RSSAll Entries in the "Life Safety Code" Category

Documentation question regarding The Joint Commission’s FAQs

As a quick follow up to my post last week about The Joint Commission’s updated FAQs, I wanted to discuss related documentation.

Remember those nifty little “D” icons in the EC, emergency management, and life safety standards that tell us what has to be documented? I don’t see ’em on the FAQ page. [more]

New Joint Commission FAQs should prompt a critical review

I want to jump in with a couple of thoughts relative to the increased activity on the The Joint Commission’s Web site in the FAQ section — especially in the EC, emergency management, and life safety sections. There are nine new FAQs available for your viewing pleasure right now. Go check ’em out (I’ll wait for you to come back).

Back? Good! I think you probably noticed that the topics are scattered across the spectrum. I’m not exactly sure what’s prompted this flurry (it is, after all, winter) of activity, but if you’ll allow me some extrapolation space, it may be that the FAQs have become a venue for moving physical environment compliance into the future. [more]

New life safety EP speaks to documentation concerns

As part of its new EPs that came out last week, The Joint Commission added a provision to life safety standard LS.01.01.01 that requires hospitals to maintain records of inspections and approvals by local and state fire authorities.

I can’t imagine any organization that undergoes some sort of inspection process by AHJs of any stripe would elect not to maintain evidence of that process, or indeed any equivalencies, etc., that might be granted. [more]

New Joint Commission FAQ about life safety deficiencies

I just happened to notice a new Joint Commission FAQ (posted January 6) giving folks 45 days to correct a Life Safety Code deficiency before bumping it up to PFI status. That’s good news for the folks in the field.

Joint Commission suddenly releases more new EPs for 2009

Hi everyone, it’s Scott Wallask.

In an about-turn from what it said throughout 2008, The Joint Commission has released a slew of new elements of performance (EPs) that were not previously in the accreditor’s 2009 standards. And how’s this: The EPs went into effect January 1, but were just released January 5. Surveyors won’t score the new EPs until July 1, 2009, though, and it’s possible further changes are coming.

And to be fair, the new requirements seem minor or things many of you are already doing.


A couple of thoughts about PFIs–they’re only a matter of time (and resources, and . . .)

Among the many requirements that didn’t change when the Life Safety Code leapt to its own chapter is the timely completion of PFIs (and that yawning chasm of shame if you miss the mark).
So, when it comes to planning your PFIs under your Statement of Conditions, you need to be very realistic when you identify how long it’s going to take to repair or otherwise bring into compliance the individual items.
Ultimately, the timeframe for completion is dictated by how long it will take to resolve the condition (yeah, I know–big surprise). But two suggestions:
  • The first thing I’d look at is the severity of the repairs. For example, is the PFI a barrier wall in a patient care area?
  • Then look at what resources need to be brought to bear to manage the long-term items (e.g., time, materials, staffing, access, and whatever else comes into play in figuring out how the conditions will be resolved).
While you do have some flexibility when corrections are delayed due to unforeseen circumstances, the correction of PFIs looks so much better when you don’t have to ask for an extension.
I suspect that this might be my last missive before Christmas, so please accept my best wishes to you for a joyous, happy, safe, sage, and prosperous existence.

Using alcohol-based hand sanitizers in psychiatric areas

Someone on HCPro’s Patient Safety Talk listserv recently asked about using alcohol-based hand sanitizers in psych units.
The key here is whether the results of your organization’s risk assessment indicate that you can safely place the dispensers in that particular care environment. A psych patient population is absolutely unique to a given organization, and when it comes to matters of safety as a function of medical condition/diagnosis, you really need to use that uniqueness (uniquity?) as the basis of the evaluation.
Also, consider these concerns:
  • What product do you use? Foam-based products might be a little safer in a psych application than a liquid.
  • How is the psych environment configured? Is there a safer way to install the dispensers?
Particularly with the likely scrutiny of this type of a thing as a function of The Joint Commission’s National Patient Safety Goals, there will be any number of folks who will take issue with whatever you end up doing. The psych safety zealots will condemn you for using the alcohol-based hand rubs and the infection control zealots will chastise you for not using the product.
I’d work the process through and base the decision on what will work for your patient population.

New Joint Commission FAQs posted

Hi everyone, it’s Scott Wallask. Just wanted to give you a quick heads-up that The Joint Commission has updated it’s FAQs page.

Many of the existing FAQs have simply been updated to stay current, but there are also new ones on the following topics:

  • Labeling of medical gas cylinders
  • Locking electrical panels
  • Locking soiled utility rooms
  • Mounting of sharps containers
  • Patient-owned equipment
  • Placement of alcohol-based hand rub dispensers
  • Smoke-free campuses
  • Computers-on-wheels in corridors
  • Sprinkler protection for wardrobe cabinets

FAQs–along with the actual standards and Perspectives newsletter–are the only “official” venues for Joint Commission changes and interpretations, so they’re worth checking out.

The murky origins of CMS and OSHA provisions for fire drill participation

I have heard of inspectors from the Centers for Medicare & Medicaid Services (CMS), as well as some OSHA inspectors, who not only look for attendance records of fire drills, but also look for some sort of accounting on an annual basis of how many staff members actually participated in fire drills.
That said, I’m not exactly sure where the genesis of that particular notion might be.
Some time back, The Joint Commission “relaxed” its requirements for participation in drills to indicate it should be “to the extent called for in the facility’s fire plan” (see EC.5.30). Similar language will be retained in EC.5.30’s successor, EC.02.03.03.
The Life Safety Code doesn’t really get too far into the specifics of drill participation, and CMS’ Conditions of Participation are absolutely mum on the subject of fire drills, never mind participation in them.
Finally, I also checked the applicable OSHA standards and could find no mention of specific documentation or participation requirements.
My best advice would be to really look at who needs to participate in the drills, based on your plan, and develop strategies to get to as many of those folks as possible (I can’t imagine that weekends wouldn’t be in the mix for that).

Life safety management plans could connect to EC.01.01.01

Strictly speaking, with the transfer of Life Safety Code compliance into The Joint Commission’s life safety standards in 2009, there is no specific requirement for a related written management plan.
The way I plan on covering this programmatic aspect will be to include it in the fire safety management plan, which will still be required as a written document under EC.01.01.01.
The only document required under the life safety standards is a written policy for interim life safety measures.