1. The Joint Commission Update 2013
Dave Dagenais 1

2. Ranking Results: 11 out of 21 in 2012
Top 20 Rank
Standard
2012 RFIs
2011 RFIs
Subject 2 LS
51%
56%
Means of Egress 3 LS
46%
52%
General LSC Requirements 5 EC
40%
Features of Fire Safety 6 LS
39%
45%
Life Safety Protection 7 EC
35%
31%
Built Environment 9 LS
34%
29%
Fire Suppression Systems 10 EC
33%
23%
Utility Systems (Ventilation) 11 EC
30%
25%
Hazardous Materials & Waste 15 EC
22%
Medical Gases 17 EC
26%
Emergency Power 21 EC
19%
21%
Fire Safety

3. #2: LS %
The hospital maintains the integrity of the means of egress.
EP 1 Door locking
EP 13 Corridor Clutter
EPs 16 – 21 Suites issues
Boundaries & Size defined
Sleeping Suite <5000 sq ft
Non-sleeping suite <10,000 sq ft
EP 22: Patient sleeping room is not locked
EP 27-28: Lighting

4. Doors: Locking EP 1
Doors within a required means of egress shall not be locked from the egress side
Exceptions
Clinical needs of the patient for security measures – staff must be able to unlock at all times
One (1) delayed-egress lock in any egress path
Access controlled in accordance with
3 types of locking arrangements found:
Clinical Needs Locking
Delayed Egress Locking
Access Control Locking
For full text and any exceptions, refer to NFPA : 18/
A door may be locked from the outside to protect the occupants from unauthorized entry, but from the occupant side the door must be unlocked, with certain exceptions.
If based on clinical assessment the door should be locked to protect staff or the patient from harm, the door must be able to be unlocked by staff at all times. Locks may be mechanical (i.e. key) or electronic (i.e. card swipe action). (See NFPA )
Only one delayed egress door is allowed in an egress pathway. (See NFPA / exception 2)

5. Corridor Storage “If the corridor looks cluttered…it probably is”
Carts Allowed:
Crash Carts
Isolation Carts
Chemo Carts
Anything in the egress corridor more than 30 minutes is storage
Dead end corridors may be used for storage
Less than or equal to 50sqft space

6. Suites
Not identified on drawings
Boundaries
Dimensions
Exits

7. Egress Illumination EP 27
Means of egress are illuminated
Corridors
Passageways
Stairways
Stairway Landings
Exit Doors
Exit Discharges
Angles and Intersections of the above
Must be illuminated within 10 seconds
For full text and any exceptions, refer to NFPA : 18/ and
Floors and other walking surfaces within an exit and within the portions of exit access and exit discharge must be illuminated to at least 1 ft. candle measured at the floor.
Metal halide and sodium do not meet the 10 second requirement.

8. Egress Illumination EP 28
Failure of one bulb or fixture shall not result in total darkness
Minimum illumination required is 0.2 foot-candle in any designated area
For full text and any exceptions, refer to NFPA :
When using motion sensor type controls, they must be of the fail safe type and set at a minimum of 15 minutes duration.

9. #3: LS.02.01.10 46% EP 9 Fire Barrier Penetrations
Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
EP 9 Fire Barrier Penetrations
EPs 5 – 7 Door issues
EPs 1 & 2 Building Type issues
EP 8 Duct issues

10. #5: EC.02.03.05 40% Features of fire protection
The hospital maintains fire safety equipment and fire safety building features.
Features of fire protection

11. Need for Inventory EC.02.03.05 EP 1 – 20:
Each device that is required to be tested must be documented in an inventory
If x devices were tested last year, and x-1 were tested this year, which device was missed?
Each device must be on the inventory to identify which device was missed
Total number of devices (quantity) is not adequate
Lack of an inventory (written, electronic or other) results in a finding at each EP

12. EC.02.03.05 EPs 1 -20: LD.04.01.05 EP 4: Staff held accountable
Missing documentation: scored at each EP as non- compliant
Also write a finding at EP 25 for documentation not being readily available to the AHJ
LD EP 4: Staff held accountable
If 3 or more findings at EC EP 1 – 20

13. EC.02.03.05 EP 25 Name of the activity Date of the activity
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

14. #6: LS %
The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
EPs 16 – 23 Smoke Barriers & Doors
EP2 Hazardous Areas

15. LS.02.01.30 EP 1 Vertical Openings
The following vertical openings must be enclosed with at least 1-hour fire rated construction:
Exit stairs (unless >4 stories, then 2-hour FRR)
Ramps
Elevator Shafts
Ventilation Shafts
Light Shafts
Trash or linen chutes
Utility chases LS
Existing vertical openings (other than exit stairs) are enclosed with 1-hour fire-rated construction. In new construction, vertical openings (other than exit stairs) are enclosed by 1-hour fire-rated walls when connecting three or fewer floors and 2-hour fire-rated walls when connecting four or more floors. (See also LS , EP 4)
Note: These vertical openings include, but are not limited to, communicating stairs, ramps, elevator shafts, ventilation shafts, light shafts, trash chutes, linen chutes, and utility chases. (For full text and any exceptions, refer to NFPA :18/ ) *
Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
Exception No. 1: This requirement shall not apply where otherwise specified by , , , or Chapters 11 through 42.
Exception No. 2: This requirement shall not apply to escalators and moving walks protected in accordance with
Exception No. 3*: This requirement shall not apply to expansion or seismic joints designed to prevent the penetration of fire and shown to have a fire resistance rating of not less than the required fire resistance rating of the floor when tested in accordance with ANSI/UL 2079, Test of Fire Resistance of Building Joint Systems.
Exception No. 4: Enclosure shall not be required for pneumatic tube conveyors protected in accordance with
Exception No. 5: This requirement shall not apply to existing mail chutes where one of the following conditions is met:
(a) The cross-sectional area does not exceed 16 in.2 (103 cm2).
(b) The building is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.

16. LS.02.01.30 EP 2 Hazardous areas defined, include, but not limited to:
Laboratories that use flammable or combustibles in quantities less than those considered severe hazard
Laboratories that are determined severe hazard
Areas used for general storage >50ft2
Central / bulk laundries >100ft2
Boiler or furnace room
Soiled Linen & Trash Collection Rooms
Fuel storage
Janitor closets and
Maintenance & Paint shops LS
All hazardous areas are protected by walls and doors in accordance with NFPA / (See also LS , EP 5; LS , EP 18) Hazardous areas include, but are not limited, to the following:
Boiler/fuel fired heater rooms
■ Existing boiler/fuel-fired heater rooms have sprinkler systems, resist the passage of smoke, and have doors with self-closing or automatic-closing devices; or the rooms have 1-hour fire-rated walls and ¾-hour fire-rated doors.
■ New boiler/fuel fired heater rooms have sprinkler systems and have 1-hour fire-rated walls and ¾-hour fire-rated doors.
Central/bulk laundries larger than 100 square feet
■ Existing central/bulk laundries larger than 100 square feet have sprinkler systems, resist the passage of smoke, and have doors with self-closing or automatic-closing devices; or the laundries have 1-hour fire-rated walls and ¾-hour fire-rated doors.
■ New central/bulk laundries larger than 100 square feet have sprinkler systems and have 1-hour fire-rated walls and ¾-hour fire-rated doors.
Flammable liquid storage rooms (See NFPA : and )
■ Existing flammable liquid storage rooms have 2-hour fire-rated walls with 1½-hour fire-rated doors.
■ New flammable liquid storage rooms have sprinkler systems and have 2-hour fire-rated walls with 1½-hour fire-rated doors.
Laboratories (See NFPA to determine if a laboratory is a “severe hazard” area)
■ Existing laboratories that are not severe hazard areas have sprinkler systems, resist the passage of smoke, and have doors with self-closing or automatic closing devices; or the laboratories have walls fire rated for 1 hour with ¾ hour fire-rated doors.
■ New laboratories that are not severe hazard areas have sprinkler systems, resist the passage of smoke, and have doors with self-closing or automatic-closing devices.
■ Existing laboratories that are severe hazard areas (See NFPA : ) have 2-hour fire-rated walls with 1.-hour fire-rated doors. When there is a sprinkler system, the walls are fire rated for 1 hour with ¾-hour fire-rated doors.
■ New laboratories that are severe hazard areas (See NFPA : ) have sprinkler systems and have 1-hour fire-rated walls with ¾-hour fire-rated doors.
■ Existing flammable gas storage rooms in laboratories have 2-hour fire-rated walls with 1½-hour fire-rated doors. (See NFPA : )

17. LS.02.01.30 EP 4 & 5 Interior Wall, Floor, and Ceiling Finishes
In existing buildings, interior finishes are required to be rated Class A or B
When newly installed, finishes must be Class A LS
Existing wall and ceiling interior finishes are rated Class A or B for limiting smoke development and the spread of flames. Newly installed wall and ceiling interior finishes are rated Class A. (For full text and any exceptions, refer to NFPA : 18/ )
Newly installed interior floor finishes in corridors of smoke compartments without sprinkler systems have a Class I radiant flux rating. (For full text and any exceptions, refer to NFPA : )
Interior Wall and Ceiling Finish.
Interior wall and ceiling finish materials complying with shall be permitted as follows:
(1) Existing materials — Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with
(2) Newly installed materials — Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.
Interior Floor Finish.
Newly installed interior floor finish complying with shall be permitted in corridors and exits if Class I. No restrictions shall apply to existing interior floor finish.
Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with , no interior floor finish requirements shall apply.

18. LS.02.01.30 EP 6 & 7 Corridor Partitions
Partitions that separate corridors in unsprinklered areas must be:
½-hour Fire rating, continuous from floor slab to underside of the floor or roof above, through any concealed spaces, such as those above suspended ceilings and including interstitial spaces
Constructed to limit the transfer of smoke with all penetrations properly sealed
NOTE: If sprinklered, ceiling is allowed to be the smoke barrier
In new buildings, unrated walls are smoke tight LS
Existing corridor partitions are fire-rated for ½ hour, are continuous from the floor slab to the floor or roof slab above, extend through any concealed spaces (such as those above suspended ceilings and interstitial spaces), are properly sealed, and are constructed to limit the transfer of smoke.
Note 1: Unsealed spaces ⅛-inch wide or less around pipes, conduits, ducts, and wires above the ceiling are permitted.
Note 2: In smoke compartments protected throughout with an approved supervised sprinkler system, corridor partitions are allowed to terminate at the ceiling if the ceiling is constructed to limit the passage of smoke. The passage of smoke can be limited by an exposed, suspended-grid acoustical tile ceiling. The following ceiling features also limit the passage of smoke: sprinkler piping and sprinklers that penetrate the ceiling; ducted heating, ventilating, and air conditioning (HVAC) supply and return-air diffusers; speakers; and recessed lighting fixtures. (For full text and any exceptions, refer to NFPA : and )
In new buildings, corridor walls are constructed to limit the transfer of smoke. (For full text and any exceptions, refer to NFPA : )
* Construction of Corridor Walls.
Corridor walls shall form a barrier to limit the transfer of smoke. Such walls shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. No fire resistance rating is required for corridor walls.

19. LS EP 9 – 11
Corridor Doors
Doors must be substantial, made of >1¾ inch solid bonded wood core or equivalent (without louvers unless wet locations)
Free of protective plates >48” above the bottom of the door
Doors must be fitted with positive latching hardware and able to restrict the movement of smoke
All corridor doors must swing. Pocket or sliding doors are not acceptable Ls
In existing buildings, all corridor doors are constructed of 1¾ inch or thicker solid bonded wood core or equivalent material and do not have ventilating louvers or transfer grills (with the exception of bathrooms, toilets, and sink closets that do not contain flammable or combustible materials). (For full text and any exceptions, refer to NFPA : and )
Corridor doors do not have non-rated protective plates that are placed higher than 48 inches above the bottom of the door. (For full text and any exceptions, refer to NFPA : 18/ )
Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of door pairs is no wider than ⅛ inch, and undercuts are no larger than 1 inch. Roller latches are not acceptable.
Note: For existing doors, it is acceptable to use a device that keeps the door closed when a force of 5 foot-pounds are applied to the edge of the door. (For full text and any exceptions, refer to NFPA : 18/ , 18/ , and ) *
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1¾-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with , the door construction requirements of shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.
Nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door shall be permitted. *
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with

20. #7: EC.02.06.01 35% The organization must provide a safe environment
EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided
The organization must provide a safe environment
Unsecured oxygen cylinders
Child safe plugs

21. EC
EP 13 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided
Ventilation:
i.e. doors held open by air pressure; odors
Temperature:
Hot / Cold calls
Humidity
Primary concern is for areas >60%RH
Mold growth is possible
EP 20: Patient care areas are clean and free of offensive odors

22. #9: LS %
EP 1: monitor authorized automatic sprinkler system
EP 2: water flow alarm
There are 18” or more of open space maintained below the sprinkler deflector to the top of storage.
NOTE: Perimeter wall and stack shelving may
NFPA , 5-6.6

23. 18” rule Perimeter Shelving Perimeter Shelving Ceiling 18” 18” WallOK OK OK
Wrong

24. #10: EC %
EC EP 1: Improper system design
Inability of the mechanical system to achieve required results
EC EP 4: Lack of written inspection, testing & maintaining frequencies
Continuous monitoring by a building automation system (BAS) is acceptable

25. EC
EC EP 6: Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies
Specific areas lack
negative or positive pressures in relationship to adjacent areas
i.e. Endoscopy Processing Room should be negative to the egress corridor
the correct number of air changes per hour
Improper filtration

26. EC EP 6
In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.
Note: Areas designed for control of airborne contaminants include spaces such as operating rooms, special procedure rooms, delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in “protective environment” rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms. For further information, see Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the Facility Guidelines Institute and published by the American Society for Healthcare Engineering (ASHE).
Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies
Specific areas lack
negative or positive pressures in relationship to adjacent areas
i.e. Endoscopy Processing Room should be negative to the egress corridor
the correct number of air changes per hour
Improper filtration
MERV = Minimum Efficiency Reporting Value

27. Air Pressure Relationship Testing
Electronic Monitoring
Smoke Testing
Flutter Strip Testing

28. #11: EC.02.02.01 30% Hazardous Materials and Waste EP 1: Inventory
EP’s 3 – 5: Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures
EP’s 6 – 7: Hazardous energy sources
Escorts to Hot Lab based on organization policy
Perspectives, July 2012

29. Personal Protective Equipment Testing
DOSIMETRY BADGES
Self -Contained
Breathing
Apparatus
LEAD APRONS
Accurate inventory
Testing frequencies (based on policy)
Training for PPE users

30. Gases & Vapors
EP 10: Gases and vapors that are monitored include, but are not limited to
Formaldehyde
Ethylene Oxide (EtO)
Glutaraldehyde
Waste anesthetic gases
Acetic Acid
Methyl/Ethyl Alcohol

31. #15: EC.02.05.09 23% Medical Gas Systems
EP 1: Inspection Testing and Maintaining
EP 2: Test when modified, installed or repaired
EP 3: Obstructions
EP 3: Labeling
Contents of piping
Areas served
Accuracy

32. #17: EC.02.05.07 22% 12 times per year between 20 & 40 days
EPs 4 – 7
Missed Generator & Automatic Transfer Switch (ATS) Tests
12 times per year between 20 & 40 days
Each emergency generator must be tested with a load of at least 30% of nameplate
Each ATS must be tested
Missed triennial 4 hour test

33. #21: EC.02.03.01 19% Fire Safety (EP 1) Open junction boxes
More than 300cuft of nonflammable medical gases (i.e. oxygen) per smoke compartment, open to the egress corridor
Fire Plan (EP 9 & 10)
Lack of fire safety training as per fire plan
Surgical site fires

34. Categorical Waivers

35. S&C 13-58
Issued August 30th, 2013
Covers several “categorical waivers”

36. Medical Gas Master Alarms
Allows substitution of a centralized computer system for (one) Category 1 medical gas master alarm.

37. Openings in Exit Enclosures
Permits existing openings in exit enclosures to mechanical equipment spaces if they are protected by fire-rated door assemblies.

38. Emergency Generators and Standby Power Systems
Reduces the annual diesel- powered generator exercising requirement from two (2) continuous hours to one hour and 30 minutes.

39. Doors
Allows more than one delayed- egress lock in the egress path where the clinical needs require specialized security measures or when a patient requires specialized protective measures for safety.

40. Suites
Accommodates the use of suites by allowing: (1) one of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior; and (3) an increase in sleeping room suite size up to 10,000 ft2.

41. Extinguishing Requirements
Allows for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type waterflow alarm devices to semiannual, and electric motor-driven pump assemblies to monthly.

42. Clean Waste & Patient Record Recycling Containers
Allows the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96-gallons

43. S&C 12-21 Corridor Width New “Effective” Corridor width
Fixed furniture allowed
Rolling carts, equipment and movement aids allowed
Bench
c.c.
5’-0”
8’-0”

44. Decorations
Increases the amount of wall space that may be covered by combustible decorations
20% Not Sprinklered
30% Sprinklered
50% Sprinklered in patient room (less than 4)

45. Kitchens
Allows certain types of alternative type kitchen cooking arrangements including kitchens, serving less than 30 residents, to be open to corridors as long as they are contained within smoke compartments

46. Fireplaces
Allows the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of
solid fuel burning fireplaces in areas other than patient sleeping areas

47. S&C 13-25 OR Relative Humidity
lowering the humidity requirement for operating rooms and other anesthetizing locations from at least 35percent to at least 20 percent.

48. How to request a categorical waiver
Document your desire and that you comply with the waiver provisions in your policy and procedures manual.
Verbally announce that you are requesting the waivers at each entrance interview of a survey
Check with your State Agency and verify the waivers will be accepted for licensing
Indicate Life Safety waiver requests in your BBI
Indicate Environment of Care waiver requests in your management plan

49. Questions