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Joint Commission: Life Safety revisions for behavioral healthcare

The Joint Commission has revised its Life Safety standards LS.04.01.20 through LS.04.02.50 for its Behavioral Health Care Accreditation program. The changes apply to residential behavioral health care facilities and go into effect July 1, 2018. The revisions change the “residential occupancy” requirements so they align with the 2012 edition of the National Fire Protection Association’s NFPA 101: Life Safety Code®.

The accreditor says these changes aren’t major, and they mostly address two things:

•    Updating the NFPA chapter references used in the elements of performance
•    Making it easier to discern between the requirements for existing and new buildings and for small and large organizations.

You can read the prepublication standards here. 

CMS and Joint Commission change hospital eligibility requirements

Both organizations have changed their expectations on the defintion of a hospital. CMS’s new S&C Memo 17-44-Hospitals says that surveyors will use average daily census (ADC) and average length of stay (ALOS) data to determine if the hospital is primarily engaged in providing services to inpatients, and “a hospital must have inpatients at the time of survey in order for surveyors to directly observe the actual provision of care and services to patients, and the effects of that care” to determine if the facility is meeting the Conditions of Participation (CoP) in Medicare.

In addition, both CMS and The Joint Commission say that hospitals will need at least two active inpatients on site for an accreditation survey to be done. This change is effective immediately.

CMS memo defines ligature risk and clarifies expectations

A new CMS memo creates a definition of a ligature risk, a time frame for correcting them, and interim guidance for surveyors, plus requirements for requesting a time extension for a plan of correction taking longer than 60 days. CMS says that while not all ligature risks can be eliminated, hospitals are expected to show how they identify patients at risk and the steps they are taking to minimize those risks.

According to the S&C Letter 18-06, a ligature risk (or point) is “anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.” That includes handles, coat hooks, pipes, shower rails, radiators, bedsteads, window and door frames, ceiling fittings, hinges, and closures.

CMS is still collaborating with healthcare organizations and patient safety groups on more comprehensive guidance on ligature risks. The agency says it expects to have the update done in six months. Until then, accrediting organizations (AO) are allowed to use their own judgment on ligature risks. That includes the definition of a ligature risk, plans for correction, how deficiencies are ranked, and how long a facility has to correct the problem. Facilities should double-check with their AO’s ligature risk and self-harm requirements.

Joint Commission to Increase Hand Hygiene Focus

The Joint Commission will soon be scrutinizing hand hygiene more closely.

Starting in 2018, if a surveyor from the accrediting organization witnesses an individual who directly cares for patients fail to perform required hand hygiene, the person’s healthcare organization will receive a citation under The Joint Commission’s Infection Prevention and Control (IC) standard IC.02.01.01, element of performance 2, which requires organizations to use precautions such as hand hygiene to reduce infection risk. In addition, healthcare facilities must meet National Patient Safety Goal (NPSG) 07.01.01, which requires them to implement and maintain a hand hygiene program.

The change, announced Thursday, will go into effect on January 1, 2018.

Previously, healthcare organizations were not penalized for an individual failure to perform proper hand hygiene if that organization had an otherwise compliant hand hygiene program. But under this change, if a surveyor spots an individual who does not properly wash his or her hands, the surveyor will cite the organization for a deficiency resulting in a Requirement for Improvement.

In 2004, TJC first required all healthcare organizations to implement hand hygiene programs and keep track of individual performance within that plan. Proper hand hygiene, of course, is critical for preventing infections in a healthcare setting.

FDA bans 24 ingredients in healthcare antiseptics

The FDA has banned two dozen active ingredients used in healthcare products because they weren’t generally recognized as safe and effective for use in over-the-counter (OTC) products. The ban is specifically aimed at OTC products used primarily in medical settings like hospitals, clinics, and doctors’ offices. The ingredients had been used in antiseptic hand washes and rubs, surgical hand scrubs, and patient antiseptic skin preps.

“Ensuring the safety and effectiveness of over-the-counter health care antiseptics has been a priority for the FDA, not only because these products are an important component of infection control strategies in health care settings, but also because of the role these products may play in contributing to antimicrobial resistance if they’re not manufactured or used appropriately,” said FDA Commissioner Scott Gottlieb, MD. “Health care providers are on the front lines of care. They need and deserve to have safe and effective means for preventing the spread of infection.”

With the exception of triclosan, none of the ingredients are currently being used in any marketed health care antiseptic products. And at industry urging, the FDA is deferring their final rulemaking for a year for six ingredients to give manufacturers more time to complete the scientific studies on their safety: alcohol (ethanol), isopropyl alcohol, povidone-iodine, benzalkonium chloride, benzethonium chloride, and chloroxylenol (PCMX).


2018 version of “Patient Safety Systems” Chapter available

The Joint Commission has released the most recent versions of it’s PS Chapter for hospitals, nursing care centers, critical access hospitals, behavioral healthcare centers, laboratories, and more.

Main manual for CMS’ hospital Interpretive Guidelines updated

For the first time in two years, the online version of CMS’ State Operations Manual, Appendix A — also known as SOMA by some — is showing it has been revised!

The date on the appendix, which offers CMS surveyors Interpretive Guidelines to follow when implementing the hospital Conditions of Participation (CoP), is now Nov. 17, 2017. The last revision had been in November 2015.

The most recent update appears to mainly reflect changes to how CMS defines a hospital for survey. Those changes were announced in S&C memo 17-44-ALL-Hospitals.

And more changes should be on the way, especially in light of the recent publication of a new S&C memo on ligature risk. Among other things, S&C 18-06-Hospitals memo notes changes under Tag A-0701 that appear to delete references to emergency preparedness — now under their own set of CoP outlined in Appendix Z— and adds guidelines for checking out other physical safety concerns along with ligature risk within the environment of care.

Study: Concurrent surgeries are safe

A review of more than 2,000 neurosurgical cases published in the Journal of the American Medical Association, found no greater risk of postoperative complications for patients operated on by surgeons conducting overlapping surgeries. This casts a new light on the controversial practice, which is routine at many facilities nationwide.

The study, published earlier this month, examined patients who underwent neurosurgical procedures at Emory University Hospital in Atlanta from 2014 to 2015. Of the 2,275 cases reviewed, about 43% had the surgeon remain with the patient through the entire procedure. In the other 57% of cases, the primary surgeon performed two procedures in different operating rooms.

In the 90 days following their operations, no difference was found in morbidity, mortality, or worsened outcome measures between the two groups of patients. The researchers concluded that this data suggests overlapping neurosurgeries are safe and may benefit patients by allowing sought-after specialists to see more patients.

That said, researchers did note that overlapping surgeries were notably longer than when one surgery was done at a time. And guidelines from the American College of Surgeons require that patients be informed that they’ll be undergoing a concurrent surgery.

“Surgeons must use their experience, keen intuition and respect for their own ability and limitations to carefully select patients” for overlapping surgery, the authors wrote.

Workplace violence prevention resources

More than 70% of significant WPV injuries occur in healthcare and social service settings. That number has been on the rise, and the victims are primarily healthcare workers. Here are some other free resources and training on workplace violence prevention in your healthcare organization:

1.    The Center for Health Design’s Safety Risk Assessment Toolkit
2.    The CDC’s Workplace Violence Prevention for Nurses  
3.    OSHA’s Guidelines for Preventing Workplace Violence in Healthcare and Social Services    
4.    OSHA’s Preventing Workplace Violence: A Road Map for Healthcare Facilities
5.   The Emergency Nurses Association’s Workplace Violence Page
6.    ASIS International’s Managing Disruptive Behavior and Workplace Violence in Healthcare

Know the medical gas cylinder storage requirements

Editor’s note: This update was provided by Brad Keyes, CHSP, owner and senior consultant for Keyes Life Safety Compliance, LLC, and a consulting editor for Healthcare Life Safety Compliance.

 The following medical gas cylinder storage requirements are relative to the National Fire Protection Association (NFPA) Standards 99 Health Care Facilities (2005 edition) and are updated for 2017. In January 2007, CMS issued Survey and Certification memo 07-10, which clarified how oxygen cylinders should be stored, based on the 2005 edition of NFPA 99. The Joint Commission and the other accreditation organizations (AO) have adopted these clarifications and established clear requirements concerning medical gas cylinder storage. These AOs will assess your facility for compliance based on the following standards.

Medical gas cylinder storage

  • An aggregate total of compressed medical gases (e.g., oxygen, nitrogen, nitrous oxide) up to 300 cubic feet may be stored per smoke compartment in any room or alcove without special requirements for that room. Compressed gas cylinders must be secured in racks or by chains.
  • Quantities of compressed medical gases of more than 300 cubic feet but less than 3,000 cubic feet must be stored in specially designated rooms that meet the following requirements:
    • Rooms must be of noncombustible or limited-combustible construction (gypsum wallboard, tiled walls, etc.) with a door that can be secured from unauthorized entry (e.g., locked).
    • Oxygen may not be stored with other flammable gases or liquids.
    • Oxygen cylinders must maintain a minimum distance of 20 feet from combustibles (5 feet if room is sprinklered) or be placed within an enclosed cabinet having a fire rating of at least a half hour.
    • Cylinders must be secured in racks or by chains.
  • Quantities of compressed medical gases more than 3,000 cubic feet must be stored in specially designated rooms that meet the following requirements:
    • The room must have sufficient room to maneuver cylinders.
    • The room is able to be secured with lockable doors.
    • The room is constructed with noncombustible or limited-combustible construction, with a minimum fire rating of one hour (no allowances for fully sprinklered rooms). The entrance door to this room must also be fire rated for one hour, and not ¾ hour as allowed for other one-hour rated barriers.
    • The room is compliant with NFPA 70 National Electric Code, with electrical devices located at or above 5 feet from the finished floor.
    • The room is heated by indirect means, if heat is required. “Indirect” means gas-fired unit heaters and electric unit heaters are not permitted. Steam or hot water heating systems are permitted.
    • The room contains adequate racks constructed of noncombustible or limited-combustible materials and chains to secure all cylinders, full or empty.
    • The room contains a dedicated, continuously operating mechanical ventilation system that draws air from within 12 inches of the floor, with a means of make-up air provided.
    • In lieu of a mechanical ventilation system, and where natural ventilation is permitted, the room includes a natural ventilation system consisting of two louvered openings, each having a minimum free area of 72 square inches with one opening located 12 inches from the floor and the other located 12 inches from the ceiling. NOTE: Louvered natural ventilation openings are not permitted in an exit access corridor.


  • One E-size cylinder = 24.96 ft.³
  • Twelve E-size cylinders = 299.52 ft.³
  • Therefore, up to 12 E-size cylinders may be stored in any smoke compartment without special requirements for the room.
  • One H-size cylinder = 250 ft.³
  • Therefore, one H-size and two E-size cylinders may be stored in any smoke compartment without special requirements for the room.
  • Cylinders on gurneys, crash carts, wheelchairs, etc., are considered “in use” and not subject to the total count for “in storage.”
  • Cylinders in a rack are “in storage.”
  • Empty cylinders are not considered part of “in use” or “in storage.”
  • A cylinder is considered “full” provided it still has its seal from the supplier. Once the seal has been removed, the cylinder is no longer considered full.
  • TJC says that full and partially full cylinders are permitted to be stored together, unless the organization’s policy requires further segregation.
  • NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders.
  • NFPA 99 does not define the point where a cylinder is considered empty. All storage
    requirements are based on the total volume of gas in cylinders being stored. For the purpose of
    segregating empty and full cylinders, the facility should establish a level of where this delineation
    would be made. The Joint Commission issued a clarification on this issue, stating that for the
    purposes of segregating cylinders, once one has been opened it is then considered empty
    regardless of how much of the gas has been used. This is specifically for segregation purposes
    and does not prevent a facility from having a “partial” cylinder designation. For facilities not
    accredited by The Joint Commission, NFPA 99 is still silent on this and leaves it to the facility to
  • For the purpose of calculation of aggregate quantities of stored medical gas cylinders, empty cylinders must be considered as full cylinders since residual gas will remain in the cylinders.

Updated to reflect The Joint Commission’s stance on storing partials and full cylinders 

See the 2016 Joint Commission Standards FAQ here