successful on anything that you do related to healthcare,” Mills said during an April webinar hosted by the American Society for Healthcare Engineering (ASHE). The two codes are already mandatory for healthcare facilities, he noted. The purpose of his presentation was to help professionals nationwide make sense of the still-evolving wording in The Joint Commission’s EC and LS chapters.

“The actual language here is proposed language. It may be modified. It may be edited,” Mills said, noting that his team was awaiting the signoff of CMS officials. “My thinking is, probably this fall, we’ll have a pretty good idea where we’re at with these and be able to do a pre-publication release like we did last year in November.”

In the meantime, Mills said, facilities should take a look at what’s in store and plan accordingly. Below are several selected proposed changes, as explained by Mills. (The full webinar will be made available online at www.ashe.org/education/ondemand.shtml.)

Environment of Care chapter

Within the EC chapter of The Joint Commission’s accreditation standards, a number of proposed revisions stem from the CMS application of NFPA’s codes. These include tweaks to the fire response plan requirements, guidelines for power strips, and proper labeling of piping systems, among others.

Dust off that fire response plan. Hospitals have been required to maintain a fire response plan in writing, pursuant to EC.02.03.01. This year, the expanded element of performance (EP) includes a requirement that each hospital’s fire response plan define roles for various healthcare personnel, with procedures for reporting and containing fire and smoke, directions for fire extinguishers, plans for helping move patients, and subsequent plans to evacuate the places where people will seek shelter during an emergency.

The proposed language expected to take effect early next year, Mills said, includes additional specifications regarding how information in the fire response plan is communicated to healthcare personnel.

“In 2017, we asked that you have included in your fire response plan how a system would update patients and how to evacuate the areas of refuge,” Mills said. “In 2018, it’s been expanded again to include that employees are periodically instructed and kept informed of their duties and a copy of the plan is readily available.”

Double-check those power strips. Extension cords must not be used as a substitute for permanent wiring within your facilities, and any use of temporary power taps must adhere to general precautions, pursuant to EC.02.04.03. The forthcoming edits include a proposal to add specificity under EC.02.05.01, Mills said.

“It does not say you cannot use extension cords,” he added. “It’s just that if we see an extension cord and it’s been stapled to a wall or something, with staples, then we would say that’s no longer temporary.”
When using an extension cord temporarily, you must remove it immediately after the task for which it was installed has concluded.

Label your pipes. Supply and shutoff valves for hospital vacuum systems and medical gas piping must be accessible and clearly identified, pursuant to EC.02.05.09. That expectation will likely become much more specific next year, Mills noted.

“You’ll notice in all of the new EPs that I wrote for us, I was very much more prescriptive than we have been in the past,” he said. “A lot of people come up and ask me, ‘George, just tell us what you want us to do.’ So I took that and them at their word.”

Under the proposed modification, piping must be labeled by stencil or adhesive markers. The label must include the gas or vacuum system’s name or chemical symbol and be color-coded.

“We don’t want paint on these pipes,” Mills noted.

Furthermore, there should never be more than 20 feet between labels, and there should be at least one label in every room through which the piping system passes and on every floor.

Mills advised having facilities personnel begin checking now for these forthcoming specifications.

Life Safety chapter

Application of the NFPA’s codes has resulted in a number of proposed tweaks within the LS chapter of The Joint Commission’s accreditation standards as well, including EPs pertaining to illumination in the means of egress, managing labs with hazardous materials, and providing alcohol-based hand sanitizer safely, among others.

Light your exit routes. Illuminating means of egress within a hospital has been a requirement of LS.02.01.20, which specifies the minimum amount of light (0.2 foot-candles) that must be provided, even if a single bulb or fixture fails. Under the proposed change, the standard will specify that the lighting must be sustained during an emergency for 90 minutes.

“I just want to point out this is a modification where we’re adding how long you need to be providing that emergency lighting—for at least a 90-minute duration—and that the system is tied into emergency power as well,” Mills said.

Ask how hazardous your labs are. Under the proposed edits to LS.02.01.30, laboratories with materials that are combustible, flammable, or hazardous and in quantities deemed a “severe hazard” will be subject to Section 8.7 of the NFPA’s Health Care Facilities Code, which addresses proper administration, testing, and maintenance of such labs. The logical question, then, is how to define a “severe hazard” and which of your labs qualify as such.

“This is usually assessed by your local authority having jurisdiction,” Mills said. “So when in doubt, bring in your local fire marshal, show him your concern areas in the lab, and if they’re concerned about the volume of loading you have there, you move out from ‘light duty’ to ‘severe hazard,’ and Chapter 8.7 will give you protective requirements for that space for that.”

Hand hygiene can be a hazard. When CMS adopted the 2012 LSC, officials warned that the presence of alcohol-based hand rub (ABHR) dispensers should be guarded against “inappropriate access,” a phrase that found its way into the proposed modifications to LS.02.01.30.

“When I asked them what do they mean by that, what I was told is this is so that, if I’m in a behavioral health unit, that the clients in that area do not have access to alcohol-based hand rub because it can be drank or somehow consumed to give them an altered state,” Mills said. “So you would want to make sure that the dispensers are not readily available to the occupants if the occupants are not able to function with those.” The dispensers could pose a similar risk to children, Mills noted.

ABHR dispensers can also present a fire risk, which is why the proposed edits include specifications that dispensers must not be installed within an inch of any ignition source and that the composition of the ABHR itself must not exceed 95% alcohol.

“We want these readily available,” Mills said, “but we have to also look at the staff and the patients and the visitors in the areas and make sure we do the right thing to protect them.”

Perhaps you can afford that bonus room after all. If you wished to take a patient care room out of service and convert it to storage, that would technically constitute a new use, requiring you to turn to Chapter 18 of the LSC for standards governing new healthcare; however, under Chapter 43, there is a loophole of sorts that permits hospitals to meet a lesser standard, Mills said. Although the storage space must have a full sprinkler system and proper door closure, it would not need one-hour fire-rated walls, lifting a significant burden that would otherwise be imposed by Chapter 18.

“So there’s a major relief to us as far as not bringing those walls up and making them not on the one-hour construction,” Mills said. “If you’ve ever tried to add a wall up over the interstitial space, it’s a nightmare to do it, so this becomes a very important EP for us as we look for areas that we can store patient care equipment in our buildings.”




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