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Top EC problems include infection control, risk assessments, documentation


December 7, 2019

by A.J. Plunkett (aplunkett@decisionhealth.com)

Beyond ligature risk, the top concerns found under The Joint Commission’s (TJC) Environment of Care (EC) standards are infection control, risk assessments, and documentation. Herman A. McKenzie, MBA, CHSP, the new director of TJC’s Department of Engineering, offered a rundown of the top-cited problems during this year’s Chicago session of the commission’s annual Executive Briefings.


Hospitals are required to inspect, test, and maintain utility systems under EC.02.05.05.

To avoid serious findings, McKenzie advised that facilities ensure maintenance staff have a good system for setting and tracking scheduled maintenance. Many facilities are now using an electronic tracking system, he said.

You will need risk assessments for your high-risk systems, such as medical gases, as well as controlling ventilation and exhaust systems critical to infection control. Plus, requirements for improvement are edging up under element of performance (EP) 6 for low-risk utility systems. Check your battery-powered lighting. Remember, you must document your non-high-risk utility system components on your inventory and show completion date and results of testing, maintenance, and inspection activities.

And when using an alternative equipment maintenance (AEM) program, you must be able to show a 100% completion rate on activities, whether it’s for high- or low-risk utility systems.


Hospitals are required to manage hazardous materials and waste, and EP 5, which requires hospitals to minimize risks “associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals,” is most often the culprit under this EC standard.

Often the problem is eyewash stations, said McKenzie.

While there is not a specific requirement in the standards involving eyewash stations, if your risk assessment shows you need one in a particular area, you are required to follow OSHA standards and other authorities on the maintenance and operation of those stations.

Make sure you’re doing weekly checks of your eyewash stations, said McKenzie. If you’re asking who should do those checks, also ask who might be using the stations. “If you work in a lab, you should know how to use your safety equipment.”

In addition, said McKenzie, “Make sure if you have the eyewash station, you don’t have clutter in front of it.” Also, ensure the water is at the correct temperature.

Review your risk assessments to ensure they are meeting OSHA standards (see OSHA’s eyewash fact sheet at www.osha.gov/Publications/OSHA3818.pdf). Also check what version of the American National Standards Institute (ANSI) reference you are using, advised McKenzie.

While noting there is no regulatory enforcement behind it, OSHA (and therefore CMS and other authorities) references the ANSI publication ANSI/ISEA Z358.1-2014: Emergency Eyewash and Shower Standard for eyewash station requirements.

Other deficiencies identified under this standard include problems with personal protective equipment. Often the equipment is either not available, not worn correctly, or not worn at all.


There are two key problematic EPs under this standard, which require hospitals to manage risks associated with utility systems.

Under EP 9, hospitals are cited for not having the appropriate labels for utility system controls “to facilitate partial or complete emergency shutdowns.”

Make sure you and your staff know where your gas shutoffs are and that the labels are correct, warns McKenzie. “You don’t want to shut off the wrong things,” he said.

Under EP 14, surveyors are citing serious problems with managing waterborne pathogens such as Legionella.

Make this a priority, because surveyors will.

TJC surveys will become more robust and more stringent when looking at water management in 2020 as the commission moves to be even more in line with CMS requirements outlined under Quality, Safety & Oversight (QSO) memo QSO-17-30- Hospitals/CAHs/NHs REVISED, said McKenzie.

Conduct risk assessments for potential areas of growth and spread of waterborne pathogens, and implement a water management program that considers the ASHRAE industry standard and CDC toolkit, which includes control measures. (See other water management requirements outlined at Executive Briefings by Sylvia Garcia-Houchins, TJC’s director of infection prevention and control, in the November issue of HSL.)

Provide water management reports to your infection control committee, recommended McKenzie. The reports can be annual, or they can be more often, but they need to be communicated to the “highest levels of your organization,” he said.


The main deficiencies identified under this standard for the inspection, testing, and maintenance of medical gas and vacuum systems are under EP 11 for main supply and shutoff valves and EP 12 for—you guessed it—cylinder storage.

The main issue with EP 12 was human error, said McKenzie. “Staff are putting cylinders in the wrong place.” Reinforce requirements with staff, refer as needed to TJC’s FAQ on oxygen cylinder storage management (see https://tinyurl.com/TJC-oxy-cyl) and if you still have questions, call TJC’s Standards Interpretation Group for help. McKenzie reminded the executives in the audience that as accredited customers, they can request a conference call with staff.

With EP 11, the main problem is keeping access to the main shutoff valves open and ensuring the valves are clearly identified, McKenzie said. Remind staff that the shutoff valves can never be blocked, even by something that’s mobile. “You cannot put it in front of a shutoff valve,” he emphasized.

For labeling requirements, McKenzie said to refer to NFPA 99-2012, Health Care Facilities Code®, with specific reference to sections,, and And check to ensure compliance during environmental rounds.


This standard requiring fire drills is often cited under EP 3, which requires that quarterly fire drills are unannounced and unexpected.

Vary your fire drills more often. “Make sure you are programming once per quarter and not at the same time every time,” said McKenzie. For help, TJC has created a fire drill matrix, available online at www.jointcommission.org/tool_to_assist_organizations_schedule_and_organize_fire_drills.


Pay attention to your documentation of maintenance fire safety equipment and fire safety building features. EP 28 is the most often cited culprit under this standard, which requires all documentation to include the following:

  • Name of the activity
  • Date of the activity
  • Inventory of devices, equipment, or other items
  • 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 

To comply with this standard, you need to make sure your documentation is complete, with dates, who completed it, and the appropriate NFPA references, which can be found in Life Safety Code® Chapter 2, Referenced Publications, noted McKenzie.

Be particularly careful when testing fire alarm devices such as strobes. Many facilities contract out the testing of such devices; you need to make sure that the service provider is reconciling the testing results with the previous year’s results.

For instance, if you’re testing 75 strobes this time, but your report shows you tested a different number the last time, “What happened to those other devices?” McKenzie asked. “You need to reconcile the numbers or we’re going to ask if you missed some then or now.”

Sometimes alarms are deactivated because of construction, or they’ve been removed. That’s OK, he said, as long as you explain why and reconcile the numbers.

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