All Entries in the "Joint Commission" Category

BMP and a tale of hiding in plain sight

Over the past few weeks, in doing client work, a number of folks have been bemoaning the departure of The Joint Commission’s building maintenance program (BMP) as a means of ensuring Life Safety Code compliance.

And of course there have been rumors of the BMP returning, [more]

The mythical annual EC report to leadership

Despite a commonly held myth, there is not now, nor has there ever been, an environment of care (EC) requirement for a “report” to leadership.

There is, and has been for some time, a requirement for [more]

ASHE: You need to file waivers with CMS for six-year damper tests

ASHE sent a notice to its members Friday indicating that if hospitals want to observe six-year damper testing — as allowed by The Joint Commmission and the 2007 editions of NFPA 80, Fire Doors and Other Opening Protectives, and NFPA 105, Installation of Smoke Door Assemblies — they’ll need to apply for a waiver from CMS.

CMS doesn’t formally recognize the six-year frequencies, due to the fact the 2000 edition of the Life Safety Code, which CMS enforces, references older editions of NFPA 80 and 105, ASHE said.

I’ll try to get confirmation about this from CMS, but I have no reason to doubt what ASHE is saying. The full notice is only available to ASHE members.

Watch out for the ‘E’ in your RACE procedures

As you probably know, the RACE acronym standards for Rescue, Alarm, Confine, and Extinguish/Evacuate.

That last part about what exactly “E” stands for may have some bearing on how surveyors [more]

ILSMs are more than just construction project buffers

The practical application of interim life safety measures (ILSM) does not begin and end with construction or renovation projects. Rather, ILSMs should be considered (not necessarily implemented) for Life Safety Code (LSC) deficiencies in general.

Any time you have an LSC deficiency, [more]

NFPA reference that allows wall storage within 18 inches of sprinklers

Hi everyone, it’s Scott Wallask, and I was just on the ASHE e-mail group talking about 18-inch clearance requirements for sprinklers in storage areas. The question of storage along walls seems to come up a lot.

As many of you know, there is an exception for perimeter walls that allows you to forgo the 18-inch clearance [more]

Staff training for ILSMs must mirror the risks involved

When it comes to interim life safety measures (ILSM) under LS.01.02.01, poor staff education can result in some exposure during survey, minimally as a direct impact finding. Problems can also lead to conditional and preliminary denial of accreditation from The Joint Commission.

The means of providing ILSM education, while largely self-determined, need to [more]

No BMP coming in 2010, says George Mills

Hi everyone, it’s Scott Wallask. I got a chance to ask George Mills, senior engineer at The Joint Commission, about the future of the building maintenance program (BMP). Mills spoke at a Joint Commission Resources audio conference on Wednesday.

Mills said there is no plan [more]

Follow-up about computers-on-wheels in corridors

I was talking to Steve MacArthur earlier today about some comments and e-mails we received regarding computers-on-wheels (COWs) in egress corridors, which Steve wrote about last week.

In his post, he noted a CMS memo that mentioned which wheeled items can remain in corridors. Two points we wanted to clarify [more]

Don’t park your wheeled computers in egress corridors

When it comes to computers-on-wheels (COWs) in corridors, the same rule applies as it would for most other items in egress corridors. Any item in a corridor (regardless of it’s purpose) may be left unattended for up to 30 minutes, after which, CMS has determined, the item ceases to be “in use” and becomes “storage.”

There are two exceptions [more]